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COPD: reducing hospitalisations this winter

Belinda R. Miller
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Services provided by these teams may include outreach services with rapid response such as a mobile assessment and treatment service (assessment by medical practitioner and outreach nurse) and home visit assessment service. Other home services, such as physiotherapy and pharmacy, may also be accessible. The evidence is not yet available for the overall patient and economic benefits of home care, but a systematic review of seven studies found no significant differences in readmission rates or mortality, and ‘Hospital at Home’ schemes were preferred by patients and carers.38 Some patients may need initial hospital assessment, and may then be able to return to their own homes with increased social support and a supervised medical care package.

Prompt treatment of exacerbations

Early identification of a COPD exacerbation and early primary care management may reduce the need for hospitalisation. Initial management includes use of short-acting bronchodilators, oral corticosteroids and/or antibiotics. Indications for hospitalisation of patients with a COPD exacerbation are shown in Box 5

Follow up after hospitalisation

All patients discharged from hospital after an exacerbation of COPD should have an early (preferably within one week) follow-up consultation with their GP. The risk of readmission is highest within three months of discharge, and more than half of patients are readmitted within 12 months. All the preventive strategies for COPD exacerbations discussed above should be revisited during this consultation, including revising the patient’s COPD self-management or action plan. Pulmonary rehabilitation has been shown to reduce readmissions if provided within one week.39

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This may also be an appropriate time to discuss advance care directives with patients and, if appropriate, their family and carers. End-of-life issues are relevant for patients with severe and moderate COPD; most patients with end-stage COPD wish to participate in end-of-life management decisions and would prefer to do so in a nonacute setting. For some patients, palliative care team involvement can be helpful.

Conclusion

To help reduce the number of hospitalisations due to COPD exacerbations in the colder winter months, GPs should ensure that their patient’s usual COPD management is effective and appropriate. They can also encourage their patients to be vaccinated against influenza and pneumococcus, avoid exposure to cigarette smoking, participate in regular exercise and have a healthy diet and good nutritional state. Educating patients with COPD to pay particular attention to their respiratory symptoms, follow their self-management plan, seek early treatment for any decline in their condition and avoid exposure to other people with coughs and colds will also help reduce their risk of a severe exacerbation. 

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A checklist of the strategies recommended when reviewing patients with COPD is given in Box 6.    RMT

 

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COMPETING INTERESTS: Associate Professor Miller has received support from AstraZeneca, Boehringer Ingelheim and GlaxoSmithKline for scientific meeting and clinical advisory group attendances, and has been principal investigator in an AstraZeneca sponsored drug trial.

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Associate Professor Miller is a Senior Specialist in Respiratory Medicine at The Alfred Hospital, Melbourne; and a Clinical Adjunct Associate Professor in the Department of Medicine, Monash University, Melbourne, Vic.