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COPD- Specialist Management of acute exacerbation
Key
Background
1
Backing Information
Primary Care
COPD – acute exacerbation specialist care
Information resources for
patients and carers
3
Secondary Care
Referral Template
2
Admission advice to inform effective discharge
4
Consider differential diagnosis
5
Clinical assessment
6
7
Complete the venous
thromboembolism (VTE) risk
assessment
8
Further investigations
Patient not in respiratory failure
Patient in respiratory failure
9
10
Initial treatment
11
Consider
ventilatory support
13
Bronchodilators
Oxygen
therapy
14
Corticosteroid
therapy
16
15
Monitor progress
20
23
Consider ventilatory support
12
Planning for discharge
24
Antibiotic and
other available
treatments
17
Progress
satisfactory
18
Monitor progress
21
Pulmonary rehabilitation
25
Informing effective discharge
26
Follow-up care
28
30
Refer back to primary care
27
Informing
effective
discharge
Follow-up care
29
Long- term follow-up
31
Planning for
discharge
32
Refer back to
primary care
Go to stable COPD pathway
Long- term followup
33
Go to Stable COPD
pathway
Approval Date: March 2011
Review Date: March 2013
Page 1 of 16
Progress not
satisfactory
19
Consider
palliative
22 care
1 Background information
Scope:
 early detection, diagnosis, assessment and management of chronic obstructive pulmonary
disease (COPD) in adults
 interventions include:
o inhaled and oral therapies
o oxygen therapy
o pulmonary rehabilitation
o surgical interventions
o management of psychological sequelae
o health promotion and preventive measures
 management of complications of COPD including:
o respiratory failure
o cor pulmonale
o abnormal body mass index (BMI)
 covers criteria for specialist referral
 covers principles of palliative care in COPD
Out of scope:
 smoking cessation
 palliative care
Definition:
 COPD is characterised by airflow obstruction:
o forced expiratory volume in 1 second (FEV1) less than 80% predicted and FEV1/forced
vital capacity (FVC) ratio less than 0.7
 airflow obstruction is due to a combination of airway and parenchymal damage
 COPD is an umbrella term that includes:
o emphysema
o chronic bronchitis
o chronic airflow limitation
o the definition may include some cases of chronic asthma
Incidence and prevalence:
 an estimated 3 million people are effected by COPD in the UK:
o approximately 2 million of these remain undiagnosed
 rate of COPD in the population is estimated to be between 2-4%
 incidence is difficult to determine as disease develops insidiously
 prevalence rates are increasing in women but have reached a plateau in men
Prognosis:
 COPD accounts for approximately 30,000 deaths each year in the UK (more than 90% of
these occur in those over age 65 years)
 mortality from COPD in England shows a strong urban rural gradient
Risk factors:
 smoking
 occupational exposure
 increasing age
 deprived communities
Click here to go back to the pathway
2 Information resources for patients and carers
Patients and carers can access this pathway through NHS Choices at
http://www.nhs.uk/conditions/chronic-obstructive-pulmonary-disease/pages/introduction.aspx
The following resources have been produced by organisations certified by The Information
Standard:
 'COPD' (PDF) from BMJ at http://www.group.bmj.com
Date agreed: February 2011
Review Date: February 2013
Page 2 of 16





'Chronic Obstructive Pulmonary Disease (COPD)' (URL) from BUPA at http://www.bupa.co.uk
'Chronic obstructive pulmonary disease' (URL) from Datapharm at
http://www.medguides.medicines.org.uk
'Understanding NICE guidance: Chronic obstructive pulmonary disease' (PDF) from national
Institute for Health and Clinical Excellence (NICE) at http://www.nice.org.uk
'Chronic Obstructive Pulmonary Disease' (URL) from Patient UK at http://www.patient.co.uk
The Carers Resource at http://www.carersresource.org
Information for carers and people with disabilities is available at:
 'Caring for someone' (URL) from Directgov at http://www.direct.gov.uk
 'Disabled people' (URL) from Directgov at http://www.direct.gov.uk
Explanations of clinical laboratory tests used in diagnosis and treatment are available at
‘Understanding Your Tests’ (URL) from Lab Tests Online-UK at http://www.labtestsonline.org.uk.
