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. Jennings 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 (odds ratio [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, CI 0.42 to 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].