Early discharge for patients with exacerbations of chronic obstructive pulmonary disease: a randomised controlled trial

Background-We have previously reported the use of a hospital based respirat ory nurse service (Acute Respiratory Assessment Service, ARAS) to support h ome treatment of patients with exacerbations of chronic obstructive pulmona ry disease (COPD). A controlled trial was undertaken to compare early disch arge with home treatment supported by respiratory nurses with conventional hospital management of patients admitted with exacerbations of COPD. Methods-Patients with COPD admitted as emergencies were identified the next working day. They were eligible for inclusion in the study if the differen tial diagnosis included an exacerbation of COPD, but were excluded if other medical conditions or acidotic respiratory failure required inpatient inve stigation or management. Of 360 patients reviewed, 209 were being assessed for other active medical problems and were excluded, 33 potential participa nts were already involved in research studies and so were ineligible, and 3 7 did not wish to participate in the study. Eighty one patients were random ised to receive conventional inpatient care (n=40) or to planned early disc harge the next working day (n=41). Those discharged early continued treatme nt at home under the supervision of specialist respiratory nurses. Outcome measures were readmission, additional hospital days, and deaths within 60 d ays of initial admission. Process measures included number of visits, durat ion of follow up by the respiratory nurse, and additional treatment provide d to support early discharge. Results-On an intention to treat basis, a policy of early discharge reduced inpatient stay from a mean of 6.1 (range 1-13) days with conventional mana gement to 3.2 (1-16) days with an early discharge policy. Twelve patients ( 30% conventional management, 29.3% early discharge) were readmitted in each group giving a mean difference in readmission of 0.7% (95% CI of the diffe rence -19.2 to 20.6). In the conventional management group readmitted patie nts spent a mean of 8.75 additional days in hospital compared with 7.83 day s in the early discharge group, giving a mean difference of 0.92 days (95% CI of the difference -6.5 to 8.3). There were two deaths (5%) in the conven tional management group and one (2.4%) in the early discharge group, a mean difference of 2.6% (95% CI of the difference -5.7 to 10.8). Conclusions-Patients with acute exacerbations of COPD uncomplicated by acid otic respiratory failure or other medical problems can be discharged home e arlier than is current practice with support by visiting respiratory nurses . No difference was found in the subsequent need for readmission.