Early assisted discharge with generic community nursing for chronic obstructive pulmonary disease exacerbations: results of a randomised controlled trial

Abstract

ObjectivesTo determine the effectiveness of early assisted discharge for chronic obstructive pulmonary disease (COPD) exacerbations, with home care provided by generic community nurses, compared with usual hospital care.DesignProspective, randomised controlled and multicentre trial with 3-month follow-up.SettingFive hospitals and three home care organisations in the Netherlands.ParticipantsPatients admitted to the hospital with an exacerbation of COPD. Patients with no or limited improvement of respiratory symptoms and patients with severe unstable comorbidities, social problems or those unable to visit the toilet independently were excluded.InterventionEarly discharge from hospital after 3 days inpatient treatment. Home visits by generic community nurses. Primary outcome measure was change in health status measured by the Clinical COPD Questionnaire (CCQ). Treatment failures, readmissions, mortality and change in generic health-related quality of life (HRQL) were secondary outcome measures.Results139 patients were randomised. No difference between groups was found in change in CCQ score at day 7 (difference in mean change 0.29 (95% CI −0.03 to 0.61)) or at 3 months (difference in mean change 0.04 (95% CI –0.40 to 0.49)). No difference was found in secondary outcomes. At day 7 there was a significant difference in change in generic HRQL, favouring usual hospital care.ConclusionsWhile patients’ disease-specific health status after 7-day treatment tended to be somewhat better in the usual hospital care group, the difference was small and not clinically relevant or statistically significant. After 3 months, the difference had disappeared. A significant difference in generic HRQL at the end of the treatment had disappeared after 3 months and there was no difference in treatment failures, readmissions or mortality. Early assisted discharge with community nursing is feasible and an alternative to usual hospital care for selected patients with an acute COPD exacerbation.Trial registration: NetherlandsTrialRegister NTR 1129.

Variability of hospital resources for acute care of COPD patients: the European COPD Audit

“…In a recent randomised controlled trial, an early supported discharge programme with community nurses resulted in a feasible alternative to traditional hospital admission [18].…”

Prediction of Hospitalization Stay in COPD Exacerbations: The AECOPD-F Score

“…Although many studies have shown that the supported discharge programs allow a significant reduction in stay of subjects hospitalized for COPD and reduce the utilization of hospital resources without increasing the risk of hospital readmissions, subjects' inclusion criteria for early discharge were not clearly defined. [32][33][34][35] The AECOPD-F score could be used to identify subjects who could be discharged earlier and those who may need more prolonged hospitalization and/or extended support at home. The implementation of this score in the planning of the management of such subjects could be evaluated in a future study.…”

Transitional care interventions: Relevance for nursing in the community

“…() reported that patients expressed a preference for home‐based treatment despite a slightly lower ability to resume activities, and slightly greater rates of feeling unsafe at night. However, generic health‐related quality of life was higher in the hospital care group at 7 days (Utens et al., ). Despite these mixed findings, Utens et al.…”

“…Factors linked to effective implementation included the coordination of services (Parsons et al., ), home visits prior to hospital discharge, and the clarification of expectations about home visiting (Utens et al., ). Barriers to implementing transitional care included lack of specialist training of community nurses to cater for specific patient's needs (Utens et al., ). Accessibility and distance were also identified as barriers to transitional care for patients living in remote areas (Blair et al., ).…”

“…The Cochrane Risk of Bias Tool was used to evaluate the quality of randomized controlled trials (Higgins & Green, 2011; as recommended by Zeng et al (2015) This risk of bias tool covers the following six domains: random sequence generation (selection bias), allocation concealment (selection bias), blinding of participants and researchers (performance bias), blinding of outcome assessment (detection bias), incomplete outcome data (attrition bias), selective reporting (reporting bias), and other forms of bias. The RCTs showed largely low risk of bias (Fischer et al, 2012;Stewart et al, 2012Stewart et al, , 2014, although one demonstrated both high and unclear risks of various specific forms of bias (Utens et al, 2012(Utens et al, , 2013.…”