Chronic Obstructive Pulmonary Disease (COPD) management at home to reduce emergency department presentations: a randomised controlled, feasibility trial

Use of respiratory nursing service (RNS) and extended care paramedics (ECP's) to support home management of patients with a COPD (chronic obstructive pulmonary disease) exacerbation to reduce emergency department presentation and hospital admissions Brief name: COPD at home Participant education materials: All will be printed and given to the participant as an information package *Respiratory nursing service information: RNS, The Queen Elizabeth Hospital (TQEH) *COPD fact sheet: Central Adelaide Local Health Network (CALHN) intranet *advance care directive, infection control-wash wipe cover, falls- medicines and balance, falls- making your home your haven: http://inside.sahealth.sa.gov.au/wps/wcm/connect/Non-public+content/sa+health+intranet/ SA Health website *depression streess anxiety, breathing techniques, eating well with lung disease, continence and lung disease: pulmonary rehabilitation education series, Department of Health, Government of South Australia *Quality of life through patient support: http://lungfoundation.com.au/ Folder for communication between services kept at patient home and includes: * A4 poster COPD at home phone number * Name and demographic page * Only intervention group participants will be provided with a written COPD Action Plan and emergency pack if they do not have and receive education on how to use, and additional education on COPD management. Control group will not be given a written COPD action plan or emergency pack or receive additional education- they will receive their usual care from their health providers. Both groups will complete the questionnaires as previously identified. Where the intervention participant does not already have a COPD action plan or emergency pack both will be obtained from the Respiratory Registrar/Physician rostered to TQEH hospital consult service. The COPD Action Plan developed by Lung Foundation Australia will be used for the intervention participants that require one provided. Intervention participants only will receive education on the use of their inhalers in exacerbation management. Intervention participants will also be educated on when to commence their emergency pack of prednisolone or antibiotics as per their COPD Action Plan. Having a COPD Action plan and emergency pack is a pre-requisite for participants in this study as this is the tool to facilitate exacerbation management. *Medical contact log *Current medication list *Observation Chart General Practitioner letter advising of patient participation and summary of proposed research Hospital switchboard instructions South Australian Ambulance Service (SAAS), ECP: work instruction sheet-process to review participants and separation summary for RNS and GP describing review and recommendations made with participant PROCEDURE RNS: performs baseline assessment, reviews COPD optimisation and education. Can occur at participants residence or as an outpatient with a time period of 2 hours. Planned contact: phone calls at 1 week and 3 months will be performed by a nurse from the RNS- to monitor healthcare utilisation, perform a respiratory phone assessment, provide phone coaching of symptom management, arrange reviews (rapid response) dependant on severity of respiratory symptoms Final assessment at 6 months: same as baseline review with addition of semi-structured questionnaire. There will be one Respiratory Nurse who performs the assessments and phone calls at timed reviews. This respiratory nurse will not provide any of the clinical care during the trial period. Clinical care will be delivered by other members of the Respiratory Nursing Service. Unplanned contact: participants identifying change in respiratory symptoms to contact COPD at home as per number provided (TQEH switchboard). During business hours weekdays will be directed to RNS, after hours, weekends and public holidays will be transferred to SAAS ECP's. If no answer within 15mins participant will be instructed to utilise GP, locum GP, emergency department or SAAS emergency '000' If participant contacts RNS a respiratory phone assessment will occur including use of Modified Medical Research Council (MMRC) and COPD assessment test (CAT). RNS triage will occur and follow up actions will be based on the assessment * early change in symptoms identified: use of action plan, GP, follow up phone review * moderate to severe symptoms identified: rapid response review by RNS by outpatient or home visit, or may recommend contacting SAAS on '000'. If participant remains home will be supported to do so by RNS and in negotiation with GP. SAAS: ECP’s will follow their ‘work instruction’ for participants. Phone calls will be triaged by the ECP coordinator who will determine the deployment of ECP or ambulance response (priority 2) based on severity of participant symptoms. Phone assessment: not an emergency: ECP to review at participant residence for assessment and management of symptoms. If safe to stay home ECp will advise RNS and GP by email and/or facsimile of the visit, if safe to remain home and recommendations provided to participant , for follow up review by RNS and/or GP If ECP assessment determines need to present to the emergency department SAAS ECP will coordinate. ECP will notify RNS only via email, GP will receive separation summary of presentation on discharge as per standard practice. Participants will be enrolled for a 6 month period and may access COPD at home as often as required. Feasibility outcomes will be collected via documentation from nursing and SAAS records following phone calls made to and from patients during the intervention period.