Background: Acute exacerbations of Chronic Obstructive Pulmonary Disease (AECOPD) are a major driver of hospitalizations. With a goal of reducing AECOPD admissions at the Cleveland VA Medical Center (VAMC), an interdisciplinary team was developed after a literature review and discussion with high-performing VA groups.
Purpose: Primary aim was to decrease AECOPD hospitalizations and readmissions at the Cleveland VAMC. Process measures included prescription of rescue packs and increasing 12-week pulmonary follow-up as per GOLD guidelines.
Description: Adult veterans admitted to the Cleveland VAMC with AECOPD were reviewed from September 2019 using a dashboard to identify any patient using oral prednisone 20mg or greater and/or use of methylprednisolone. Baseline admissions were analyzed from January 2020 through January 2021. Post-intervention, identified patients were reviewed for inclusion and the treating provider was encouraged to implement the interventions. The first two interventions were initiated in February 2021 with the third in June 2021. Data was analyzed through August 2021 with data collection and project implementation ongoing.Interventions:1. Standardize inpatient care by creation and implementation of COPD EHR notes and electronic order sets, which encouraged the prescription of rescue packs at discharge.2. Inpatient consultations by Pulmonary Nurse Practitioners with a goal of optimizing COPD medication and improving transition to outpatient care by scheduling follow-up visits and providing a contact number for the patient to call if symptoms arose after discharge.3. Pharmacy education on inhaler techniques at discharge.The project was heavily affected by the COVID-19 pandemic, during which, a significant reduction in AECOPD admissions was noted at the Cleveland VAMC (20.3/month pre-pandemic vs. 11.8/month since 3/2020). Special cause variation was observed starting in March 2020 and AECOPD admissions have not returned to pre-pandemic highs.Data analysis revealed the following:1. The Pulmonary consult team saw 50 of 84 admissions for AECOPD after intervention (59.5%).2. No change was seen in number of AECOPD admissions from pandemic baseline throughout the study period; admissions have not returned to pre-pandemic highs.3. Significant improvement in 12 week pulmonary follow up rates (38.5% pre-intervention to 69.0% post-intervention, p-value < 0.001)4. Early implementation of Inpatient Pharmacy inhaler teaching was moderately robust (16/28 patients with AECOPD received education from June through August).5. Readmission rates to the Cleveland VAMC for AECOPD decreased from 15.8% prior to intervention to 10.7%, but this change was not significant (p-value, 0.48).6. Poor uptake of EHR note and order set with negative provider feedback on utility.7. Poor uptake of rescue packs with providers citing discomfort with prescription on discharge unless follow-up was assured.
Conclusions: While the inpatient COPD interventions had mixed results, likely due to poor uptake of EHR orderset and rescue pack use among the hospitalist group, there was a positive impact with the interdisciplinary interventions. The primary outcome of reducing admissions or readmissions for AECOPD was not achieved, but a majority (57%) of patients in the initial period received dedicated inhaler teaching and 12-week follow-up with Pulmonology nearly doubled. Further steps include re-evaluating the EHR initiatives and optimizing the interdisciplinary interventions.