Impact of a COPD care bundle on hospital readmission rates

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of mortality worldwide and contributes considerably to morbidity and health care costs. In October 2014, the Centers for Medicare and Medicaid Services introduced financial penalties followed by bundled payments for care improvement initiatives in patients hospitalized with COPD.

OBJECTIVES

This study seeks to evaluate whether an evidence-based interprofessional COPD care bundle focused on inpatient, transitional, and outpatient care would reduce hospital readmission rates.

METHODS

A pre- and postintervention analysis comparing readmission rates after a hospitalization for COPD in subjects who received standard of care versus an interprofessional team-led COPD care bundle was conducted. The primary outcome was 30-day all-cause readmissions; secondary outcomes included 60- and 90-day all-cause readmissions, escalation of pharmacotherapy, interprofessional interventions, and hospital length of stay.

RESULTS

A total of 189 subjects were included in the control arm and 127 subjects in the COPD care bundle arm. A reduction in 30-day all-cause readmissions between the control arm and COPD care bundle arm (21.7% vs. 11.8%, P = 0.017) was seen. Similar outcomes were seen in 60-day (18% vs. 8.7%, P = 0.013) and 90-day all-cause readmissions (19.6% vs. 4.7%, P < 0.001). Pharmacists consulted with 68.5% of subjects and assisted with access to outpatient medications in 45.7% of subjects in the COPD care bundle arm. An escalation in maintenance therapy occurred more often in the COPD care bundle arm (22.2% vs. 44.9%, P < 0.001) than the control arm.

CONCLUSIONS

An interprofessional team-led COPD care bundle resulted in significant reductions in all-cause hospital readmissions at 30, 60, and 90 days.

The Impact of a Home Respiratory Therapist to Reduce 30-Day Readmission Rates for Exacerbation of COPD

BACKGROUND

In 2015, the Centers for Medicare and Medicaid Services limited payments to hospitals with high readmission rates for patients admitted with COPD exacerbation. Decreasing readmissions in this patient population improves patient health and decreases health care utilization of resources. We hypothesized a COPD disease management program delivered by a respiratory therapist (RT) in the patient's home may reduce readmission rates for COPD exacerbation.

METHODS

We performed a pre/post interventional study comparing hospital readmissions for subjects with COPD exacerbation that received standard of care in the home versus an RT-led home COPD disease management program. Subjects discharged home from Atlantic Health System with COPD exacerbation were enrolled in the pre-intervention group. Subsequently, an evidence-based home COPD disease management program was implemented by an RT from At Home Medical in the home. The home COPD Disease Management Program was implemented from April 2017-September 2019, and this served as the post-intervention group. The primary end point was readmission rates at 30 d. Secondary end points included 60-d and 90-d readmission rates.

RESULTS

A total of 1,093 participants were included in the study, 658 in the pre-intervention cohort and 435 participants in the post-intervention group. Approximately 22.3% (n = 147) of subjects in the pre-intervention group was readmitted within 30 d of discharge compared to 12.2% (n = 53) in the post-intervention group (P < .001). A reduction in 60-d (33.9% vs 12.0%, P < .001) and 90-d all-cause readmissions (43.5% vs 13.1%, P < .001) was also seen. Participation in the COPD Disease Management Program was significantly associated with decreased 30-, 60-, and 90-d readmission rates adjusting for age, gender, race, ethnicity, and smoking status (odds ratio 0.48 [95% CI 0.33-0.70]; odds ratio 0.26 [95% CI 0.18-0.38]; odds ratio 0.20 [95% CI 0.14-0.27];P < .001, for all 3 readmission rates).

CONCLUSIONS

The COPD Disease Management Program is significantly associated with decreased readmission adjusting for demographics and smoking status.

Evaluation of dexmedetomidine withdrawal in critically ill adults

BACKGROUND

Dexmedetomidine (DEX) withdrawal syndrome has been reported in the pediatric population, but literature describing DEX withdrawal in critically ill adults is limited. The purpose of this study was to determine the incidence of DEX withdrawal in adult patients and to identify factors associated with DEX withdrawal syndrome.

