Reducing Chronic Obstructive Pulmonary Disease 30-Day Readmissions A Nurse-Led Evidence-Based Quality Improvement Project Joan Agee, DNP, RN, CNOR

Reducing Chronic Obstructive Pulmonary Disease 30-Day Readmissions

A Nurse-Led Evidence-Based Quality Improvement Project Joan Agee, DNP, RN, CNOR Chronic obstructive pulmonary disease (COPD) is a debilitating disease resulting in frequent hospitalizations and increased healthcare costs. As leaders of multidisciplinary teams, acute care nurse leaders are challenged to reduce readmissions and costs. In October 2014, the Centers for Medicare and Medicaid Services expanded readmission penalties for 30-day readmissions to include COPD, making this an important issue for nurse leaders. This article describes how a regional medical center was able to decrease COPD readmissions. Chronic obstructive pulmonary disease (COPD) is the 3rd leading cause of mortality. In the United States, the estimated direct costs of COPD are $32.1 billion annually, and the indirect costs are another $3.9 billion.1 Costs are projected to increase to $49.0 billion annually by 2020.1 Much of the cost results from managing acute exacerbations with costly medications and frequent hospital admissions. Frequent hospital and emergency department (ED) admissions may result from the lack of patient and caregiver understanding of the progression of the disease and how to best manage the anxiety, pain, and dyspnea that accompany intermittent exacerbations. Prescribed medications to control symptoms do not stop disease progression. The patient"s ability to carry out normal activities of daily living decreases as the disease progresses, thus negatively impacting quality of life (QOL). Current approaches to care for patients are generally limited to symptom management and the treatment of acute exacerbations. The Centers for Medicare and Medicaid Services announced that effective October 2014, it would begin applying penalties to acute care hospitals for unplanned 30-day COPD readmissions. The intent of the penalty is to increase the quality of care and decrease costs related to COPD readmissions.2 A report from the study site hospital_s electronic medical record (EMR) system identified patients by the discharge diagnostic codes of 491, 492, and 494 revealed a 34% all-cause COPD readmission rate. The literature was reviewed to determine what evidence existed to guide practice on reducing COPD readmissions. Literature suggests that demonstrated methods to reduce readmissions of patients with chronic conditions such as congestive heart failure and diabetes should not be assumed effective for COPD.3 The body of evidence suggests that at least 2 or more interventions were effective in decreasing the rate of hospital and ED readmissions3-6; however, it could not be determined which intervention had the most positive effect. Interventions that proved effective in reducing COPD readmissions include self-care management education provided by trained professionals,3-5,7-9 clinical care pathways,10,11 Global Initiative of Chronic Obstructive Disease (GOLD) guidelines,12 pulmonary rehabilitation,13-16 and community partnerships to support patients after discharge.3,9,11 A consistent theme emerged from the review of the literature revealing that study participants lack a good understanding of what a COPD diagnosis and prognosis means.17-19 This lack of knowledge or understanding on the part of the patient may contribute to the problem of COPD readmissions and may explain JONA Vol. 47, No. 1 January 2017 35 Author Affiliation: Vice President, Patient Care Services, and Chief Nursing Officer, St. Joseph Regional Medical Center, Lewiston, Idaho. The author declares no conflicts of interest. Correspondence: Dr Agee, St. Joseph Regional Medical Center, 415 6th St, Lewiston, ID 83501 DOI: 10.1097/NNA.0000000000000434 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. why simple interventions such as education, postdischarge home visits, and follow-up phone calls contribute to a decrease in readmissions.7,8,20,21 An Evidence-Based Program The purpose of this article is to describe the implementation of a quality improvement (QI) project aimed at decreasing hospital readmissions and improving the QOL (decreased anxiety, pain, and shortness of breath) of adults with COPD. Using the framework of the chronic care model (CCM), a chief nursing officer (CNO)Yled multidisciplinary team composed of associates from the Regional Medical Center (RMC), an acute care 145-bed hospital, and community partners designed an evidence-based QI program. The intent was to create cost avoidance by reducing the risk of readmission penalties, without negatively impacting the quality of care. A 1-year goal of a 10% reduction in COPD readmissions was set. Readmissions for COPD were defined for this project as a hospital admission within 30 days of discharge from the ED or inpatient setting. The project was reviewed by Gonzaga University and approved as a QI project that did not require institutional review board approval. The hospital administration and quality council approved the project. Multidisciplinary QI team The multidisciplinary QI team included hospital staff from various departments such as administration, nursing, respiratory therapy (RT), physical therapy (PT), dietary, pharmacy, hospitalist services, ED, information technology, palliative care, social services, and quality. Additional QI team members included representatives from community agencies such as skilled nursing facilities (SNFs), primary care provider (PCP) clinics, home health agencies, the