Pre-hospital and emergency department pathways of care for exacerbations of chronic obstructive pulmonary disease (COPD)

Prevalence and Economic Impact of Acute Respiratory Failure in the Prehospital Emergency Medical Service of the Madrid Community: Retrospective Cohort Study

Background

Chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and acute pulmonary edema (APE) are serious illnesses that often require acute care from prehospital emergency medical services (EMSs). These respiratory diseases that cause acute respiratory failure (ARF) are one of the main reasons for hospitalization and death, generating high health care costs. The prevalence of the main respiratory diseases treated in a prehospital environment in the prepandemic period and during the COVID-19 pandemic in Spain is unknown. The Madrid Community EMS is a public service that serves all types of populations and represents an epidemiological reference for supporting a population of 6.4 million inhabitants. The high volume of patients treated by Madrid's medical advanced life supports (ALSs) allows us to analyze this little-studied problem.

objectives

Our goal was to lay the groundwork for comprehensive data collection and surveillance of respiratory failure, with an emphasis on the most prevalent diseases that cause it, an aspect that has been largely overlooked in previous initiatives. By achieving these objectives, we hope to inform efforts to address respiratory failure and establish a standardized methodology and framework that can facilitate expansion to a continuous community-wide registry in Madrid, driving advances in emergency care and care practices in these pathologies. The aim of this retrospective observational study was to determine the pathologies that have mainly caused respiratory failure in patients and required medicalized ALS and to evaluate the cost of care for these pathologies collected through this pilot registry.

Methods

A multicenter descriptive study was carried out in the Madrid Community EMS. The anonymized medical records of patients treated with medical ALS, who received any of the following medical diagnoses, were extracted: ARF not related to chronic respiratory disease, ARF in chronic respiratory failure, exacerbations of COPD, APE, CHF, and bronchospasm (not from asthma or COPD). The prevalence of each pathology, its evolution from 2014 to 2020, and the economic impact of the Medical ALSs were calculated.

Results

The study included 96,221 patients. The most common pathology was exacerbation of COPD, with a prevalence of 0.07% in 2014; it decreased to 0.03% in 2020. CHF followed at 0.06% in 2014 and 0.03% in 2020. APE had a prevalence of 0.01% in 2014, decreasing to 0.005% in 2020 with the pandemic. The greatest economic impact was on exacerbation of COPD in 2015, with an annual cost of €2,726,893 (which equals to US $2,864,628).

Conclusions

COPD exacerbations had the higher prevalence in the Madrid region among the respiratory diseases studied. With the COVID-19 pandemic, the prevalence and costs of almost all these diseases decreased, except for ARF not related to chronic disease. The cost of these pathologies over 5 years was €58,791,031 (US $61,832,879).

Pediatric Esophageal Button Battery Protocol Reduces Time From Presentation to Removal

OBJECTIVE

Evaluate implementation of an institutional protocol to reduce the time to removal of esophageal button battery (BB) and increase use of mitigation strategies.

METHODS

We developed a protocol for esophageal BB management [Zakai's Protocol (ZP)]. All cases of esophageal BB impaction managed at a tertiary care center before and after implementation from 2011 to 2023 were reviewed. Time to BB removal, adherence to critical steps, and use of mitigation strategies (honey/sucralfate, acetic acid) were evaluated.

RESULTS

Fifty-one patients (38 pre-ZP, 13 post-ZP) were included. Median age was 2.3 years (IQR 1.3-3.4). After implementation, the time from arrival at the institution to arrival in the operating room (OR) reduced by 4.2 h [4.6 h (IQR 3.9-6.5) to 0.4 h (IQR 0.3-0.6), p < 0.001] and there was improvement in all management steps. The number of referrals direct to otolaryngology increased from 51% to 92%, arrival notification increased from 86% to 100%, avoidance of second x-ray increased from 63% to 100%, and direct transfer to OR increased from 92% to 100%. Adherence to mitigation strategies such as preoperative administration of honey or sucralfate increased from 0% to 38%, intraoperative use of acetic acid from 3% to 77%, and nasogastric tube insertion from 53% to 92%.

CONCLUSION

Implementation of ZP substantially reduced the time to BB removal and the use of mitigation strategies in our tertiary care institution. Additional strategies focused on prevention of BB ingestion, and shortening the transfer time to the tertiary care hospital are required to prevent erosive complications.

LEVEL OF EVIDENCE

3, Case-series Laryngoscope, 134:5170-5177, 2024.

