**6. The Hospital at Home approach to elderly patients with COPD exacerbation: Principles for patient selection and management**

About 20% of patients admitted to the Emergency Department and referred to the HHS of Torino are affected by an exacerbation of COPD.

From an operational point of view, an acute exacerbation of COPD is defined on the basis of Anthonisen criteria as an increase in breathlessness, sputum volume, or purulence for at least 24 hours requiring acute hospitalization (Anthonisen et al., 1987).

Patients that can't be safely managed at home by HHS are those without a family or social support, with severe hypoxemia (PO2 < 50 mmHg), severe acidosis or alkalosis (pH < 7.35 or > 7.55), suspected pulmonary embolism, suspected myocardial infarction.

In the ED all COPD patients undergo baseline standard clinical evaluation; blood tests (blood cell count, routine biochemical tests and arterial blood gas tensions); pulse oximetry; 12-lead electrocardiography; chest radiographs and hand-held spirometry. Further investigations (including pneumologist's assessment) are performed when required, according to the clinical judgement of the ED physician. Patients eligible for HHS are immediately transferred home by ambulance.

HHS patients receive hospital-level treatments and services at home as dictated by their condition. Treatment of COPD exacerbations is based on the optimized use of bronchodilators as well as the administration of systemic corticosteroids and antibiotics, when requested, administered intravenously in about 90% of patients, and oxygen therapy by nasal cannula or Venturi mask. Non-invasive mechanical ventilation is administered at home in collaboration with pneumologists. Acute administration of nutritional support is possible at home, if requested.

The home care program emphasize patient and caregiver education on the knowledge of the disease giving advices about smoking cessation, nutrition, management of activities of daily living and energy conservation, understanding and use of drugs, health maintenance and early recognition of triggers of exacerbation that required medical intervention. Protocols for prevention of nosocomial infections, bed sores, immobilization, dysphagia are routinely adopted for frail patients. Moreover, a counselling service is offered to the most frail patients and caregivers . Aim of the counselling process is to offer to users the opportunity of exploring, discovering and clarify thought and action patterns, thus enabling them to make a better use of their resources in that specific situation of need. Within a situation of crisis and complexity, the counsellor aims at obtaining a safe, confident and cooperative environment capable of transmitting information, implementing support, modifying

and 4317 medical visits were conducted. The mean age of our patients was 80 years (range

In 2010 the Piedmont Region issued a decree to regulate this HHS model and acknowledged a refund of 165 Euros*/*day for DRG included in MDC number 1, 4, 5, 16, 17 (neurological, respiratory, cardiovascular, haematologic and neoplastic diseases), and 145 Euros for the

About 20% of patients admitted to the Emergency Department and referred to the HHS of

From an operational point of view, an acute exacerbation of COPD is defined on the basis of Anthonisen criteria as an increase in breathlessness, sputum volume, or purulence for at

Patients that can't be safely managed at home by HHS are those without a family or social support, with severe hypoxemia (PO2 < 50 mmHg), severe acidosis or alkalosis (pH < 7.35 or

In the ED all COPD patients undergo baseline standard clinical evaluation; blood tests (blood cell count, routine biochemical tests and arterial blood gas tensions); pulse oximetry; 12-lead electrocardiography; chest radiographs and hand-held spirometry. Further investigations (including pneumologist's assessment) are performed when required, according to the clinical judgement of the ED physician. Patients eligible for HHS are

HHS patients receive hospital-level treatments and services at home as dictated by their condition. Treatment of COPD exacerbations is based on the optimized use of bronchodilators as well as the administration of systemic corticosteroids and antibiotics, when requested, administered intravenously in about 90% of patients, and oxygen therapy by nasal cannula or Venturi mask. Non-invasive mechanical ventilation is administered at home in collaboration with pneumologists. Acute administration of nutritional support is

The home care program emphasize patient and caregiver education on the knowledge of the disease giving advices about smoking cessation, nutrition, management of activities of daily living and energy conservation, understanding and use of drugs, health maintenance and early recognition of triggers of exacerbation that required medical intervention. Protocols for prevention of nosocomial infections, bed sores, immobilization, dysphagia are routinely adopted for frail patients. Moreover, a counselling service is offered to the most frail patients and caregivers . Aim of the counselling process is to offer to users the opportunity of exploring, discovering and clarify thought and action patterns, thus enabling them to make a better use of their resources in that specific situation of need. Within a situation of crisis and complexity, the counsellor aims at obtaining a safe, confident and cooperative environment capable of transmitting information, implementing support, modifying

**6. The Hospital at Home approach to elderly patients with COPD exacerbation: Principles for patient selection and management** 

least 24 hours requiring acute hospitalization (Anthonisen et al., 1987).