Click here to go back to the pathway
3 COPD - acute exacerbation specialist care
 definition:
o sustained worsening of the patient's symptoms from their usual stable state which is
beyond normal day-to-day variations, and is acute in onset. Commonly reported
symptoms are worsening breathlessness, cough, increased sputum production and
change in sputum colour. The change in these symptoms often necessitates a change
in medication
 diagnosis of exacerbation is made clinically – it does not depend on the results of
investigations, but investigations may at times assist in ensuring appropriate treatment is
given
 worsening of previously stable condition
 presenting features of acute exacerbations of chronic obstructive pulmonary disease (COPD):
o increased wheezing (rhonchi)
o increased dyspnoea
o increased sputum volume
o increased sputum purulence
o cough
o chest tightness
o fluid retention
o respiratory failure
Click here to go back to the pathway
4 Admission advice to inform effective discharge
Maintaining high quality medical records is a fundamental and crucial component of good clinical
practice. Omissions, errors, and illegible records undermine the quality and safety of clinical care
and expose doctors and health care providers units to increased risk of clinical incidents,
complaints, and litigation. [Bridgelal Ram]
The following is designed to serve as a concise reminder for clinicians to ensure patient discharge
notes are accurate, and to facilitate effective discharge.
HIU Discharge Summary
The following should be recorded and updated throughout the patient's hospital stay:
GP details: record the details of the patient’s usual GP.
Patient details: record the patient details, including NHS number and home address.
Admission details: record the method of admission (e.g. emergency, elective, transfer,
maternity), hospital site, responsible Trust, and date of admission.
Discharge details: record date of discharge, method (e.g. on clinical advice, self-discharge),
discharge destination, discharging consultant, and discharging specialty/department.
Clinical information: record diagnosis at discharge, operations and procedures performed
during admission, relevant legal information (e.g. Mental Capacity Act 2005), allergies, risks and
Date agreed: February 2011
Review Date: February 2013
Page 3 of 16
warnings, clinical narrative, outstanding investigations, measures of physical ability and cognitive
function, medication changes, and discharge medications.
Advice, recommendations, and future plan: record actions required by hospital and/or GP,
actions requested/planned/agreed with community, and specialist services.
Patient’s concerns, expectations, and wishes
Information given to patient and/or authorised representative
Results awaited
Person completing the summary: record doctor’s name and GMC number, grade, signature,
date of completion, and bleep number.
High quality discharge notes ensure proper documentation of patient care and treatment plans,
minimise variability and errors during discharge, and assure continuity of care and
communication between care providers.
The Health Informatics Unit of the Royal College of Physicians (RCP), London, UK, working on
behalf of the Academy of Medical
Royal Colleges (AMRC) developed a discharge medical record keeping standard. [RCP 1, RCP 2]
The standard was approved by the AMRC in 2008.
The standard is designed to encourage formal discharge planning at the point of admission for all
in-patients and effective transfer of care tailored to the patient’s health needs and local care
provider context.
Click here to go back to the pathway
5 Consider differential diagnoses
 differential diagnoses:
o pneumonia
o pneumothorax
o left ventricular failure
o pulmonary embolism
o lung cancer
o upper airways obstruction
Click here to go back to the pathway
6 Clinical assessment
History:
 particular note should be made of:
o the known exercise tolerance (which should include a careful record both of how
independent the patient is under normal circumstances and during the exacerbation)
o current treatments, especially the use of nebulisers and long-term oxygen therapy
(LTOT)
o time course of the current exacerbation
o the patient's social circumstances and quality of life – especially whether living alone,
alone with support, with family and an indication of the suitability of the
accommodation
o number of previous admissions in the past 5 years, including admissions to the
intensive care unit (ICU)
o smoking history
Examination:
 signs suggesting a significant deterioration include:
o infection (pyrexia, frankly purulent sputum)
o severe airways obstruction (audible wheeze [rhonchus], tachypnoea, use of accessory
muscles)
o peripheral oedema
o cyanosis
o confusion
Click here to go back to the pathway
Date agreed: February 2011
Review Date: February 2013
Page 4 of 16
7 Further investigations
For all patients referred to hospital:
 chest X-ray
 arterial blood gas tensions (record inspired oxygen concentration (FiO2), e.g. if breathing air
FiO2 = 0.21
 full blood count (FBC) and urea and electrolytes
 theophylline level in patients on theophylline at admission
 electrocardiogram (ECG) (to exclude co-morbidities)
 sputum microscopy and culture if purulent
 if pyrexial (or pneumonia is suspected), blood cultures are recommended
Click here to go back to the pathway
8 Complete the venous thromboembolism (VTE) risk assessment
All patients should undergo venous thromboembolism (VTE) risk assessment as per National
