Download Referral form for Early Supported Discharge for patients with acute

Knowsley Community COPD Service – Early Supported Discharge (ESD)
Referral form: For patients with acute exacerbation of COPD
(Knowsley COPD patients only)
(NB: All patients with COPD, registered with Knowsley GP and fulfil inclusion/exclusion
criteria can be offered early supported discharge. Please fax the completed referral form to
0151289 9158 and one of the specialist nurses will contact you immediately. If you would like
to discuss about a patient or have any queries, please telephone 0151 676 5112)
Name:
GP Name:
Address:
Address:
Date of Birth:
Tel No:
Sex M/F:
Fax No:
Tel No:
Hospital name
NHS No:
Consultant Physician:
Next of Kin and Tel No:
Ward details including telephone no:
1. Date of referral:
2. Date of admission to hospital
Date of planned discharge
3. Primary Diagnosis and brief summary of inpatient care:
4. Other diagnosis / past medical history
5. Medications on discharge
6. Does the patient have home oxygen: Yes / No. If yes please fill the following
Long term O2.…………………..litres…………………hours/day
Ambulatory O2…………………litres…………………hours/day
Short burst O2…………………..litres………………....hours/day
7. Vital signs (most recent):
HR
Latest SaO2
Temp
RR
BP
(state whether this is on air or on Fio2…….…litres or %)
Last ABG result (if available):
PH
PCO2
PO2
HCO3
BE
Fio2 used
8. CXR or CT findings:
9. Any positive sputum culture or abnormal bloods:
10. Social circumstances: (The ESD service cannot provide social support)
Does the patient need any social support – Yes / No.
If yes, has this been addressed – Yes / No
11. Has the patient been reviewed by the Consultant Physician: Yes or No
12. Has the patient been seen by the Respiratory medical team: Yes or No
13. Future investigations planned including hospital follow up: Yes or No. If yes
– please elaborate
14. Has the patient agreed to ESD – Yes / No
15. Patient Eligibility: Inclusion criteria must be answered ‘YES’ and exclusion
criteria ‘NO’ for the patient to be eligible for early supported discharge
INCLUSION CRITERIA
YES
NO
FEV1 <80% predicted and
FEV1 / FVC ratio < 70 % *
Systolic BP >100mmHg
PH >7.35
PO2 > 7kPa
**
PCO2, < 8kPa
WCC 4-20
EXCLUSION CRITERIA
Definite asthma
Pneumothorax
Cardiac failure
Acute ECG changes /MI
Acute unresolved confusion
Requires full-time nursing
<18 years of age
IV therapy ***
Pneumonia
***
* A spirometry test is not required for early supported discharge in patients who are
unable to perform spirometry (or) those with known COPD.
** Those patients already on LTOT can be taken home providing their pO2 is > 7kPa
on their usual oxygen flow (i.e. 2 or 3 litres without CO2 rise).
*** Patients with resolving pneumonia may be suitable, we may be able to provide iv
antibiotics at home. Please discuss with the COPD team
Signature
Name
Designation
Tel & Bleep number:
Fax no:
Please fax on 01512899158
For queries, ring 01516765112
Office use: Appropriate / Inappropriate
Date ESD implemented