> 7.55), suspected pulmonary embolism, suspected myocardial infarction.

30-101). Mean length of stay was 14 days.

Torino are affected by an exacerbation of COPD.

immediately transferred home by ambulance.

possible at home, if requested.

other diseases.

attitudes, promoting health education to the patient and the family and finally enabling them to better cope with the situation*.* The counsellor do not provide standardized information to increase the caregiver's skill in caregiving; rather, counselors focused on helping caregivers understand and resolve their reactions to caregiving process.

In the first days after admission in HHS each patient is visited at home on a daily basis by physicians and nurses. In the following days the patients is seen every day by a nurse and at intervals of 2-3 days or less by the doctor, as required by the patient's clinical condition. Hospital at home staff is available at all times for urgent home visits, which occur within 20- 30 minutes by the telephone call. Home visit include: physical examination, measurement of vital signs (pulse, blood pressure, respiratory rate, temperature, oxygen saturation), administration and revision of therapy, if necessary. Essential skills for members of the HHS team are the ability to take a comprehensive clinical history and assess clinical condition, familiarity with pharmacological and non-pharmacological approaches, good communication skills, understanding of airway clearance techniques.

Upon admission, for each patients are recorded: blood pressure, spirometric parameters (FEV1, FVC, FEV1/FVC%), hematocrit, blood glucose, serum creatinine concentration, serum hepatic enzymes, serum nutritional parameters (e.g, total proteins, albumin, transferrin, lymphocytes) and electrolytes, arterial blood gas levels (pH, partial pressure of oxygen, partial pressure of carbon dioxide, bicarbonate, pulse oximetry), sputum culture if possible. During the HHS admission clinical assessment and routine observations are useful in assessing the rate of recovery from an exacerbation. Blood tests, including arterial blood gases measurement and spirometry are repeated according to the clinical condition of the patient. A chest X ray at home is possible, if necessary.

At home, a multidimensional geriatric assessment is conducted using validated instruments. The multidimensional geriatric assessment include the evaluation of comorbidity using the Cumulative Illness Rating Scale (Conwell et al., 1993), severity of illness using the Acute Physiology And Chronic Health Evaluation (Knaus et al., 1985), depression status using the Geriatric Depression Scale (Yesavage et al., 1982), functional status using Katz Activities of Daily Living and Lawton Instrumental Activities of Daily Living (Katz et al., 1963; Lawton & Brody, 1969), cognitive status using the Mini-Mental State Examination (Folstein et al., 1975), quality of life using the Nottingham Health Profile (Hunt et al., 1985), nutritional status using the Mini Nutritional Assessment (Guigoz et al., 1997), characteristics of caregiver with special attention to the level of stress using the Relatives' Stress Scale (Greene et al., 1982), and satisfaction using an "ad hoc" questionnaire for customer satisfaction (Figure 2).

The HHS patients undergo acute rehabilitative care at home, including pulmonary rehabilitation when needed, and their caregivers are encouraged to actively participate in the rehabilitation process. Education and psychological support are important for the overall success of rehabilitation. Education improves knowledge, coping and selfmanagement, actively engaging patients to maintain strategies that reduce dyspnoea, maintain good lifestyle habits and participate in decision-making when acute exacerbation occur.

When patients recover from an acute exacerbation of COPD the dimission is planned, making arrangements with General Pratictioner. District Health Services are activated if required.

