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![Page 1: 0 Jeff Pretto, Vanessa McDonald, Peter Wark and Michael Hensley Department of Respiratory & Sleep Medicine John Hunter Hospital, Newcastle, New South Wales.](https://reader036.fdocuments.in/reader036/viewer/2022062423/5697bfa91a28abf838c9a14e/html5/thumbnails/1.jpg)
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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”