METHODS

A retrospective chart review was performed in the adult intensive care units of two tertiary medical centers. Eligible patients were at least 18 years of age and received DEX for 24 h or more. Patients were excluded if they presented with a primary neurologic diagnosis, had a history of substance abuse, or received any other α2-agonists 24 h before discontinuation of DEX. The primary outcome was the percentage of patients who developed withdrawal as defined by the presence of two or more symptoms (tachycardia, hypertension, vomiting, agitation) within the 24 h following DEX discontinuation.

RESULTS

Of the 165 patients included, 50 patients experienced withdrawal (30.3%), lasting a median of two days. The incidence of withdrawal was higher in surgical (40%) compared to medical (28%) or cardiac (32%) patients (p = 0.004). Median duration of infusion was 52.5 h (interquartile range [IQR], 37.8 to 102.8) in the withdrawal group and 52 h (IQR, 41 to 87) in the non-withdrawal group (p = 0.887). Median DEX dose was 0.56 μg/kg/h (IQR, 0.39 to 0.83) in the withdrawal group and 0.48 μg/kg/h (0.36 to 0.65) in the non-withdrawal group (p = 0.12). Weaning did not reduce the incidence of withdrawal as compared to abrupt discontinuation (p = 0.68). The withdrawal group was more likely to have concomitantly discontinued opioids (54% vs 12.2%) and benzodiazepines (36% vs 0%) at the time of DEX discontinuation compared to the non-withdrawal group (p = 0.004).

CONCLUSION

Development of DEX-associated withdrawal occurred in approximately 30% of adult patients, comparable to rates reported in pediatric literature. There appeared to be no correlation between dose, exposure, and weaning in the occurrence of withdrawal, but concomitant discontinuation of opioids or benzodiazepines as well as ICU admission type could highlight cases requiring closer monitoring.

Lower serum endocan levels are associated with the development of acute lung injury after major trauma

PURPOSE

Endocan is a proteoglycan expressed by endothelial cells in the lung that may inhibit leukocyte recruitment and thus prevent the development of acute lung injury (ALI). We tested the association of serum endocan levels with subsequent development of ALI after major trauma.

MATERIALS AND METHODS

This was a single-center nested case-control study within a prospective cohort study of major trauma patients. Using an enzyme-linked immunosorbent assay test, we measured endocan levels from admission serum in 24 controls (no ALI) and 24 cases (ALI within 5 days of trauma). Multivariable logistic regression was used to test the association of admission serum endocan levels with subsequent ALI.

RESULTS

Patients who developed ALI had lower levels of endocan on admission (mean, 3.5 ± 1.4 ng/mL vs 4.9 ± 2.6 ng/mL in controls; P = .02). For each 1-unit increase in serum endocan level, the odds ratio for ALI development decreased (0.69; 95% confidence interval, 0.49-0.97; P = .03). Lower endocan levels remained associated with a higher incidence of ALI after adjustment for age and illness severity.

CONCLUSIONS

Lower levels of serum endocan on admission are associated with subsequent development of ALI in trauma patients. These observations may be explained by endocan-mediated blockade of leukocyte recruitment in the lung.

Factors associated with nonadherence to early goal-directed therapy in the ED

BACKGROUND

Protocol-driven early goal-directed therapy (EGDT) has been shown to reduce mortality in patients with severe sepsis and septic shock in the ED. EGDT appears to be underused, even in centers with formalized protocols. The aim of our study was to identify factors associated with not initiating EGDT in the ED.

METHODS

This was a cohort study of 340 EGDT-eligible patients presenting to a single center ED from 2005 to 2007. EGDT eligibility was defined as a serum lactate >or= 4 mmol/L or systolic BP< 90 mm Hg after volume resuscitation. EGDT initiation was defined as the measurement of central venous oxygen saturation via central venous catheter. Multivariable logistic regression was used to adjust for potential confounding.

RESULTS

EGDT was not initiated in 142 eligible patients (42%). EGDT was not completed in 43% of patients in whom EGDT was initiated. Compliance with the protocol varied significantly at the physician level, ranging from 0% to 100%. Four risk factors were found to be associated independently with decreased odds of initiating EGDT: female sex of the patient (P = .001), female sex of the clinician (P = .041), serum lactate (rather than hemodynamic) criterion for EGDT (P = .018), and nonconsultation to the Severe Sepsis Service (P < .001).

CONCLUSIONS

Despite a formalized protocol, we found that EGDT was underused. We identified potential barriers to the effective implementation of EGDT at the patient, clinician, and organizational level. The use of a consultation service to facilitate the implementation of EGDT may be an effective strategy to improve protocol adherence.