Institute for Health and Clinical Excellence (NICE) guidance:
 upon admission
 for a second time, within 24 hours of initial assessment
 regularly thereafter for the duration of the inpatient stay, and, in some cases, following
discharge
 whenever the clinical situation changes
Click here to go back to the pathway
9 Patient not in respiratory failure
Respiratory failure = failure to maintain adequate gas exchange – characterised by abnormalities
of arterial blood gas tensions:
 partial pressure of oxygen in arterial blood (PaO2) less than 8.0kPa with or without PaCO2
more than 6.7kPa
Click here to go back to the pathway
10 Patient in respiratory failure
Respiratory failure = failure to maintain adequate gas exchange – characterised by abnormalities
of arterial blood gas tensions:
 partial pressure of oxygen in arterial blood (PaO2) less than 8.0kPa with or without PaCO2
more than 6-0kPa
Click here to go back to the pathway
11
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




Initial treatment
bronchodilators
corticosteroid therapy
Oxygen therapy
Antibiotic
respiratory stimulants:
o use doxapram only when non-invasive ventilation is unavailable/considered
inappropriate
pulmonary emboli are more common than is usually recognised in severe COPD but the
benefit of prophylactic anticoagulation treatment has not been evaluated
Click here to go back to the pathway
Date agreed: February 2011
Review Date: February 2013
Page 5 of 16
12 Consider ventilatory support
Ventilatory support:
 either non-invasive intermittent positive pressure ventilation (NIPPV) or invasive intermittent
positive pressure ventilation (IPPV) via an endotracheal tube
 consider in patient with:
o pH of less than 7.35; and/or
o rising partial pressure of carbon dioxide in arterial blood (PaCO2) which fails to
respond to supportive treatment and controlled oxygen therapy
 the decision to institute or to withhold ventilatory support must be made by a senior person
with as much information as possible about the patient's pre morbid state
Non-invasive ventilation (NIV):
 treatment of choice for persistent hypercapnic ventilatory failure despite optimal medical
therapy
 deliver in a dedicated setting with experienced staff trained in its application
 when starting NIV, agree clear plan covering:
o what to do in the event of deterioration
o ceilings of therapy
 consider NIV for patients who are slow to wean from invasive ventilation
 refer to a specialist centre for consideration of long-term NIV
Local Information
Non-Invasive Ventilation is currently only available on ITU at Morriston. A Ward-based service is
under consideration.
Invasive ventilation:
 factors to encourage use of IPPV:
o a demonstrable remedial reason for current decline, e.g. radiographic evidence of
pneumonia or drug over-dosage
o the first episode of respiratory failure
o an acceptable quality of life or habitual level of activity
Factors likely to discourage use of IPPV:
 previously documented severe COPD that has been fully assessed and found to be
unresponsive to relevant therapy
 a poor quality of life, e.g.. being housebound, in spite of maximal appropriate therapy
 severe co-morbidities, e.g.. pulmonary oedema or neoplasia
NB: Neither age alone nor the PaCO2 are a good guide to the outcome of assisted ventilation in
hypercapnic respiratory failure due to COPD (a pH of more than 7.35 is a better predictor of
survival during the acute episode).
Click here to go back to the pathway
13 Consider ventilatory support
Ventilatory support:
 either non-invasive intermittent positive pressure ventilation (NIPPV) or invasive intermittent
positive pressure ventilation (IPPV) via an endotracheal tube
 consider in patient with:
o pH of less than 7.35; and/or
o rising partial pressure of carbon dioxide in arterial blood (PaCO2) which fails to
respond to supportive treatment and controlled oxygen therapy
 the decision to institute or to withhold ventilatory support must be made by a senior person
with as much information as possible about the patient's pre morbid state
Non-invasive ventilation (NIV):
 treatment of choice for persistent hypercapnic ventilatory failure despite optimal medical
therapy
 deliver in a dedicated setting with experienced staff trained in its application
Date agreed: February 2011
Review Date: February 2013
Page 6 of 16



when starting NIV, agree clear plan covering:
o what to do in the event of deterioration
o ceilings of therapy
consider NIV for patients who are slow to wean from invasive ventilation:
consider respiratory stimulant if NIV is not available
Local Information
Non-Invasive Ventilation is currently only available on ITU at Morriston. A Ward-based service is
under consideration.
Invasive ventilation:
 factors to encourage use of IPPV:
o a demonstrable remedial reason for current decline, e.g. radiographic evidence of
pneumonia or drug over-dosage
o the first episode of respiratory failure
o an acceptable quality of life or habitual level of activity
Factors likely to discourage use of IPPV:
 previously documented severe COPD that has been fully assessed and found to be
unresponsive to relevant therapy
 a poor quality of life, e.g.. being housebound, in spite of maximal appropriate therapy
 severe co-morbidities, e.g.. pulmonary oedema or neoplasia
NB: Neither age alone nor the PaCO2 are a good guide to the outcome of assisted ventilation in
hypercapnic respiratory failure due to COPD (a pH of more than 7.35 is a better predictor of
survival during the acute episode).
