Reliable adherence to a COPD care bundle mitigates system-level failures and reduces COPD readmissions: a system redesign using improvement science

Zafar, Muhammad Ahsan; Panos, Ralph J.; Ko, Jonathan; Otten, Lisa; Gentene, Anthony J.; Guido, M.; Clark, Katherine; Lee, Caroline; Robertson, Jamie; Alessandrini, Evaline A.

doi:10.1136/bmjqs-2017-006529

Cited by 29 publications

(47 citation statements)

References 28 publications

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“…We designed and implemented a COPD care bundle to mitigate these failures, which led to a 35% reduction in 30-d allcause readmissions. 20 Despite an impressive reduction in readmissions of hospitalized patients with COPD exacerbations, our ED revisit rates of patients discharged from the ED observation unit remained high. Effectiveness of COPD care bundles in ED observation unit settings has not been tested.…”

Section: Introductionmentioning

confidence: 94%

“…The COPD care bundle was developed by a multidisciplinary team as part of an inpatient COPD readmission reduction project. 20 The bundle was designed after a comprehensive analysis of local care delivery failures identified by retrospective review of medical records of COPD subjects who were readmitted, identification of unmet patient needs that potentially contributed to readmissions through patient interviews, and recognition of known best practices published in literature. The leading failures identified were inadequate medication regimen, lack of follow-up appointments, late follow-up appointments, lack of standard emergency plan, confusion about inhalers due to different brands and devices leading to inappropriate inhaler use.…”

Section: Copd Care Bundlementioning

confidence: 99%

“…The leading failures identified were inadequate medication regimen, lack of follow-up appointments, late follow-up appointments, lack of standard emergency plan, confusion about inhalers due to different brands and devices leading to inappropriate inhaler use. 20 The bundle components were limited to 5 to focus on high-yield opportunities. The process of bundle development and explanation of bundle component selection has been described previously.…”

Section: Copd Care Bundlementioning

confidence: 99%

“…The process of bundle development and explanation of bundle component selection has been described previously. 20 Each bundle component is evidence-based, applicable to all COPD patients, and was deemed highyield for local context. The bundle components were designed to provide an appropriate COPD medication regimen, 22 a 30-d medication supply of insurance-compatible inhalers, 23 personalized inhaler education, 24 standardized discharge instructions, 24 and a primary care follow-up appointment scheduled within 15 d.…”

Section: Copd Care Bundlementioning

confidence: 99%

“…In our first multidisciplinary team meeting, the existing process was mapped, and the COPD bundle delivery process from the inpatient setting was reviewed. 20 Differences in inpatient and ED observation unit settings were identified, and a proposed process map was formed for bundle component delivery in the ED observation unit. Multiple, iterative, plan-do-study-act (PDSA) testing cycles were performed.…”

Section: Implementation Of Copd Care Bundlementioning

confidence: 99%

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

et al. 2019

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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.

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Section: Introductionmentioning

confidence: 94%

Section: Copd Care Bundlementioning

confidence: 99%

Section: Copd Care Bundlementioning

confidence: 99%

Section: Copd Care Bundlementioning

confidence: 99%

Section: Implementation Of Copd Care Bundlementioning

confidence: 99%

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

et al. 2019

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Pharmacist review of chronic inhaler therapy appropriateness for hospitalized patients with COPD or asthma

Parrott,

Wallace,

Niehoff

et al. 2023

J Am Coll Clin Pharm

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Patients with asthma and chronic obstructive pulmonary disease rely on inhaler therapy to reduce disease progression and exacerbation risk. Patients admitted to the hospital are at an increased risk for exacerbations and readmission if their inhaler therapy upon discharge is not aligned with current guidelines and/or affordable. The objective of this study was to assess the appropriateness of the chronic inhaler regimen for patients admitted to the hospital based on clinical practice guidelines and insurance coverage. A sub‐study was designed to analyze a cohort of a single‐center, pragmatic, prospective randomized controlled trial at a large academic medical center. Patients admitted to a medicine service with a pharmacist and prescribed a long‐acting inhaler were included. Participants randomized to a pharmacist‐led intervention were assessed for inhaler appropriateness based on clinical guidelines and patient insurance. The objective of this sub‐study is to assess the number of inhalers identified as inappropriate based on the pharmacist's review. A patient was considered to have an inappropriate inhaler regimen if any of their inhalers were inconsistent with guideline recommendations or not covered by insurance. Descriptive statistics were used to characterize appropriate inhaler use. The study pharmacist reviewed 552 unique inhalers for 348 patients. Overall, 42% of inhalers were inappropriate, affecting 50.3% of participants; 20% of inhalers were inappropriate based on insurance, 26% were inappropriate based on guidelines, and 7% were inappropriate based on both criteria. Recommendations were placed via a pharmacy consult for 198 patients (57%), most recommending an inhaler initiation (55%), followed by inhaler discontinuation (38%). A pharmacist‐led review of chronic inhaler therapy for patients admitted to the hospital identified the need for a change in therapy based on financial or clinical guidelines in over half of the patients reviewed. Interventions to increase the appropriateness of prescribed inhalers are needed to reduce disease progression and disease exacerbation.

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

Lycouras,

Cieri‐Hutcherson,

Kersten

et al. 2024

J Am Coll Clin Pharm

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IntroductionChronic 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.

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Reliable adherence to a COPD care bundle mitigates system-level failures and reduces COPD readmissions: a system redesign using improvement science

Abstract: System-level failures and unmet patient needs are modifiable risks for readmissions. Development and reliable implementation of a COPD care bundle that mitigates these failures reduced COPD readmissions.

Cited by 29 publications

References 28 publications

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

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

Pharmacist review of chronic inhaler therapy appropriateness for hospitalized patients with COPD or asthma

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

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