An alternative method of acute lung injury classification for use in observational studies

BACKGROUND

In observational studies using acute lung injury (ALI) as an outcome, a spectrum of lung injury and difficult-to-interpret chest radiographs (CXRs) may hamper efforts to uncover risk factor associations. We assessed the impact of excluding patients with difficult-to-classify or equivocal ALI diagnosis on clinical and genetic risk factor associations for ALI after trauma.

METHODS

This study was of a prospective cohort of 280 critically ill trauma patients. The primary outcome was the development of ALI. Patients were classified into one of three groups: (1) definite ALI (patients who fulfilled the American-European Consensus Conference [AECC] criteria for ALI), (2)equivocal ALI (patients who had difficult-to-interpret CXRs), and (3) definite non-ALI. We compared clinical and genetic ALI risk factor associations between two classification schemes: AECC classification (definite ALI vs rest) and alternative classification (definite ALI vs definite non-ALI, excluding equivocal ALI).

RESULTS

Ninety-three (35%) patients were classified as definite ALI, 67 (25%) as equivocal, and 104 (39%) as definite non-ALI. Estimates of clinical and genetic ALI risk factor associations were farther from the null using the alternative classification. In a multivariable risk factor model, the C statistic of the alternative classification was significantly higher than that derived from the AECC classification (0.82 vs 0.74; P < .01).

CONCLUSIONS

The ability to detect ALI risk factors may be improved by excluding patients with equivocal or difficult-to-classify ALI. Such analyses may provide improved ability to detect clinical and genetic risk factor associations in future epidemiologic studies of ALI.

Plasma levels of receptor for advanced glycation end products, blood transfusion, and risk of primary graft dysfunction

RATIONALE

The receptor for advanced glycation end products (RAGE) is an important marker of lung epithelial injury and may be associated with impaired alveolar fluid clearance. We hypothesized that patients with primary graft dysfunction (PGD) after lung transplantation would have higher RAGE levels in plasma than patients without PGD.

OBJECTIVES

To test the association of soluble RAGE (sRAGE) levels with PGD in a prospective, multicenter cohort study.

METHODS

We measured plasma levels of sRAGE at 6 and 24 hours after allograft reperfusion in 317 lung transplant recipients at seven centers. The primary outcome was grade 3 PGD (Pa(O(2))/Fi(O(2)) < 200 with alveolar infiltrates) within the first 72 hours after transplantation.

MEASUREMENTS AND MAIN RESULTS

Patients who developed PGD had higher levels of sRAGE than patients without PGD at both 6 hours (median 9.3 ng/ml vs. 7.5 ng/ml, respectively; P = 0.028) and at 24 hours post-transplantation (median 4.3 ng/ml vs. 1.9 ng/ml, respectively; P < 0.001). Multivariable logistic regression analyses indicated that the relationship between levels of sRAGE and PGD was attenuated by elevated right heart pressures and by the use of cardiopulmonary bypass. Median sRAGE levels were higher in subjects with cardiopulmonary bypass at both 6 hours (P = 0.003) and 24 hours (P < 0.001). sRAGE levels at 6 hours were significantly associated with intraoperative red cell transfusion (Spearman's rho = 0.39, P = 0.002 in those with PGD), and in multivariable linear regression analyses this association was independent of confounding variables (P = 0.02).

CONCLUSIONS

Elevated plasma levels of sRAGE are associated with PGD after lung transplantation. Furthermore, plasma sRAGE levels are associated with blood product transfusion and use of cardiopulmonary bypass.