Hospital at Home for Elderly Patients

What I think about:

3. Medical explanations on diagnosis

6. Medical and nurses attitudes

hospital/inpatient treatment

4. Medical explanations on disease course and

7. Feeling of safety and protection about home

8. Satisfaction about your home hospital/inpatient

1. Medical care 2. Nursing care

treatment 5. Nursing advice

treatment

 *Detailed comments* 

Positive aspects

...................................... Issues to be improved

...................................... Date,......../......../........

Fig. 2. Questionnaire on customer's satisfaction

*Please, answer to the following questions.* 

with Acute Exacerbation of Chronic Obstructive Pulmonary Disease 387

QUESTIONNAIRE ON CUSTOMER'S SATISFACTION

...............................................................................................................................................................

...............................................................................................................................................................

Patients in both groups received COPD-related treatment at similar rates. The incidence of selected medical complications did not differ between the two setting of care, with the exception of urinary tract infections, which were observed in about 6% of GMW patients and only in 1% of HHS patients (p=.049). There was a lower incidence of hospital readmission for HHS patients compared with GMW patients at 6-month follow-up (42% versus 87%, p<0.001). Cumulative mortality at six months was 20.2% in the total sample, without significant differences between the two study groups. Patients managed in HHS had a longer mean length of stay than those cared for in GMW (15.5 + 9.5 v 11.0 + 7.9 days, p = 0.010). It is important to highlight that all patients discharged from HHS had completed the care program at home, whereas 11.5% of GMW patients continued their care in longterm facility after hospital discharge, with an average daily cost of \$ 174.7 for a mean period

Your answers will enable us to improve the quality of our care.

Thank you for your comments on the back side of this sheet.

You may be helped by a family member or a friend.

The questionnaire is anonimous and will be processed in a sealed envelope.

 **Excellent Very** 

**good** 

**Poor Unsatisfactory** 

Recently, two papers on hospital- at-home treatment of elderly patients with an acute exacerbation of COPD have been published by HHS of San Giovanni Battista Hospital of Torino (Aimonino Ricauda et al., 2007, 2008). Between April 2004 and April 2005 a prospective randomized controlled single-blind trial was conducted to evaluate hospital readmission rates and mortality at 6 month follow up in selected elderly patients with acute exacerbation of COPD. One hundred and four elderly patients admitted to hospital for acute exacerbation of COPD were randomly assigned to General Medical Ward (GMW, n=52) or to Hospital at Home Service (HHS, n=52). Baseline sociodemographic information, clinical data, functional, cognitive, nutritional status, depression and quality of life were obtained (Table 2). All patients were elderly, multimorbid, and functionally and cognitively impaired.


Normal range \* 0-6, † 0-14, ‡ 0-30, § 0-30, ║0-30, # 0-14, \*\*1-5, †† 0-100, ‡‡ 0-38. SD = standard deviation; FEV1 = forced expiratory volume in 1 second.

Table 2. Baseline Characteristics of the Study Populations

#### QUESTIONNAIRE ON CUSTOMER'S SATISFACTION

*Please, answer to the following questions.* 

 Your answers will enable us to improve the quality of our care. The questionnaire is anonimous and will be processed in a sealed envelope. You may be helped by a family member or a friend. Thank you for your comments on the back side of this sheet.

#### What I think about:

386 Chronic Obstructive Pulmonary Disease – Current Concepts and Practice

Recently, two papers on hospital- at-home treatment of elderly patients with an acute exacerbation of COPD have been published by HHS of San Giovanni Battista Hospital of Torino (Aimonino Ricauda et al., 2007, 2008). Between April 2004 and April 2005 a prospective randomized controlled single-blind trial was conducted to evaluate hospital readmission rates and mortality at 6 month follow up in selected elderly patients with acute exacerbation of COPD. One hundred and four elderly patients admitted to hospital for acute exacerbation of COPD were randomly assigned to General Medical Ward (GMW, n=52) or to Hospital at Home Service (HHS, n=52). Baseline sociodemographic information, clinical data, functional, cognitive, nutritional status, depression and quality of life were obtained (Table 2). All patients were elderly, multimorbid, and functionally and cognitively impaired.

