X3.7 Discharge planning

Patients with COPD discharged from hospital following an exacerbation should receive comprehensive follow-up lead by the primary healthcare team [evidence level I, strong recommendation]

Discharge planning involves the patient, external lay and professional carers, the multidisciplinary hospital and com­munity team and the patient’s regular GP. It should com­mence on admission and be documented within 24–48 hours (see Box 14).

Lung Foundation Australia has developed the Managing COPD Exacerbation Checklist available at: https://lungfoundation.com.au/resources/?search=managing%20a%20copd%20exacerbation%20checklist which provides guidance on managing a patient at three stages – in hospital; prior to leaving hospital; and on an ongoing basis 1-4 weeks post-discharge.

Appropriate patient education and attention to pre­ventive management are likely to reduce the frequency of further exacerbations. Assessment of social supports and domestic arrangements are critical in discharge plan­ning. Medicare items support aspects of discharge planning. See http://www.health.gov.au/internet/main/publishing.nsf/Content/mbsprimarycare-factsheet-chronicdisease.htm

A discharge pack, which includes general information about COPD, advice on medication use and written instruc­tions on use of inhalation and oxygen devices, if appropriate, as well as a plan for management of worsening symptoms, should be provided. The GP (and respiratory outreach program, if available) should be notified during the patient’s admission. A case conference involving the multidisciplinary team and GP may assist successful transition to the commu­nity. Medicare Benefits Schedule Enhanced Primary Care item numbers may be claimed for “participation in a case conference” and “contribution to a care plan” (see section D).

Before discharge, referral to a comprehensive pulmonary rehabilitation program should be considered.

Box 14: Criteria for discharge

Suggested criteria for a patient’s readiness for discharge include:

  • The patient should be in a clinically stable condition and have had no parenteral therapy for 24 hours
  • Inhaled bronchodilators are required less than four-hourly
  • Oxygen delivery has ceased for 24 hours (unless home oxygen is indicated)
  • If previously able, the patient is ambulating safely and independently, and performing activities of daily living
  • The patient is able to eat and sleep without significant episodes of dyspnoea
  • The patient or caregiver understands and is able to administer medications
  • Follow-up and home care arrangements (eg, home oxygen, home-care, Meals on Wheels, community nurse, allied health, GP, specialist) have been completed.

A meta-analysis which included an appraisal of four RCTs across three countries and which demonstrated that the use of COPD discharge bundles reduced hospital readmissions by 20% showed no demonstrable benefit in terms of LOS or mortality (Ospina 2017). Outpatient follow-up was found to be a core element to reduce re-admissions.

A systematic literature review of 13 evidence based clinical pathways used in either primary care or hospital settings across 10 countries has demonstrated a reduction in COPD re-admissions by 34% (OR 0.66, 95% CI 0.49 to 0.88) [evidence level I], although with little reduction in length of stay.  Studies with longer follow ups appeared more likely to detect benefits (Plishka 2019).