Click here to go back to the pathway
14 Oxygen therapy
 oxygen should be prescribed to achieve target saturations of 94-98% for most acutely ill
patients or 88-92% for those at risk of hypercapnic respiratory failure
 check blood gases after 30-60 minutes (or if there is clinical deterioration) even if the initial
PaCO2 level was normal
 the target saturation should be written on the drug chart
 if the PaO2 is raised but PH is greater or equal to 7.5, patient has probably got long standing
COPD, maintain target range of 88-92% saturation
 if the patient is hypercapnic (PaCO2 greater than 6KPA or 46mm of mercury) and acidotic (PH
less than 7.35 or hydrogen ion concentration more than 45nmol/L), consider non invasive
ventilation, especially if acidosis has persisted for more than 30 minutes despite appropriate
therapy
 pH less than 7.35 - consider ventilatory support
Click here to go back to the pathway
15 Bronchodilators
 increase frequency of bronchodilator use - consider giving via a nebuliser
 nebulised bronchodilators should be given on arrival and at 4-6 hourly intervals thereafter
(more frequently if required)
 moderate exacerbations - give beta-agonist (salbutamol 2.5-5mg or terbutaline 5-10mg) or
an anticholinergic drug (ipratropium bromide 0.25-0.5mg)
 if severe exacerbations/response to either treatment alone is poor, both beta agonist and
anticholinergic drug may be administered
 oxygen can continue to be given by nasal prongs at 1-2L/min during nebulisation in order to
prevent the fall in oxygen saturation that sometimes occurs with the use of nebulisers
 if patient is hypercapnic/acidotic, the nebuliser should be driven by compressed air, not
oxygen (to avoid worsening hypercapnia) – oxygen therapy can be administered
simultaneously by nasal cannulae if needed
Date agreed: February 2011
Review Date: February 2013
Page 7 of 16
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

formal assessment after recovery from the acute episode is still required
if the patient is not responding, intravenous (IV) methylxanthines by continuous infusion
(aminophylline 0.5mg/kg per hour) should be considered (measure blood levels of
theophylline daily)
nebulised bronchodilators should be continued for 24-48 hours or until the patient is
improving clinically – bronchodilators can then be given by metered-dose aerosol or dry
powder inhaler
Click here to go back to the pathway
16 Corticosteroid therapy
 use in conjunction with other therapies in all patients admitted to hospital
 use 7-14 day course of systemic corticosteroids (prednisolone 30mg/day or hydrocortisone if
the oral route is not possible) if:
o the patient is already on maintenance oral corticosteroids; or
o there is a previously documented response to oral corticosteroids; or
o the airflow obstruction fails to respond to an increase in bronchodilator dosage; or
o this is the first presentation of airways obstruction
 discontinue after the acute episode, unless they have shown to be effective when the patient
is clinically stable or there is a definite indication for long-term treatment
 assess need for long-term inhaled corticosteroids separately
 osteoporosis prophylaxis - consider if frequent corticosteroid courses are required
 withdrawal after chronic therapy (more than 7 days) must be gradual (i.e. tapered off over
weeks or months)
Click here to go back to the pathway
17 Antibiotic and other available treatments
Antibiotic treatment in acute exacerbations of chronic obstructive pulmonary disease (COPD):
 use if:
o increased sputum purulence and either increased breathlessness or increased sputum
volume
o consolidation on a chest radiograph
o clinical signs of pneumonia
 initial empirical treatment should be an aminopenicillin, a macrolide, or a tetracycline
 always take account of any guidance issued by their local microbiologist
 appropriateness of antibiotic treatment should be checked against laboratory culture and
sensitivities when they become available
Intravenous (IV) theophylline:
 use only:
o after a trial of short-acting and long-acting bronchodilators
o as an adjunct if there is inadequate response to nebulised bronchodilators
 dose of theophylline prescribed should be reduced at time of exacerbation if macrolide or
fluoroquinolone antibiotics are prescribed
 be cautious of interactions with other drugs and potential toxicity if patient has been on oral
theophylline:
o particular caution is recommended in elderly patients due to:
 differences in pharmacokinetics
 increased likelihood of co-morbidities
 use of other medication
 monitor levels within 24 hours of starting treatment and subsequently as frequently as
clinically indicated
 effectiveness of treatment should be assess by improvement in the following:
o symptoms
o activities of daily living
o exercise capacity
o lung function
Date agreed: February 2011
Review Date: February 2013
Page 8 of 16
Respiratory stimulants:
 use doxapram only when non-invasive ventilation is unavailable/considered inappropriate
Pulmonary emboli are more common than is usually recognised in severe COPD but the benefit of
prophylactic anticoagulation treatment has not been evaluated.
