COPD Care Bundle Research Articles

Implementation of a pharmacist‐driven chronic obstructive pulmonary disease transitions of care service at a large academic medical center

AbstractIntroductionChronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality in the United States, and one in five COPD hospitalizations result in a readmission within 30 days. Pharmacists have been identified as key members of interdisciplinary teams to improve transitions of care.ObjectiveThe objective of this study was to develop, implement, and evaluate outcomes for a pharmacist‐driven COPD transitions of care bundle at an academic medical center.MethodsA COPD care bundle was implemented for patients presenting with a COPD exacerbation from December 1, 2021 to February 28, 2022. A historical control group was created from patients who were discharged between December 1, 2020 and February 28, 2021. Patient characteristics, pharmacist‐driven interventions, and time required for the intervention were assessed descriptively. Inhaler technique was assessed before and after pharmacist education utilizing standardized rubrics. The percentage change in inhaler scores was assessed with a Wilcoxon signed‐rank test. Readmission outcomes were analyzed using a chi‐squared test.ResultsThere were 30 patients in the intervention group and 46 in the control group. There were 104 interventions requiring provider collaboration, of which 84 (81%) were accepted. A median (interquartile range, IQR) of 46 (37–55) min was spent per patient in the intervention group. At baseline, patients scored a median of 84.6% (75–100) of steps correctly across all inhaler device types. After pharmacist education, patient scores increased to a median of 100% [92.3–100] (p < 0.0001). There were eight (26.7%) 30‐day all‐cause readmission rates in the intervention group and 15 (32.6%) in the control group (p = 0.58).ConclusionMost pharmacist recommendations were accepted by providers. Medication education led to improved understanding of inhaler technique, but there was no difference in 30‐day readmission rates. Further development of this service is warranted based on these findings.

Impact of a COPD care bundle on hospital readmission rates

BackgroundChronic obstructive pulmonary disease (COPD) is one of the leading causes of mortality worldwide and contributes considerably to morbidity and health care costs. In October 2014, the Centers for Medicare and Medicaid Services introduced financial penalties followed by bundled payments for care improvement initiatives in patients hospitalized with COPD. ObjectivesThis study seeks to evaluate whether an evidence-based interprofessional COPD care bundle focused on inpatient, transitional, and outpatient care would reduce hospital readmission rates. MethodsA pre- and postintervention analysis comparing readmission rates after a hospitalization for COPD in subjects who received standard of care versus an interprofessional team–led COPD care bundle was conducted. The primary outcome was 30-day all-cause readmissions; secondary outcomes included 60- and 90-day all-cause readmissions, escalation of pharmacotherapy, interprofessional interventions, and hospital length of stay. ResultsA total of 189 subjects were included in the control arm and 127 subjects in the COPD care bundle arm. A reduction in 30-day all-cause readmissions between the control arm and COPD care bundle arm (21.7% vs. 11.8%, P = 0.017) was seen. Similar outcomes were seen in 60-day (18% vs. 8.7%, P = 0.013) and 90-day all-cause readmissions (19.6% vs. 4.7%, P < 0.001). Pharmacists consulted with 68.5% of subjects and assisted with access to outpatient medications in 45.7% of subjects in the COPD care bundle arm. An escalation in maintenance therapy occurred more often in the COPD care bundle arm (22.2% vs. 44.9%, P < 0.001) than the control arm. ConclusionsAn interprofessional team–led COPD care bundle resulted in significant reductions in all-cause hospital readmissions at 30, 60, and 90 days.

Decreasing Hospital Readmissions Utilizing an Evidence-Based COPD Care Bundle.

