Category: Professional Posters
Purpose: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines provide recommendations for the management of chronic obstructive pulmonary disease (COPD) exacerbation. Pharmacologic therapy includes a systemic corticosteroid treatment course of prednisone 40 mg orally daily for 5 days, short-acting muscarinic antagonists or beta-agonists, and antibiotics in select patients. Previous studies demonstrated a shortened hospital length of stay (LOS) with guideline-adherent systemic corticosteroids. There are no published studies that have evaluated the impact of an inpatient orderset on patient-oriented outcomes. The current study sought to determine the impact of an orderset with guideline-adherent recommendations on clinical outcomes.
Methods: This institutional review board approved quasi-experimental, single-center, cohort study included adult patients admitted to an internal medicine service for a documented COPD exacerbation from January 1, 2014 to December 31, 2015 (pre-orderset) and January 1, 2017 to December 31, 2018 (post-orderset). No orderset was available for use for the pre-orderset group. A pharmacy and therapeutics committee approved orderset with guideline-adherent systemic corticosteroids, scheduled short-acting bronchodilators and antibiotics was utilized in the post-orderset group. Education on appropriate orderset use was provided to the medical residents and attending physicians during a formal lecture and monthly at the start of each new internal medicine rotation. The primary outcome was hospital LOS. Secondary outcomes included 30-day all-cause and COPD-related readmission rates, systemic corticosteroid related adverse events and antibiotic use. Data were collected from date of hospital admission until 30 days following discharge. Data were analyzed using Chi-square or Fisher’s exact test for categorical data and Student’s t-test for continuous data.
Results: Three hundred fifty-eight unique patient encounters were identified including 220 patients (61.5%) in the pre-orderset group and 138 patients (38.5%) in the post-orderset group. Hospital LOS was significantly shorter in the post-orderset group (4.3 vs. 3.4 [2.4]; P=0.004). Thirty-day all-cause (15.9% vs. 18.1%; P=0.58) and COPD-related (7.3% vs. 10.8%; P=0.24) readmission rates were not significantly different between groups. The mean systemic corticosteroid dose administered for the entire treatment course was 438.3 (381.7) mg of prednisone equivalents (PE) in the pre-orderset group and 341.3 (376.1) mg of PE in the post-orderset group (P=0.02). The number of short-acting bronchodilator doses administered was significantly higher in the post-orderset group (18.5 [17.8] vs. 24.1 [21.5]; P=0.01). Overall antibiotic use decreased in the post-orderset group (90.2% vs. 71%; P < 0.001) and significant increases in guideline-adherent antibiotics utilized were observed with doxycycline (2.3% vs. 10.5%; P=0.003) and azithromycin (20.1% vs. 39.5%; P < 0.001). There was a significant reduction in new blood glucose elevation (79.1% vs. 49.3%; P < 0.001); however, no significant differences in new blood pressure elevation (39.1% vs. 41.3%; P=0.68) were observed between groups.
Conclusion: A significant reduction in hospital LOS was found with the implementation of a pharmacist-driven COPD exacerbation orderset. No differences in 30-day readmission rates were observed. Use of a COPD exacerbation orderset was associated with lower total treatment course doses of systemic corticosteroids and subsequently lower rates of new-onset hyperglycemia. While more short-acting bronchodilator doses were administered, antibiotic utilization was reduced.