public health department, personnel from nursing visiting agencies, and local critical access hospitals. Chronic Care Model The CCM served as the framework because it identifies successful methods to manage the complex needs of patients with chronic disease such as COPD.22 The model includes a community focus on providing patient self-management support and resources such as preventative health and regular patient follow-up. The CCM components are (a) self-management (eg, patient education and self-care action plans), (b) delivery system design (eg, clinical pathways and standardized care protocols), (c) decision support (eg, clinical practice guidelines), (d) clinical information systems (eg, a patient registry and methods to track patient progress), and (e) community partnerships to support patients after hospital discharge.9 Global Initiative of Chronic Obstructive Disease The GOLD12 document consists of evidence-based strategies and serves to guide healthcare providers in the treatment of patients with COPD. Because COPD is a global problem, the document was developed by international experts who established a global strategy to manage and treat COPD. The document provides education as well as universal standards to diagnose and treat COPD. Methods Setting The RMC, located in a rural community of northern Idaho, is a major healthcare provider serving approximately 185,000 residents in a region encompassing 20,860 rural miles. Factors that may have contributed to COPD readmissions at the RMC include (a) no pulmonary rehabilitation program within 30 miles of the community, (b) no formalized community coordination of care for patients with COPD, (c) no standardized treatment plan or education program for patients with COPD in the RMC, and (d) a lack of PCP appointment availability for a COPD patient when experiencing worsening symptoms. Target Population The target population included adult patients older than 18 years who had a diagnosis of COPD upon discharge. Overview of Methodology The initial multidisciplinary team meeting consisted of a review of research findings and clinical practice guidelines. The team agreed with the finding that although patients may be informed of their diagnosis by their PCP, they still fail to recognize that they have a chronic disease, which advances to physical and psychosocial distress as severe as lung cancer.23,24 The team motto became Bno patient would be discharged from the RMC without knowing they had been diagnosed with COPD or how to better manage their disease.[ The multidisciplinary team members chose to implement several evidence-based strategies (Figure 1). Because of the complexity and broad scope of this project, the multidisciplinary team elected to divide into 3 work teams, each with a distinct area of focus: (a) education, (b) standardized pathway, and (c) community. As the project lead, the CNO and quality department representatives participated 36 JONA Vol. 47, No. 1 January 2017 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. on each work team to maintain consistency and effort on project aims. Education Team The 9-member education team consisted of a representative from the nursing education department, pharmacy, RT, PT, dietary, and social services. They selected patient self-management education tools, which included a standardized patient education handbook, a symptom tracker, and a magnetized plastic sleeve to hold discharge teaching materials. A Krames education booklet, BLiving Life to the Fullest with COPDi,[ was selected as the patient education handbook. The handbook met the 6th-grade reading level recommendation,25 had clear visual pictures, and was well organized by topics such as medications, breathing treatments, diet, and exercise, which facilitated teaching key concepts by each discipline (nursing, PT, RT, pharmacy, dietary, and social services). The team selected teach-back as an evidencebased method for patients to retain and comprehend education.26,27 The patients were asked to teach back the information provided to them after each education session. The patient was provided a symptom tracker tool and taught to record daily symptoms of shortness of breath, cough, and sputum production. This increased the patient"s awareness of symptom changes that might require action, such as a PCP visit. The education book, the patient"s medication reconciliation form, and the symptom tracker were kept in a magnetized sleeve and mounted in the patient"s hospital room. Upon discharge, the patient was instructed to place it on their refrigerator door for easy access and to bring it to their next PCP or ED visit. To ensure standardized patient education, a nurse educator trained in teach-back methodology provided education to the staff regarding execution. Standardized Pathway Team The 10-member standardized pathway team consisted of inpatient and ED nurses, pharmacy, PT, occupational therapy, RT, dietary, and social services, who collaborated with ED physicians and hospitalists to develop standardized order sets based on GOLD guidelines.12 Physicians initiate the order sets upon the COPD patient"s admission. The orders automatically send a referral to RT, PT, dietary, pharmacy, social services, and palliative care to teach a section of a COPD patient handbook. Patients are instructed in how to live life successfully with COPD, how to use inhalers, methods to achieve energysustaining nutrition and physical exercise, and how to recognize symptoms to avoid an exacerbation. A standardized form in the EMR was developed for each specialty to document the completed