Acute exacerbation of chronic obstructive pulmonary disease in United States emergency departments, 2010-2018

OBJECTIVES

Little is known about the recent status of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in the U.S. emergency department (ED). This study aimed to describe the disease burden (visit and hospitalization rate) of AECOPD in the ED and to investigate factors associated with the disease burden of AECOPD.

METHODS

Data were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2010-2018. Adult ED visits (aged 40 years or above) with AECOPD were identified using International Classification of Diseases codes. Analysis used descriptive statistics and multivariable logistic regression accounting for NHAMCS's complex survey design.

RESULTS

There were 1,366 adult AECOPD ED visits in the unweighted sample. Over the 9-year study period, there were an estimated 7,508,000 ED visits for AECOPD, and the proportion of AECOPD visits in the entire ED population remained stable at approximately 14 per 1,000 visits. The mean age of these AECOPD visits was 66 years, and 42% were men. Medicare or Medicaid insurance, presentation in non-summer seasons, the Midwest and South regions (vs. Northeast), and arrival by ambulance were independently associated with a higher visit rate of AECOPD, whereas non-Hispanic black or Hispanic race/ethnicity (vs. non-Hispanic white) was associated with a lower visit rate of AECOPD. The proportion of AECOPD visits that were hospitalized decreased from 51% to 2010 to 31% in 2018 (p = 0.002). Arrival by ambulance was independently associated with a higher hospitalization rate, whereas the South and West regions (vs. Northeast) were independently associated with a lower hospitalization rate. The use of antibiotics appeared to be stable over time, but the use of systemic corticosteroids appeared to increase with near statistical significance (p = 0.07).

CONCLUSIONS

The number of ED visits for AECOPD remained high; however, hospitalizations for AECOPD appeared to decrease over time. Some patients were disproportionately affected by AECOPD, and certain patient and ED factors were associated with hospitalizations. The reasons for decreased ED admissions for AECOPD deserve further investigation.

The clinical journey of patients with a severe exacerbation of chronic obstructive pulmonary disease (COPD): from the ambulance to the emergency department to the hospital ward

Background

Exacerbations of chronic obstructive pulmonary disease (COPD) are acute complications that often require emergency management by ambulance, emergency department (ED) and hospital services. Given the high mortality and morbidity of exacerbations, better understanding of the epidemiology of patients with COPD presenting to EDs is needed, as well as identification of predictive factors for adverse outcomes from exacerbations.

Methods

This retrospective observational study involved patients who presented to an ED in the state of Queensland and received either an ED or hospital diagnosis of COPD in 2015 and 2016. Administrative data from ambulance, ED, hospital and death registry databases were linked to provide a comprehensive picture of the emergency healthcare pathway for these patients.

Results

A total of 16,166 patients (49% female, 51% male) had 29,332 presentations to an ED in Queensland and received either an ED or hospital principal diagnosis of COPD during 2015 and 2016. These patients had a significant comorbidity burden with 54% having two or more comorbidities. Sixty-nine percent of ED presentations involved ambulance transport, and most of these (74%) involved administration of oxygen therapy and/or other medications by paramedics. Prehospital oxygen administration and ≥10 comorbidities were associated with >1 admission [odds ratio (OR) 1.3, 95% confidence interval (CI) 1.1-1.5; OR 4.3, 95% CI: 3.1-5.8, respectively], greater than average lengths of stay (OR 1.5, 95% CI: 1.3-1.6; OR 22.1, 95% CI: 18.1-27.2) and mortality (OR 1.6, 95% CI: 1.5-1.8; OR 5.3, 95% CI: 4.2-6.8). Of the ambulance presentations, 90% were admitted or received ongoing care.

Conclusions

COPD places considerable burden on the emergency healthcare pathway including ambulances and EDs in Queensland. Patients with COPD most commonly present to the ED by ambulance and receive extensive pre-hospital management. These patients have significant comorbidity burden and experience high rates of admission and mortality. More research is required to investigate the emergency pathway to further identify reversible factors and enhance healthcare practice and policy for COPD management.

Mapping of Modifiable Factors with Interdisciplinary Chronic Obstructive Pulmonary Disease (COPD) Guidelines Adherence to the Theoretical Domains Framework: A Systematic Review

BACKGROUND

COPD guidelines non-concordance is a challenge frequently highlighted by respiratory experts. Despite the provision of comprehensive evidence-based national and international guidelines, the COPD burden to frontline healthcare services has increased in the last decade. Suboptimal guidelines concordance can be disruptive to health-related quality of life (HRQoL), hastening pulmonary function decline and surging overall morbidity and mortality. A lack of concordance with guidelines has created an escalating economic burden on health-care systems. Identifying interdisciplinary interventions to facilitate improved adherence to guidelines may significantly reduce re-admissions, enhance HRQoL amongst patients and their families, and facilitate economic efficiency.

