Multi-disciplinary community respiratory team management of patients with chronic respiratory illness during the COVID-19 pandemic.

The Greater Glasgow & Clyde NHS Trust Community Respiratory Response Team was established to manage patients with chronic respiratory disease at home during the COVID-19 pandemic. The team aimed to avert hospital admission while maximally utilising remote consultations. This observational study analysed outcomes of the triage pathway used, use of remote consultations, hospital admissions and mortality among patients managed by the team. Patients' electronic health records were retrospectively reviewed. Rates of emergency department attendance, hospital admission and death within 28 days of referral were compared across triage pathways. Segmented linear regression was carried out for emergency admissions in Greater Glasgow and Clyde pre- and post- Community Respiratory Response Team implementation, using emergency admissions for chronic obstructive pulmonary disease in the rest of Scotland as control and adjusting for all-cause emergency admissions. The triage category correlated with hospital admission and death. The red pathway had the highest proportion attending the emergency department (21%), significantly higher than the amber and green pathways (p = 0.03 and p = 0.004, respectively). The highest number of deaths were in the blue "end-of-life" pathway (p < 0.001). 87% of interactions were undertaken remotely. Triage severity appropriately led to targeted home visits. No nosocomial COVID-19 infections occurred among patients or staff. The Community Respiratory Response Team was associated with a significant decrease in emergency admissions (RR = 0.96 for each additional month under the Poisson model) compared to the counterfactual if the service had not been in place, suggesting a benefit in reducing secondary care pressures. The Community Respiratory Response Team effectively managed patients with chronic respiratory disease in the community, with an associated reduction in secondary care pressures during the COVID-19 pandemic.

Introduction

The COVID-19 pandemic resulted in significant pressure on healthcare services worldwide. Services were re-designed to manage existing healthcare needs alongside the burden of COVID-19-associated illness[1]. In the UK, a significant volume of elective healthcare activity was postponed to deal with rising COVID-19 cases. Between April 2020 and July 2021, the BMA estimated there were over 26 million fewer NHS outpatient attendances compared with the previous years[2] and, in Scotland, 396,771 patients still awaited new outpatient appointments as of August 2021[3]. The burden the pandemic placed on secondary care resources, as well as the increased risks of COVID-19 infection in patients with chronic health conditions, created a need to manage patients away from the hospital setting, particularly patients with pre-existing respiratory diseases.

Delivering effective care in the community was a key focus of the Scottish response to COVID-19[4], and the redeployment of healthcare staff to support community services during the pandemic provided the opportunity to assess the utility of multidisciplinary community care.

NHS Greater Glasgow and Clyde (GGC) is the largest health board in the UK, with a catchment population of 1.14 million across both urban and rural settings[5]. Within the Trust, there is a high burden of chronic respiratory disease with an overall prevalence of COPD in those aged over 45 years of 6.26%[6]. About 34,115 hospital bed days were attributed to COPD in NHS GGC in 2018/2019, the highest for any trust in Scotland[7].

The NHS GGC Community Respiratory Response Team (CRRT) was created in March 2020 as an emergency measure to support patients with chronic respiratory illnesses in their own homes during the COVID-19 pandemic. Its aim was to avert hospital admission, where possible, in order to reduce the risk of nosocomial COVID-19 infection and to alleviate pressure on acute medical services. The service operated from 31 March to 30 Sept 2020 for the first UK COVID-19 wave and reformed for the second wave in November 2020.

The CRRT was formed by amalgamating six community respiratory teams across NHS GGC to create a multidisciplinary team (MDT) led by respiratory specialist nurses, physiotherapists, occupational therapists and pharmacists, with remote respiratory consultant support. The team operated between 8 a.m. and 6 p.m. 7 days a week throughout the pandemic and accept referrals for all respiratory diagnoses from all patients in NHS GGC. It received over 1200 referrals and provided over 3600 consultations, including both telephone consultations and home visits to patients, in its first 66 days; averaging 20 referrals and 70 consultations per day.

A referral was made electronically by primary care, COVID assessment centre staff, secondary care, or patient self-referral. The majority of patients received a telephone contact from the service on the day of referral. Patients who had been discharged from the hospital or begun treatment via their GP on the day of referral were contacted the following day. Senior clinical team members, defined as advanced nurse practitioners (NHS Scotland Band Seven) or senior nurses (NHS Scotland Band Six) experienced in community respiratory care, made this initial contact and triaged patients into “red”, “amber” or “green” pathways denoting high to low risk of imminent admission; or as “blue” for patients who required home oxygen or other respiratory intervention as part of the end-of-life care (Fig. 1). Triage decisions were made clinically based on the review of electronic patient records, referral details and information provided by the patient regarding whether they felt their condition continued to worsen, had stabilised or was improving.

Fig. 1

CRRT triage pathway and patient outcomes by pathway.

Outcomes of patients referred to the CRRT. Percentage values refer to proportions of individual pathways.

Patients triaged as red received a further consultation, either at home or via telephone, within 24 h. Patients triaged as amber received two contacts within 1 week. Patients triaged as green were discharged from the service with a management plan. Patients triaged as blue were provided with equipment or palliative input as required. Remote reviews were undertaken where possible, with home visits minimised and personal protective equipment (PPE) utilised to minimise the risk of COVID-19 infection to patients and staff. Daily virtual ward rounds were undertaken to discuss patients of clinical concern with senior team members.

Previous studies have shown that multidisciplinary and nurse-led community respiratory teams are effective and can lead to a reduction in emergency hospital admissions among respiratory patients[8-12]. This study analysed the effectiveness of the CRRT service overall by assessing the key components and outcomes of the CRRT triage pathway in prioritising patients for review, use of remote patient-clinician interactions, and the impact of the service on hospital attendance and mortality.

