Joan Escarrabill

Home hospitalisation of exacerbated chronic obstructive pulmonary disease patients

It was postulated that home hospitalisation (HH) of selected chronic obstructive pulmonary disease (COPD) exacerbations admitted at the emergency room (ER) could facilitate a better outcome than conventional hospitalisation. To this end, 222 COPD patients (3.2% female; 71±10 yrs (mean±sd)) were randomly assigned to HH (n=121) or conventional care (n=101). During HH, integrated care was delivered by a specialised nurse with the patients free-phone access to the nurse ensured for an 8‐week follow-up period. Mortality (HH: 4.1%; controls: 6.9%) and hospital readmissions (HH: 0.24±0.57; controls: 0.38±0.70) were similar in both groups. However, at the end of the follow-up period, HH patients showed: 1) a lower rate of ER visits (0.13±0.43 versus 0.31±0.62); and 2) a noticeable improvement of quality of life (Δ St Georges Respiratory Questionnaire (SGRQ), −6.9 versus −2.4). Furthermore, a higher percentage of patients had a better knowledge of the disease (58% versus 27%), a better self-management of their condition (81% versus 48%), and the patients satisfaction was greater. The average overall direct cost per HH patient was 62% of the costs of conventional care, essentially due to fewer days of inpatient hospitalisation (1.7±2.3 versus 4.2±4.1 days). A comprehensive home care intervention in selected chronic obstructive pulmonary disease exacerbations appears as cost effective. The home hospitalisation intervention generates better outcomes at lower costs than conventional care.

Personalized Respiratory Medicine: Exploring the Horizon, Addressing the Issues. Summary of a BRN-AJRCCM Workshop Held in Barcelona on June 12, 2014

This Pulmonary Perspective summarizes the content and main conclusions of an international workshop on personalized respiratory medicine coorganized by the Barcelona Respiratory Network ( www.brn.cat ) and the AJRCCM in June 2014. It discusses (1) its definition and historical, social, legal, and ethical aspects; (2) the view from different disciplines, including basic science, epidemiology, bioinformatics, and network/systems medicine; (3) the bottlenecks and opportunities identified by some currently ongoing projects; and (4) the implications for the individual, the healthcare system and the pharmaceutical industry. The authors hope that, although it is not a systematic review on the subject, this document can be a useful reference for researchers, clinicians, healthcare managers, policy-makers, and industry parties interested in personalized respiratory medicine.

The impact of home hospitalization on healthcare costs of exacerbations in COPD patients

Home-hospitalization (HH) improves clinical outcomes in selected patients with chronic obstructive pulmonary disease (COPD) admitted at the emergency room due to an exacerbation, but its effects on healthcare costs are poorly known. The current analysis examines the impact of HH on direct healthcare costs, compared to conventional hospitalizations (CH). A randomized controlled trial was performed in two tertiary hospitals in Barcelona (Spain). A total of 180 exacerbated COPD patients (HH 103 and CH 77) admitted at the emergency room were studied. In the HH group, a specialized respiratory nurse delivered integrated care at home. The average direct cost per patient was significantly lower for HH than for CH, with a difference of 810€ (95% CI, 418–1,169€) in the mean cost per patient. The magnitude of monetary savings attributed to HH increased with the severity of the patients considered eligible for the intervention.

How to manage the ED crisis when hospital and/or ED capacity is reaching its limits. Report about the implementation of particular interventions during the Christmas crisis.

Emergency admissions are continuing to rise. The massive use of the urban ED during winter is annually accentuated in the Christmas period, which includes the last week of the year and the first week of the new year. The causes of Christmas crisis are complex, but respiratory infections are definitely a major factor. Provision of acceptable patient care under such circumstances requires a fundamental reordering of ED priorities and procedures. Although acute responses have been described that include redesignating wards, redeploying staff, and boarding patients elsewhere in the hospital, few have been evaluated.

