COPD inpatient management : guideline development, implementation and followup in the acute hospital

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COPD in-patient management guideline
development, implementation and follow-up in the
acute hospital setting

• Don Campbell
• Caroline Brand

Clinical Epidemiology Health Service
Evaluation Unit Melbourne Health
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Acknowledgements

• Report
• Dr Caroline Brand and Ms Fiona Landgren
• Project Conception
• Dr Donald Campbell
• Dr Peter Greenberg
• Dr Harry Teichtahl
• Prof Anne Maree Kelly
• Prof Peter Cameron

• Project Development and Research Design
• Dr Caroline Brand
• Ms Fiona Landgren
• Ms Jill Nosworthy
• Dr Don Campbell
• Data collection 
• Ms Fiona Landgren
• Ms Ana Hutchinson
• Ms Catherine Jones
• Dr Caroline Brand
• Data analysis
• Dr Lachlan MacGregor
• Dr Caroline Brand

Funding support EBCPRP, SRDC, NHMRC
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Clinical Practice Guidelines

• Systematically developed statements developed to
  assist practitioner and patient decisions about
  appropriate health care for specific
  circumstances .
• What is known about
• Implementation?
• Long-term impact?

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• What did we do?
• What did we find?
• What difference did it make?
• Was it sustainable?
• What would we do differently?

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What we set out to do

• Goal
• To improve the standard of care and health
  related quality of life for patients who have
  experienced an acute exacerbation of COPD
  requiring hospitalisation at Royal Melbourne
  (RMH) and Western Hospitals (WH).
• Aim
• Development and implementation of evidence-based
  clinical practice guidelines for the acute
  in-patient episode.

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Project activities

• 1 Examine VIMD database
• 2 Prospective case-note audit (pre/post
  intervention)
• 3 CPG development
• pathway
• decision nodes
• evidence-based (consensus driven)
• Implementation Strategy
• multi-faceted, evidence-based

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Project activities 2

• 5 Outcome measures
• Patient Satisfaction HRQoL
• Institution LOS Readmission rate
• 6 Process measures
• medication use, tests
• clinical indicators (ACHS for asthma, ?? For COPD)

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Guideline Implementation and Evaluation

• Time period
• pre-implementation phase 3/6/99 to 9/9/99
• post-implementation phase 7/11/99 to 31/3/00
• Patients admitted
• WH RMH
• pre-implementation 141 68
• post- implementation 138 62

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Demographic characteristics

• WH RMH
• Parameter Pre Post Pre Post
• Av Age (yrs) 68 69 70 72
• Males ( of total) 60 52 71 51
• Current Smokers ( of total) 35 32 31 30
• Ex Smokers ( of total) 63 62 56 57
• Language Barrier( of total) 11 11 25 10
• Presentation to hospital 51 72 43 51 previous
  12 months ( of total)
• Average duration of illness 4.1 5.7 8.6 5.8
• for presenting episode (in days)
• No of deaths ( total) 0 0 4 (6) 3 (5)

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What happened?

• Short-term impact evaluation

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LOS and Readmission rates

• WH RMH
• Pre Post Pre Post
• (172) (173) (72) (70)
• Ave LOS (days) 7.1 7.1 8.4 4.5
• (6,1-50) (5,1-37) (7,0-28) (4, 1-13)
• Unplanned re-admission
• 28 days post discharge 18 16 3 8
• ( of total) (10) (9) (4) (11)

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Hours in ED

• WH RMH
• Pre Post Pre Post
• (65) (65) (68) (63)
• Ave Time in ED (hrs) 9.4 8.8 8.7 12.4
• median 8.2 7.8 7.3 9.8
• (range) (1-23) (2-34.2) (0.8-26.4)
  (2.7-34.6)

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Test use at initial assessment

• Triage Category Pulse Ox (SpO2) ABG CXR FBE
• 1 X X X X
• 2 X X X X
• 3 X X X
• 4 X ?X ?X
• 5 X ?X ?X
• (X indicates test recommended)
• CXRs and ABGs-
• Reduced at RMH (unchanged at WH).
• ABG reduction significant at RMH (?2 11.44, p 0.001).
• Sputum mc tests reduced at WH.

