Needs Assessment and Identification of the Multifaceted COPD Care Bundle in the Emergency Department of a Tertiary Hospital in Nepal

Abstract

Roshana Shrestha,1 Anmol Purna Shrestha,1 Taylor Sonnenberg,2 Janki Mistry,3 Rajeev Shrestha,4,5 Theodore MacKinney3 1Department of General Practice and Emergency Medicine, Kathmandu University School of Medical Sciences, Dhulikhel, Kavrepalanchok, Nepal; 2Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA; 3Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA; 4Department of Pharmacology, Kathmandu University School of Medical Sciences, Dhulikhel, Kavrepalanchok, Nepal; 5Nepal Pharmacovigilance Unit/Research & Development Division, Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Kavrepalanchok, NepalCorrespondence: Roshana ShresthaDepartment of General Practice and Emergency Medicine, Kathmandu University School of Medical Sciences, Dhulikhel, NepalTel + 977 9841558332Email [email protected]: Acute care of patients with exacerbation of chronic obstructive pulmonary disease (AECOPD) in the emergency department (ED) is crucial, however not studied extensively in Nepal. The purpose of this study is to identify the opportunities for succinct measures to optimize the AECOPD care in ED with a multifaceted bundle care approach in a resource-limited setting.Methods: We conducted a prospective cross-sectional observational study as an initial baseline stage of the quality improvement project. Demographic data, clinical characteristics, the current diagnosis and treatment performances of AECOPD were recorded. The primary outcome measures were 30-day ED revisit and near-fatal events which were compared with other variables and performances with binary and logistic regression. The multidisciplinary team performed the root cause and Pareto analysis to identify the potential gaps in the AECOPD care.Results: The AECOPD performance measures were suboptimal. Written AECOPD emergency management clinical guidelines and advice regarding pulmonary rehabilitation were absent. Among the 249 AECOPD encounters, bilevel positive-airway pressure ventilation was started in 6.4%. At discharge, 11.8% and 39.7% were given oral steroids and antibiotics respectively; 2.2% were advised vaccination. Near-fatal events and 30-day revisit occurred in 19% and 38.2% of the encounters respectively. Those who required domiciliary oxygen had significantly higher 30-day revisits (OR=2.5; 95% CI=1.43– 4.4; P value =0.001) as did those who were previously admitted (OR=1.98; 95% CI 1.11– 3.59; P value =0.022). Those who had a 30-day revisit had increased near-fatal events (OR=2.86; 95% CI=1.362– 6.18; P value =0.006). The opportunities for improving the ED care were identified and feasible interventions and their indicators are summarized for future implementation.Conclusion: The current COPD performance measures were suboptimal with high 30-day revisit and near-fatal outcomes. We suggest the urgent implementation of the enlisted feasible bundles-care involving multifaceted team and protocol-based management plans for AECOPD in a busy resource-limited ED.Keywords: clinical practice guideline, near-fatal outcome, performance measure, quality improvement, resource-limited setting, root cause analysis

Keywords

• clinical practice guideline
• near fatal outcome
• performance measure
• quality improvement
• resource-limited setting
• root cause analysis