Recomendaciones sobre la atención al final de la vida en pacientes con EPOC

Over the last 20 years, advances in the treatment of patients with chronic obstructive pulmonary disease (COPD) have improved survival even among patients in the most advanced stages of the disease, such as those requiring domiciliary oxygen therapy. This improvement—in principle a positive development—has given rise to considerable clinical problems associated with the establishment of a therapeutic ceiling and the di culty of determining prognosis in some of these patients. in this situation, the clinician should consider introducing palliative care, that is, care aimed at improving symptom control, communication, physical activity, and emotional support, in order to achieve the best possible quality of life for the patient. Palliative care is generally associated with the advanced stages of a disease’s natural history, but in the case of COPD it is important to emphasize it does not necessarily mean that death is imminent. The lack of a generally accepted deinition for “end-stage COPD” makes it di cult to compare studies. Table 1 deines the basic concepts. improving the management of advanced-stage COPD not only has a direct impact on the quality of care received by the patient, but also has a positive effect on the health care system as a whole in that it reduces hospital admissions shifts the burden of care from the hospital to the community, and reduces unnecessary and unscheduled admissions to intensive care units. Many patients with COPD remain undiagnosed, and some of those diagnosed do not fulill the accepted criteria, and it is therefore extremely di cult to establish how many patients actually have very severe COPD, though it is estimated that the proportion may range between 3% and 15% of the total. The concern with broadening the clinician’s approach beyond actions taken primarily to prolong the patient’s life has developed more recently in the context of COPD in comparison with other diseases. nonetheless, and despite the lack of precise deinitions and the unpredictability of this disease, this broader approach should be an indispensable component of good practice in pulmonology. figure 1 summarizes the inal stages of life in patients with COPD.

Seasonality, ambient temperatures and hospitalizations for acute exacerbation of COPD: a population-based study in a metropolitan area

Background Excluding the tropics, exacerbations of chronic obstructive pulmonary disease (COPD) are more frequent in winter. However, studies that directly relate hospitalizations for exacerbation of COPD to ambient temperature are lacking. The aim of this study was to assess the influence of temperature on the number of hospitalizations for COPD. Methods This was a population-based study in a metropolitan area. All hospital discharges for acute exacerbation of COPD during 2009 in Barcelona and its metropolitan area were analyzed. The relationship between the number of hospitalizations for COPD and the mean, minimum, and maximum temperatures alongside comorbidity, humidity, influenza rate, and environmental pollution were studied. Results A total of 9,804 hospitalization discharges coded with COPD exacerbation as a primary diagnosis were included; 75.4% of cases were male with a mean age of 74.9±10.5 years and an average length of stay of 6.5±6.1 days. The highest number of admissions (3,644 [37.2%]) occurred during winter, followed by autumn with 2,367 (24.1%), spring with 2,347 (23.9%), and summer with 1,446 (14.7%; P<0.001). The maximum, minimum, and mean temperatures were associated similarly with the number of hospitalizations. On average, we found that for each degree Celsius decrease in mean weekly temperature, hospital admissions increased by 5.04% (r2=0.591; P<0.001). After adjustment for humidity, comorbidity, air pollution, and influenza-like illness, only mean temperatures retained statistical significance, with a mean increase of 4.7% in weekly admissions for each degree Celsius of temperature (r2=0.599, P<0.001). Conclusion Mean temperatures are closely and independently related to the number of hospitalizations for COPD.

Long-term mechanical ventilation in amyotrophic lateral sclerosis

BACKGROUND Acute respiratory insufficiency (ARI) with alveolar hypoventilation or incapacitating dyspnoea but without peripheral muscle involvement can be an early manifestation of respiratory involvement in amyotrophic lateral sclerosis (ALS). Some of these patients benefit from assisted ventilation. The object of this study was to analyse the results of long-term mechanical ventilation (LTMV) in ten patients with ALS. METHODS A retrospective analysis of intensive care unit (ICU) or ambulant patients with ALS who underwent LTMV in a conventional hospital ward was performed. Erect and supine spirometry, blood gas analysis and pulse oximetry were performed before the start and during the course of ventilation. RESULTS Ten patients on LTMV were included. Four from the ICU were ventilated via tracheostomy, and six ambulant patients had non-invasive (nasal) ventilation. In all cases, ventilation was performed in a conventional hospital ward. The ambulant patients improved symptomatically during ventilation, confirmed by measurement of gas exchange and of SaO2 by continuous pulse oximetry. Three of the ten patients survive in long-term care--two with nasal and one with tracheostomy ventilation. CONCLUSIONS LTMV outside ICU was possible in ten patients, seven of whom returned home. Returning home is very difficult for patients dependent on a ventilator who lack family support.

