What should be included in a comprehensive discharge plan for a patient with Chronic Obstructive Pulmonary Disease (COPD)?

COPD Discharge Planning

A comprehensive COPD discharge plan must include pre-discharge clinical stabilization, medication optimization with verified inhaler technique, early pulmonary rehabilitation referral within 4 weeks, structured follow-up within 30 days, and assessment of home support needs. 1

Pre-Discharge Clinical Assessment

Before discharge, several critical assessments must be completed to ensure patient stability and guide ongoing management:

• Record FEV1 measurement to establish baseline post-exacerbation lung function for future comparison 2, 1
• Check arterial blood gases on room air in patients who presented with hypercapnic respiratory failure or significant hypoxemia on admission, as this guides assessment for long-term oxygen therapy (LTOT) 2, 1
• Transition from nebulized bronchodilators to standard inhaler at least 24-48 hours before discharge to confirm the patient can manage their device independently 1, 3
• Confirm clinical stability with less dyspnea, improved peak flow, and improved oxygen saturation before discharge 1

The 24-48 hour stabilization period on discharge medications is critical—discharging before this significantly increases relapse and readmission risk. 3

Medication Optimization

Bronchodilators

• Prescribe short-acting beta-agonist (salbutamol/albuterol) MDI with spacer at 2 puffs (200 mcg) every 2-4 hours as needed for symptom relief 3
• Verify and document proper MDI technique before discharge, as incorrect technique is a major cause of treatment failure 3
• Patients must demonstrate correct spacer use including slow deep inhalation, 5-second breath hold, and waiting 30-60 seconds between puffs 3

Corticosteroids

• Stop oral corticosteroids abruptly after 7-14 days unless there are specific reasons for long-term use 1, 3
• Do not continue corticosteroids beyond the acute treatment period, as this increases adverse effects without proven benefit 1

Antibiotics

• Complete 5-7 day course if started for purulent sputum or increased sputum volume 3
• Antibiotics typically do not need continuation beyond 7 days 2, 1

Medication Review

• Review all medications including non-respiratory treatments 2
• Provide sufficient medication supply to last until next consultation, typically 30 days 1
• Include written prescriptions with clear dosing instructions 1

Oxygen Therapy Assessment

• Assess for LTOT if PaO2 ≤7.3 kPa (55 mmHg) or SaO2 ≤88% on room air despite optimal therapy, confirmed twice over 3 weeks 1
• Prescribe LTOT for at least 15 hours/day to improve survival in patients with chronic respiratory failure 1
• Reassess oxygen requirements 4-6 weeks post-discharge if oxygen was initiated during hospitalization, as many patients will no longer meet criteria once stabilized 3

Patient and Caregiver Education

Education is a cornerstone of successful discharge planning and must be documented:

• Verify patient (or carer) understands the treatment prescribed and can demonstrate proper use of all delivery devices before discharge 1
• Provide written action plan that includes instructions on recognizing early signs of exacerbation and when to initiate treatment or seek medical attention 1
• Ensure patient knows how and when to take medications 2
• Provide information about the disease and explain treatment rationale 4

Smoking Cessation

• Counsel all current smokers on smoking cessation and offer pharmacotherapy (nicotine replacement, varenicline, or bupropion) plus behavioral support 1, 5
• Assessment of environmental exposures should also be conducted 5

Pulmonary Rehabilitation Referral

Refer all patients to pulmonary rehabilitation program to begin within 4 weeks of discharge, as this is one of the most evidence-based interventions for improving outcomes. 1, 5

• Pulmonary rehabilitation improves exercise capacity and quality of life with benefits evident at 6 months 1
• Early initiation provides maximum benefit 1
• Do not delay this referral—it is a critical component of the discharge bundle 1

Follow-Up Care and Continuity

Structured follow-up is essential to reduce readmission rates:

• Schedule follow-up within 30 days of discharge (ideally within 2 weeks) to reduce exacerbation-related readmissions 1, 5
• Inform the patient's GP within 48 hours of discharge with complete discharge summary including medications, follow-up plans, and any pending investigations 1
• Post-discharge support significantly reduces readmission rates within 30 days and may reduce readmissions up to 180 days 6

Social Support and Home Assessment

A multidisciplinary approach is needed to assess the patient's ability to cope at home:

• Ensure adequate home support including assessment of living situation and suitability of accommodation 2, 1
• Arrange home care services if needed, including district nursing, home oxygen delivery, or social services support 1
• Assess mobilization and provide preliminary instruction in rehabilitation 2
• Evaluate home needs such as shopping, cleaning, obtaining medication, and provision of equipment to assist in daily living 2
• Conduct financial assessment, as patients with COPD may be eligible for disability benefits and mobility allowances 2

Inadequate social support is a major risk factor for readmission and must be addressed before discharge. 1

Use of Assessment Tools

• Use an assessment proforma, protocol, or integrated care pathway to deliver uniform care and facilitate audit 2
• Assessment tools help confirm COPD diagnosis, confirm exacerbation, determine safety of home management, and tailor treatment 2

Hospital-at-Home and Early Supported Discharge

For appropriate patients, alternative discharge pathways can be considered:

• Hospital-at-Home and early supported discharge schemes are safe and effective and should be used as an alternative to traditional admission or prolonged hospital stay 2
• The multidisciplinary team should include allied health professionals with experience in managing COPD, including nurses, physiotherapists, occupational therapists, and generic health workers 2
• Patient selection should depend on resources available and absence of factors associated with worse prognosis such as acidosis, impairment of consciousness, confusion, or inadequate social support 2
• Reducing inpatient stay through supported discharge is not associated with increased readmission rate or mortality 2

Common Pitfalls to Avoid

Several critical errors can compromise discharge success:

• Do not discharge patients on nebulized therapy without confirming they can manage with standard inhalers, as this indicates inadequate recovery 1, 3
• Do not continue oral corticosteroids indefinitely without specific indication 1
• Do not discharge without confirming adequate social support 1
• Do not skip inhaler technique verification, as poor technique is a leading preventable cause of treatment failure 3
• Do not continue oxygen therapy without physiological reassessment if started during acute phase 3
• Do not discharge before 24 hours of stability on MDI therapy 3
• Do not delay pulmonary rehabilitation referral 1

Discharge Bundle Implementation

Evidence suggests that comprehensive discharge bundles comprising these evidence-based practices can reduce readmissions, lower mortality risk, and improve quality of life. 5 The four core bundle items are: (1) smoking cessation and environmental exposure assessment, (2) treatment optimization, (3) pulmonary rehabilitation, and (4) continuity of care. 5

Barriers to implementation include resource constraints, lack of staff engagement and knowledge, and complexity of the COPD population, which can be addressed through healthcare practitioner education and audit/feedback mechanisms. 5