Validation study of an automated electronic acute lung injury screening tool

OBJECTIVE The authors designed an automated electronic system that incorporates data from multiple hospital information systems to screen for acute lung injury (ALI) in mechanically ventilated patients. The authors evaluated the accuracy of this system in diagnosing ALI in a cohort of patients with major trauma, but excluding patients with congestive heart failure (CHF). DESIGN Single-center validation study. Arterial blood gas (ABG) data and chest radiograph (CXR) reports for a cohort of intensive care unit (ICU) patients with major trauma but excluding patients with CHF were screened prospectively for ALI requiring intubation by an automated electronic system. The system was compared to a reference standard established through consensus of two blinded physician reviewers who independently screened the same population for ALI using all available ABG data and CXR images. The system's performance was evaluated (1) by measuring the sensitivity and overall accuracy, and (2) by measuring concordance with respect to the date of ALI identification (vs. reference standard). MEASUREMENTS One hundred ninety-nine trauma patients admitted to our level 1 trauma center with an initial injury severity score (ISS) >/= 16 were evaluated for development of ALI in the first five days in an ICU after trauma. Main RESULTS The system demonstrated 87% sensitivity (95% confidence interval [CI] 82.3-91.7) and 89% specificity (95% CI 84.7-93.4). It identified ALI before or within the 24-hour period during which ALI was identified by the two reviewers in 87% of cases. CONCLUSIONS An automated electronic system that screens intubated ICU trauma patients, excluding patients with CHF, for ALI based on CXR reports and results of ABGs is sufficiently accurate to identify many early cases of ALI.

Association of RBC Transfusion With Mortality in Patients With Acute Lung Injury

BACKGROUND

RBC transfusion has been associated with increased morbidity and mortality in a variety of clinical settings. We assessed the effect of RBC transfusion on in-hospital mortality in patients with acute lung injury (ALI).

METHODS

Cohort study of 248 consecutive patients with ALI. RBC transfusion was evaluated as both dichotomous and continuous variables, with outcome being in-hospital mortality adjusted for clinical confounders and length of total hospital stay.

RESULTS

Overall in-hospital mortality rate was 39.5%. Of these patients, 207 of 248 patients (83.5%) received > or = 1 U of packed RBCs. The transfusion of any packed RBCs was associated with an increased risk of death (adjusted odds ratio [OR], 3.12; 95% confidence interval [CI], 1.28 to 7.58; p < 0.001). The overall OR per unit was 1.06 (95% CI, 1.04 to 1.09; p < 0.001) in the complete multivariable model. Transfusion after ALI onset was associated with an adjusted OR of 1.13 (95% CI, 1.07 to 1.20; p < 0.001), while transfusion before ALI onset was not associated with higher risk. The adjusted OR per unit of nonleukoreduced RBC transfused was 1.14 (95% CI, 1.07 to 1.21; p < 0.001), while the adjusted OR for leukoreduced cells per unit transfused was 1.06 (95% CI, 1.03 to 1.09; p < 0.001).

CONCLUSIONS

Transfusion of RBCs in patients with ALI was associated with increased in-hospital mortality. This risk occurred with RBC transfusion after the onset of ALI, and was greater for nonleukoreduced than for leukoreduced RBCs. Aggressive transfusion strategies in patients with established ALI should be questioned, pending further study.

Microsphaeropsis olivacea keratitis and consecutive endophthalmitis

PURPOSE

To report a case of fungal keratitis with consecutive endophthalmitis caused by Microsphaeropsis olivacea.

METHODS

Case report.

RESULTS

A 51-year-old man developed fungal keratitis and consecutive endophthalmitis after sustaining a penetrating injury to the right eye. Cultures of the aqueous humor yielded M. olivacea. Infection resolved after intraocular fungal debridement, intravitreous amphotericin B, and aggressive topical natamycin and oral fluconazole. Persistent, low-grade smoldering corneal and intraocular inflammation required topical corticosteroid therapy.

CONCLUSION

M. olivacea is an exceedingly rare ocular pathogen. The intraocular portion of the infection responded quickly to intravitreal antifungal treatment; however, the course was prolonged by smoldering corneal inflammation. Prompt recognition of intraocular spread and aggressive treatment may be beneficial in fungal infections caused by unusual organisms with uncertain virulence.

Myocardial infarction in the young

Coronary angiography was done in 88 patients of myocardial infarction (MI) less than 40 years of age (Group I) and the results were compared with an equal number of patients with MI over 40 years (Group II). Severity of coronary stenosis was evaluated by a coronary index (CI) which determined the extent of myocardium at jeopardy. The severity of coronary artery disease increased with age (CI in Group I = 6.2; Group II = 8.4). Normal coronaries (16% vs 5.7%) and single vessel disease (41% vs 23%) were common in Group I. Smoking was the commonest risk factor in both groups, its prevalence being higher in Group I (66% vs 42%) while the prevalence of diabetes was lower (4.5% vs 21.5%).