Standardizing admission and discharge processes to improve patient flow: A cross sectional study

BackgroundThe aim of this study was to evaluate how hospital capacity was managed focusing on standardizing the admission and discharge processes.MethodsThis study was set in a 900-bed university affiliated hospital of the National Health Service, near Barcelona (Spain). This is a cross-sectional study of a set of interventions which were gradually implemented between April and December 2008. Mainly, they were focused on standardizing the admission and discharge processes to improve patient flow. Primary administrative data was obtained from the 2007 and 2009 Hospital Database. Main outcome measures were median length of stay, percentage of planned discharges, number of surgery cancellations and median number of delayed emergency admissions at 8:00 am. For statistical bivariate analysis, we used a Chi-squared for linear trend for qualitative variables and a Wilcoxon signed ranks test and a Mann–Whitney test for non-normal continuous variables.ResultsThe median patients’ global length of stay was 8.56 days in 2007 and 7.93 days in 2009 (p < 0.051). The percentage of patients admitted the same day as surgery increased from 64.87% in 2007 to 86.01% in 2009 (p < 0.05). The number of cancelled interventions due to lack of beds was 216 patients in 2007 and 42 patients in 2009. The median number of planned discharges went from 43.05% in 2007 to 86.01% in 2009 (p < 0.01). The median number of emergency patients waiting for an in-hospital bed at 8:00 am was 5 patients in 2007 and 3 patients in 2009 (p < 0.01).ConclusionsIn conclusion, standardization of admission and discharge processes are largely in our control. There is a significant opportunity to create important benefits for increasing bed capacity and hospital throughput.

Requerimientos técnicos de los espirómetros en la estrategia para garantizar el acceso a una espirometría de calidad

Access to quality spirometry is an essential objective in order to be able to minimize the underdiagnosis of respiratory diseases, especially in those that are most frequent, such as COPD and asthma. This objective can be reached in the short term, but it requires the simultaneous integration of different strategies: training of the health-care professionals who perform spirometry, definition of standards for the transmission of the information, technical requirements for acquiring apparatuses and the correct interpretation of the results. This present study shows the use of standards for the electronic exchange of clinical information. In order to normalize the treatment of the data related with spirometry and to enable the exchange of information, we have used the standard CDA R2 (Clinical Document Architecture, Release 2) of HL7 (Health Level Seven), version 3. HL7 is a product by HL7 International, a non-profit organization that deals in the production of standards in the health-care setting in order to facilitate interoperability. Furthermore, defining these standards is essential for ensuring that they are adopted by spirometer manufacturers. Be means of this process, the base is set for facilitating access to spirometry at the health-care level, while at the same time it is a fundamental technical element for designing quality control programs of the explorations.

Recommendations for End-of-Life Care in Patients With Chronic Obstructive Pulmonary Disease

Over the last 20 years, advances in the treatment of patients with chronic obstructive pulmonary disease (COPD) have improved survival even among patients in the most advanced stages of the disease, such as those requiring domiciliary oxygen therapy.1,2 This improvement—in principle a positive development—has given rise to considerable clinical problems associated with the establishment of a therapeutic ceiling and the difficulty of determining prognosis in some of these patients. In this situation, the clinician should consider introducing palliative care, that is, care aimed at improving symptom control, communication, physical activity, and emotional support, in order to achieve the best possible quality of life for the patient. Palliative care is generally associated with the advanced stages of a disease’s natural history, but in the case of COPD it is important to emphasize it does not necessarily mean that death is imminent. The lack of a generally accepted definition for “end-stage COPD” makes it difficult to compare studies.3 Table 1 defines the basic concepts. Improving the management of advanced-stage COPD not only has a direct impact on the quality of care received by the patient, but also has a positive effect on the health care system as a whole in that it reduces hospital admissions shifts the burden of care from the hospital to the community, and reduces unnecessary and unscheduled admissions to intensive care units.4 Many patients with COPD remain undiagnosed, and some of those diagnosed do not fulfill the accepted criteria, and it is therefore extremely difficult to establish how many patients actually have very severe COPD, though it is estimated that the proportion may range between 3% and 15% of the total.5,6 The concern with broadening the clinician’s approach beyond actions taken primarily to prolong the patient’s life has developed more recently in the context of COPD in comparison with other diseases. Nonetheless, and despite the lack of precise definitions and the unpredictability of this disease, this broader approach should be an indispensable component of good practice in pulmonology. Figure 1 summarizes the final stages of life in patients with COPD.