Evaluation of the quality of emergency department management for patients with chronic obstructive pulmonary disease

Article information

Clin Exp Emerg Med. 2024;11(3):268-275

Publication date (electronic) : 2024 May 23

doi : https://doi.org/10.15441/ceem.24.197

Pascale J. King¹, Lana Ramic², Janet Wilson², Shawn Aaron³, Ian G. Stiell^,4

¹Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada

²Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada

³Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada

⁴Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada

Correspondence to: Ian G. Stiell Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, 501 Smyth Box 511, Ottawa, ON K1H 8L6, Canada Email: istiell@ohri.ca

Received 2024 February 5; Revised 2024 April 15; Accepted 2024 April 16.

Abstract

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a chronic lung disease secondary to inflammation and narrowing of the airways, parenchymal destruction, mucous hypersecretion, and hypoxic vasoconstriction [1]. COPD leads to frequent hospitalizations due to infectious and noninfectious acute exacerbations with a mix of viral and bacterial aetiologies [2]. COPD exacerbations account for 1% of all emergency department (ED) visits [3]. Those who experience frequent exacerbations of disease are at risk of serious outcomes including death and endotracheal intubation. Evidence-based therapies currently recommended for optimization of bronchodilation and reduction of inflammation during COPD exacerbations including inhaled short-acting β-agonists or short-acting anticholinergics, long-acting anticholinergics, systemic corticosteroids, and antibiotics [4].

In 2014, ED researchers developed the Ottawa COPD Risk Scale (OCRS) which includes 10 highly predictive signs of serious adverse events in patients with COPD [5]. When validated in 2018, it was determined that a score of ≥2 was an indication for hospitalization to reduce short-term serious outcomes at 30 days [6]. In the study, it was estimated that an 11.6% increase in admission to hospital of patients with COPD exacerbations would be necessary to diminish the rate of secondary serious outcomes by 1.2%. Following the introduction of the OCRS, physicians at Canadian EDs described it as useful and likely to be applied [7].

The goal of this study was to determine the appropriateness of treatment of COPD exacerbations in the ED. We also investigated the OCRS, patient disposition, and the rate of serious short-term outcomes.

METHODS

Appropriateness of treatment

Cases were judged for appropriateness of treatment according to explicit indications and standards developed by a senior respirology physician and ED physician (Figs. 1, 2). The development of the treatment standards of care was based on the most recent GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines for acute COPD exacerbation management [1]. The recent 2023 update included no substantive changes to the management of COPD exacerbation [8].

Fig. 1.

Emergency department chronic obstructive pulmonary disease exacerbation treatment standard (oxygen therapy). SaO₂, oxygen saturation; NIV, noninvasive positive pressure ventilation.

Fig. 2.

Emergency department chronic obstructive pulmonary disease (COPD) exacerbation treatment standard (pharmacotherapy). PO, per oral; PRN, as needed; IV, intravenous.

Fig. 1 outlines the algorithm for oxygen therapy with a target saturation of 88% to 92% with either a venturi mask or nasal prongs. NIV is required if patients have any signs of respiratory failure. Invasive mechanical ventilation is indicated for any signs of life-threatening respiratory failure, contraindications to NIV, or failed NIV.

Fig. 2 displays the algorithm for pharmacotherapy, giving the standard for administration of inhaled short-acting β₂-agonists, inhaled anticholinergics, and systemic corticosteroids. Indications for antibiotics administration are signs of bacterial infection: fever, increased sputum production or purulence, opacity on chest x-ray, or sepsis. The recommended antibiotic regimens differed on risk factors for pseudomonas infection.

Determination of appropriateness of treatments was made by the senior authors (PJK, IGS) according to the explicit criteria outlined in Figs. 1 and 2. In all cases, consensus was reached by discussion.

RESULTS

Of 2,696 COPD exacerbation patient visits between July 1, 2017, to June 30, 2020, 745 visits were reviewed. Of these 745 patient visits, 245 were excluded due to incorrect diagnosis, inadequate documentation of the patient’s presenting symptoms, and missing investigative clinical data (ECG, chest x-ray, and blood work) (Fig. 3).

