Exploring Factors Contributing to Chronic Obstructive Pulmonary Disease (COPD) Guideline Non-Adherence and Potential Solutions in the Emergency Department: Interdisciplinary Staff Perspective

Abstract

Purpose Acute exacerbations of chronic obstructive pulmonary disease (COPD) have a significant and prolonged impact on health-related quality of life, patient outcomes, and escalation of pulmonary function decline. COPD-X guidelines published in 2003 subsist to facilitate a shift from the emphasis on pharmacological treatment to a more holistic multi-disciplinary interventions approach. Despite the existing comprehensive recommendations, readmission rates have increased in the last decade. Evidence to date has reported sub-optimal COPD guidelines adherence in emergency departments. This qualitative study explored contributing factors to interdisciplinary staff non-adherence and utilisation of COPD-X guidelines in a major Southern Queensland Emergency Department. Methods Semi-structured qualitative interviews with interdisciplinary staff were conducted in an emergency department. A purposive sample of doctors, nurses, physiotherapists, pharmacist and a social worker were recruited. Interviews were digitally recorded, de-identified and transcribed verbatim. Data analysis followed a coding process against the Theoretical Domains Framework (TDF) to examine implementation barriers and potential solutions. Identified factors affecting non-adherence and underutilisation of guidelines were then mapped to the capability, opportunity, motivation, behaviour model (COM-B) and behaviour change wheel (BCW) to inform future implementation recommendations. Results Prominent barriers influencing the clinical uptake of COPD guidelines were identified using TDF analysis and included knowledge, professional role clarity, clinical behaviour regulation, memory, attention, and decision process, beliefs about departmental capabilities, environmental context and resources. Potential interventions included education, training, staffing, funding and time-efficient digitalised referrals and systems management reminders to prevent COPD readmissions, remissions and improve patient health-related quality of life. Conclusion Implementation strategies such as electronic interdisciplinary COPD proforma that facilitates a multimodal approach with appropriate patient/staff resources and referrals prior to discharge from an ED require further exploration. Greater clarity around which components of the COPD X guidelines must be applied in ED settings needs to stem from future research.

Mapping of Modifiable Factors with Interdisciplinary Chronic Obstructive Pulmonary Disease (COPD) Guidelines Adherence to the Theoretical Domains Framework: A Systematic Review

“…The development and validation of appropriate educational tools for inhaler technique is necessary to assist clinicians and other health-care professionals who are involved in selecting inhalation devices 33,49 Inhaler technique educational videos for patient education in clinical practice 15 Self-learning E-modules for staff in all departments 15 Training all nurses, pharmacists and allied health to share responsibility in inhaler device and technique education 15,49 Increasing education and disseminating guidelines in the working area utilising better implementation and change management strategies 12 10/37 Misalignment of prescribing with GOLD a recommendations between respiratory physician and general physician 36 Lack of clinician and multidisciplinary team co-operation 18,38 The role of carers was poorly recognised in end stage COPD 61 Palliative care or advance care planning not offered to end stage COPD a patients 61…”

“…Patient centred and coordinated interdisciplinary care across Primary, acute and community sectors 38 Integrated, multidisciplinary services, are urgently required to address the unmet needs of people and carers with advanced COPD 31 COPD a quality initiative framework for systematic follow-up of guideline to avoid variance of practice 15,65 Care pathway implementation improves adherence with guidelines 19, Pharmacological and non-pharmacological treatment options with cognitive behavioural based therapies, education, patient centred programmes 59 Automatic electronic linkage between hospital and community 15 Simple preformatted order sets may be readily integrated into the diverse electronic health record platforms that currently exist across different hospitals 10,12,47,54 Message alerts on computer login screens 11,12,20,24 16/37…”

“…Point of care checklist in respiratory wards have improved guideline adherence 12 Health professional education and self-learning resources 38 Decision-making algorithms (including electronic systems) and reminders at the time of consultation, and continuous quality assurance programmes 54 Admission bundle with electronic prescribing system 20 Easy access to guidelines in clinical areas 12 Electronic order sets [10][11][12]18,20,33,47,54 Lack of adherence to long-acting bronchodilators (LABD a ) 36,46 Poor concordance with AECOPD a guidelines was observed in terms of antibiotic prescribing 48 Lack of prevention of future exacerbations with particular attention to smoking cessation, current vaccination knowledge of current therapy including inhaler technique and self-management 22 Inconsistent pharmacotherapy adherence with GOLD a guidelines 48 Poor compliance and variability in clinician practice with NIV a , bronchodilators and systemic steroids in the emergency department 11,12,41 Systemic corticosteroid regimens used in clinical practice are administered for much longer periods and at higher doses than recommended in guidelines 18,37,42 Low utilisation of pulmonary rehabilitation 10,12,20,33,36,52,65 Lack of implementation of vaccination 10,29 Unvaccinated patients not vaccinated in the acute setting 15 Low utilisation of spirometry and ABG a for COPD a diagnosis 22,23,31,…”

“…39 A reported disjunct exists between holistic respiratory ward-based COPD clinical pathways and atomistic acute ED clinical pathways generally due to the difference in care focus, time constraints, national targets, and lack of human and fiscal resources such as beds, clinicians, staff, and high patient turnover (environmental context and resources). 11,15,23,40 Targeted speciality care order sets specifically designed for departmental needs and care focus such as in the ED is highly recommended for implementation. 11,15,41…”

“…13 Sub-optimal dissemination and implementation impede adoption into clinical practice by interdisciplinary health professionals. 14,15 Guidelines assist with the incorporation of evidence into clinical practice to improve patient outcomes. 16,17 However, worldwide research reports lack of COPD guideline adherence.…”