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

Abstract

BACKGROUND: 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). METHODS: 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 5 50) and postbundle (n 5 83) period over 5-month and 7-month intervals, respectively. Comparisons were made using t tests and chi-square tests with P < .05 significance. RESULTS: 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 5 .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 5 .16). Subject characteristics were similar in the baseline and postbundle periods. CONCLUSIONS: Reliable adherence to a COPD care bundle reduced 30-d ED revisits among those treated in the ED observation unit.

Does pay-for-performance improve patient outcomes in acute exacerbation of COPD admissions?

“…A recent French study 30 also concluded that a COPD discharge care bundle had no impact on 28-day AECOPD readmission or mortality. However, one recent US study 31 found that all-cause readmissions reduced after implementing a COPD care bundle. It is worth noting that all these bundle studies have comparatively small numbers of included patients and generally compare outcomes at a population-level rather than the patient-level as we have done in this study.…”

“…However, over 50% of the readmissions in our study were for either AECOPD or pneumonia and some of the other studies discussed used all-cause readmission as an outcome too. 18 31 A limitation of the data set that we used is that it is not clear which specific elements of the discharge bundle have been completed, we are simply provided with a binary 'yes, bundle completed' response and as Morton et al 18 noted, certain elements of the discharge bundle are not always well completed.…”

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

“…A number of studies exploring the bundles of interventions have been shown to reduce the readmission rate and mortality. [20][21][22] There is a lack of data on economic evaluation of COPD from resource limited settings. The priorities and feasibility of the bundles in the COPD care vary according to the gap in care and the resources available and cannot be generalized.…”

“…A number of individual interventions or bundles of interventions have been shown to reduce the readmission rate and mortality. [20][21][22] Interventions to prevent ED revisits after AECOPD are urgently needed to improve outcomes and reduce costs. A small number of quality improvement (QI) studies have been done in Nepal 23,24 in other domains, including primary care and community settings, 25,26 but there have been virtually no studies based in EDs.…”

Feasibility and Short‐Term Effects of a Multi‐Component Emergency Department Blood Pressure Intervention: A Pilot Randomized Trial

“… 13 , 14 While several ED‐based intervention bundles have been developed for other conditions such as substance use disorders, few have specifically targeted hypertension self‐management. 15 , 16 , 17 In one recent pilot trial, a multicomponent intervention that provided education and support as part of an ED visit led to improved BP among racial and ethnic minorities. 18 However, more work is needed to identify which and how interventions are effective in improving hypertension control during the transition from ED care to primary care.…”