Introduction: Patients with COPD often have complex needs and multiple co-morbidities. Some need nutritional support; many still smoke. Pulmonary Rehabilitation(PR) improves those who complete it. Immunisation for influenza and pneumonia work; good inhaler technique is essential. For those in hospital with exacerbations early discharge is possible; use of a discharge bundle with community referral increases service access. We provide community in-reach to the admission areas, review after discharge, PR, and oxygen services and work closely together with hospital colleagues. Methods: We carried out nested audits to examine our referrals, changes to admissions, potential for interventions and patients with frequent admissions. Results: In 2017 referrals were 997, 64% after in-patient stay. Patients have severe disease,7.6% NIV/CPAP. 17% oxygen, 25% nebulised therapy: 21% smoke, 5.5% BMI<18. 2015-7 In reach to admission areas saw 463 patients, 149 discharged<24hr; Length of stay fell 2013-4 v 2016-7, 7.6 v 5.9days. More in-patients are now known to service, 30% 2015, 76% 2017. A discharge bundle including community referral use in 59%, Jan2015: 95% 2017. In 66 high risk patients with 3 or more admissions/yr in 2015-6 41% died <6mo; after identification/interventions admissions fell in 6/12 after v 6/12 before, 124 v 56, P<0.001, hospital days 899 v 486, P<0.001. In 2016-7, 44 further patients showed reduction in admissions (107 v 54, P<0.001:days 838 v 298, P<0.05. In the later group 27% BMI<18 all had nutrition support,23% azithromycin and 41% PR; 30% smokers. Conclusions: A focus on identifying potential interventions leads to less hospital load even in those with severe disease.

We serve 450,000 people in Essex, UK, with close integration between community and hospital based respiratory teams, referral to community team as part of the discharge process bundle, pulmonary rehabilitation, oxygen services, and regular review of COPD patients in the community. Community based nurses visit the hospital for in-reach to facilitate early discharge. Patients with severe disease are discussed at a multi-disciplinary MDT. Methods: We carried out a series of nested audits to examine the clinical characteristics of our patients, the effect of nurse in-reach and the effect of an integrated approach on admissions and length of stay. Results: In 2016 there were 1234 referrals to the community team. 95% with COPD. There were 459 oxygen and 586 direct pulmonary rehabilitation referrals. In 2015-6 compared to 2014-5 the activities of the integrated team lead to a reduction in admissions from 841-774 (8.4%) This has continued into 2016-7 with April to October admissions for 2014 of 367, 2015, 320, and 2016, 329. This is a 10.4% drop between 2014-6. Length of stay 2014 was 7.4 days; 2015: 6.1 days. In 2016 nurse in-reach saw 323 patients, 285 in A&E or acute admission wards and 38 elsewhere. 264 were identified as suffering from COPD; 109 patients were discharged that day. Referral to the community team as part of the discharge bundle occurred in 87.4% of patients discharged alive from our area. Conclusion: Integration of community and hospital respiratory teams with use of a robust discharge process and access to community PR and oxygen services leads to reduction in admissions and appropriate care for patients with COPD.

To identify the impact of a community integrated respiratory team on early discharge after exacerbation of COPD, need for pulmonary rehabilitation and care provision in the community. A rolling audit of all referrals to the team to identify comorbidity, complexity of disease and need for pulmonary