Background-Prescription and use of long term oxygen treatment were audited in a large group of patients after more than five years of use of the guidelines for its prescription. Methods-Patients with a concentrator were interviewed at home with a structured questionnaire in three family health service authorities in East London. Stable oxygen saturation (Sao,) breathing air and oxygen, forced expiratory volume in one second (FEV,)

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IntroductionNon-invasive ventilation (NIV) in the management of acute type II respiratory failure in patients with chronic obstructive pulmonary disease (COPD) represents one of the major technical advances in respiratory care over the last decade. The National Institute for Health and Clinical Excellence (NICE) recommend that NIV be available in all hospitals admitting patients with COPD. 1 This has led to a rapid expansion in the provision of NIV services with over 90% of UK admitting hospitals offering this intervention. The UK national audit of acute hospital COPD care in 2003, however, suggested that treatment was often applied to patients outside the existing British Thoracic Society (BTS) inclusion criteria. 2,3 This document updates the 2002 BTS guidance and provides a specific focus on the use of NIV in COPD patients with acute type 2 respiratory failure. While there are a variety of ventilator units available most centres now use bi-level positive airways pressure (BiPAP) units and this guideline refers specifically to this form of ventilatory support although many of the principles encompassed are applicable to other forms of NIV. The guideline has been produced for the clinician caring for COPD patients in the emergency and ward areas of acute hospitals. Guideline development was in accordance with the AGREE principles and is summarised in the online version of this guideline (www.rcplondon. ac.uk/pubs/brochure.aspx?e=258). An extended version of this guideline encompassing service provision is available on the BTS website. Clinical contextNon-invasive ventilation, within the intensive care unit and the ward environment, has been shown in randomised controlled trials and systematic reviews to reduce intubation rate and mortality in COPD patients with decompensated respiratory acidosis (pH <7.35 and PaCO 2 >6 kPa) following immediate medical therapy. 5-14 It should therefore be considered within the first 60 minutes of hospital arrival in all patients with an acute exacerbation of COPD in whom a respiratory acidosis persists despite maximum standard medical treatment, which includes:• controlled oxygen to maintain SaO 2 88-92% • nebulised salbutamol 2.5-5 mg • nebulised ipratroprium 500 µg • prednisolone 30 mg • antibiotic agent (when indicated).A clearly documented treatment plan for NIV, including how potential failure will be dealt with and whether escalation to intubation and mechanical ventilation is indicated, should be documented in the case notes at the outset of treatment. Whenever possible the patient and carers should be involved in these discussions. Once started, patient comfort, breathing synchrony and enhanced compliance are key factors in determining outcome. Low starting pressures increase patient compliance but should be quickly adjusted upwards to achieve therapeutic effect. If effective, treatment will usually be required until the acute cause has resolved, commonly about two to three days.s CONCISE GUIDELINES

ObjectivesWe evaluated the impact of a COPD discharge care bundle on readmission rates following hospitalisation with an acute exacerbation.DesignInterrupted time series analysis, comparing readmission rates for COPD exacerbations at nine trusts that introduced the bundle, to two comparison groups; (1) other NHS trusts in London and (2) all other NHS trusts in England. Care bundles were implemented at different times for different NHS trusts, ranging from October 2009 to April 2011.SettingNine NHS acute trusts in the London, England.ParticipantsPatients aged 45 years and older admitted to an NHS acute hospital in England for acute exacerbation of COPD. Data come from Hospital Episode Statistics, April 2002 to March 2012.Main Outcome MeasuresAnnual trend readmission rates (and in total bed days) within 7, 28 and 90 days, before and after implementation.ResultsIn hospitals introducing the bundle readmission rates were rising before implementation and falling afterwards (e.g. readmissions within 28 days +2.13% per annum (pa) pre and -5.32% pa post (p for difference in trends = 0.012)). Following implementation, readmission rates within 7 and 28 day were falling faster than among other trusts in London, although this was not statistically significant (e.g. readmissions within 28 days -4.6% pa vs. -3.2% pa, p = 0.44). Comparisons with a national control group were similar.ConclusionsThe COPD discharge care bundle appeared to be associated with a reduction in readmission rate among hospitals using it. The significance of this is unclear because of changes to background trends in London and nationally.

ObjectivesAnnual vaccination against influenza (flu) is recommended for all UK National Health Service (NHS) staff to help reduce the risk of contracting the virus and transmitting it to patients. However, despite flu campaigns and vaccination promotion, uptake remains low. The aim of this study was to investigate staff attitudes to flu vaccination to see how this may influence their decision to be vaccinated.MethodsAn online survey was sent to staff members across 6 NHS trusts, asking if staff had been vaccinated in the preceding flu season (2013–2014); the survey included questions about beliefs and attitudes to the vaccination, scored on a 5-point Likert scale.Results3059 NHS staff members responded to the survey (86% in the 26–59 age group, 77% female and 84% hospital based). 68% of respondents reported being vaccinated in the preceding year. Using a stepwise regression model, the survey response retained as a positive predictor of having been vaccinated was ‘people working in healthcare should have the flu vaccination every year’ (p<0.001), and the responses retained as negative predictors were ‘the flu vaccination will make me unwell’ (p<0.001) and ‘the flu vaccination was too much trouble for me’ (p<0.001). Analysis by staff group showed a significant difference in the response to ‘the flu vaccination will make me unwell’ between groups (p=0.01), with doctors having a greater tendency to disagree with this statement than other staff members.ConclusionsThese results suggest that addressing NHS staff beliefs around the need for vaccination, while ensuring that practical barriers to having the vaccination are removed, may help to increase uptake. An emphasis on alleviating the concerns of particular staff groups regarding adverse effects of the vaccine may also be of benefit in improving uptake, to protect patients as well as staff.