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

Figures & data

Table 1 Characteristics of Patients Presenting to ED with AECOPD (n=249)

Variables
Age in years, Mean (95% CI)		69(67.8–70.2)
Gender, female, n (%)		169 (67.9)
Educational background, n (%)
No formal education		210 (84.3)
School level (grade 1–12)		33 (13.3)
High level (>grade 12)		6 (2.4)
Smoking status, n (%)
Past smoker		177 (71.1)
Present smoker		32 (12.9)
Never smoked		40 (16.1)
Lifetime woodfire exposure, n (%)		172 (69.1)
Mode of transportation, n (%)
Hired vehicle		138 (55.4)
Private vehicle		27 (10.8)
Ambulance		84 (33.7)
Self-reported compliance to Rx, n (%)		193 (77.5)
Comorbidities, n (%)
HTN		47 (18.9)
IHD		6 (2.4)
DM		18 (7.2)
Previous visits to the ED, n (%)
No		69 (27.7)
Within last 30 days		95 (38.2)
	Within last 3 days	6 (6)
	Within last 3–7 days	21 (22)
	Within last 7–30 days	68 (72)
Within last 1 month-1 year		85 (34.1)
Previous inpatient admission, n (%)
Not admitted		97 (39)
Admitted to ward		134 (53.8)
Admitted to ICU		18 (7.2)
Domiciliary oxygen, n (%)		97 (39)
Vaccination pneumococcal/influenza, n (%)		27 (10.8)
Spirometry used, n (%)		5 (2)

Abbreviations: AECOPD, acute exacerbation of chronic obstructive pulmonary disease; ED, emergency department; CI, confidence interval; DM, diabetes mellitus; HTN, hypertension; ICU, intensive care unit; IHD, ischemic heart disease.

Table 2 Clinical Characteristics of the Patients on Presentation to ED with AECOPD (n=249)

Variables
Triage category, n (%)
Red (level 1)	27 (10.8)
Orange (level 2)	119 (47.8)
Yellow (level 3)	103 (41.4)
Presenting complaints, n (%)
Dyspnea	233 (93.6)
Productive cough	126 (50.6)
Fever	70 (28.1)
Chest pain	72 (28.9)
Edema	70 (28.1)
Vitals at triage, mean (± SD)
Heart rate at triage	102 (21)
Respiratory rate	24 (6)
Oxygen saturation	75 (16)
Systolic BP, mean	123 (28)
Diastolic BP, mean	76 (17)

Abbreviations: ABG, arterial blood gas; AECOPD, acute exacerbation of chronic obstructive pulmonary disease; BP, blood pressure; BiPAP, bilevel positive airway pressure ventilation; ED, emergency department; IQR, interquartile range; LAMA, left against medical advice; SD, standard deviation.

Table 3 Current ED Treatment Pattern, Disposition and Discharge Details of AECOPD Patients

Investigation and Treatment in the ED n=249
Parental Corticosteroid in the ED, n (%)	188 (75.5)
Antibiotic in the ED, n (%)	72 (28.9)
MgSO4 in the ED, n (%)	24 (9.6)
Intubation, n (%)	7 (2.8)
BiPAP, n (%)	16 (6.4)
CXR, n (%)	151 (60.4)
LUS, n (%)	28 (11.2)
CRP, n (%)	55 (22%)
ABG (n=87), median (IQR)	50.7 (41.2–61.3), max 131
Duration of stay in the ED, hours, median (IQR)	5.27 (3.14–7.38) max 22
Outcome, n (%)
Discharge	136 (54.6)
Admission in ward	73 (29.3)
Admission in ICU	10 (4)
LAMA	18 (7.2)
Refer	9 (3.6)
Mortality in the ED	3 (1.2)
Near-fatal outcome, (n=231; LAMA excluded)	44 (19)
Discharge details (n=136), n (%)
Oxygen advised	88 (64.7)
Combination of inhaled LABA and steroid	106 (77.9)
Oral corticosteroid	16 (11.8)
Antibiotics	54 (39.7)
Education on inhaler technique (self-reported by patients)	116 (85.3)
Education on when to return to the ED	107 (78.7)
Advice on vaccination	3 (2.2)
Expected follow up	110 (80.9)
Written action plan	0(0)
Inhaler technique reaffirmed by staff in the ED	18 (13.2)

Abbreviations: ABG, arterial blood gas; AECOPD, acute exacerbation of chronic obstructive pulmonary disease; BiPAP, bilevel positive airway pressure ventilation; CRP, C-reactive protein; CXR, chest X-ray; ED, emergency department; LUS, lung ultrasound; MgSO4, magnesium sulphate; ICU, intensive care units; IQR, interquartile range; LABA, long acting beta-agonist; LAMA, left against medical advice; SD, standard deviation.

