Use of a care bundle in the emergency department for acute exacerbations of chronic obstructive pulmonary disease: a feasibility study

Abstract

Cormac McCarthy,1 John R Brennan,1 Lindsay Brown,1 Deirdre Donaghy,1 Patricia Jones,1 Rory Whelan,2 Niamh McCormack,3 Ian Callanan,4 John Ryan,2 Timothy J McDonnell1,3 1Department of Respiratory Medicine, St Vincent's University Hospital, Dublin, Ireland; 2Department of Emergency Medicine, St Vincent's University Hospital, Dublin, Ireland; 3Clinical Strategy and Programmes Directorate, Health Service Executive, Dublin, Ireland; 4Department of Audit, St Vincent's University Hospital, Dublin, Ireland Aim: To determine the efficacy and usefulness of a chronic obstructive pulmonary disease (COPD) care bundle designed for the initial management of acute exacerbations of COPD and to assess whether it improves quality of care and provides better outcomes. Introduction: The level of care provided in the emergency department (ED) for COPD exacerbations varies greatly, and there is a need for a more systematic, consistent, evidence-based quality improvement approach to improve outcomes and costs. Methods: A prospective before and after study was carried out in a university teaching hospital. Fifty consecutive patients were identified in the ED with COPD exacerbations and their management was reviewed. Following the education of ED staff and the implementation of a COPD care bundle, the outcome for 51 consecutive patients was analyzed. This COPD care bundle consisted of ten elements considered essential to the management of COPD exacerbations and was scored 0–10 according to the number of items on the checklist implemented correctly. Results: Following implementation, the mean bundle score out of 10 improved from 4.6 to 7 (P<0.001). There was a significant decrease in the unnecessary use of intravenous corticosteroids from 60% to 32% (P=0.003) and also a marked improvement in the use of oxygen therapy, with appropriate treatment increasing from 76% to 96% (P=0.003). Prophylaxis for venous thromboembolism also improved from 54% to 73% (P=0.054). The 30-day readmission rate did not significantly improve. Conclusion: The use of a bundle improves the delivery of care for COPD exacerbations in the ED. There is more appropriate use of therapeutic interventions, especially oxygen therapy and intravenous corticosteroids. Keywords: COPD, checklist, bundle, exacerbations, steroids