Click here to go back to the pathway
18 Progress satisfactory
 monitor by regular clinical assessment of their symptoms and observation of their functional
capacity
 use pulse oximetry to monitor the recovery of patients with non-hypercapnic, non-acidotic
respiratory failure
 use intermittent arterial blood gas measurements to monitor recovery of patients with
respiratory failure who are hypercapnic or acidotic, until they are stable
 do not perform daily monitoring of peak expiratory flow (PEF) or forced expiratory volume in
1 second (FEV1) routinely
Click here to go back to the pathway
19 Progress not satisfactory
 monitor by regular clinical assessment of their symptoms and observation of their functional
capacity
 use pulse oximetry to monitor the recovery of patients with non-hypercapnic, non-acidotic
respiratory failure
 use intermittent arterial blood gas measurements to monitor recovery of patients with
respiratory failure who are hypercapnic or acidotic, until they are stable
 do not perform daily monitoring of peak expiratory flow (PEF) or forced expiratory volume in
1 second (FEV1) routinely
Click here to go back to the pathway
20 Monitor progress
Monitoring and management as the patient recovers:
 in addition to the routine hospital observations, the following should be considered:
o forced expiratory volume in 1 second (FEV1) should be recorded before discharge from
hospital
o patients with low partial pressure of oxygen in arterial blood (PaO2) on admission
should have arterial blood gas tensions checked on air before discharge
o this gives a guide to the need for later formal re-assessment for long-term oxygen
therapy (LTOT therapy)
 as the clinical condition improves (less dyspnoea, improved oxygen saturation of arterial
blood [SaO2]) the nebulised bronchodilator can be changed to the patient's usual inhaler,
ideally at least 24-48 hours before discharge
 antibiotics usually do not need to be continued for more than 7 days
 if oral corticosteroids have been used they can usually be stopped abruptly after 7 days,
unless there are positive reasons for long-term usage
Click here to go back to the pathway
21 Monitor progress
Monitoring and management as the patient recovers:
 in addition to the routine hospital observations, the following should be considered:
o forced expiratory volume in 1 second (FEV1) should be recorded before discharge from
hospital
Date agreed: February 2011
Review Date: February 2013
Page 9 of 16
patients with low partial pressure of oxygen in arterial blood (PaO2) on admission
should have arterial blood gas tensions checked on air before discharge
o this gives a guide to the need for later formal re-assessment for long-term oxygen
therapy (LTOT)
as the clinical condition improves (less dyspnoea, improved oxygen saturation of arterial
blood [SaO2]) the nebulised bronchodilator can be changed to the patient's usual inhaler,
ideally at least 24-48 hours before discharge
antibiotics usually do not need to be continued for more than 7 days
if oral corticosteroids have been used they can usually be stopped abruptly after 7 days
unless there are positive reasons for long-term usage
consider hospital-at-home or assisted-discharge scheme
o




Click here to go back to the pathway
22 Consider palliative care
Palliative care:
 opioids can be used for the palliation of breathlessness in patients with end-stage chronic
obstructive pulmonary disease (COPD) unresponsive to other medical therapy
 also use benzodiazepines, tricyclic antidepressants, major tranquillisers and oxygen when
appropriate for the palliation of breathlessness in patients with end-stage COPD unresponsive
to other medical therapy
 involve patients with end-stage COPD, their family, and carers with multidisciplinary palliative
care teams and services, including admission to hospices
Click here to go back to the pathway
23 Planning for discharge
 aim to improve the ability of patients to cope within their limitations at home and to reduce
the need for future admissions
 make adequate arrangements for follow-up and home care (such as visiting nurse, oxygen
delivery, referral for other support)
 the patient, family and physician should be confident that he or she can manage successfully
Arrange a multidisciplinary assessment and consider:
 medical factors:
o a review of all medication (including non-respiratory treatments)
o establish on optimal therapy before discharge
o review inhaler technique
o measure spirometry
o ensure the patient knows how and when to take his or her medication
o for the few patients discharged on a nebuliser, the specific reasons for continuing
nebulised treatment should be recorded
o patients who have had an episode of respiratory failure should have satisfactory
oximetry or arterial blood gas results before discharge
 social factors and ability to manage at home:
o assessment of mobilisation and giving preliminary instruction in rehabilitation
o assessment of home needs such as shopping, cleaning, obtaining medication, and
provision of equipment to assist in daily living
o financial assessment – patients with chronic obstructive pulmonary disease (COPD)
may be eligible for financial help from a number of different benefits
Click here to go back to the pathway
24 Pulmonary rehabilitation
Pulmonary rehabilitation:
 should be available to all appropriate patients with chronic obstructive pulmonary disease
(COPD), including those recently hospitalised for an acute exacerbation
Date agreed: February 2011
Review Date: February 2013
Page 10 of 16
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
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programme should be:
o multidisciplinary programme of care
o individually tailored to optimise the individual's physical and social performance and
autonomy
o be held at times that suit patients, and in buildings that are easy for the patient to get
to
in practice, usually offered to those who consider themselves functionally disabled by COPD
(usually MRC grade 3 and above)
not suitable for those:
o unable to walk
o with unstable angina
o who have had a recent myocardial infarction
should include:
o physical training
o disease education
o nutritional intervention
o psychological intervention
o behavioural intervention
patient should be made aware of the benefits of rehabilitation and the commitment required
to gain these benefits
MRC dyspnoea scale.
