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Abstract
Background COPD exacerbations (eCOPD) deleteriously effects patient outcomes and healthcare spending. Emergency Department observation units (ED-Obs) provide short-term acute care in order to reduce resource utilisation, however successful COPD-specific programs in ED-Obs are lacking.
Objectives Achieve 90% reliable implementation of COPD care-bundle among eCOPD patients discharged from ED-Obs by April 2017. The overall goal is to reduce 30 day all-cause ED revisits for eCOPD patients discharged from ED-Obs from the baseline rate of 49%.
Methods Setting: An 800-bed academic hospital with 700 eCOPD ED encounters/year, out of which 20% triage to ED-Obs. All patients triaged to ED-Obs with eCOPD diagnosis were included. A five-element COPD bundle designed to mitigate system-level failures, was adopted from in-patient setting. The bundle components were: appropriate inhaler regimen, 30 day inhaler supply, personalised inhaler education, standardised discharge instructions and follow-up in 15 days. A multidisciplinary team was formed to support bundle implementation within the 24 hours ED-Obs stay using Model for Improvement. Bundle component adherence and 30 day ED revisit rates were monitored using SPC p-charts. Hospitalisation rate from ED-Obs was used as balancing measure.
Results The patient characteristics were similar in baseline and post-bundle period. Multiple PDSA cycles were performed to achieve a final process (Figure 1). The adherence to COPD care bundle components has maintained >90% from 4/2017–8/2017 (Figure 2). The 30 day all-cause ED revisit rate reduced from 49% to 28% with a pending system-shift on SPC (Figure 3). Hospitalisation rate remained unchanged.
COPD care bundle delivery process in ED observation unit. COPD: chronic obstructive pulmonary disease, ED: emergency department, Obs: observation, d/c; discharge, dispo: disposition, Rx: prescription, HER: electronic health record, INH: inhalers, PCP: primary care provider
Process measure: adherence to COPD care bundle components. RT: respiratory therapists, MLP: mid-level provider, EMR: electronic health record
Outcome measure: 30 day all-cause ED revisit rate. COPD: chronic obstructive pulmonary disease
Conclusions Improving care at discharge transition of eCOPD patients from ED-Obs to home through reliable adherence to COPD care-bundle reduces 30 day all-cause ED revisits.