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The aim was to study the overall content and organisational aspects of pulmonary rehabilitation programmes from a global perspective in order to get an initial appraisal on the degree of heterogeneity worldwide.A 12-question survey on content and organisational aspects was completed by representatives of pulmonary rehabilitation programmes that had previously participated in the European Respiratory Society (ERS) COPD Audit. Moreover, all ERS members affiliated with the ERS Rehabilitation and Chronic Care and/or Physiotherapists Scientific Groups, all members of the American Association of Cardiovascular and Pulmonary Rehabilitation, and all American Thoracic Society Pulmonary Rehabilitation Assembly members were asked to complete the survey via multiple e-mailings.The survey has been completed by representatives of 430 centres from 40 countries. The findings demonstrate large differences among pulmonary rehabilitation programmes across continents for all aspects that were surveyed, including the setting, the case mix of individuals with a chronic respiratory disease, composition of the pulmonary rehabilitation team, completion rates, methods of referral and types of reimbursement.The current findings stress the importance of future development of processes and performance metrics to monitor pulmonary rehabilitation programmes, to be able to start international benchmarking, and to provide recommendations for international standards based on evidence and best practice. @ERSpublications Differences in aspects of pulmonary rehabilitation programmes suggest caution in generalisation of research findings

Abbreviations: COPD, chronic obstructive pulmonary disease; FEV 1 , forced expiratory volume in 1 second; LOS, length of stay 837 www.thoraxjnl.com

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Studies report high in-hospital and post-discharge mortality of chronic obstructive pulmonary disease (COPD) exacerbations varying depending upon patient characteristics, hospital resources and treatment standards. This study aimed to investigate the patient, resource and organisational factors associated with in-hospital and 90-day post-discharge mortality and readmission of COPD exacerbations within the European COPD Audit. The audit collected data of COPD exacerbation admissions from 13 European countries.On admission, only 49.7% of COPD patients had spirometry results available and only 81.6% had blood gases taken. Using logistic regression analysis, the risk associated with in-hospital and post-discharge mortality was higher age, presence of acidotic respiratory failure, subsequent need for ventilatory support and presence of comorbidity. In addition, the 90-day risk of COPD readmission was associated with previous admissions. Only the number of respiratory specialists per 1000 beds, a variable related to hospital resources, decreased the risk of post-discharge mortality.The European COPD Audit identifies risk factors associated with in-hospital and post-discharge mortality and COPD readmission. Addressing the deficiencies in acute COPD care such as making spirometry available and measuring blood gases and providing noninvasive ventilation more regularly would provide opportunities to improve COPD outcomes. @ERSpublications Hospital-admitted COPD exacerbation needs better risk stratification: spirometry and gas analysis improve outcomes http://ow.ly/RTbdk

There were large variations between centres for many of the variables studied. A forced expiratory volume in one second measurement was found in only 53% of cases. Of the investigations recommended in the acute management arterial blood gases were performed in 79% (interhospital range 40 -100%) of admissions and oxygen was formally prescribed in only 64% (range 9 -94%). Of those cases with acidosis and hypercapnia 35% had no further blood gas analysis and only 13% received ventilatory support. Long-term management was also deficient with 246 cases known to be severely hypoxic on admission yet two-thirds had no confirmation that oxygen levels had returned to levels above the requirements for long-term oxygen therapy. Only 30% of current smokers had cessation advice documented.To conclude, the median standards of care observed fell below those recommended by the guidelines. The lowest levels of performance were for patients not under the respiratory specialists, but specialists also have room for improvement. The substantial variation in the process of care between hospitals is strong evidence that it is possible for other centres with poorer performance to improve their levels of care. Chronic obstructive pulmonary disease (COPD) has a high prevalence and is one of the most common causes of emergency medical admission with a respiratory disorder in the UK [1,2]. Several national and international Thoracic Bodies have produced management guidelines [3 -7] but relatively little is known about the standards of care of COPD as practised. Published studies encompass few hospitals, small patient numbers, and are not measured against nationally agreed standards. For example data from a sample of l00 cases from the West of Scotland suggested that care by respiratory specialists was better than that given by generalists [8]. A study from a single New Zealand hospital concluded that process of care was "adequate" measured against a local consensus view [9]. Following the launch of the British guidelines [7] the British Thoracic Society (BTS) performed an audit of the clinical practise of hospital care of patients admitted with acute exacerbations of COPD. The aims of the audit were to establish data on the current management of acute COPD in UK hospitals judged against the British guidelines and to identify differences in management between respiratory and nonrespiratory specialists. MethodsHospitals within the UK with acute Respiratory Medicine Departments were approached to participate in the study. All were asked to complete retrospective audit sheets from information held in case-note records on 40 consecutive admissions from September 1, 1997 with a clinical diagnosis of acute exacerbation of COPD as the admission criterion. The audit proforma developed by the BTS audit group, comprised 38 questions some with two or more stems covering the following areas of care: 1) background information and history prior to admission; 2) assessment and measurements on admission; 3) initial management; 4) continuing management and ...

We therefore undertook a study to assess the accuracy of this technique in measuring arterial blood gas tensions in patients with chronic respiratory disorders and with a wide range of values of arterial Po2 and Pco2. We also conducted a survey of other hospitals to find out how commonly the technique is used elsewhere, and the reasons, if any, for not adopting this method. MethodsForty patients with chronic respiratory disease were studied. Their diagnoses were chronic obstructive pulmonary disease and bronchiectasis (29 patients

Concern exists that the transition from student to doctor is abrupt and stressful, and that new graduates lack both clinical skills and confidence. This paper explores the effect of a preparation programme on the confidence and skills of new graduates commencing their first clinical post. Fifty-three participants in two English hospitals undertook a two-week induction combining life support, emergency and clinical skills training with administrative induction and shadowing the outgoing house officer. Questionnaires and focus groups at the beginning, end, and one month following the programme explored participants' perceptions. Respondents were initially anxious about starting work, concerned mainly about clinical skills; taking responsibility; being alone; non-technical skills; and local geography and procedures. Confidence increased following the programme, and the programme's contents directly mitigated some fears. Shadowing was most highly valued, though experiences varied; acute emergency training was also valued, but clinical skills revision was more variably received. Having commenced work, these perceptions remained. Confidence increased further, but clinical practice still represented a steep learning curve. This programme to support the transition from medical student to practising doctor was useful and effective, but could be improved. Increasing responsibility during shadowing could effect an even smoother transition.