Around 516 patients were referred to CRRT in May 2020. All patients resided within the NHS GGC health board area. COPD was the most common primary diagnosis, accounting for 65% of patients referred, and this figure increased to 72% when patients with COPD/asthma were included. The second most common diagnosis was asthma (12%), followed by interstitial lung disease (IP) (7%), with a smaller number of patients presenting with other respiratory diagnoses (Table 1). Diagnoses categorized as ‘other’ included obstructive sleep apnea, pulmonary embolism and lung cancer. The average age of patients referred was 69 years old. 340 (66%) patients were female and 176 (34%) were male. Women outnumbered men in all primary respiratory diagnoses except PID, in which 21 of 36 patients were men (Table 1).
Emergency department attendance, hospital admissions and death rates
Sixty-six patients (13%) visited the emergency department within 28 days of referral to the CRRT. Fifty-five patients (83%) who visited the emergency department were subsequently admitted to hospital, suggesting a real need for hospital care among the majority of patients who visited the emergency department. Eight patients were admitted directly to the hospital without going to the emergency department, meaning that a total of 63 patients (12%) were admitted to the hospital (Table 2 and Supplementary Table 1).
Twenty-five patients (4%) died within 28 days of referral. The mean number of days from referral to death was 11 (range 0–28, median 12, IQR 3–15). The mean age at death was 78 years (range 53–98, median 79, IQR 72–84). Fifteen deceased patients were female and ten were male. Eight (32%) patients who died within 28 days were nursing home residents. Deaths occurred in 11 COPD patients (3% of COPD patients), one patient with COPD/asthma overlap (3% of overlapping patients), one patient with bronchiectasis (10% of the group) and five patients identified as being at the end of life (56%). Two patients died in the other/unknown group (12%), both with metastatic malignancies. Six patients died after being diagnosed with COVID-19, three of which were triaged with COVID-19 as the primary diagnosis, and five patients underwent confirmatory virology testing. No deaths occurred in patients with a primary respiratory diagnosis of asthma.
Utility of the yard track
19% of patients were sorted in red, 46% in orange, 27% in green and 8% in blue (Fig. 1). Scoring the red, orange, and green pathways according to triage severity (where red is highest and green is lowest severity), attendance, admission, and death were negatively correlated (R = −0 .98, −0.96 and −0.97 respectively), that is, the higher the severity of the triage, the lower the proportion of people present or admitted.
The red lane had the highest proportion of ER attendance (21%), which was significantly higher than the orange and green lanes (p= 0.03 and p= 0.004, respectively), but not the blue channel (p= 0.419). As only seven patients were admitted directly to the hospital without going to the emergency room, the proportions of the 63 admitted patients were similar: 21 (21%) red, 26 (11%) amber, 11 (8%) green and five ( 13%) blue pathway patients (Table 2). The highest number of deaths was in the blue end-of-life triage lane (P
Use of remote consultations
The total number of CRRT consultations in the study population was 2261. Of these, 1971 (87%) were carried out remotely by telephone or via an online video call platform. For their first consultation, 431 (84%) patients were assessed by teleconsultation and 85 (16%) by home visit. About 181 patients (35%) had at least one home visit during follow-up (mean 1.6; range 1–8; median 1.6, IQR 1–2), meaning that 335 patients referred (65 %) were fully supported remotely.
Patients received an average of 4.4 consultations (range 1–44; median 3; IQR 1–5). A higher number of consultations was not significantly associated with emergency department attendance (Pearson correlation r= 0.036, p= 0.416), hospitalization (r= 0.074, p= 0.095) or death (r= −0.085, 0.055). This was also true when blue channel data was removed from the analysis. 33% of patients who presented to the emergency department had only one CRRT consultation, while only 22 (13%) of the 169 patients who had only one consultation presented to the emergency department.
The proportion of patients receiving a home visit was correlated with the severity of the triage category. A significantly higher proportion received a home visit in the red pathway; 71% of patients versus 32% of amber patients (ppppp= 0.005) and 13% of blue patients (p= 0.037). It should be noted that a large number of patient referrals to the blue pathway were requests for palliative oxygen administration rather than requests for patient examination; this includes ten (71%) of the 14 blue pathway patients who died and 38% of all patients who died within 28 days of baseline.
Patients seen face-to-face initially after referral were not significantly more likely to visit the emergency room (15% of initial home visits versus 12% of remote visits, p= 0.388), being hospitalized (15 vs 11%, p= 0.288), or die within 28 days (5 vs 4%, p= 0.802).
It is important to note that no nosocomial COVID-19 infections have been identified due to CRRT input among CRRT staff or patients cared for at home.
Workforce and cost analysis
In total, the CRRT employed a total of 26 nurses, 12 physiotherapists, one occupational therapist and two respiratory therapy consultants. Of the employees employed, 25 worked full-time for the CRRT while the others either worked part-time or combined work for the CRRT with other duties. 93% of referrals were made on weekdays, with an average of 24 referrals per weekday and 4 per weekend day. Staffing has been adjusted accordingly, with an average of 23 staff working each weekday and 13 each weekend to cover new referrals and follow-up consultations. The team provided an average of 490 consultations per week, which meant that each member of staff carried out an average of 14 consultations per day, including telephone consultations and home visits. The contribution of the respiratory consultants to the daily rounds of the virtual rooms required approximately three sessions per week with an estimated annual cost of £28,000 per year.
Based on the staffing levels above, the cost of staffing the service across the NHS GGC was approximately £48,789 per week, or £2,543,815 per year (Table 3) . Therefore, the average cost was £86 per CRRT consultation and £378 per patient referred in May 2020. This is compared to an average cost of £3602 per patient for admission to secondary care in the NHS GGC in 2018-2019 .19 and £3,000 per COPD-related hospital stay in NHS Scotland20.
Effect on COPD emergency attendance
Patients with COPD were the most represented group referred to the CRRT (Table 1 and Supplementary Table 1). Prior to the implementation of CRRT, increases in COPD AEs over time were evident in GGC, while the trend for all-cause AEs was roughly stable (Fig. 2). Conversely, in RoS, COPD AEs decreased and all-cause AEs increased slightly over time. Following the onset of the pandemic and the establishment of the CRRT service, a sharp drop was observed in both GGC and RoS in all-cause EAs and COPD EAs. This was then followed by a sharp increase, a reduction and a second increase in all-cause EAs (likely reflecting the waves of the pandemic, as people went to the ER less during the lockdown periods). However, AE COPD did not see as large an increase in either area (Fig. 2). Adjusting for changes in COPD EAs in RoS, there is a significant decrease in the trend of COPD EAs in GGC (RR = 0.96 (0.94, 0.98) for each additional month under the Poisson model) compared to the counterfactual, i.e. if the service had not been in place (Fig. 3 and Table 4).