Background
Methods
Eligibility criteria
Patient eligibility
| |
Patients with any of the following conditions: | • Pneumonia – CAP or HAP [radiological consolidation and symptoms/signs of respiratory infection] N.B. if CURB-65 ≥ 3 MUST have had at least 24hrs of in-patient observation before recruitment. |
• Non-pneumonic lower respiratory tract infection [No radiological consolidation but symptoms/signs of respiratory infection] | |
• Pneumonia with concomitant COPD (if this service is not provided elsewhere) | |
Inclusion criteria
| |
Features on history | • Patient able to give fully informed consent |
• Has a phone | |
• Age > 18yrs old | |
Features on examination (stability indicator) | • Early warning score ≤2 (EWS, a score calculated using baseline observations) AND SBP > 90 AND mild confusion only (Abbreviated mini-mental test score [AMTS] ≥ 7). All observations must be stable for 12-24hrs |
• Stable/improving inflammatory markers (WCC/CRP) | |
• Stable/improving U&Es | |
Features of social situation | • Can manage ADLs with current support (immediate OT/physiotherapy/social care can be arranged) |
Exclusion criteria
| |
Features on history | • Well enough for discharge without home care support |
• No fixed abode | |
Features on examination (instability indicator) | • SBP < 90 mmHg |
• For patients with chronic respiratory illness: saturations <88% on air [except asthma] | |
• For patients without chronic respiratory illness: saturations <92% on air | |
Features of diagnosis (indicating cause for concern) | • Suspected MI/raised TnI/T consistent with NSTEMI within 5 days of discharge |
• Empyema or complicated parapneumonic effusion | |
• Tuberculosis suspected | |
• Neutropenia | |
• Acute exacerbations of COPD – infective & non-infective (other services are already provided) | |
• Serious co-morbidities requiring hospital treatment (e.g: CKD, CCF) or deemed unstable (significant AKD) | |
Features of social situation | • Patients unable to manage at home even with maximal support (e.g. IV drug users, alcohol excess or mental health problems) |
Randomisation and approval
Study sites
Study intervention
Screening and recruitment
Outcomes and operational questions
Safety
Sample size and statistical methods
Results
Reasons for non-recruitment
| N | % |
---|---|---|
Confusion (Abbreviated Mini-mental Test Score [AMTS] <7) | 37 | 20 |
Require more complex multi-disciplinary team [MDT] input (physiotherapy, OT, social services) | 35 | 19 |
Infective exacerbation of COPD [other services available] | 20 | 11 |
Other co-morbidities requiring in patient stay | 18 | 9.5 |
Clinical deterioration or mental health issues | 17 | 9 |
Patient declined | 13 | 7 |
Awaiting investigations to exclude pulmonary emboli | 11 | 6 |
‘Missed’ | 10 | 5 |
Too well (suitable for discharge without support) | 10 | 5 |
Carer/next of kin (NOK) declined | 5 | 2.5 |
Too hypoxic | 4 | 2 |
No respiratory infection | 3 | 2 |
INR issues | 3 | 2 |
Total | 186 | 100 |
Patient consent
Declined | Recruited | |||
---|---|---|---|---|
Patient (n = 13) | NOK (n = 5) | SHC (n = 6) | ESDS (n = 8) | |
Age (mean [range])
| 66 [25 – 84] | 79 [68 – 87] | 70 [52 – 90] | 61 [29 – 82] |
Gender (M:F)
| 6 : 7 | 3 : 2 | 2 : 4 | 5 : 3 |
Smoking status
| Not recorded | Ex – 3 | Ex – 3 | |
Current – 2 | Current – 2 | |||
Never – 1 | Never – 3 | |||
Social history
| Live alone – 4 | Live alone – 5 | Live alone – 3 | Live alone – 1 |
With spouse – 6 | With spouse – 2 | With spouse – 5 | ||
With family – 3 | ||||
With family – 1 | With family – 2 | |||
CURB–65 (median [range])
| Not recorded | 2 [1 – 3] | 1 [0 – 2] | |
Total hospital LOS (mean days [range])
| 8.33 [1 – 31] | 3.4 [1 – 7] | ||
New radiological consolidation
| Definite – 5 | Definite – 4 | ||
Possible – 0 | Possible – 2 | |||
None – 1 | None – 2 |
Safety and efficacy of intervention
Medical | • Pneumonia may be a vague diagnosis in hospital practice therefore large numbers of patients with respiratory infection need to be screened to find eligible patients |
• Lack of capacity to give consent | |
Staff | • Lack of physician ‘buy-in’ and resistance to change |
Social | • Hospital stay may be seen as a respite opportunity for some carers |
Patient belief | • Some patients believe that they must be 100% better before hospital discharge; some were suspicious of a new or research-based service. |