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Recommended ongoing therapy for COPD

• WH RMH
• Pre Post Pre Post
• (65) (65) (68) (63)
• IV line inserted 85 74 93 54
• IV removed at 24 hours 24 35 25 47
• Oral Antibiotics (wards) 89 80 80 53
• IV Antibiotics (wards) 56 35 60 25
• Oral Csteroids (wards) 91 95 85 77
• IV Csteroids (wards) 64 49 20 11
• Ipratropium nebs (wards) 94 88 88 74
• MDI (/- spacer) (wards) 88 85 57 61

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Recommended post discharge management

• WH RMH
• Pre Post Pre Post
• (65) (65) (68) (63)
• Inhaler education 8 42 10 8
• Communication with GP 86 68 7 8
• (fax)
• Follow up arrangements
• (not recorded) 8 6 24 11
• Provision of a discharge pack

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Results

• Quality of life
• Disease specific QOL (SOLQ)-
• Coping reduced 28 days after discharge.
• Generic QOL (SF12) post implementation-
• MCS improved at both hospitals (NS).
• Satisfaction with care moderately high at both
  hospitals
• (low score for hospital reputation post
  implementation at one hospital )

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Long-term sustainability?

• Two years later

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CPG-Two Year Evaluation

• 1 Medical Record Audit
• (6 months post implementation)
• 2 Staff survey awareness use of CPGs
• Survey Intranet access and CPG quality
• Focus Groups Key Informant Interviews

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Summary Audit

• Some medical units may be protocol driven
• Specific drug recommendations accepted
• ? related to CPG use
• Poor uptake
• process of care and non drug recommendations
• Uptake of CPG recommendations usually but not
  invariably relates to level of evidence

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CPG - Staff Survey N188

• Medical 43.7 Nursing 29.0 Students 21.3
• Age 20-49 (75.4)
• Medical (57.9) Surgical (22)
• Senior staff 73
• Gender F80M57 (39yrs F20M52)

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Staff Survey Summary- CPG use

• Barriers
• Difficult to locate
• Poor Index
• Too prescriptive
• No allowance for variation
• Not evidence based
• Lack of time
• Too general

• Facilitating Factors
• Represent best practice
• Evidence-based
• Easy to access
• Expedite decision making
• Concise
• Support treatment decisions
• Refresh memory

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Intranet Survey Summary

• Variable access to department home sites
• Inconsistency layout, terminology and content
• Poor adherence to NHMRC guidelines for CPG
  construction

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Focus Groups and Key Informant Interviews

• Most health professionals favoured use of
  CPG/protocols
• Some staff expressed concern about cookbook
  medicine
• Emphasis on use as guidelines not proscriptive
  documents
• Access and quality of guidelines is a major issue
• Occupational preferences identified-
• nurses prefer protocols/pathways
• nurses do not make decisions where there is
  ambiguity
• Departments are variably protocol driven ED,
  ICU, Renal
• Medicolegal issues not a major concern
• High staff turnover limited corporate memory and
  training in use

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Summary

• Senior clinician support and advocacy essential
• Consistency in terminology needs to be addressed
• Existing access to guidelines needs to be
  reviewed
• Infrastructure for access to decision support
  systems is required
• Integration with ongoing education programs is
  essential
• Establishment of KPI around audit and guidelines
  implementation is necessary
• Greater involvement of consumers in guideline
  development required
• Integration with formal hospital quality
  processes is lacking

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Contextual analysis

• Staff turnover
• Relationship to quality program
• Interdisciplinary teams?
• (or professional isolation multitude of teams)
• Information Technology support?
• Integrated care?
• Executive Leadership??

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Signposts for the future

• Finding the imperatives that will drive systems
  integration in public sector health care
• Narrative to find simple rules
• Values and ethical frameworks
• Science of complexity
• Rewarding teamwork

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Knowing what we now know, what would we do
(differently) next time?

• Leadership
• Build into Quality framework
• Communication
• Simple rules for providing quality care
• Patient-centred involve from Day 1- meet needs
• Collaborative build manager-clinician
  partnership
• Knowledge-based CPG plus expertise
• Reward and recognition
• Team-play
• Communication