Study Reveals Positive Benefits of COPD Transition Bundle
By Melinda Young
A study of a care transition bundle that included a care coordinator revealed COPD patients in the bundle cohort were less likely to be readmitted to the hospital within seven days and 30 days, but 90-day readmissions were unchanged.1
The purpose of the COPD transition bundle was to standardize discharge across hospital sites, says Michael Stickland, PhD, professor in the division of pulmonary medicine in the department of medicine, and director of the G.F. MacDonald Centre for Lung Health Covenant Health at the University of Alberta in Canada. He also is the scientific director of the Medicine Strategic Clinical Network — Respiratory Section at Alberta Health Services.
The health system includes primary care networks and hospitals, covering nearly 1 million people. “This was an attempt to harmonize some of the discharge and connection components together,” Stickland says. “We still have a bit of disconnect with the primary care piece.”
More than half of the cost of managing COPD in North America and Europe is due to hospitalizations from symptom exacerbations.2 The purpose of standardizing COPD transition care is to help patients better manage their symptoms and prevent exacerbations that lead to a hospitalization.
With the discharge bundle, patients saw their physicians quickly, but the primary care networks are not on the same electronic medical records. Care coordinators had to send data to primary care.
“We use discharge care coordinators who are in charge of communicating,” Stickland says. “The discharge coordinator helps facilitate the patient going back to the community.”
Unintended Side Effects
The bundle was associated with greater risk of a 30-day ED visit and with a longer length of stay (LOS).1
“The length of stay increase was an unintended side effect, which might be related to a slightly greater risk of patients staying a little longer in the hospital,” Stickland explains. “It may be a delay on discharge in getting some of the bundle items completed.”
Without the bundle, COPD patients would visit the ED and then be admitted to the hospital. Researchers found that with the bundle, they would still visit the ED, but were less likely to be admitted.
“They came back with milder COPD conditions and were sent home,” Stickland adds. “We interpret this that the bundle made people more aware of their symptoms and more aware of self-management. While they unfortunately went back to the ED, they were not admitted.”
The increased ED visits could mean patients are more sensitive to their symptoms and seeking help from the ED before a COPD exacerbation occurred because they lacked adequate community support.
“There were some people who were feeling unwell at 6:00 at night and they’d go to the emergency department,” Stickland explains. “One of the proposed solutions is to have these kinds of patients call a phone number and speak with a physician or nurse instead of coming all the way down to the ED.”
Even with the longer LOS and more ED visits, the bundle was effective at reducing costs. “We did an economic evaluation, and the net savings was about $3 million from the trial,” Stickland says.
The study took place before the pandemic. Now that health systems and patients are more accustomed to virtual visits, it is possible COPD patients are more willing to connect with providers remotely, rather than visiting the ED.
“It’s highlighted how elements of virtual hospitals are ways to connect with healthcare professionals who are not the emergency department,” Stickland says.
Seven Bundle Items
The bundle was implemented in the health system’s new electronic medical record system and now is standard care. COPD patients receive the discharge bundle as part of the care pathway. Also, care coordinators primarily perform the follow-up calls and help facilitate the bundle items.
These are the seven bundle items:
- Ensure patients demonstrate adequate inhaler technique, a skill required to administer medication. Make sure they use it properly before discharge.
- Send a discharge summary to the family physician and arrange follow-up care. “We know if patients go to their family doctor after discharge, they’re less likely to come back to the hospital,” Stickland says. “It’s important for the physician to know they are being discharged.”
- Optimize and reconcile medication, including inhalers. Pharmacists assist with this.
- Provide written discharge plans and assess patients’ understanding of discharge instructions, including making an appointment with their family doctors.
- Refer the patient to pulmonary rehab. Pulmonary rehab reduces readmission rates, studies show.1-3
- Screen for frailty and comorbid conditions, which can increase the risk of readmission.
- Assess for smoking status, provide counseling, and refer to smoking cessation, as appropriate.
To develop the seven bundle items, researchers held focus groups with patients and clinicians to understand the most beneficial aspects for discharge. They created a survey for clinicians and patients to drill down into what they thought were the most important items.
“It was fascinating to get the perspective of respirologists on primary care discharge and then to hear from physicians and patients,” Stickland says. “We packaged that into the discharge bundle and tried to implement that into the real world with patients, studying the implementation and effectiveness.”
Hospital case managers help with discharge care, but when patients leave the hospital, their role ends. The care coordinators follow up with discharged COPD patients, ensuring they filled their prescriptions and received a referral to pulmonary rehab.
“These seven items in the bundle are good clinical practice, but we also have a backstop to provide support and make sure these things are done, and it’s not just writing on a piece of paper,” Stickland explains. “It seems like acute care staff are able to execute many of these pieces.”
The study results show academics and researchers can work with healthcare administrators and frontline clinicians to create a tool that reduces readmission rates and improves mortality and standard of care rates.
“To work with frontline clinicians to evaluate this was a good example of university and clinicians coming together,” Stickland adds. “It was a pretty large implementation program.”
REFERENCES
- Atwood CE, Bhutani M, Ospina MB, et al. Optimizing COPD acute care patient outcomes using a standardized transition bundle and care coordinator: A randomized clinical trial. Chest 2022;162:321-330.
- Criner GJ, Bourbeau J, Diekemper RL, et al. Prevention of acute exacerbations of COPD: American College of Chest Physicians and Canadian Thoracic Society Guideline. Chest 2015;147:894-942.
- Özmen I, Yildirim E, Öztürk M, et al. Pulmonary rehabilitation reduces emergency admission and hospital rates of patients with chronic respiratory diseases. Turk Thorac J 2018;19:170-175.
A study of a care transition bundle that included a care coordinator revealed COPD patients in the bundle cohort were less likely to be readmitted to the hospital within seven days and 30 days, but 90-day readmissions were unchanged.
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