Fig. 3.

Inclusion and exclusion of patients visits. ECG, electrocardiogram; AMA, acute medical assessment.

Table 1 displays the patient characteristics for the 500 patient visits: mean age (71.9 years), female sex (51.2%), mean heart rate (97.7 beats/min), mean respiratory rate (23.1 breaths/min), mean oxygen saturation (93%), and mean temperature (36.7 °C). Most patients were currently smoking tobacco or had a history of tobacco use (95.6%). Many had a listed diagnosis of COPD in their medical chart (94.8%). We confirmed the diagnosis of the remaining 4.2% with a reported pulmonary function test (forced expiratory volume in the first second of expiration to forced vital capacity ratio, <0.7) or presumed by a chronic smoking history (>40 years). Many patients had other comorbidities including hypertension (57.8%), cancer (27.0%), diabetes (24.8%), myocardial infarction or angina (21.0%), heart failure (19.4%), atrial fibrillation (18.0%), and chronic renal failure (10.8%). Most had prescribed outpatient medications for COPD including inhaled β-agonist (70.2%), inhaled anticholinergic (57.4%), and inhaled corticosteroids (51.4%). Home oxygen was prescribed for 12.6% of patients. Worsening cough was the most common presenting symptom (94.8%), followed by dyspnea (74.4%), increased sputum production (56.0%), and sputum purulence (42.8%).

Table 1.

Characteristics of patients with COPD exacerbations

The calculated OCRS results of these patients varied from 1 to 10 on a maximum scale of 16 (Table 2). Of note, the OCRS was only calculated on one of the 500 patient visits (0.002%). A minority of patients had a score of <2 (29.8%) which is associated with a risk of SSO <4%. Most had scores of ≥2 (70.8%). These higher scores reflect a risk of SSO >7.2%. The OCRS scores and risk categories for SSO is displayed in Supplementary Material 1.

Table 2.

OCRS criteria and calculated score of 500 patients with COPD (n=500)

Table 3 outlines the frequency of treatments provided for 500 patient visits: inhaled β-agonist (82.6%), inhaled anticholinergic (76.6%), corticosteroids (intravenous or per oral, 75.2%), antibiotics (intravenous or per oral, 71.0%), oxygen therapy (63.8%), NIV (8.8%), and endotracheal intubation (0.6%). Disposition of patients included: ward (42.0%), monitored setting (9.6%), and discharge home (48.4%). Of those admitted to hospital, 92 patients had a serious short-term outcome: transfer to a monitored setting (12.5%), endotracheal intubation (1.6%), myocardial infarction (4.3%), and NIV (17.4%). Of the 242 patients discharged home, 58 returned to the ED within 30 days for COPD-related reasons. The SSO of the discharged patients upon return included the following: admission to monitored setting (2.1%), endotracheal intubation (0.8%), and NIV (0.8%). Death at 30 days occurred in 22 patients (4.4%). These deaths were most associated with acute hypoxemic respiratory failure (50.0%), followed by cancer (22.7%), gastrointestinal causes (13.6%), and infection (13.6%).

Table 3.

Disposition and treatments in the ED

Table 4 displays the appropriateness of treatments given. The treatment was determined to be appropriate in half of the patients (50.0%). The frequency of the missing treatments are as follows: corticosteroids (24.4%), inhaled anticholinergic (22.6%), inhaled β-agonist (17.0%), antibiotics (12.8%), and NIV (2.0%).

Table 4.

Appropriate treatments not given when indicated in 500 COPD patient visits in the emergency department

DISCUSSION

This study sought to seek how appropriately patients with COPD exacerbations were being treated in the ED. Overall, 50% of cases were judged to have had suboptimal treatment. Notably, corticosteroids and antibiotics were often missed. This raises concern for how these patients may fare without the needed therapy in avoiding complications. Of all included patients, two-thirds were admitted. A considerable number of discharged patients returned to the ED for treatment within 30 days. With appropriate treatment, we may decrease the number of returning patients to the ED. This entails the benefits of decreased ED volumes and health care expenditure. The returning patient may be having similar or unchanged symptoms, seeking more treatment that may have been missed from their first encounter.