Chronic obstructive pulmonary disease (COPD) is a chronic condition that leads to significant morbidity and mortality. Management of COPD hospitalizations utilizing an evidence-based care bundle can provide consistent quality of care and may reduce readmissions. This single-center retrospective cohort study evaluated readmission rates in patients hospitalized with a COPD exacerbation. Patients in the pre-intervention cohort received usual care, whilepatients inthe post-intervention cohort received an innovative inpatient COPD care bundle. The bundle focused on optimizing care in five areas: consults, inpatient interventions, education, transitions of care, and after discharge care. In this study, 149 subjects were included in the pre-intervention cohort and 214 subjects were included in the post-intervention cohort. Thirty-day readmission rates were lower in the post-intervention cohortcompared to the pre-intervention cohort, 22.4% vs. 38.3% (p = 0.001). A reduction in 60-day and 90-day readmission rates was also observed, 13.7% vs. 40.3% (p < 0.001) and 10.1% vs. 32.2% (p < 0.001), respectively. Bundled care is an effective and inexpensive method for institutions to provide consistent and quality care. The findings of this study demonstrate that the implementation of a COPD care bundle is an effective strategy to decrease hospital readmissions.

Needs Assessment and Identification of the Multifaceted COPD Care Bundle in the Emergency Department of a Tertiary Hospital in Nepal.

PurposeAcute care of patients with exacerbation of chronic obstructive pulmonary disease (AECOPD) in the emergency department (ED) is crucial, however not studied extensively in Nepal. The purpose of this study is to identify the opportunities for succinct measures to optimize the AECOPD care in ED with a multifaceted bundle care approach in a resource-limited setting.MethodsWe conducted a prospective cross-sectional observational study as an initial baseline stage of the quality improvement project. Demographic data, clinical characteristics, the current diagnosis and treatment performances of AECOPD were recorded. The primary outcome measures were 30-day ED revisit and near-fatal events which were compared with other variables and performances with binary and logistic regression. The multidisciplinary team performed the root cause and Pareto analysis to identify the potential gaps in the AECOPD care.ResultsThe AECOPD performance measures were suboptimal. Written AECOPD emergency management clinical guidelines and advice regarding pulmonary rehabilitation were absent. Among the 249 AECOPD encounters, bilevel positive-airway pressure ventilation was started in 6.4%. At discharge, 11.8% and 39.7% were given oral steroids and antibiotics respectively; 2.2% were advised vaccination. Near-fatal events and 30-day revisit occurred in 19% and 38.2% of the encounters respectively. Those who required domiciliary oxygen had significantly higher 30-day revisits (OR=2.5; 95% CI=1.43–4.4; P value =0.001) as did those who were previously admitted (OR=1.98; 95% CI 1.11–3.59; P value =0.022). Those who had a 30-day revisit had increased near-fatal events (OR=2.86; 95% CI=1.362–6.18; P value =0.006). The opportunities for improving the ED care were identified and feasible interventions and their indicators are summarized for future implementation.ConclusionThe current COPD performance measures were suboptimal with high 30-day revisit and near-fatal outcomes. We suggest the urgent implementation of the enlisted feasible bundles-care involving multifaceted team and protocol-based management plans for AECOPD in a busy resource-limited ED.

COPD Care Bundle in Emergency Department Observation Unit Reduces Emergency Department Revisits

COPD exacerbations lead to accelerated decline in lung function, poor quality of life, and increased mortality and cost. Emergency department (ED) observation units provide short-term care to reduce hospitalizations and cost. Strategies to improve outcomes in ED observation units following COPD exacerbations are needed. We sought to reduce 30-d ED revisits for COPD exacerbations managed in ED observation units through implementation of a COPD care bundle. The study setting was an 800-bed, academic, safety-net hospital with 700 annual ED encounters for COPD exacerbations. Among those discharged from ED observation unit, the 30-d all-cause ED revisit rate (ie, the outcome measure) was 49% (baseline period: August 2014 through September 2016). All patients admitted to the ED observation unit with COPD exacerbations were included. A multidisciplinary team implemented the COPD bundle using iterative plan-do-study-act cycles with a goal adherence of 90% (process measure). The bundle, adopted from our inpatient program, was developed using care-delivery failures and unmet subject needs. It included 5 components: appropriate inhaler regimen, 30-d inhaler supply, education on devices available after discharge, standardized discharge instructions, and a scheduled 15-d appointment. We used statistical process-control charts for process and outcome measures. To compare subject characteristics and process features, we sampled consecutive patients from the baseline (n = 50) and postbundle (n = 83) period over 5-month and 7-month intervals, respectively. Comparisons were made using t tests and chi-square tests with P < .05 significance. During baseline and postbundle periods, 410 and 165 subjects were admitted to the ED observation unit, respectively. After iterative plan-do-study-act cycles, bundle adherence reached 90% in 6 months, and the 30-d ED revisit rate declined from 49% to 30% (P = .003) with a system shift on statistical process-control charts. There was no difference in hospitalization rate from ED observation unit (45% vs 51%, P = .16). Subject characteristics were similar in the baseline and postbundle periods. Reliable adherence to a COPD care bundle reduced 30-d ED revisits among those treated in the ED observation unit.

