The Mater Hospital Multiprofessional Care Pathway for Acute Exacerbations of Chronic Obstructive Pulmonary Disease

Abstract

Introduction: Chronic obstructive pulmonary disease (COPD) is a common condition associated with an increasing mortality and morbidity. There are also significant economic implications with hospital admission accounting for the majority of the total COPD health care expenditure. Mild exacerbations of COPD can be treated at home; severe exacerbations require hospitalization. The purpose of this programme of care was to integrate and optimize treatment using current guidelines. Methods: This was a prospective study of management of severe exacerbations of COPD following implementation of a structured care pathway. The project was based at a district general hospital in inner city Belfast. Key measures of improvement were length of hospital stay, readmission rates within one month and hospital mortality. A multidisciplinary care pathway incorporated a score that was developed with one point for each of the following markers of a severe exacerbation: dyspnoea at rest, bed bound, tachypnoea (>25), tachycardia (>110), pyrexia (>38.5), use of accessory muscles of respiration and peripheral oedema. We have called this the ‘Mater COPD score’. The aim was for optimal management, education and identification of appropriate time for discharge. Patient treatment was standardized using oral steroid therapy, nebulized bronchodilators (air cylinders were used to provided nebulization where appropriate) and antibiotic therapy. Results: A total of 85 patients were studied, 40 men with a mean (SEM) age of 68.6 (1.7) years. The mean COPD score on admission was 2.3 (range 0–6). Mean score on discharge was 0.4 (range 0–3). Mean forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) were 0.97 and 1.83 L, respectively. Seven patients were readmitted within one month. The mean length of an episode was reduced from 9.4 to 5.5 days, with a national average of 9.7 days at that time. However, delayed discharge in 25 cases (due to co-morbidity, social problems or other factors) resulted in the overall length of stay being reduced to 6.5 days. Continued follow-up using this pathway reduced the length of stay of all admissions with COPD by four days to 5.4 days. Nebulizers were routinely changed from oxygen driven to air driven. There was a 1700% increase in air cylinders used over the two years following introduction. This was associated with a 57% reduction in mortality. Conclusions: A multidisciplinary care pathway in the management of acute exacerbations of COPD ensures optimal treatment for patients and results in a significant reduction in the length of stay and a reduced mortality rate without increasing readmission rates.