Another surprising finding was the lack of calculation of the OCRS by ED providers. We found only one chart with the calculated score in the 500 reviewed. The OCRS is a clinical decision tool that may alter our disposition for patients as it permits calculation of a risk for SSO in 30 days. It appears that most patients that warranted an admission considering a calculated score of ≥2 were admitted. This may indicate that ED providers may already be aware of the clinical findings that increase the risk of SSO. It could be that ED providers are also relying heavily on the walk test for oxygenation to determine admission versus discharge for patients. As we know, a failure walk test alone scores 2 on the OCRS, warranting admission due to increased risk of SSO.

There are many publications that review management [9,10] or predict outcomes of patients with COPD exacerbations [11,12]. There are only a few, however, that discuss optimal management in the ED, through use of treatment bundles in observation units [13,14]. No previous studies have evaluated the appropriateness of ED management of COPD exacerbations and tied this to the use of the OCRS in the ED. The rate of admission was comparable to a previous study by Garcia-Sanz et al. [3] quoting a 57% admission rate. In fact, a considerable number of patients admitted to hospital had short-term complications with admission to ICU and use of NIV being the most common. Although complications occur in a minority of patients, these events significantly increase health care expenses [15]. Admittedly, the complications of ICU admission and NIV use were often combined as a negative pressure room was necessary due to concerns from aerosol generating procedures since the COVID-19 pandemic. Perhaps with appropriate treatment in the ED, the patients could anticipate an admission to hospital with less or no complications. Our recorded 30-day mortality of 4.4% was lower than described in previous data. In fact, Roche et al. [16]. in 2008 had a 7.4% mortality at 90 days. Our rate of patients returning to the ED after discharge home is comparable to previous quoted return rates of one in five patients [17].

This study had some limitations. Firstly, a total of 134 patients were excluded as shown in Fig. 3, due to lack of blood work or investigations such as ECG and chest x-ray. This represents approximately 5.6% of the total 745 patients visits reviewed prior to exclusion. These patients were likely low-risk patients who may not warrant further investigations and who were more likely to have been dispositioned home with less risk of SSO. Second, some patients may have had withheld treatments due to a pending admission. We did note that many of the missing treatments were later provided by the consulting service. However, we would argue that effective treatments should not be delayed for the admission of a consultant as these medications are readily available in the ED. Third, we did not follow patients to determine if outcomes varied by appropriateness of ED treatment.

Overall, this study clarified the current management of COPD exacerbations in the ED. Certainly, our findings have the potential of improving patient care by making ED providers aware of the pitfalls of current management. Implementation of explicit treatment standards should lead to improved patient care of this common and serious respiratory condition. A method which may directly affect patient care would be the building of integrated COPD exacerbation order sets on electronic medical systems based on our predetermined treatment standards. This may lead to increased rates of indicated antibiotics and corticosteroids which were the two therapies most missed. Certainly, it appears that clinicians were utilizing adverse event predictors from the OCRS without necessarily calculating the score. Perhaps physician gestalt is performing similarly to the explicit calculation of the score. This resulted in admission and monitoring of patients who had the highest rates of adverse events. An integrated treatment algorithm or pathway may decrease the number of missed indicated therapies.

Further evaluation of the role of brief smoking cessation counselling in the ED as part of the management standard of COPD exacerbations may be interesting in pursuing as it is the only reversible cause to this chronic pulmonary disease. An evaluation of the impact of introducing an ED COPD exacerbation treatment algorithm may also help identify if it is an appropriate quality improvement strategy. Finally, future studies could evaluate the impact of appropriateness of ED treatment on 30-days outcomes.

In conclusion, adequate treatment of COPD exacerbation was lacking in 50% of patients in these two large academic EDs. Concerning were the number of patients not receiving corticosteroids or antibiotics. Implementation of explicit treatment standards should lead to improved patient care of this common and serious respiratory condition.

Supplementary materials

Article information Continued

Notes