Chronic obstructive pulmonary disease (COPD) exacerbations occur in a significant proportion of hospitalizations but are often treated with substandard care. This may include inappropriate use of medications during and after hospitalization and failing to receive appropriate referrals for subspecialty care and rehabilitation. After discharge, lack of adequate education can lead to inappropriate medication use. As a result, rates of readmission and global costs to accountable care organizations (ACOs) during and after hospitalization for COPD remain stubbornly high.
To implement a COPD Longitudinal Inpatient Pathway and Transition (CLIPT) that encompasses: (1) evidence‐based computer order‐entry (CPOE) order sets for use in the ED, inpatient ward, and at discharge: (2) linkages with protocols used by respiratory therapists that reinforce therapeutics, education, and assessment of postdischarge resources; (3) postdischarge referrals to pulmonary medicine and pulmonary rehabilitation; and (4) linkages with existing discharge transitions‐of‐care processes.
Our COPD Inpatient Care Workgroup, composed of hospitalists, pulmonologists, respiratory therapists, pharmacists, and information systems specialists, has implemented the CPOE pathway, which is a multilayered, comprehensive approach to inpatient COPD care. It optimizes management across the continuum of care. Order sets are available for initiation in the ED, at or after admission, and at discharge. These trigger a respiratory care pathway, which currently include protocols for secretion clearance, supplemental oxygen, and inhaled medications. In addition, respiratory therapists will provide education to the patient/family and participate in risk and needs assessment for referrals after discharge. On discharge, a discharge order set not only provides commonly prescribed medications, but also referrals to outpatient pulmonary medicine and pulmonary rehabilitation.
Since implementation, CLIPT has been initiated in 46% of patients admitted with ICD‐9 codes associated with acute exacerbations. Further study will be needed to assess outcomes during and after hospitalization, such as adherence to recommended therapies, length of stay, and pharmacy costs. Mechanisms to better capture exacerbations will be needed to improve order set penetration. Future evolution of this pathway may include implementation of risk assessment for pulmonary rehabilitation, a COPD flow sheet, and standardized communication between physicians, respiratory care, and nursing.
Summary of COPD Order Sets Initiated between September 7, 2012, and December 22, 2012
|ICD-9 Code||Description||Total Hospitalizations for Diagnosis Code||Admit Order Sets Initiated||Stand-Alone Order Sets Initiated||Order Set Penetration|
|491.22||Acute bronchitis with COPD||3||1||1||2/3 (66%)|
|491.21||COPD exacerbation||55||13||14||26/55* (47%)|
|493.22||Acute exacerbation of chronic obstructive airway disease with asthma||1||0||0||0/1 (0%)|
|491.2||COPD bronchitis||3||0||0||0/3 (0%)|
|No COPD-associated diagnosis code||3||3|
|Total number of order sets||20**||21**|
|*An admit and stand-alone order set was initiated on the same patient/hospitalization. **Order sets initiated for each diagnosis code do not add up to total because of multiple diagnosis codes associated with the same patient/hospitalization.|
To cite this abstract:Chang W, Maynard G, Clay B. Implementation of a Computerized Copd Inpatient Pathway and Transition Pathway. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 167. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/implementation-of-a-computerized-copd-inpatient-pathway-and-transition-pathway/. Accessed July 23, 2019.