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Jeff Pretto, Vanessa McDonald, Peter Wark and Michael Hensley

Department of Respiratory & Sleep MedicineJohn Hunter Hospital, Newcastle, New South Wales

Jeff Pretto, Vanessa McDonald, Peter Wark and Michael Hensley

Department of Respiratory & Sleep MedicineJohn Hunter Hospital, Newcastle, New South Wales

An Audit of Clinical Practice for COPD Hospital Admissions

An Audit of Clinical Practice for COPD Hospital Admissions

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IntroductionIntroduction

• COPD is now acknowledged as highly prevalent disorder causing substantial healthcare burden

• Management guidelines for COPD have been developed by multiple international groups

COPD-X guidelines* most relevant in Australia & New Zealand

• However little data available on adherence in Australia, particularly with regard to admissions

*DK McKenzie et al. The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease 2007.

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AimsAims

• To document variability in clinical practice for COPD admissions in a range of acute-care hospitals

• To identify gaps in service provision from management guidelines*

• (To aid development of targeted strategies for service improvement)

*DK McKenzie et al. The COPD-X Plan: Australian & New Zealand Guidelines for the Management of COPD. 2007

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MethodsMethods

• Retrospective medical record audit of 3 consecutive months (July-Sept 2008) of admissions with DRG E65B: COPD without catastrophic or severe co-morbidities or

complications

• Eight acute care public hospitals in the Hunter New England Area Health Service Range 52 – 550 beds / hospital

• Using a validated COPD audit tool* (modified)

*CM Roberts et al. ERJ 2001, 17: 343-349

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200k

Newcastle

Sydney

Brisbane

Hunter New England Area Health ServiceHunter New England Area Health Service

• total area 130/000 km2

• Serves a population base of ~ 850,000

• 8 hospitals audited (total of 1,538 beds)

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Results: 234 Admissions - data for 221 (94%)Results: 234 Admissions - data for 221 (94%)

Median LOS (days): 5.0 5.0

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Results: Patient DetailsResults: Patient Details

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Results: Spirometry during AdmissionResults: Spirometry during Admission

COPD-X: “Assessment of severity of the exacerbation includes…spirometry... [Even the sickest of patients can perform an FEV1 manoeuvre]”

Access to any spirometry results (during adm. or within previous 5 years) was only 51%

JHH Belmont Mater TMH T’worth Armidale Moree Manning

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Results: Smoking StatusResults: Smoking Status

COPD-X: P = Prevent deterioration. ‘Smoking cessation reduces the rate of decline of lung function”

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Results: Arterial Blood Gases on AdmissionResults: Arterial Blood Gases on Admission

COPD-X: “Assessment of severity of the exacerbation includes… in severe cases, blood gas measurements”

JHH Belmont Mater TMH T’worth Armidale Moree Manning

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Results: Conversion from NebulisersResults: Conversion from Nebulisers

COPD-X: “The mode of [bronchodilator] delivery should be changed to MDI/spacer or DPI within 24 hours of initial dose of nebulised bronchodilator, unless the patient remains severely ill”

JHH Belmont Mater TMH T’worth Armidale Moree Manning

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Results: Ventilatory SupportResults: Ventilatory SupportCOPD-X: “Early intervention with NIPPV is suggested when ... blood pH is less than 7.35”

• 21 patients (18%) with admission pH 7.35 8 received ventilatory support

- 6 NIV

- 2 IV

13 did not receive ventilatory support

- 3 medical decision not to escalate treatment

- 2 responded to medical therapy

- 1 patient refused

- 9 no reason apparent

• 5 other patients received NIV

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Results: Pulmonary RehabilitationResults: Pulmonary RehabilitationCOPD-X: “A pulmonary rehabilitation program that includes supervised exercise training can be initiated immediately following an acute exacerbation”

JHH Belmont Mater TMH T’worth Armidale Moree Manning

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Results: Chest X-Ray on AdmissionResults: Chest X-Ray on Admission

COPD-X: “Assessment of severity of the exacerbation includes…in severe cases …chest x-ray”

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Results: Steroid TherapyResults: Steroid TherapyCOPD-X: “Oral glucocorticoids hasten resolution and reduce the likelihood of relapse”

JHH Belmont Mater TMH T’worth Armidale Moree Manning

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Results: Antibiotic TherapyResults: Antibiotic Therapy

COPD-X: “Antibiotics are given for purulent sputum to cover for typical and atypical organisms”

106 of 115 admissions (92%) with increasing sputum volume and/or change in sputum colour recorded received antibiotics

JHH Belmont Mater TMH T’worth Armidale Moree Manning

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Results: Oxygen TherapyResults: Oxygen TherapyCOPD-X: “[Oxygen therapy] is indicated in patients with hypoxia, with the aim of improving oxygen saturation to over 90% (PaO2 > 50mmHg)”

Of 175 patients on oxygen during admission, only 5 (3%) had a prescription on the medication chart.

