COPD in-patient management : guideline development, implementation and follow-up in the acute hospital setting

1. COPD in-patient management : guideline development, implementation and follow-up in the acute hospital setting Don Campbell Caroline Brand Clinical Epidemiology & Health Service Evaluation Unit Melbourne Health

2. Report Dr Caroline Brand and Ms Fiona Landgren Project Conception Dr Donald Campbell Dr Peter Greenberg Dr Harry Teichtahl Prof Anne Maree Kelly Prof Peter Cameron Project Development and Research Design Dr Caroline Brand Ms Fiona Landgren Ms Jill Nosworthy Dr Don Campbell Data collection  Ms Fiona Landgren Ms Ana Hutchinson Ms Catherine Jones Dr Caroline Brand Data analysis Dr Lachlan MacGregor Dr Caroline Brand Acknowledgements Funding support: EBCPRP, SRDC, NHMRC

3. Clinical Practice Guidelines “Systematically developed statements developed to assist practitioner and patient decisions about appropriate health care for specific circumstances” . What is known about: • Implementation? • Long-term impact?

4. What did we do? What did we find? What difference did it make? Was it sustainable? What would we do differently?

5. What we set out to do Goal To improve the standard of care and health related quality of life for patients who have experienced an acute exacerbation of COPD requiring hospitalisation at Royal Melbourne (RMH) and Western Hospitals (WH). Aim Development and implementation of evidence-based clinical practice guidelines for the acute in-patient episode.

6. Project activities 1 Examine VIMD database 2 Prospective case-note audit (pre/post intervention) 3 CPG development • pathway • decision nodes • evidence-based (consensus driven) • Implementation Strategy • multi-faceted, evidence-based

7. Project activities 2 5 Outcome measures • Patient: Satisfaction HRQoL • Institution: LOS Readmission rate 6 Process measures • medication use, tests • clinical indicators (ACHS for asthma, ?? For COPD)

8. Guideline Implementation and Evaluation Time period: pre-implementation phase: 3/6/99 to 9/9/99 post-implementation phase: 7/11/99 to 31/3/00 Patients admitted: WH RMH pre-implementation 141 68 post- implementation 138 62

9. Demographic characteristics WH RMH • Parameter Pre Post Pre Post • Av Age (yrs) 68 69 70 72 • Males (% of total) 60 52 71 51 • Current Smokers (% of total) 35 32 31 30 • Ex Smokers (% of total) 63 62 56 57 • Language Barrier(% of total) 11 11 25 10* • Presentation to hospital 51 72 43 51 previous 12 months (% of total) • Average duration of illness 4.1 5.7** 8.6 5.8 for presenting episode (in days) • No of deaths (% total) 0 0 4 (6%) 3 (5%)

10. What happened? • Short-term impact evaluation

11. LOS and Readmission rates WH RMH Pre Post Pre Post (172) (173) (72) (70) Ave LOS (days)7.1 7.1 8.4 4.5 ** (6,1-50) (5,1-37) (7,0-28) (4, 1-13) Unplanned re-admission 28 days post discharge 18 16 3 8 (% of total) (10%) (9%) (4%) (11%)

12. Hours in ED WH RMH Pre Post Pre Post (65) (65) (68) (63) Ave Time in ED (hrs) 9.4 8.8 8.7 12.4 * median 8.2 7.8 7.3 9.8 (range) (1-23) (2-34.2) (0.8-26.4) (2.7-34.6)

13. Test use at initial assessment Triage Category Pulse Ox (SpO2) ABG CXR FBE 1 X X X X 2 X X X X 3 X X X 4 X X X 5 X X X (X indicates test recommended) CXRs and ABGs- • Reduced at RMH (unchanged at WH). • ABG reduction significant at RMH (2= 11.44, p < 0.001). Sputum m&c tests reduced at WH.

14. Recommended ongoing therapy for COPD WH RMH Pre Post Pre Post (65) (65) (68) (63) IV line inserted 85% 74% 93% 54% IV removed at 24 hours 24% 35% 25% 47%* Oral Antibiotics (wards) 89% 80% 80% 53%** IV Antibiotics (wards)56% 35%* 60% 25%** Oral C’steroids (wards) 91% 95% 85% 77% IV C’steroids (wards) 64% 49% 20% 11% Ipratropium nebs (wards) 94% 88% 88% 74% MDI (+/- spacer) (wards) 88% 85% 57% 61%

15. Recommended post discharge management WH RMH Pre Post Pre Post (65) (65) (68) (63) Inhaler education 8% 42% 10% 8% Communication with GP 86% 68% 7% 8% (fax) Follow up arrangements (not recorded) 8% 6% 24% 11% Provision of a discharge pack

16. Results Quality of life Disease specific QOL (SOLQ)- • Coping reduced 28 days after discharge. Generic QOL(SF12) post implementation- • MCS improved at both hospitals (NS). Satisfaction with care moderately high at both hospitals (low score for hospital reputation post implementation at one hospital )

17. Long-term sustainability? • Two years later

18. CPG-Two Year Evaluation 1 Medical Record Audit (6 months post implementation) 2 Staff survey: awareness & use of CPG’s • Survey Intranet access and CPG quality • Focus Groups & Key Informant Interviews

19. Summary Audit • Some medical units may be protocol driven • Specific drug recommendations accepted • ? related to CPG use • Poor uptake: • process of care and non drug recommendations Uptake of CPG recommendations usually but not invariably relates to level of evidence

20. CPG - Staff Survey N=188 • Medical 43.7% Nursing 29.0% Students 21.3% • Age 20-49 (75.4%) • Medical (57.9%) Surgical (22%) • Senior staff 73% • Gender F80:M57 (>39yrs F20:M52)

21. Barriers Difficult to locate Poor Index Too prescriptive No allowance for variation Not evidence based Lack of time Too general Facilitating Factors Represent best practice Evidence-based Easy to access Expedite decision making Concise Support treatment decisions Refresh memory Staff Survey Summary- CPG use

22. Intranet Survey Summary Variable access to department home sites Inconsistency: layout, terminology and content Poor adherence to NHMRC guidelines for CPG construction

23. Most health professionals favoured use of CPG/protocols Some staff expressed concern about “cookbook” medicine Emphasis on use as guidelines not proscriptive documents Access and quality of guidelines is a major issue Occupational preferences identified- : nurses prefer protocols/pathways “nurses do not make decisions where there is ambiguity” Departments are variably protocol driven: ED, ICU, Renal Medicolegal issues not a major concern High staff turnover limited corporate memory and training in use Focus Groups and Key Informant Interviews

24. Summary • Senior clinician support and advocacy essential • Consistency in terminology needs to be addressed • Existing access to guidelines needs to be reviewed • Infrastructure for access to decision support systems is required • Integration with ongoing education programs is essential • Establishment of KPI around audit and guidelines implementation is necessary • Greater involvement of consumers in guideline development required Integration with formal hospital quality processes is lacking

25. Contextual analysis Staff turnover Relationship to quality program Interdisciplinary teams? (or professional isolation: multitude of teams) Information Technology support? Integrated care? Executive Leadership??

26. Signposts for the future “Finding the imperatives that will drive systems integration in public sector health care” • Narrative to find simple rules • Values and ethical frameworks • Science of complexity • Rewarding teamwork

27. Knowing what we now know, what would we do (differently) next time? Leadership Build into Quality framework Communication Simple rules for providing quality care • Patient-centred: involve from Day 1- meet needs • Collaborative: build manager-clinician partnership • Knowledge-based: CPG plus expertise Reward and recognition • Team-play • Communication