Royal Wolverhampton Hospital - HOSPITAL AT HOME SERVICE FOR COPD PATIENTS

Royal Wolverhampton Hospital NHS Trust

Introduction

The ‘hospital at home’ service was the ‘brain child’ of a respiratory nurse consultant and was designed ultimately as an integrated care pathway for patients with chronic obstructive pulmonary disease (COPD).  It was observed that COPD patients were admitted to hospital on a regular basis and that this was both distressing for the patient and family.  COPD patient’s often endured prolonged stays in hospital which could be have been avoided

Key Milestones

Undertaking research to establish the prevalence of the re-admittance rate and the reasons why this occurred established a chain of events which required further review by respiratory clinicians and nursing staff.  It was soon established that a number of changes were required to prevent unnecessary admission to hospital and integrate the care of the COPD patient between the community and hospital staff.

The development of a specialist service was agreed by both the hospital respiratory nurse specialists at the hospital and the community based immediate care team.

What is it achieving? 

• Patients treatment and conditions reviewed at home
• Hand held records kept with the patient
• The service is available 24 hours, 7 days a week
• The team liaise closely with the GP, respiratory therapists, Respiratory Medical Doctors, and community intermediate care team
• Personal health records are held with the patient and used as part of their review and treatment planning
• Any referral and re-admittance is co-ordinated directly with the hospital respiratory medical staff 
• Care pathway and ongoing assessment models developed 
• Less stress and trauma for patients
• Treatment personalised 
• Respiratory training and communication improved between professionals 
• Traffic light home assessment record developed  
• Interest from other Trusts in adopting this service and care pathway materials.

The Key Message 

One key outcome was that the COPD patients were admitted hospital due to a lack of knowledge of the patient’s disease progression and often what had been considered abnormal test results but were often within the normal range for that particular patient.  The hand held records which are used by community and hospital staff provides a seamless source of information to manage the patient between community and hospital professionals.