1. 0 Jeff Pretto, Vanessa McDonald, Peter Wark and Michael Hensley Department of Respiratory & Sleep Medicine John Hunter Hospital, Newcastle, New South Wales Jeff Pretto, Vanessa McDonald, Peter Wark and Michael Hensley Department of Respiratory & Sleep Medicine John Hunter Hospital, Newcastle, New South Wales An Audit of Clinical Practice for COPD Hospital Admissions

2. 1 Introduction COPD is now acknowledged as highly prevalent disorder causing substantial healthcare burden Management guidelines for COPD have been developed by multiple international groups  COPD-X guidelines* most relevant in Australia & New Zealand However little data available on adherence in Australia, particularly with regard to admissions *DK McKenzie et al. The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease 2007.

3. 2 Aims To document variability in clinical practice for COPD admissions in a range of acute-care hospitals To identify gaps in service provision from management guidelines* (To aid development of targeted strategies for service improvement) *DK McKenzie et al. The COPD-X Plan: Australian & New Zealand Guidelines for the Management of COPD. 2007

4. 3 Methods Retrospective medical record audit of 3 consecutive months (July-Sept 2008) of admissions with DRG E65B:  COPD without catastrophic or severe co-morbidities or complications Eight acute care public hospitals in the Hunter New England Area Health Service  Range 52 – 550 beds / hospital Using a validated COPD audit tool * (modified) *CM Roberts et al. ERJ 2001, 17: 343-349

5. 4 200k Newcastle Sydney Brisbane Hunter New England Area Health Service total area 130/000 km 2 Serves a population base of ~ 850,000 8 hospitals audited (total of 1,538 beds)

6. 5 Results: 234 Admissions - data for 221 (94%) Median LOS (days): 5.0 5.0

7. 6 Results: Patient Details

8. 7 Results: Spirometry during Admission COPD-X: “Assessment of severity of the exacerbation includes…spirometry... [Even the sickest of patients can perform an FEV1 manoeuvre]” Access to any spirometry results (during adm. or within previous 5 years) was only 51% JHH Belmont Mater TMH T’worth Armidale Moree Manning

9. 8 Results: Smoking Status COPD-X: P = Prevent deterioration. ‘Smoking cessation reduces the rate of decline of lung function”

10. 9 Results: Arterial Blood Gases on Admission COPD-X: “Assessment of severity of the exacerbation includes… in severe cases, blood gas measurements” JHH Belmont Mater TMH T’worth Armidale Moree Manning

11. 10 Results: Conversion from Nebulisers COPD-X: “The mode of [bronchodilator] delivery should be changed to MDI/spacer or DPI within 24 hours of initial dose of nebulised bronchodilator, unless the patient remains severely ill” JHH Belmont Mater TMH T’worth Armidale Moree Manning

12. 11 Results: Ventilatory Support COPD-X: “Early intervention with NIPPV is suggested when... blood pH is less than 7.35” 21 patients (18%) with admission pH  7.35  8 received ventilatory support -6 NIV -2 IV  13 did not receive ventilatory support -3 medical decision not to escalate treatment -2 responded to medical therapy -1 patient refused -9 no reason apparent 5 other patients received NIV

13. 12 Results: Pulmonary Rehabilitation COPD-X: “A pulmonary rehabilitation program that includes supervised exercise training can be initiated immediately following an acute exacerbation” JHH Belmont Mater TMH T’worth Armidale Moree Manning

14. 13 Results: Chest X-Ray on Admission COPD-X: “Assessment of severity of the exacerbation includes…in severe cases …chest x-ray”

15. 14 Results: Steroid Therapy COPD-X: “Oral glucocorticoids hasten resolution and reduce the likelihood of relapse” JHH Belmont Mater TMH T’worth Armidale Moree Manning

