Aims & objectives: Individuals with COPD have increased risk of severe pneumonia and poor outcomes when they develop SARS-CoV-2 (Hoffmann 2020). We hypothesised that there would be a difference in survival between COPD phenotypes with SARS-CoV-2 infections requiring hospital admission. Methods: Observational retrospective analysis of individuals admitted to critical care was performed during the first peak of the SARS-CoV-2 pandemic. Individuals with COPD were identified and grouped into phenotypes; frequent exacerbators (≥2 severe exacerbations in the last 12 months), emphysema-predominant, chronic bronchitis (cough and sputum production) and eosinophilic-predominant (plasma eosinophil count ≥ 300 cells/µL). Survival for all phenotypes was compared using Kaplan-Meier methodology. Results: 508 individuals were admitted to hospital with SARS-CoV-2 infection. 55 (11%) of these individuals had a diagnosis of COPD. Survival was significantly lower in all individuals with SARS-CoV-2 infection (34%) compared to individuals with SARS-CoV-2 infection and co-existing COPD (58%) (p=0.0003). There was no difference between baseline characteristics between COPD phenotypes. Median (IQR) FEV1 0.79 (0.62, 1.75) L, FVC 2.68 (1.83, 3.22) L. There was no significant difference in survival between all 4 phenotypes; median survival for frequent exacerbators, emphysema-predominant, chronic bronchitis and eosinophilia-predominant (113 vs 7 vs 39 vs 36 respectively), X2 (2) = 3.9, p=0.3. Conclusions: These data do not support the hypothesis that COPD phenotype would result in a difference in a difference in survival. Further study should investigate factors which predict survival of SARS-CoV-2 infection in individuals with co-existent COPD in a larger population.

ABSTRACT The Royal College of Physicians (RCP) recently published the National Early Warning Score 2 (NEWS2), aiming to improve safety for patients with hypercapnic respiratory failure by suggesting a separate oxygen saturation (SpO2) parameter scoring system for such patients. A previously published study of patients (n=2,361 admissions) with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) demonstrated alternative scoring systems at admission did not outperform the original NEWS. Applying NEWS2 SpO2 parameters to this previously described cohort would have resulted in 44% (n=27/62) of patients who scored ≥7 points on the original NEWS and subsequently died being placed in a lower call-out threshold. NEWS2 loses the benefits of a unified, standardised scoring system and we suggest prospective research in this area before applying this adjustment.

Kent Surrey Sussex (KSS) region is in the South East of England, has a population of approximately 4.2 million and contains 11 acute hospital trusts. The KSS Respiratory Programme commenced in 2010, initially linked to the English COPD outcomes strategy. A main aim of the programme was to reduce variation in care and outcomes. We developed a COPD Dashboard, updated quarterly and circulated widely with accompanying commentary, enabling commissioners and providers to compare performance in key indicators. In 2014 we commenced a COPD discharge bundle programme, and distribute quarterly reports on process outcomes. Teams are supported by collaborative sessions, which include aspects of service improvement, and a regular newsletter. We were interested in looking at trends over time, to see if there had been reduction in variation in key outcomes and whether there had been any change in COPD Bed Days. The table shows the results. Conclusion: In KSS from 2011/12 to 2015/16 there has been an overall reduction of COPD ‘raw’ bed days. There has been a reduction in average length of stay of 0.75 days with no increase in 30 day re-admission rate. However, there remains significant variation in outcomes between acute trusts. We feel there is potential for improvement; to date only 28% of all recorded acute COPD admissions are receiving all 5 elements of the COPD Discharge Bundle.

Kent Surrey Sussex (KSS) region in the South East of England has a population of 4.2 million. The KSS Respiratory Programme started in 2010, linked to the English COPD outcomes strategy. One aim of the program was to reduce the proportion of people with COPD who were undiagnosed. We developed a COPD Dashboard, and circulate this quarterly with commentary, so clinicians and managers can compare performance in key indicators. This is linked to educational sessions, a regular e-publication and advice to clinicians and commissioners. General Practices in England receive a proportion of income from the Quality and Outcomes Framework (QoF) which sets standards of care that patients should receive. It is possible to 9except9 patients from the system if appropriate, e.g. terminal illness, however we noted variations in the number of 9excepted9 patients. We were interested in looking at trends over time. Change in COPD Registrations over time is shown. The number of registered COPD cases has increased in each of the counties with a total of 7,403 additional cases. There has been a highly significant reduction in COPD patients excepted from QoF assessments. The mean number of patients excepted in our 20 CCGs in 2010/11 was 13.9% and in 2014/15 it was 10.2% (CI for difference 1.7% to 4.6%, P<0.001, paired t test).Conclusion: In KSS from 2011/12 to 2014/15 there has been a 10.5% increase in the number of COPD patients entered on GP registers and a significant reduction in QoF exceptions. We believe these are important changes which have led to 8,845 additional patients receiving COPD reviews in primary care.

Background The National Early Warning Score (NEWS), proposed as a standardised track and trigger system, may perform less well in acute exacerbation of COPD (AECOPD). This study externally validated NEWS and modifications (Chronic Respiratory Early Warning Score (CREWS) and Salford-NEWS) in AECOPD.Methods An observational cohort study (2012-2014, two UK acute medical units (AMUs)), compared AECOPD (2361 admissions, 942 individuals, International Statistical Classification of Diseases and Related Health Problems-10 J40-J44 codes) with AMU patients (37 109 admissions, 20 415 individuals).Outcome In-hospital mortality prediction was done by admission NEWS, CREWS and Salford-NEWS assessed by discrimination (area under receiver operating characteristic curves (AUROCs)) and calibration (plots and Hosmer-Lemeshow (H-L) goodness-of-fit).Results Median admission NEWS in AECOPD was 4 (IQR 2-6) versus 1 (0-3) in AMUs (p <= 0.001), despite mortality of 4.5% in both. AECOPD AUROCs were NEWS 0.74 (95% CI 0.66 to 0.82), CREWS 0.72 (0.63 to 0.80) and Salford-NEWS 0.62 (0.53 to 0.70). AMU NEWS AUROC was 0.77 (0.75 to 0.78). At threshold NEWS=5 for AECOPD (44% of admissions), positive predictive value (PPV) of death was 8% (5 to 11) and negative predictive value (NPV) was 98% (97 to 99) versus AMU patients PPV of 17% (16 to 19) and NPV of 97% (97 to 97). For NEWS in AECOPD H-L p value=0.202.Conclusion This first validation of the NEWS in AECOPD found modest discrimination to predict mortality. Lower specificity of NEWS in patients with AECOPD versus other AMU patients reflects acute and chronic respiratory physiological disturbance (including hypoxia), with resultant low PPV at NEWS=5. CREWS and Salford-NEWS, adjusting for chronic hypoxia, increased the specificity and PPV but there was no gain in discrimination.