Pragmatic Challenge of Sustainability: Long-Term Adherence to COPD Care Bundle Maintains Lower Readmission Rate

After implementation of the COPD care bundle, 30-day all-cause readmissions reduced from 22.7% to 14.7%. In 2016 the project transitioned from implementation to the sustainability phase. A four-member sustainability team was formed (pulmonologist, hospitalist, respiratory therapist, and pharmacist) with clearly defined roles for monitoring and facilitating sustainability actions. The process of bundle delivery was purposefully designed for higher reliability. Staff education and daily operations were updated to incorporate the new process. Outcome (readmission rate) and process (bundle adherence) measures were monitored monthly. Any significant drop (special cause variation) would be reviewed by the team and further action taken, if needed. The National Health Service sustainability model was used, with adjustments made to meet our contextual needs. The 30-day all-cause readmission rate remained the same as during the initial implementation phase (14.9%). Adherence to COPD care bundle components was 87.7%. During the two-year period, three occasions triggered a team discussion and detailed review. Sustainability requires a purposefully designed, resilient process; standard work; engagement of the team and leadership; and a monitoring system of key process and outcome measures. Application of sustainability models should be adjusted for specific contextual needs.

COPD exacerbation care bundle improves standard of care, length of stay, and readmission rates.

IntroductionCOPD is the third leading cause of death in the world. Utilizing care bundles during acute COPD exacerbations results in fewer complications and lower costs. Our aim was to construct a COPD exacerbation care bundle and evaluate the effects on patient care.MethodsWe conducted a prospective analysis of 44 patients admitted with a COPD exacerbation to a single tertiary care facility. Primary outcomes included length of stay, readmission rates, and hospital costs. Secondary outcomes included patient education, pulmonologist follow-up, and timeliness of medication administration. Two cohorts were analyzed: those treated with an electronic COPD care bundle (cases; N=22) versus those treated without the care bundle (controls; N=22).ResultsMean length of stay (51.2 vs 101.1 hours in controls; P-value =0.001), 30-day readmission rates (9.1% vs 54.4% in controls; P-value =0.001), and 60-day readmission rates (22.7% vs 77% in controls; P-value =0.0003) decreased in the care bundle group. Ninety-day hospital costs had a significant difference in the care bundle group (US$7,652 vs US$19,954 in controls; P-value =0.044). Secondary outcomes included a 100% rate of COPD inhaler teaching (vs 27.3% in controls; P-value <0.001), 59.1% rate of pulmonologist follow-up after discharge (vs 18.2% in controls; P-value =0.005), and a mean reduction in time to steroid administration (7.0 hours; P-value =0.015) seen in the care bundle cases.ConclusionOur significant findings coupled with the recent success of standardized algorithms in managing COPD exacerbations stress the importance of enforcing clinical guidelines that can enhance patient care. We demonstrated improved care for COPD exacerbation patients during hospitalizations, thereby decreasing morbidity and the financial burden hospitals face in regard to this increasingly prevalent disease.