The primary aims were to determine (1) whether the triage system was effective in identifying high-risk patients; (2) how extensively remote consultations were used and face-to-face consultations targeted towards patients most in need; and (3) whether CRRT input affected rates of emergency department attendances (EAs), hospital admission and death among patients at 28 days after an initial consultation.

Methods

Study population and data sources

This was a population-based, retrospective, observational study. Data were collected from the electronic records of all patients referred to the CRRT during the month of May 2020. Data on the reason for referral, triage category, primary respiratory diagnosis and patient demographics were collected from the original referral documentation to the CRRT. Information on the number and type of consultations was collected from the CRRT electronic consultation notes. Data on admissions and deaths within 28 days of referral to CRRT were collected from hospital admission records and, where further information was necessary, from inpatient notes and discharge letters viewable in the electronic patient record. The six teams provided the total numbers of staff involved, percentage of their time committed to the CRRT, and the number of staff working per day. These were used in conjunction with payroll details to calculate the cost of staffing the service. Monthly emergency attendance (EA) data for all causes and COPD only (COPD EA) from January 2018 to May 2021 were obtained for NHS GGC and the rest of Scotland, with the exception of Fife, Lothian and Tayside health boards, from Public Health Scotland. COPD EAs are defined as those coded as ICD-10 J40-J44[13].

Statistical analysis

Two stages of analysis were undertaken. The first stage analysed individual-level data to produce data summaries and compare the utility of the service in its various forms and outcomes between triage pathways. Chi-squared tests were used for comparisons of pathways.

The second stage used ecological data to measure the impact of the service on emergency hospital attendance. Using regional data, emergency department (ED) attendances with a primary diagnosis of COPD in GGC was compared before and after the onset of the service with a 1-month phase-in period, using segmented linear regression. The rest of Scotland (apart from Fife, Tayside and Lothian) (RoS) was used as a control. The model adjusted for all-cause EAs to control for the impact of COVID-19 on COPD EAs during this period. The model was carried out first using linear regression and included autoregressive terms[14,15] and a Fourier term to adjust for seasonality[16]. A Poisson model was then run—preferable for count data—also with a Fourier term adjustment. Sensitivity analyses included removing the final data point and significant outliers and modelling with and without adjustment for autoregression, as recommended[17]. Poisson models also included adjusting for all-cause EAs as an offset term, i.e. adjustment for the rate of COPD EA per all-cause EA. These models are available on request from the authors. These models produced different parameter estimates but the same overall conclusion.

Ethics

Both the patient and public health Scotland data used were collected as part of service evaluation and therefore did not require research ethics committee approval[18]. For the same reason, written informed patient consent was not sought.

Table 1

Patient demographics n = number and overlap refers to a primary respiratory condition with features of both asthma and COPD.

Primary Respiratory Condition	n		Mean age (Median, IQR)	Female:Male
Total	516		69 (71, 62–79)	1.93
COPD	336	65%	71 (72, 64–79)	1.87
Asthma	63	12%	51 (52, 43–60)	3.85
ILD	36	7%	75 (78, 68–82)	0.71
Overlap	34	7%	71 (71, 62–79)	1.43
COVID-19	11	2%	74 (88, 82–91)	1.75
Bronchiectasis	10	2%	84 (73, 68–76)	9.00
End-of-life care	9	2%	82 (80, 75–91)	3.50
Other/Unknown	17	3%	71 (70, 64–83)	3.25

Table 2

Patient Demographics and Outcomes by CRRT Triage Pathway % relates to proportion of pathway.

Pathway	n	Gender		Mean Age (Median, IQR)	ED Attendance		Admitted		Died
		F	M			%		%		%
RED	99	67	32	71 (72, 62−78)	21	21%	21	21%	4	4%
AMBER	235	154	81	68 (70, 60−78)	28	12%	26	11%	4	2%
GREEN	142	89	53	68 (70, (61−78)	11	8%	11	8%	1	1%
BLUE	40	30	10	81 (84, 75−87)	6	15%	5	13%	14	35%
TOTAL	516	340	176	69 (71, 62−79)	66	13%	63	12%	23	4%

Table 3

Projected costs of staffing the CRRT based on staffing levels required during the month of May 2020.

	WTE	Hours	£	£
Band 7 specialist nurse	6.8	255	9306	485,237
Band 6 nurse	20.8	780	24,155	1,259,442
Band 7 physiotherapist	3	112.5	4106	214,075
Band 6 physiotherapist	8.4	315	9755	508,621
Band 6 occupational therapist	0.8	30	929	48,440
Respiratory consultant	3.3	12	538	28,000
	43.1	1504.5	48,789 per week	2,543,815 per annum

Table 4

Parameter estimates, standard error, relative risk and 95% confidence intervals, and p values from the segmented Poisson regression predicting COPD EAs, adjusting for seasonality.

	Parameter estimate	SE	RR (95% CI)	p-value
Intercept	3.402	0.223	30.02 (19.40, 46.46)	<0.001
Additional GGC level at baseline	0.302	0.083	1.35 (1.15, 1,59)	<0.001
Trend pre-intervention	0.020	0.002	0.98 (0.98, 0.98)	<0.001
Additional GGC trend pre-intervention	0.018	0.002	1.02 (1.01, 1.02)	<0.001
All other cause of EA trend (per 1000)	0.044	0.004	1.04 (1.04, 1.05)	<0.001
Level change post-phase-in period	−0.166	0.100	0.85 (0.70, 1.03)	0.099
Trend change post-phase-in period	0.025	0.007	1.03 (1.01, 1.04)	<0.001
Additional level change in GGC	−0.191	0.103	0.83 (0.68, 1.01)	0.063
Additional trend change in GGC	−0.039	0.011	0.96 (0.94, 0.98)	<0.001