**Characteristic Geriatric Home** 

Percentage of predicted FEV1 38 47

Smoking history, n (%)

Arterial blood gas, mean ± SD

SD†

II score, mean ± SD††

Normal range \*

Instrumental Activities of Daily Living score, mean ±

Cumulative Illness Rating Scale score, mean ± SD

Acute Physiology and Chronic Health Examination

Nottingham Health Profile score, mean ± SD‡‡

Age, mean ± SD 80.1± 3.2 79.2± 3.1 .20

Male, n (%) 29 (56) 39 (75) .06 Married, n (%) 27 (52) 29 (56) .84 Family support at home, n (%) 52 (100) 52 (100) .89

Respiratory rate, mean ± SD 24 ± 5 25 ± 7 .32 Home oxygen use before admission, n (%) 18 (35) 12 (23) .45

Geriatric Depression Scale score, mean ± SD‡ 16.1 ± 6.1 17.2 ± 6.8 .45 Mini Nutritional Assessment, mean ± SD§ 17.1 ± 6.5 18.3 ± 6.2 .37 Mini-Mental State Examination score, mean ± SD║ 21.8 ± 6.9 21.8 ± 6.3 .89

0-6, † 0-14, ‡ 0-30, § 0-30, ║0-30, # 0-14, \*\*1-5, †† 0-100, ‡‡ 0-38.

SD = standard deviation; FEV1 = forced expiratory volume in 1 second.

Table 2. Baseline Characteristics of the Study Populations

Comorbidity index# 2.6 ± 1.5 3.0 ± 1.8 .24 Severity index\*\* 2.5 ± 0.5 2.6 ± 0.5 .19

9.5 ± 4.0

20.6± 9.6

pH 7.40 ± 0.04 7.41 ± 0.03 .19 Partial pressure of oxygen 69 ± 19 65 ± 14 .23 Partial pressure of carbon dioxide 44 ± 12 46 ± 12 .47 Activities of Daily Living score, mean ± SD\* 2.3 ± 2.2 1.9 ± 2.2 .36

Current smoker, n (%) 7 (13) 6 (11) .97 Ex-smoker, n (%) 34 (65) 35 (67) .95 Nonsmoker, n (%) 11 (21) 11 (21) .81 Number of cigarettes/d ± SD 20 ± 11 21 ± 15 .83 FEV1, mean ± SD 0.92 ± 0.4 1.04 ± 0.5 .18

**Hospitalization Service (n=52)** 

**General Medical Ward (n=52)** 

7.1 ± 4.9 8.1 ± 4.2 .27

10.3 ± 4.0

.29

.46

19.3± 8.2

**P-Value** 



Fig. 2. Questionnaire on customer's satisfaction

Patients in both groups received COPD-related treatment at similar rates. The incidence of selected medical complications did not differ between the two setting of care, with the exception of urinary tract infections, which were observed in about 6% of GMW patients and only in 1% of HHS patients (p=.049). There was a lower incidence of hospital readmission for HHS patients compared with GMW patients at 6-month follow-up (42% versus 87%, p<0.001). Cumulative mortality at six months was 20.2% in the total sample, without significant differences between the two study groups. Patients managed in HHS had a longer mean length of stay than those cared for in GMW (15.5 + 9.5 v 11.0 + 7.9 days, p = 0.010). It is important to highlight that all patients discharged from HHS had completed the care program at home, whereas 11.5% of GMW patients continued their care in longterm facility after hospital discharge, with an average daily cost of \$ 174.7 for a mean period

Hospital at Home for Elderly Patients

Fig. 3. The MyDoctor@Home Platform

Fig. 4. MyDoctor@Home: Computer work station at HHS office

with Acute Exacerbation of Chronic Obstructive Pulmonary Disease 389

of 25 + 8.7 days. Only HHS patients experienced improvements in depression and quality of life scores. Satisfaction at discharge was very good or excellent for 94% of HHS patients and 88% of acute hospital patients (p=0.83). On a cost per patient per day basis, HHS costs were lower than costs in GMW (\$ 101.4 ± 61.3 versus \$ 151.7 ± 96.4, p=0.002). Analysis of costs for hospital-at-home patients revealed that 79% of costs were due to drugs, durable medical equipment, diagnostic procedures, medications, and other nonstaff costs.