P257 Sub-optimal Inhaler Technique In Patients Aged Over 75 Years

<h3>Introduction and objectives</h3> NICE guidelines highlight the importance of adequate inhaler technique to ensure sufficient drug delivery in asthma and C. O. P. D. Whilst adequate inhaler technique can be a problem for patients of any age, the delivery of inhaled medication continues to be a particular problem for elderly patients. Despite the existence of pressurised metered-dose inhalers and breath-actuated inhalers, physical and cognitive impairment continues to make the use of hand-held inhalers difficult in the elderly. It is therefore likely that inhaler use in the elderly is suboptimal, regardless of device used. <h3>Methods</h3> We assessed 50 consecutive patients aged over 75 years with C. O. P. D or asthma at our centre (mean age 78.24 ± 7.32). All had inhaler therapy prescribed prior to examination. Two observers assessed inhaler technique against guidelines adapted from the National Asthma Council of Australia¹ (see Table). Patients used either an Evohaler (pressurised metered-dose inhaler) or Accuhaler (breath-actuated inhaler) according to their choice. <h3>Results</h3> In the Evohaler group (25 patients), the average age was 78 (±5.5) with an average score of 6.6 (±1.81) / 10. In the Accuhaler group (25 patients), average age was 77 (±6.4) with an average score of 7.2 (±2.0) /10. ‘Crucial’ steps to adequate inhaler technique were also assessed.² The score in the Evohaler group was 4.4 (±1.2) /6, and in the Accuhaler group was 4.3 (±1.0) /6. <h3>Conclusion</h3> This study shows that despite the availability of both Evohaler (pressurised metered-dose inhaler) and Accuhaler (breath-actuated inhaler) effective use by the elderly is still sub-optimal. The very elderly need extra support when considering and prescribing inhalers. Whilst many centres have ‘good inhaler technique’ as a pillar of their COPD care bundle, it may be the case that specialist services, including the use of specialist devices, directed at the elderly may help to alleviate the problems of physical and cognitive impairment when using inhalers. <h3>References</h3> National Asthma Council Australia. Inhaler technique in adults with asthma or COPD. Melbourne: National Asthma Council Australia, 2008 Newman S. P. Inhaler treatment options in COPD. <i>Eur Respir Rev</i> 2005;14(96):102-108

P156 Can Specialist Nurses Predict Which Patients Will Readmit Following Delivery Of A Copd Care Bundle?

Introduction Adequate follow up is a key element of COPD care bundles (CB). COPD nurse specialists responsible for completing follow up consultations may be able to utilise clinical judgment and measures of health status to predict which patients are at greater risk of readmission. Objective We explored whether COPD nurse specialists working in the REspiratory Discharge Service (REDS), who delivered the CB, could predict whether patients would readmit within15 days post discharge. We also explored levels of health and psychological status for those patients who the REDS team thought were and were not at risk of readmission. Methods This was a retrospective audit of patients who received a COPD discharge CB from April 2013 to March 2014. Readmission likelihood was recorded by the REDS team after completion of a 2 day post-discharge phone consultation. Patients also completed the COPD Assessment Test (CAT), MRC breathlessness scale and the Hospital Anxiety and Depression Scale (HADS). Mean between-group differences for the ‘will admit’ and ‘will not admit’ groups were analysed using independent t-tests. Results Readmission risk was recorded for 1003 patients who received the CB prior to discharge. A total of 100 patients of these 1003 readmitted (readmission rate of 9.7%). The REDS team correctly predicted that 39 of these 100 patients would be readmitted. There were statistically significant between-group differences for MRC, CAT and HADS scores (see table): Patients placed in the ‘will readmit’ group had significantly worse CAT, HADS anxiety and depression scores compared those placed in the will not readmit group. Conclusions COPD nurse specialists were unable to correctly predict the majority of readmissions. Patients deemed at risk of readmision had worse levels of psychological and health status than those who were not thought to be at risk of readmission. This suggests other factors must be important in predicting COPD readmissions.

P290 Impact of a Combined Admission and Discharge COPD Care Bundle on Hospital Mortality and Readmission Rates

BackgroundA care bundle is a group of evidence based interventions which if consistently delivered should improve outcomes. Published work (Thorax 2012) has demonstrated the impact of a COPD discharge bundle...