Grade
Degree of breathlessness related to activities
1
Not troubled by breathlessness except on strenuous exercise
2
Short of breath when hurrying or walking up a slight hill
3
Walks slower than contemporaries on level ground because of breathlessness, or has to
stop for breath when walking at own pace
4
Stops for breath after walking about 100m or after a few minutes on level ground
5
Too breathless to leave the house, or breathless when dressing or undressing
Local Information
Due to limited access to pulmonary rehab services in the ABMU Health Community this service is
only available by consultant referral. Any patients assessed as meeting the criteria in primary
care should be referred to a secondary care specialist, requesting assessment for pulmonary
rehab.
Click here to go back to the pathway
25 Planning for discharge
 aim to improve the ability of patients to cope within their limitations at home and to reduce
the need for future admissions
 make adequate arrangements for follow-up and home care (such as visiting nurse, oxygen
delivery, referral for other support)
 the patient, family and physician should be confident that he or she can manage successfully
Arrange a multidisciplinary assessment and consider:
 medical factors:
o a review of all medication (including non-respiratory treatments)
o establish on optimal therapy before discharge
o review inhaler technique
o measure spirometry
o ensure the patient knows how and when to take his or her medication
o for the few patients discharged on a nebuliser, the specific reasons for continuing
nebulised treatment should be recorded
o patients who have had an episode of respiratory failure should have satisfactory
oximetry or arterial blood gas results before discharge
 social factors and ability to manage at home:
o assessment of mobilisation and giving preliminary instruction in rehabilitation
Date agreed: February 2011
Review Date: February 2013
Page 11 of 16
o
o
assessment of home needs such as shopping, cleaning, obtaining medication, and
provision of equipment to assist in daily living
financial assessment – patients with chronic obstructive pulmonary disease (COPD)
may be eligible for financial help from a number of different benefits
Click here to go back to the pathway
26 Informing effective discharge
Maintaining high quality medical records is a fundamental and crucial component of good clinical
practice. Omissions, errors, and illegible records undermine the quality and safety of clinical care
and expose doctors and health care providers units to increased risk of clinical incidents,
complaints, and litigation. [Bridgelal Ram]
The following is designed to serve as a concise reminder for clinicians to ensure patient discharge
notes are accurate, and to facilitate effective discharge.
HIU Discharge Summary
The following should be recorded and updated throughout the patient's hospital stay:
GP details: record the details of the patient’s usual GP.
Patient details: record the patient details, including NHS number and home address.
Admission details: record the method of admission (e.g. emergency, elective, transfer,
maternity), hospital site, responsible Trust, and date of admission.
Discharge details: record date of discharge, method (e.g. on clinical advice, self-discharge),
discharge destination, discharging consultant, and discharging specialty/department.
Clinical information: record diagnosis at discharge, operations and procedures performed
during admission, relevant legal information (e.g. Mental Capacity Act 2005), allergies, risks and
warnings, clinical narrative, outstanding investigations, measures of physical ability and cognitive
function, medication changes, and discharge medications.
Advice, recommendations, and future plan: record actions required by hospital and/or GP,
actions requested/planned/agreed with community, and specialist services.
Patient’s concerns, expectations, and wishes
Information given to patient and/or authorised representative
Results awaited
Person completing the summary: record doctor’s name and GMC number, grade, signature,
date of completion, and bleep number.
High quality discharge notes ensure proper documentation of patient care and treatment plans,
minimise variability and errors during discharge, and assure continuity of care and
communication between care providers.
The Health Informatics Unit of the Royal College of Physicians (RCP), London, UK, working on
behalf of the Academy of Medical
Royal Colleges (AMRC) developed a discharge medical record keeping standard. [RCP 1, RCP 2]
The standard was approved by the AMRC in 2008.
The standard is designed to encourage formal discharge planning at the point of admission for all
in-patients and effective transfer of care tailored to the patient’s health needs and local care
provider context.
Click here to go back to the pathway
27 Informing effective discharge
Maintaining high quality medical records is a fundamental and crucial component of good clinical
practice. Omissions, errors, and illegible records undermine the quality and safety of clinical care
and expose doctors and health care providers units to increased risk of clinical incidents,
complaints, and litigation. [Bridgelal Ram]
The following is designed to serve as a concise reminder for clinicians to ensure patient discharge
notes are accurate, and to facilitate effective discharge.
