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

Abstract

Purpose

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

Abbreviation

AECOPD, acute exacerbation of chronic obstructive pulmonary disease; ABG, arterial blood gas; BiPAP, bilevel positive airway pressure ventilation; BP, blood pressure; COPD, chronic obstructive pulmonary disease; CI, confidence interval; DH-KUH, Dhulikhel Hospital-Kathmandu University Hospital; DM, diabetes mellitus; ED; emergency department; EP; emergency physician; EMR, electronic medical records; HTN, hypertension; ICU, intensive care unit; IQR, interquartile range; IHD, ischemic heart disease; KUSMS, Kathmandu University School of Medical Sciences; LAMA, leave against medical advice; LMIC, low and middle income countries; LUS, lung ultrasound; MCW, Medical College of Wisconsin; NCD, non-communicable disease; OPD, outpatient department; OR, Odds ratio; PDSA, Plan Do Study Act; QI:quality improvement; SD, standard deviation; SPSS, statistical package for social sciences; YLD, years lived with disability.

Data Sharing Statement

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Ethical Approval

Ethical approval was provided by the institutional review committee of Kathmandu University School of Medical Sciences/Dhulikhel Hospital (KUSMS-DH, number: 166/19). The written consent was waived as this is a part of the quality improvement project. Verbal consent was taken from the participants prior to administration of the 5-item survey questionnaire before discharge.

Acknowledgments

The authors thank DH-KUH ED staff for support during the study period, Ms. Soniya Makaju for help in data collection. We highly appreciate the generosity of Dr Kristopher Brickman, University of Toledo, USA for making the BiPAP machines available in our ED.

Author Contributions

RS, AP and TM conceptualized the study. RS, APS, TM and RaS obtained ethical approval. APS, RS and JM performed data collection and analysis. RS, APS, TM and JM wrote the draft manuscript. All authors contributed to data analysis, drafting or revising the article, have agreed on the journal to which the article will be submitted, gave final approval of the version to be published, and agree to be accountable for all aspects of the work.

Disclosure

The authors report no conflicts of interest in this work.

Additional information

Funding

There is no funding to report.