Prognostic tools are used in a wide range of clinical settings, but hitherto COPD was a neglected area. Such tools do not seek to replace clinical judgement, but rather to enhance this by providing an objective and accurate estimate of the risk of particular outcome. This provides a sound basis for truly informed shared decisions with patients, and improves selection for place and level of care, alongside other aspects of management.

In exacerbations of COPD triaged for admission, DECAF and PEARL are the best available predictors of risk of in-hospital death and post-discharge readmission respectively. A randomised controlled trial (RCT) has shown that hospital at home selected by low-risk DECAF score is safe, clinically and cost-effective, and preferred by 90% of patients.

Prof Stephen Bourke, Consultant in Respiratory Medicine, Northumbria Healthcare NHS FT and Honorary Professor, Newcastle University, will provide an overview of the evidence supporting the use of these tools and share existing clinical resources. Following the event, he and Dr Carlos Echevarria, Consultant in Respiratory and General Internal Medicine at Newcastle’s Royal Victoria Infirmary, will offer support to centres wishing to implement new services over the coming year.

The event will be of particular interest to respiratory physicians, respiratory specialist nurses, respiratory physios and pharmacists.

If you have additional needs, please email sarah.black@ahsn-nenc.org.uk and we’ll do what we can to help you.

How can DECAF and PEARL be used?

DECAF

Low risk DECAF 0-1:

• Admission avoidance in A&E, if no additional acute care need. Avoiding unnecessary admissions and improving flow through the department.
• Hospital at home: this provides care patients would normally receive in hospital, including 24/7 specialist support, controlled oxygen therapy if required, nebulised bronchodilators etc. There is the potential to extend this service to include exacerbations of bronchiectasis and pneumonia.
• Early discharge: if 24/7 support is not an option, you can at least discharge low risk patients earlier.

High risk DECAF 3+:

• Empirical antibiotic choice - median time to death in those who die is 2 days - one bite at the cherry.
• Close monitoring. Specialist respiratory ward or higher level of care. Don't board.

PEARL: selection for supported discharge services aiming to reduce readmission risk.

DECAF AND PEARL

The PEARL score is a simple tool that can effectively stratify patients' risk of 90-day readmission or death, which could help guide readmission avoidance strategies within the clinical and research setting. It is superior to other scores that have been used in this population.

The DECAF Score is a simple yet effective predictor of mortality in patients hospitalised with an exacerbation of COPD and has the potential to help clinicians more accurately predict prognosis, and triage place and level of care to improve outcome in this common condition.

Speakers

Professor Stephen Bourke

Consultant in Respiratory Medicine and Honorary Professor, Newcastle University

Prof Bourke's areas of specialty are the chronic obstructive pulmonary disorder (COPD), non-invasive ventilation (NIV) and sleep clinical services, and respiratory research.

Prof Bourke qualified from Queen’s University Belfast with Honours in 1991. He joined the trust as a consultant physician in 2003 and, having been heavily involved in their development, is the lead for the COPD, NIV and sleep services and the respiratory research programme. He also helped establish the thoracoscopy service within the trust which has led to much more rapid diagnosis and treatment for people with pleural disease, including cancer.

He chaired the British Thoracic Society COPD Specialist Advisory Group and served on the Royal College of Physicians National COPD Audit Committee from 2016 to 2019, and currently sits on the British Thoracic Society Standards of Care Committee. He has been invited to present at national and international meetings and taught on NIV courses for both the British Thoracic Society and Royal College of Physicians. NIV is a way of supporting a patient’s breathing without placing a tube in their airway, offering many advantages over conventional invasive ventilation. The NIV service Prof Bourke has developed with the specialist physiotherapists, is highly innovative and clinical outcomes for patients during life-threatening illnesses requiring this form of ventilation are excellent (the mortality rate is half of the national average). He was invited to present the service design at the launch of a National NIV Report ‘Inspiring Change’ in 2017 and joined the committee tasked with developing National NIV Quality Standards in 2017/18.

Prof Bourke is a fellow of the Royal College of Physicians. He gained a PhD through Newcastle University and, in recognition of his contribution to respiratory research, has been awarded an honorary chair. In addition, he has represented the British Thoracic Society in the development of National Institute of Clinical Excellence (NICE) guidelines on NIV in motor neurone disease.

He leads an internationally recognised COPD and NIV research programme, supported by research fellows and nurses, and teams at other hospital trusts which have recruited patients. This includes the development of clinical risk scores to help clinicians identify which patients with COPD can be safely managed at home and those who would benefit from much closer monitoring, both in-hospital and after discharge (the ‘DECAF’ and ‘PEARL’ scores). This has led to the establishment of new clinical services for patients.

The National Institute of Health Research gave Prof Bourke a Clinical Research Impact of the year award in 2016 and identified the trust’s seminal clinical trial on ‘hospital at home’ selected by DECAF for patients with COPD as one of the studies most likely to influence clinical practice nationally. The clinical service established with the respiratory specialist nursing team based on this research won a trust innovation and quality improvement award. A similar clinical tool has been developed for patients requiring NIV; this is intended to better inform discussions between patients, their families and doctors, and clinical decisions about provision of this life-saving treatment. Earlier research includes a randomised controlled trial showing that home NIV improves survival and quality of life in motor neurone disease, leading to a marked increase in use of NIV in this condition.

Prof Bourke has published in many international medical journals and contributed chapters to post-graduate textbooks. He is involved in the education and training of medical students, doctors, nurses and allied health professionals.