HIU Discharge Summary
The following should be recorded and updated throughout the patient's hospital stay:
GP details: record the details of the patient’s usual GP.
Patient details: record the patient details, including NHS number and home address.
Date agreed: February 2011
Review Date: February 2013
Page 12 of 16
Admission details: record the method of admission (e.g. emergency, elective, transfer,
maternity), hospital site, responsible Trust, and date of admission.
Discharge details: record date of discharge, method (e.g. on clinical advice, self-discharge),
discharge destination, discharging consultant, and discharging specialty/department.
Clinical information: record diagnosis at discharge, operations and procedures performed
during admission, relevant legal information (e.g. Mental Capacity Act 2005), allergies, risks and
warnings, clinical narrative, outstanding investigations, measures of physical ability and cognitive
function, medication changes, and discharge medications.
Advice, recommendations, and future plan: record actions required by hospital and/or GP,
actions requested/planned/agreed with community, and specialist services.
Patient’s concerns, expectations, and wishes
Information given to patient and/or authorised representative
Results awaited
Person completing the summary: record doctor’s name and GMC number, grade, signature,
date of completion, and bleep number.
High quality discharge notes ensure proper documentation of patient care and treatment plans,
minimise variability and errors during discharge, and assure continuity of care and
communication between care providers.
The Health Informatics Unit of the Royal College of Physicians (RCP), London, UK, working on
behalf of the Academy of Medical
Royal Colleges (AMRC) developed a discharge medical record keeping standard. [RCP 1, RCP 2]
The standard was approved by the AMRC in 2008.
The standard is designed to encourage formal discharge planning at the point of admission for all
in-patients and effective transfer of care tailored to the patient’s health needs and local care
provider context.
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28 Follow-up care
Follow-up in hospital or by general practitioner:
 arrangements are required for all patients 4-6 weeks after discharge
 assessment at the first follow-up to include:
o the patient's ability to cope
o measurement of forced expiratory volume in 1 second (FEV1)
o re-assessment of inhaler technique and of the patient's understanding of
recommended treatment regime
o in severe chronic obstructive pulmonary disease (COPD) the need for long-term
oxygen therapy (LTOT) and/or home nebuliser usage
o advice on smoking cessation as necessary
Follow-up thereafter is as for stable COPD:
 follow-up of patients with mild or moderate COPD will usually take place in primary care and
should include:
o highlighting in the case record the diagnosis of COPD and the values of spirometric
tests performed at diagnosis
o supervision of smoking cessation
o documenting the effects of each drug treatment as it is tried
o recording changes in spirometric parameters measured opportunistically at intervals
Severe disease:
 patients with severe COPD are likely to have frequent exacerbations leading to hospital
admissions
 they often have complex problems with co-morbidities, may be on high levels of treatment,
and need monitoring for long-term oxygen therapy (LTOT)
 shared care between the hospital and GP is the usual pattern although there are no data to
show how care should be provided to achieve the best combination of clinical and cost
effectiveness
 routine isolated peak expiratory flow (PEF) measurements once a patient is stable are of little
value because of the discordance between PEF and FEV1
Date agreed: February 2011
Review Date: February 2013
Page 13 of 16
NB: A loss of 500mL over 5 years will identify those patients with rapidly progressing disease
who may need specialist referral and investigation.
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29 Follow-up care
Follow-up in hospital or by general practitioner:
 arrangements are required for all patients 4-6 weeks after discharge
 assessment at the first follow-up to include:
o the patient's ability to cope
o measurement of forced expiratory volume in 1 second (FEV1)
o re-assessment of inhaler technique and of the patient's understanding of
recommended treatment regime
o in severe chronic obstructive pulmonary disease (COPD) chronic obstructive pulmonary
disease (COPD) the need for longterm oxygen therapy and/or home nebuliser usage
o advice on smoking cessation as necessary
Follow-up thereafter is as for stable COPD:
 follow-up of patients with mild or moderate COPD will usually take place in primary care and
should include:
 highlighting in the case record the diagnosis of COPD and the values of spirometric tests
performed at diagnosis
 supervision of smoking cessation
 documenting the effects of each drug treatment as it is tried
 recording changes in spirometric parameters measured opportunistically at intervals
Severe disease:
 patients with severe COPD are likely to have frequent exacerbations leading to hospital
admissions
 they often have complex problems with co-morbidities, may be on high levels of treatment,
and need monitoring for long-term oxygen therapy (LTOT)
 shared care between the hospital and GP is the usual pattern although there are no data to
show how care should be provided to achieve the best combination of clinical and cost
effectiveness
 routine isolated peak expiratory flow (PEF) measurements once a patient is stable are of little
value because of the discordance between PEF and FEV1
NB: A loss of 500mL over 5 years will identify those patients with rapidly progressing disease
who may need specialist referral and investigation.
