The use of a standardized order set reduces systemic corticosteroid dose and length of stay for individuals hospitalized with acute exacerbations of COPD: a cohort study

Abstract

Swati Gulati,1–3 Aline N Zouk,1–3 Jonathan P Kalehoff,4 Christopher S Wren,5 Peter N Davison,6 Denay Porter Kirkpatrick,1–3 Surya P Bhatt,1–3 Mark T Dransfield,1–3,7 James Michael Wells1–3,7 1Department of Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL, USA; 2Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL, USA; 3UAB Lung Health Center, Birmingham, AL, USA; 4Division of Internal Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL, USA; 5Harrison School of Pharmacy, Auburn University, Auburn, AL, USA; 6University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA; 7Birmingham VA Medical Center, Birmingham, AL, USA Background: Systemic corticosteroids (SC) are an integral part of managing acute exacerbations of COPD (AECOPD). However, the optimal dose and duration vary widely in clinical practice. We hypothesized that the use of a “PowerPlan” order set in the electronic health system (EHS) that includes a 5-day SC order would be associated with a reduced steroid dose and length of stay (LOS) for individuals hospitalized with AECOPD. Patients and methods: We conducted a retrospective cohort study of Medicare recipients discharged with an AECOPD diagnosis from our University Hospital from 2014 to 2016. Our EHS-based “COPD PowerPlan” order set included admission, laboratory, pharmacy, and radiology orders for managing AECOPD. The default SC option included intravenous methylprednisolone for 24 hours followed by oral prednisone for 4 days. The primary endpoint was the difference in cumulative steroid dose between the PowerPlan and the usual care group. Secondary endpoints included hospital LOS and readmission rates. Results: The 250 patients included for analysis were 62±11 years old, 58% male, with an FEV1 55.1%±23.6% predicted. The PowerPlan was used in 72 (29%) patients. Cumulative steroid use was decreased by 31% in the PowerPlan group (420±224 vs 611±462 mg, P<0.001) when compared with usual care. PowerPlan use was independently associated with decreased LOS (3 days; IQR 2–4 days vs 4 days; IQR 3–6 days, P=0.022) without affecting 30- and 90-day readmission rates. Conclusion: Use of a standardized EHS-based order set to manage AECOPD was associated with a reduction in steroid dose and hospital LOS. Keywords: COPD exacerbation, treatment, corticosteroid, electronic order set

Keywords

• COPD exacerbation
• treatment
• corticosteroid
• electronic order set