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

• Published in: Respiratory care 2020-01, Vol.65 (1), p.1-10
• Main Authors: Zafar, Muhammad A, Loftus, Timothy M, Palmer, Jack P, Phillips, Michael, Ko, Jonathan, Ward, Steven R, Foertsch, Madeline, Dalhover, Amber, Doers, Matthew E, Mueller, Eric W, Alessandrini, Evaline A, Panos, Ralph J
• Format: Article
• Language: English
• ISSN: 0020-1324; 1943-3654
• DOI: 10.4187/respcare.07088

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 ( 50) and postbundle ( 83) period over 5-month and 7-month intervals, respectively. Comparisons were made using tests and chi-square tests with < .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% ( = .003) with a system shift on statistical process-control charts. There was no difference in hospitalization rate from ED observation unit (45% vs 51%, = .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.