education. This interdisciplinary tea with 20 members and swelled to more than 35 as the word of the positive work of the project circulated into the community. This team selected a communitywide standardized education tool developed by the American Lung Association to aid patients in identifying and managing symptoms. The PCP clinics agreed to keep appointments available for COPD patients so they can be seen as soon as possible upon recognizing worsening symptoms. Respiratory therapy staff from the RMC provided education sessions to the staff in SNFs to enhance their knowledge on inhaler use and COPD exacerbation recognition. The community team worked toward increasing COPD awareness through public announcements, and a COPD community awareness event was held on November 18, 2015 (International COPD Community Awareness Day). Data Collection Using a before and after study design, 2 indicators were used to measure the effectiveness of the program: (1) hospital readmission rate and 2) the St. George Respiratory Questionnaire (SGRQ) score. The SGRQ is a COPD-specific instrument designed and validated to measure the patient"s perceived level of overall health, daily life, well-being, and QOL.28,29 Dr Jones granted permission to use the SGRQ for this project. Data Collection Procedure Readmission data were collected from the RMC secure database (Meditech) containing all patients" EMR, which include admission and discharge data. The EMR report, which identifies patients with the discharge diagnostic codes of 491, 492, and 494 and equivalent International Classification of Diseases (ICD) 10 codes J40-J44 and 347.9, captured all patients for statistical analysis. Two separate reports were run. One report was for the time period of June 1, 2014, to November 30, 2014 (before QI interventions), and the 2nd report was for June 1, 2015, to November 30, 2015 (after QI interventions). Data on QOL were obtained from the SGRQ. To obtain a reliable score, the RT staff administered the paper questionnaire according to the instructions provided by Dr Jones.28,29 The questionnaire was administered to all patients at the time of admission to the 1st PRT class and then again after attending 6 weeks of PRT. Data Analysis Data were analyzed to compare the difference in the rate of COPD readmissions before and after the QI project. During the period June 1, 2014, through November 30, 2014 (before to project), there were 408 patients and 189 readmissions. During the period June 1, 2015, through November 30, 2015 (after project), there were 377 patients and 102 readmissions. The readmission data for this project included all-cause readmissions that occurred within 30 days of the patient"s discharge from the ED or the hospital. The SGRQ score was calculated using the Excelbased scoring calculator that accompanied the SGRQ to determine whether there was an improvement in the patient"s health status after having attended at least 6 weeks of PRT. The SGRQ scores range from 0 to 100, with higher scores indicating poorer results. As a new program, a small sample of 5 PRT participants was intentional to assure effectiveness and good outcomes before program expansion. Methods Readmission and Cost Analysis The analysis of all-cause 30-day COPD readmissions found a 7.6% reduction in overall COPD hospital admissions and a 46.03% reduction in COPD readmissions (Figure 2). SGRQ Data Analysis The results collected before and after the PRT intervention revealed the patients" mean SGRQ score had a statistically significant, moderately efficacious improvement from 50.99 to 42.51 = 8.48 units. According to the American Thoracic Society, a mean change score of 4 units is statistically significant for slightly efficacious treatment, 8 units for moderately efficacious change, and 12 units for very efficacious treatment.30 Discussion In this QI project, successful strategies to manage the complex needs of patients with COPD were identified. The multidisciplinary team, which included the hospital staff and community partners, recognized that the healthcare system must change from a focus on acute care and quick triage to a system that extends into the community.11 The RMC plans to expand the Figure 2. Results from COPD interventions. 38 JONA Vol. 47, No. 1 January 2017 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. lessons learned from this project and work with community partners to implement a QI project for reduction of heart failure readmission rates. This study is significant to administration and nursing leaders who may be in a position to influence and approve QI initiatives in their organization. In an effort to meet organizational, financial, and strategic goals, the CNO is positioned to support the implementation of QI projects aimed at reducing potential penalties-related COPD readmissions. This QI project resulted in the implementation of multifaceted interventions aimed to lessen the likelihood of hospital readmission and improve the patient"s overall health status and QOL. Limitations This QI project was conducted in 1 acute care hospital located in northern Idaho with a small, nonrandomized sample; therefore, the results may not be generalizable. However, the results of this QI project and those studies using CCM interventions11,23 suggest that programs with similar design may benefit patients with chronic conditions such as COPD. 

In October 2014, the Centers for Medicare and Medicaid Services expanded readmission penalties to include those patients admitted with an exacerbation of COPD. Patient education is a key component in preventing readmission.