JHH Belmont Mater TMH T’worth Armidale Moree Manning

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Results: GP Follow-UpResults: GP Follow-UpCOPD-X: “It is recommended that the first review after a hospital admission should be by the GP and within seven days of discharge”

JHH Belmont Mater TMH T’worth Armidale Moree Manning

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Results: Specialist Clinic Follow-UpResults: Specialist Clinic Follow-UpCOPD-X: “A decision about the requirement for specialist review should be made at the time of discharge.”

JHH Belmont Mater TMH T’worth Armidale Moree Manning

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Results: Neither GP nor Clinic Follow-UpResults: Neither GP nor Clinic Follow-Up

JHH Belmont Mater TMH T’worth Armidale Moree Manning

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Results: Other FindingsResults: Other Findings

• COPD-X: “A decision about the requirement for specialist review should be made at the time of discharge.”

• COPD-X: “[Oxygen therapy] is indicated in patients with hypoxia, with the aim of improving oxygen saturation to over 90% (PaO2 > 50mmHg)”

• COPD-X: “Antibiotics are given for purulent sputum to cover for typical and atypical organisms”• COPD-X: “Oral glucocorticoids hasten resolution and reduce the likelihood of relapse”

• COPD-X: “Assessment of severity of the exacerbation includes…in severe cases …chest x-ray”

Of 175 patients on oxygen during admission, only 5 (3%) had a prescription on the medication chart.

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1. H Hosker et al. Resp Med. 2007, 101: 754-761 2. CL Chang et al. Intern Med J 2007, 37: 236-241

Discussion: COPD Admission AuditsDiscussion: COPD Admission Audits

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1. H Hosker et al. Resp Med. 2007, 101: 754-761 2. CL Chang et al. Intern Med J 2007, 37: 236-241

Discussion: COPD Admission AuditsDiscussion: COPD Admission Audits

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Key FindingsKey Findings

• Poor accessibility to spirometry results:

Within 5 years availability in only 51%

Large discrepancies in inpatient performance (4% - 58%)

• 1/3 of admitted patients are current smokers

• Infrequent ABGs on/during admission at some rural hospitals

• Wide variation in conversion from nebs (26% - 68%)

• Infrequent use of ventilatory support (received in only 38% of patients with pH 7.35)

• Similar usage rates of steroids, antibiotics and supplemental oxygen (but poor documentation of O2 prescription)

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SummarySummary

• We have identified variations in a range of clinical practices in inpatient management of AECOPD:

Between hospitals

From treatment guidelines

• These data will enable targeted strategies for standardising and improving care provision, and provide an important baseline dataset for evaluating these strategies

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AcknowledgementsAcknowledgements

• Data collection, entry and management Rose Foale

Cheryl Gorrie

Judith Swan

Cheryl Ray

• This project was supported by the Innovation and Reform Unit, Hunter New England Health Service

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IntroductionIntroduction

• Variability in the organisation and management of hospital care for COPD exacerbations in the UK*

Audit of 8,013 admissions to 233 units

Wide variation in care provision

Limited access in smaller hospitals to:

• pulmonary rehab

• specialist wards and specialty triage

• early discharge schemes

Management guidelines alone insufficient to address inequalities of care

Recommend a clear statement on minimum national standards

*H Hosker et al. Resp Med 2007, 101: 754-761

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IntroductionIntroduction

• We now have earlier discharge from AECOPD:

Outreach management

Multidisciplinary discharge planning

Pressures to reduce LOS

• In addition, there are ongoing pressures to minimise COPD admissions

• ? Potential for these factors to affect adherence to COPD management guidelines

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Results: (?Early) Discharge PlanningResults: (?Early) Discharge PlanningCOPD-X: “Discharge planning…should commence on admission and be documented within 24–48 hours”