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Specialist emergency care and COPD outcomes
  1. Nicholas David Lane1,2,
  2. Karen Brewin1,
  3. Tom Murray Hartley1,2,
  4. William Keith Gray1,
  5. Mark Burgess1,
  6. John Steer1,2 and
  7. Stephen C Bourke1,2
  1. 1 Respiratory Research Division, Research and Development, Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital, North Shields, UK
  2. 2 Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
  1. Correspondence to Professor Stephen C Bourke; Stephen.bourke{at}nhct.nhs.uk

Abstract

Introduction In exacerbation of chronic obstructive pulmonary disease (ECOPD) requiring hospitalisation greater access to respiratory specialists improves outcome, but is not consistently delivered. The UK National Confidential Enquiry into Patient Outcome and Death 2015 enquiry showed over 25% of patients receiving acute non-invasive ventilation (NIV) for ECOPD died in hospital. On 16 June 2015 the Northumbria Specialist Emergency Care Hospital (NSECH) opened, introducing 24/7 specialty consultant on-call, direct admission from the emergency department to specialty wards and 7-day consultant review. A Respiratory Support Unit opened for patients requiring NIV. Before NSECH the NIV service included mandated training and competency assessment, 24/7 single point of access, initiation of ventilation in the emergency department, a door-to-mask time target, early titration of ventilation pressures and structured weaning. Pneumonia or hypercapnic coma complicating ECOPD have never been considered contraindications to NIV. After NSECH staff-patient ratios increased, the NIV pathway was streamlined and structured daily multidisciplinary review introduced. We compared our outcomes with historical and national data.

Methods Patients hospitalised with ECOPD between 1 January 2013 and 31 December 2016 were identified from coding, with ventilation status and radiological consolidation confirmed from records. Age, gender, admission from nursing home, consolidation, revised Charlson Index, key comorbidities, length of stay, and inpatient and 30-day mortality were captured. Outcomes pre-NSECH and post-NSECH opening were compared and independent predictors of survival identified via logistic regression.

Results There were 6291 cases. 24/7 specialist emergency care was a strong independent predictor of lower mortality. Length of stay reduced by 1  day, but 90-day readmission rose in both ventilated and non-ventilated patients.

Conclusion Provision of 24/7 respiratory specialist emergency care improved ECOPD survival and shortened length of stay for both non-ventilated and ventilated patients. The potential implications in respect to service design and provision nationally are substantial and challenging.

  • COPD exacerbations
  • COPD epidemiology
  • non-invasive ventilation
  • assisted ventilation
  • emphysema

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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Footnotes

  • Presented at British Thoracic Society winter meeting 2017. (Selected by the society for press release).

  • Twitter @northumbrialung

  • Contributors SCB conceived and obtained support to conduct the study. NDL, JS and SCB designed the study. MB performed the coding searches and produced the VLAD graph. NDL, KB and TMH obtained additional patient data. NDL and WKG performed statistical analysis. NDL, JS and SCB undertook data interpretation. NDL drafted the original manuscript, revised by TMH, JS and SCB. All authors approved the final version.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests SCB, JS, NDL and TMH are currently undertaking a 10-centre NIV Outcomes trial, funded in part by Philips Respironics and Pfizer Open Air (outside the submitted work). SCB reports grants from the National Institute of Health Research, Philips Respironics and Pfizer Open Air, personal fees from ResMed, Pfizer and from AstraZeneca, and non-financial support from GSK and Boehringer Ingelheim outside the submitted work. NDL and TMH are employed and funded by Northumbria Healthcare NHS Foundation Trust Research Fellowship programme.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Any individuals or parties interested in accessing our data should contact SCB.

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