Table 4 Near-Fatal Outcome in Relation to Variables Among the AECOPD Patients (n=231)

Variables	Near-Fatal Outcomes		P value
	No, n=187	Yes, n=44
Age, mean 95% CI	69 (67–71)	69.5 (66.1–72.9)	0.597^a
Gender, female, n=154	128 (68.4)	26 (59.1)	0.236
Transportation, ambulance, n=84	57 (30.5)	21 (47.7)	0.03
Compliance to treatment, n=180	156 (83.4)	24 (54.5)	< 0.001
Present smoker, n=29	20 (10.7)	9 (20.5)	0.079
Previous admission, n=144	118 (63.1)	26 (59.1)	0.621
Home oxygen, n=94	80 (42.8)	14 (31.8)	0.183
Visit to ED within 30 days, n=90	65 (34.8)	25 (56.8)	0.007
Duration of ED stay, median (IQR)	5.15 (3.1–9)	5.45(3.0–10.2)	0.032^b
Triage saturation, median (IQR)	76 (68–84)	75.5 (58–88)	0.192^b
ABG PaCO2, median (IQR)	48.3 (41–58)	63.2 (44–75)	0.047^b
CRP, n=55	32 (15–150)	40 (10–71)	0.343^b

Notes: n=231 as LAMA cases excluded; ^aIndependent sample t-test; ^bMan-Whitney U-test; P values in bold are significant.

Abbreviations: ABG, arterial blood gas; AECOPD, acute exacerbation of chronic obstructive pulmonary disease; CRP, C-reactive protein; ED, emergency department; CI, confidence interval; IQR, interquartile range.

Table 5 30-Day ED Revisit in Relation to Other Variables Among the AECOPD Patients (n=249)

Variables	30 Days ED Revisit		P value
	No, n=154	Yes, n=95
Age, mean 95% CI	69.9(68.3.-71.5)	67.6 (65.7–69.5)	0.071^a
Gender, female, n=169	100 (64.9)	69 (72.6)	0.206
Transportation, ambulance, n=84	53 (34.4)	31 (32.6)	0.772
Compliance to medicine, n=193	120 (77.9)	73 (76.8)	0.843
Present smoker, n=32	18(11.7)	14 (14.7)	0.485
Previous admission, n=152	82 (53.2)	70 (73.7)	0.001
Domiciliary oxygen, n=97	45 (29.2)	52 (54.7)	< 0.001
Near-fatal outcome, n=44	19 (13.5)	25 (27.8)	0.007
Duration of ED stay, median (IQR)	5.34 (2.5–10.3)	4.41(3.0–7.2)	0.011^b
Triage saturation, median (IQR)	74 (66–86)	79 (68–85)	0.758^b
ABG, median (IQR)	50.25 (41.9–59.2)	53.7 (39.95–64.5)	0.0310^b

Notes: ^aIndependent sample t-test; ^bMan-Whitney U-test; P values in bold are significant.

Abbreviations: ABG, arterial blood gas; AECOPD, acute exacerbation of chronic obstructive pulmonary disease; ED, emergency department; CI, confidence interval; IQR, interquartile range.

Table 6 Interventions and Quality Indicators Planned for Phase 2 of ED AECOPD QI Project

Intervention	Indicators
Goal 1: Improve/Standardize COPD diagnosis
History checklist	Formulation of checklist and Percentage of ED patients with chronic respiratory symptoms who were assessed with the checklist
Spirometry	Increased percentage of patients with AECOPD who has a spirometry evaluation done (in the previous 15 months)
Echo	Increased percentage of patients with AECOPD who has echocardiography done
Goal 2: COPD emergency care bundle
Noninvasive ventilation	Increased percentage of patients with NIV used
Lung ultrasound (LUS)	Increased use of LUS in dyspnoeic patient in the ED
Clinical practice guidelines (agreed with internal medicine department)	Guidelines designed and adherence to the guidelines.
Goal 3: COPD discharge care bundle
Agreed discharge criteria Written action plan for self-management Drug reconciliation and education Ensuring proper inhaler technique Home oxygen education Counselling about smoking cessation and wood fire exposure	Formulation of discharge checklist Formulation of written action plan. Drugs checked and revised. Number of patients whom the inhaler technique checked and reinforced. Number of patients with education on domiciliary oxygen. Number of patients in whom smoking cessation counselling and harmful effects of woodfire exposure was done
Goal 4: Referral and follow-up
Planned follow up in OPD Referral to pulmonary rehabilitation Vaccination counselling	Number of patients with planned follow up in the OPD Number of patients attending pulmonary rehabilitation. Increased percentage of patients with COPD assessed for vaccination status and received immunization.

Abbreviations: AECOPD, acute exacerbation of chronic obstructive pulmonary disease; ED, emergency department; LUS, lung ultrasound; OPD, outpatient department; QI, quality improvement.

Figure 1 Fishbone cause and effect diagram in reference to the baseline findings.

Figure 2 Pareto chart for the errors at the time of discharge.

Notes: The errors are ranked in the X-axis in descending order of frequency from left to right. The cumulative percentage of errors from left to right are shown with the overriding red curved line.