Development of the DECAF and PEARL clinical risk scores in COPD Virtual Wards

Friday, September 15, 2023

Respiratory Futures spoke to Clare Stobbart, who, along with colleagues and Professor Stephen Bourke, has been successfully delivering virtual wards in Northumbria.

Tell us about your experience of virtual wards and Hospital at Home

On average, we support approximately 20 patients at any one time within our virtual ward, and this includes patients with COPD, pneumonia, bronchiectasis, and ILD. So far, we’ve received lots of positive feedback from patients.

Professor Stephen Bourke led the development of the DECAF and PEARL clinical risk scores in COPD, used within our Virtual Ward model, and the Randomised Controlled Trial (RCT) of Hospital at Home selected by low-risk DECAF score. This research showed that this approach is safe, preferred by most patients and less expensive – saving £1,016 per patient across health and social care costs over 90 days.

I helped develop and deliver the Hospital at Home service, (a virtual ward where patients receive more face-to-face specialist care rather than just remote digital monitoring). Hospital at Home was introduced initially within the RCT, with a working group including patients, and a multidisciplinary team across primary, secondary and social care. This was continued in the subsequent clinical service, and I support and train the specialist nurses.

Additional funding through the NHS England Virtual Wards initiative has allowed us to increase the range of conditions we manage (rebranding the service!) – but there is definitely room to expand further if given additional support. The service has benefited from strong collaboration across the clinical and managerial teams.

How does the service operate?

The service is split into two different Tiers, tailored to the patient’s clinical needs:

  • Tier 1 – Hospital at Home - 24/7 specialist on-call
  • Tier 2 – Extended Supported Early Pulmonary Discharge and admission avoidance – seven days a week, 9 to 5pm – Telephone support at weekends.

Our Tier 1 Hospital at Home service provides most treatments patients would receive in hospital except acute Non-invasive Ventilation (NIV). A substantial number require temporary controlled oxygen therapy and nebulisers, and some receive intravenous antibiotics.

We take most patients home shortly after admission (ie this does not include patients who might never have been admitted in other models), and they are cared for in the community by the Respiratory Specialist Nurses, with consultant support.

What are the benefits of using DECAF?

DECAF is more accurate than CURB-65 as a clinical prediction tool in exacerbations of COPD, including Pneumonic exacerbations. This is simple to complete following admission, at the bedside. Other models of Hospital at Home often exclude patients with new onset respiratory failure requiring controlled oxygen and those with consolidation; we include both and they do well – this shows the advantage of objective risk stratification by DECAF to safely extend the service to a wider range of patients.

Initially, we accepted patients with COPD exacerbations +/- pneumonia and DECAF 0-1, and later this also included DECAF 0-2 patients.

  • DECAF 0-1 may return home on the same day of admission.
  • DECAF 2 patients may return home after 24 hours of admission if stable or improving.

We have expanded the service to include other respiratory conditions:

  • Pneumonia and low-intermediate risk CURB-65 score (DECAF used if the patient has COPD)
  • Bronchiectasis

We also accept patients who were too unwell on admission to be considered for Hospital at Home (e.g. DECAF 3 COPD exacerbations) after approximately 48+ hours of admission, provided they are on an improving trajectory (step down).  

We are able to carry out Arterial Blood Gas (ABG) tests using EPOC machines and titrate oxygen in the patient's home when required, following our Emergency Oxygen Guidelines and also providing IV antibiotic therapy.

We cover North Tyneside and Northumberland - the largest geographical footprint of any Trust in England. We have a capacity of up to six patients on the service, and on average, this equates to between four to five patients at one time, considering travel time and patient acuity.

Tell us about the Tier 2 Extended Supported Early Discharge Service  

When patients are admitted for exacerbation of COPD (ECOPD), we review them and complete our Inpatient Structured COPD assessment. Part of this assessment is calculating the PEARL Score, which predicts the risk of readmission/mortality at 90 days post-discharge. We also address long term COPD management and comorbidities.

Rates of readmission and mortality are twice as high following ECOPD compared to post-myocardial infarction (MI); this is poorly understood by patients, clinicians and policy makers. Consequently, COPD receives less focus and long-term therapy is less likely to have been optimised – we must challenge this and be our patients’ champion!

Patients with a score of 2 or more are deemed at intermediate-high to high-risk (more likely than not to be readmitted) and are, therefore, eligible for the service. This is currently limited to North Tyneside only. The service provides:

  • Facilitation of early discharge
  • Early identification of secondary exacerbations
  • Further oxygen weaning following discharge
  • Optimisation of long-term COPD care. This includes ABGs and timely referral to home ventilation by HOT HMV (home oxygen therapy-home mechanical ventilation) criteria,

(if the patient received acute NIV).

We currently have capacity for six to eight visits per day for this service, typically supporting 16 patients.

Patients are visited on days seven and 14, or more frequently depending on need. We address all aspects of COPD care and include the assessment of co-morbidities at each point of contact.

The Tier 2 service has also expanded to include patients with other conditions, such as exacerbations of ILD and patients with viral pneumonia who are not yet weaned from oxygen/not considered well enough for discharge, but who may not require 24/7 support.

We have found that the tiered approach tailors resources to clinical need- “lean medicine”. We are tech-light and have embedded the respiratory virtual ward within the usual hospital systems.

Read more about Virtual Wards and the role of clinical risk stratification

Read more about DECAF and PEARL clinical risk scores

Access examples of a manual and assessment sheets