16. 15 Results: Antibiotic Therapy COPD-X: “Antibiotics are given for purulent sputum to cover for typical and atypical organisms” 106 of 115 admissions (92%) with increasing sputum volume and/or change in sputum colour recorded received antibiotics JHH Belmont Mater TMH T’worth Armidale Moree Manning

17. 16 Results: Oxygen Therapy COPD-X: “[Oxygen therapy] is indicated in patients with hypoxia, with the aim of improving oxygen saturation to over 90% (PaO2 > 50mmHg)” Of 175 patients on oxygen during admission, only 5 (3%) had a prescription on the medication chart. JHH Belmont Mater TMH T’worth Armidale Moree Manning

18. 17 Results: GP Follow-Up COPD-X: “It is recommended that the first review after a hospital admission should be by the GP and within seven days of discharge” JHH Belmont Mater TMH T’worth Armidale Moree Manning

19. 18 Results: Specialist Clinic Follow-Up COPD-X: “A decision about the requirement for specialist review should be made at the time of discharge.” JHH Belmont Mater TMH T’worth Armidale Moree Manning

20. 19 Results: Neither GP nor Clinic Follow-Up JHH Belmont Mater TMH T’worth Armidale Moree Manning

21. 20 Results: Other Findings COPD-X: “A decision about the requirement for specialist review should be made at the time of discharge.” COPD-X: “[Oxygen therapy] is indicated in patients with hypoxia, with the aim of improving oxygen saturation to over 90% (PaO2 > 50mmHg)” COPD-X: “Antibiotics are given for purulent sputum to cover for typical and atypical organisms” COPD-X: “Oral glucocorticoids hasten resolution and reduce the likelihood of relapse” COPD-X: “Assessment of severity of the exacerbation includes…in severe cases …chest x-ray” Of 175 patients on oxygen during admission, only 5 (3%) had a prescription on the medication chart.

22. 21 1. H Hosker et al. Resp Med. 2007, 101: 754-761 2. CL Chang et al. Intern Med J 2007, 37: 236-241 Discussion: COPD Admission Audits

23. 22 1. H Hosker et al. Resp Med. 2007, 101: 754-761 2. CL Chang et al. Intern Med J 2007, 37: 236-241 Discussion: COPD Admission Audits

24. 23 Key Findings Poor accessibility to spirometry results:  Within 5 years availability in only 51%  Large discrepancies in inpatient performance (4% - 58%) 1/3 of admitted patients are current smokers Infrequent ABGs on/during admission at some rural hospitals Wide variation in conversion from nebs (26% - 68%) Infrequent use of ventilatory support (received in only 38% of patients with pH  7.35) Similar usage rates of steroids, antibiotics and supplemental oxygen (but poor documentation of O2 prescription)

25. 24 Summary We have identified variations in a range of clinical practices in inpatient management of AECOPD:  Between hospitals  From treatment guidelines These data will enable targeted strategies for standardising and improving care provision, and provide an important baseline dataset for evaluating these strategies

26. 25 Acknowledgements Data collection, entry and management  Rose Foale  Cheryl Gorrie  Judith Swan  Cheryl Ray This project was supported by the Innovation and Reform Unit, Hunter New England Health Service

27. 26

28. 27 Introduction Variability in the organisation and management of hospital care for COPD exacerbations in the UK*  Audit of 8,013 admissions to 233 units  Wide variation in care provision  Limited access in smaller hospitals to: pulmonary rehab specialist wards and specialty triage early discharge schemes  Management guidelines alone insufficient to address inequalities of care  Recommend a clear statement on minimum national standards *H Hosker et al. Resp Med 2007, 101: 754-761

29. 28 Introduction We now have earlier discharge from AECOPD:  Outreach management  Multidisciplinary discharge planning  Pressures to reduce LOS In addition, there are ongoing pressures to minimise COPD admissions ? Potential for these factors to affect adherence to COPD management guidelines

30. 29 Results: (?Early) Discharge Planning COPD-X: “Discharge planning…should commence on admission and be documented within 24–48 hours”