NUH's COPD programme is targeted towards preventing acute attacks of COPD, prolonging the survival and improving the symptoms and quality of life for our patients. We achieve this by taking on several approaches, including medications, smoking cessation therapy, education / counselling by experienced COPD Case Managers (nurse clinicians), and pulmonary rehabilitation.
In collaboration with our colleagues in the emergency medicine department (EMD), we have also designed a comprehensive management programme for acute attacks of COPD. Severely ill patients who do not respond promptly to medical treatment will receive noninvasive ventilation (NIV) in the EMD itself to avoid the complications of tracheal intubation and prolonged ICU stays. Less ill patients will be assessed and treated in our EMD's Extended Diagnostic Treatment Unit (EDTU). If they are better, they may go home directly from the EMD. Because a chronic illness like COPD is often best managed at home, we have also introduced a Hospital At Home Programme in which an experienced Home Visit Nurse will perform a home visit and help patients and families cope more effectively with acute attacks. This is often undertaken as a continuation of EDTU treatment to ensure that our patients recover smoothly from an acute attack. For patients who are persistently symptomatic from advanced COPD, we have embarked on an advanced care programme to optimise quality of life and symptom control either at home or in a hospice setting with palliative care physicians.
Outcomes of COPD treatment in National University Hospital
Due to the careful and comprehensive management of COPD patients, NUH has had a progressive and significant decrease in the length of stays (LOS), mortality and intubation rates over the past 8 years. From April 2008 to September 2009, the average length of stay for a COPD patient was 4.1 days and the mortality rate was 2.5%, down from 6 days and 6% respectively in the year 2001. Recent audits of COPD management in UK and US hospitals reported an average LOS of 8.7 and 5.3 days and mortality of 7.4% and 4.4% respectively.2,3 Using the St Georges' Respiratory Questionnaire, NUH patients with severe and very severe COPD have also seen an improvement in their quality of life over time.
Noninvasive ventilation for acute COPD exacerbations in National University Hospital
In noninvasive ventilation (NIV), a face mask is applied onto a patient and used to move air in and out of his/her lungs. The main aims of NIV are to reduce the need for intubation and mortality. NUH's NIV programme rolled out in the intensive care unit (ICU) in 2002. However, because it was likely that earlier administration of NIV could further improve outcomes, the NIV programme was extended to the emergency medicine department (EMD) in 2003.
A recent audit showed that 100% of patients with COPD exacerbations who required NIV based on well-established clinical criteria did indeed receive NIV at NUH's EMD. Approximately 4 out of 5 patients who were placed on NIV did not require intubation. With the use of NIV, the hospital mortality for patients without do-not-resuscitate orders and for all patients was 2.3% and less than 10% respectively. These figures compare very favourably with international standards: e.g. a recent UK audit of patients treated with NIV revealed a mortality of 26%.4
- Singapore Ministry of Health: Health Facts Singapore. http://www.moh.gov.sg/mohcorp/statistics.aspx?id=5526. Date last accessed: 22 Dec 2009.
- Lindenauer PK, Pekow P, Gao S, Crawford AS, Gutierrez B, Benjamin EM. Quality of care for patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease. Ann Int Med 2006;144:894-903.
- Price LC, Lowe D, Hosker H, Anstey K, Pearson M, Roberts CM; The UK National COPD Audit 2003. Impact of hospital resources and organisation of care on patient outcome following admissions for acute COPD exacerbation. Thorax 2006;61:837-842.
- Kaul S, Pearson M, Coutts I, Lowe D, Roberts M. Non-invasive ventilation (NIV) in the clinical management of acute COPD in 233 UK hospitals: results from the RCP/BTS 2003 National COPD Audit. COPD 2009;6:171-176.
Our pharmacists run smoking cessation clinics for interested patients every Wednesday (2pm to 5pm). In addition, our Nurse Clinicians provide support by assisting patients in the daily respiratory clinics who are keen to stop smoking. We adopt behavioural support and advice and prescribe various forms of nicotine replacement therapy.