ABSTRACT
BACKGROUND: Acute exacerbations of COPD (AECOPD) are associated with high morbidity and mortality and frequent readmissions. RESEARCH QUESTION: What is the effectiveness of a COPD transition bundle, with and without a care coordinator, on rehospitalizations and ED revisits? STUDY DESIGN AND METHODS: Two patient cohorts were selected: (1) the group exposed to the transition bundle and (2) the group not exposed to the transition bundle (usual care group). Patients exposed subsequently were randomized to a care coordinator. An AECOPD transition bundle was implemented in the hospital; patients randomized to the care coordinator were contacted ≤ 72 h after discharge. Six hundred four patients (320 to the care coordinator and 284 to routine care) who met eligibility criteria from five hospitals across three cities in Alberta, Canada, were exposed to the transition bundle, whereas 3,106 patients discharged from the same hospitals received the usual care. Primary outcomes were 7-day, 30-day, and 90-day readmissions, median length of stay (LOS), and 30-day ED revisits. RESULTS: The transition bundle cohort were 83% (relative risk [RR], 0.17; 95% CI, 0.07-0.35) less likely to be readmitted within 7 days and 26% (RR, 0.74; 95% CI, 0.60-0.91) less likely to be readmitted within 30 days of discharge. Ninety-day readmissions were unchanged (RR, 1.05; 95% CI, 0.93-1.18). The transition bundle was associated with a 7.3% (RR, 1.07; 95% CI, 1.0-1.15) relative increase in LOS and a 76% (RR, 1.76; 95% CI, 1.53-2.02) greater risk of a 30-day ED revisit. The care coordinator did not influence readmission or ED revisits. INTERPRETATION: The COPD transition bundle reduced 7- and 30-day hospital readmissions while increasing LOS and ED revisits. The care coordinator did not improve outcomes. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT03358771; URL: www. CLINICALTRIALS: gov.
Subject(s)
Patient Readmission , Pulmonary Disease, Chronic Obstructive , Alberta , Emergency Service, Hospital , Humans , Length of Stay , Patient Discharge , Pulmonary Disease, Chronic Obstructive/therapyABSTRACT
BACKGROUND: Chronic obstructive pulmonary disease (COPD) is one of the most common causes of mortality and morbidity in high-income countries. In addition to the high costs of initial hospitalization, COPD patients frequently return to the emergency department (ED) and are readmitted to hospital within 30 days of discharge. A COPD acute care discharge care bundle focused on optimizing care for patients with an acute exacerbation of COPD has been shown to reduce ED revisits and hospital readmissions. The aim of this study was to explore and understand factors influencing implementation and uptake of COPD discharge care bundle items in acute care facilities from the perspective of health care providers and patients. METHODS: Qualitative methodology was adopted. Nine focus groups were conducted using a semi-structured guide: seven with acute and primary/community health care providers and two with patients/family members. Focus groups were audiotaped, transcribed verbatim, and coded and analyzed using a thematic approach. RESULTS: Forty-six health care providers and 14 patients/family members participated in the focus groups. Health care providers and patients identified four factors that can challenge the implementation of COPD discharge care bundles: process of care complexities, human capacity in care settings, communication and engagement, and attitudes and perceptions towards change. Both health care providers and patients recognized process of care complexity as the most important determinant of the COPD discharge bundle uptake. Processes of care complexity include patient activities in seeking and receiving care, as well as practitioner activities in making a diagnosis and recommending or implementing treatment. Important issues linked to human capacity in care settings included time constraints, high patient volume, and limited staffing. Communication during transitions in care across settings and patient engagement were also broadly discussed. Other important issues were linked to patients', providers', and system attitudes towards change and level of involvement in COPD discharge bundle implementation. CONCLUSIONS: Complexities in the process of care were perceived as the most important determinant of COPD discharge bundle implementation. Early engagement of health providers and patients in the uptake of COPD discharge bundle items as well as clear communication between acute and post-acute settings can contribute positively to bundle uptake and implementation success.
ABSTRACT
INTRODUCTION: Hospital and emergency department discharge for patients with chronic obstructive pulmonary disease (COPD) is often poorly organised. We developed a patient-centred, evidence-based and consensus-based discharge care bundle for patients with acute exacerbations of COPD. METHODS: A purposeful sample of clinicians and patients were invited to participate in a two-round Delphi study (July-November 2015). In round 1, participants rated on a seven-point Likert scale (1=not at all important; 7=extremely important) the importance of 29 unique COPD care actions. Round 2 comprised items selected from round 1 based on consensus (>80% endorsement for Likert values 5-7). A list of 18 care items from round 2 was discussed in a face-to-face nominal group meeting. RESULTS: Seven care items were included in the COPD discharge bundle based on clinician and patient input: (1) ensure adequate inhaler technique is demonstrated; (2) send discharge summary to family physician and arrange follow-up; (3) optimise and reconcile prescription of respiratory medications; (4) provide a written discharge management plan and assess patient's and caregiver's comprehension of discharge instructions; (5) refer to pulmonary rehabilitation; (6) screen for frailty and comorbidities; and (7) assess smoking status, provide counselling and refer to smoking cessation programme. CONCLUSION: We present a seven-item, patient-centred, evidence-based and consensus-based discharge bundle for patients with acute exacerbations of COPD. Alignment with clinical practice guidelines and feasibility of local adaptations of the bundle should be explored to facilitate wide applicability and evaluation of the effectiveness of the COPD discharge bundle.