MATERIALS AND METHODS

This review adhered to the Joanna Briggs Institute (JBI) methodology for mixed methods systematic reviews and the PRISMA ScR reporting guidelines. Two independent reviewers screened abstracts and full text articles in consonance with inclusion criteria. The convergent integrative JBI method collated quantitative, qualitative and mixed methods studies from nine databases. JBI critical appraisal tools were utilised to assess the quality of research papers. The theoretical domains framework (TDF) along with a specifically developed COPD data extraction tool were adopted as a priori to collect and collate data. Identified barriers and corresponding clinical behavioural change solutions were categorised using TDF domains and behavior change wheel (BCW) to provide future research and implementation recommendations.

RESULTS

Searches returned 1068 studies from which 37 studies were included (see Figure 1). COPD recommendations identified to be discordant with clinical practice included initiating non-invasive ventilation, over- or under-prescription of corticosteroids and antibiotics, and a lack of discharging patients with a smoking cessation plan or pulmonary rehabilitation. TDF domains with highest frequency scores were knowledge, environmental resources, and clinical behaviour regulation. Electronic order sets/digital proforma with guideline resources at point of care and easily accessible digital community referrals to target both pharmacological and non-pharmacological management appear to be a solution to improve concordance.

CONCLUSION

Implementation of consistent quality improvement intervention within hospitals for patients with COPD may exclude any implementation gap and prevent readmissions. Electronic proformas with digital referrals will assist with future evaluation audits to prioritise and target interventions to improve guidelines concordance.

ETHICS AND DISSEMINATION

Ethical approval is not required, and results dissemination will occur through peer-reviewed publication.

PROSPERO REGISTRATION NUMBER

CRD42020156267.

2021 Guideline for the Management of COPD Exacerbations: Emergency Medicine Association of Turkey (EMAT) / Turkish Thoracic Society (TTS) Clinical Practice Guideline Task Force

Chronic obstructive pulmonary disease (COPD) is an important public health problem that manifests with exacerbations and causes serious mortality and morbidity in both developed and developing countries. COPD exacerbations usually present to emergency departments, where these patients are diagnosed and treated. Therefore, the Emergency Medicine Association of Turkey and the Turkish Thoracic Society jointly wanted to implement a guideline that evaluates the management of COPD exacerbations according to the current literature and provides evidence-based recommendations. In the management of COPD exacerbations, we aim to support the decision-making process of clinicians dealing with these patients in the emergency setting.

Protocol for assessing mortality reduction with the early use of noninvasive ventilation in prehospital emergency services: A multicentre, observational cohort study in Madrid, Spain

BACKGROUND

Acute respiratory failure (ARF) has become one of the most prevalent serious pathologies encountered in the emergency medical service (EMS). In hospital settings, noninvasive ventilation (NIV) therapy prevents complications from more aggressive treatments for that condition. However, the scarce evidence on the benefits of NIV in prehospital EMS (i.e., during transport to the hospital) is inconclusive.

OBJECTIVES

To determine whether the administration of NIV during prehospital EMS in cases of ARF reduces in-hospital mortality compared with starting NIV on arrival to in-patient EMS.

METHODS

This is a multicentre, observational, prospective cohort study. We recruited a total of 317 patients from the Madrid region (Spain) who were prescribed NIV for their ARF using a nonprobabilistic consecutive sampling method. Analyses of the main outcome (in-hospital mortality) and secondary outcomes (length of hospital stay, readmissions, percentage of intensive care unit admissions, and cost-effectiveness) will include descriptive analyses of patients' characteristics, as well as bivariate and multivariate analyses and cost-effectiveness analysis.

DISCUSSION

This study will provide data on NIV management in prehospital and in-patient EMS in patients with ARF. Results will contribute to the existing evidence on the benefits of NIV in the context of prehospital EMS while underlining the importance of a standardized formal training for physicians and nurses working in prehospital and in-patient EMSs.

CONCLUSION

The VentilaMadrid study will provide valuable data on the clinical factors of patients receiving NIV in prehospital EMS. Further, were our hypothesis to be confirmed, our results would strongly suggest that the administration of NIV in prehospital EMS by medical and nursing profesionals formally trained in the technique reduces mortality and improves prognoses.