X3.5 Develop post-discharge plan and follow-up

The aim is to relieve hypoxaemia and obtain improvement in clinical signs and symptoms.

  • Clinical examination: Reduction in wheeze, accessory muscle use, respiratory rate, distress.
  • Gas exchange: Arterial blood gas levels and/or pulse oximetry levels should be monitored until the patient’s condition is stable (SpO2 88 to 92%).
  • Respiratory function testing: FEV1 should be recorded in all patients after recovery from an exacer­bation.
  • Discharge planning: Discharge planning should be commenced within 24–48 hours of admission.

As individual non-pharmacological interventions have shown some promise in reducing COPD admissions, diverse attempts have been made at “bundling” various combinations of these interventions. A large Canadian cohort study of hospitalised COPD patients compared those exposed (n=796) to a bundled intervention (inhaler device technique, follow up with primary care, medication optimization, written discharge management plan, referral to pulmonary rehabilitation, comorbidities and frailty screen, and smoking cessation) to patients not exposed (n=3344). The bundled intervention resulted in an 83% reduced risk of 7-day readmission (RR 0.17, 95% CI 0.07-0.35) and 26% reduced risk of 30-day readmission (RR 0.74, 95% CI 0.60-0.91). There was no difference in 90-day readmissions. The transition bundle however was also associated with a 7.3% (RR 1.07, 95% CI 1.0-1.15) relative increase in length of stay and a 76% (RR 1.76, 95% CI 1.53-2.02) greater risk of a 30- day ED revisit. Within this cohort was a nested RCT where patients exposed to the bundled intervention were randomised to a case coordinator (n=392) in addition to the bundled intervention versus the bundled intervention only (n=404). There was no difference in readmission between these groups, although 7.6% more patients in the care co-ordinator group visited their primary care physician within 14 days of discharge. The care co-ordinator did not provide ongoing case management beyond contact between 48 to 72 hour and 7 to 10 days after discharge (Atwood 2022) [evidence level III-2]. These data highlight the importance of COPD discharge bundles.

Jennings et al (2015) randomised 173 patients admitted to hospital with an exacerbation of COPD to usual care or a pre-discharge care bundle. The care bundle included smoking cessation counselling, screening for gastroesophageal reflux disease and depression or anxiety, standardised inhaler education, and a 48-h post-discharge telephone call. The intervention did not reduce 30 or 90-day COPD readmission rates. Where bundles have omitted proven components such as pulmonary rehabilitation, there has been no benefit for readmissions (Jennings 2015) [evidence level II]. A Tasmanian retrospective cohort study by Njoku et al (2022) demonstrated that being male (OR 1.49, 95% CI 1.06–2.09), or Indigenous (OR 2.47, 95% CI 1.31–4.66) and living in a lower socioeconomic region (OR 1.80, 95% CI 1.20–2.69) were risk factors for 30-day readmission (Njoku 2022) [evidence level III-B]. Efforts to find effective interventions are needed particularly for those at high risk of readmission.

Supportive discharge care, sometimes known as transitional care, has been demonstrated to reduce COPD admissions (OR 0.60, 95% CI 0.42-0.85) and all cause re-admissions (OR 0.72, 95% CI 0.53-0.98), with greatest likelihood of success with greater intervention duration (longer the better), use of phone calls, and multidisciplinary professional involvement (Ridwan 2019) [evidence level I].