Click here to go back to the pathway
31 Long-term follow-up
All patients with chronic obstructive pulmonary disease (COPD) require the following at follow-up:
 Follow-up in hospital or by general practitioner - arrangements are required for all patients 46 weeks after discharge
 highlight diagnosis in notes and computer database
 record results of spirometric tests at diagnosis (absolute and percentage of predicted)
 document the effects of each drug treatment as it is tried
 record opportunistic measurements of spirometric parameters (loss of 500mL over 5 years
will identify those with rapidly progressing disease – may need specialist referral and
investigation)
 assessment of disease severity should take into account:
o degree of airflow obstruction
o degree of disability
o frequency of exacerbations
o prognostic factors such as:
Date agreed: February 2011
Review Date: February 2013
Page 14 of 16
o
o
 forced expiratory volume in 1 second (FEV1)
 transfer factor for carbon monoxide (TLCO)
 breathlessness (using the MRC dyspnoea scale)
 health status
 exercise capacity
 body mass index (BMI)
 partial pressure of oxygen in arterial blood (PaO2)
 cor pulmonale
measurements required:
 FEV1 and forced vital capacity (FVC)
 BMI
 MRC dyspnoea score
clinical assessment to include:
 smoking status and desire to quit
 adequacy of symptom control:
 breathlessness
 exercise tolerance
 estimated exacerbation frequency
 presence of complications
 effects of each drug treatment
 inhaler technique
 need for referral to specialist and therapy services
 need for pulmonary rehabilitation
Follow-up in primary care of mild COPD (FEV1 50-80%) and moderate COPD (FEV1 30-49%) is
required at least twice per year and clinical assessment needs to evaluate presence of
complications.
Follow-up in primary care of severe COPD (FEV1 less than 30%) as above and:
 frequency - at least twice per year
 clinical assessment:
o presence of cor pulmonale
o need for long-term oxygen therapy (LTOT)
o patient's nutritional state
o presence of depression
o need for social services and occupational therapy input
o measurement of oxygen saturation of arterial blood (SaO2)
 regular hospital review not normally needed in stable severe COPD
 locally agreed mechanisms should allow rapid hospital assessment when needed
 likely to have frequent exacerbations leading to hospital admissions
 may need monitoring for LTOT
 shared care between the hospital and GP is the usual pattern
Click here to go back to the pathway
35 Long-term follow-up
All patients with chronic obstructive pulmonary disease (COPD) require the following at follow-up:
 Follow-up in hospital or by general practitioner - arrangements are required for all patients 46 weeks after discharge
 highlight diagnosis in notes and computer database
 record results of spirometric tests at diagnosis (absolute and percentage of predicted)
 document the effects of each drug treatment as it is tried
 record opportunistic measurements of spirometric parameters (loss of 500mL over 5 years
will identify those with rapidly progressing disease – may need specialist referral and
investigation)
 assessment of disease severity should take into account:
o degree of airflow obstruction
o degree of disability
o frequency of exacerbations
o prognostic factors such as:
Date agreed: February 2011
Review Date: February 2013
Page 15 of 16
o
o
 forced expiratory volume in 1 second (FEV1)
 transfer factor for carbon monoxide (TLCO)
 breathlessness (using the MRC dyspnoea scale)
 health status
 exercise capacity
 body mass index (BMI)
 partial pressure of oxygen in arterial blood (PaO2)
 cor pulmonale
measurements required:
 FEV1 and forced vital capacity (FVC)
 body mass index (BMI)
 MRC dyspnoea score
clinical assessment to include:
 smoking status and desire to quit
 adequacy of symptom control:
 breathlessness
 exercise tolerance
 estimated exacerbation frequency
 presence of complications
 effects of each drug treatment
 inhaler technique
 need for referral to specialist and therapy services
 need for pulmonary rehabilitation
Follow-up in primary care of mild COPD (FEV1 50-80%) and moderate COPD (FEV1 30-49%) is
required at least twice per year and clinical assessment needs to evaluate presence of
complications
Follow-up in primary care of severe COPD (FEV1 less than 30%) as above and:
 frequency - at least twice per year
 clinical assessment:
o presence of cor pulmonale
o need for long-term oxygen therapy (LTOT)
o patient's nutritional state
o presence of depression
o need for social services and occupational therapy input
o measurement of oxygen saturation of arterial blood (SaO2
 regular hospital review not normally needed in stable severe COPD
 locally agreed mechanisms should allow rapid hospital assessment when needed
 likely to have frequent exacerbations leading to hospital admissions
 may need monitoring for LTOT
 shared care between the hospital and GP is the usual pattern
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References
Please click on the below icon for the list of references
COPD Pathways
References.doc
Date agreed: February 2011
Review Date: February 2013
Page 16 of 16