Audit of acute admissions of COPD: standards of care and management in the hospital setting

C.M. Roberts; I. Ryland; D. Lowe; Y. Kelly; C.E. Bucknall; M.G. Pearson

Tables

Table 1

Demographics and disease severity at admission

	sex		Admission
	Male	Female	First	Re-admission
Sex	748 (53)	622 (44)
Age	72±9	71±10
FEV₁ L	1.09±0.58	0.81±0.39
	0.94 (0.66–1.31)	0.71 (0.55–1.00)
FEV₁ % pred	40±20	42±19
	35 (25–49)	39 (28–53)
Admission Status			400 (29)	919 (66)
Medications recorded at the time of admission
Inhaled bronchodilator			285 (71)	674 (73)
Long-acting bronchodilator			30 (8)	175 (19)
Inhaled steroid			204 (51)	597 (65)
Systemic steroid			110 (28)	344 (37)
One or more of the above four			327 (82)	845 (92)
Home nebuliser			70 (18)	445 (48)
Home oxygen			23 (6)	268 (29)
Methylxanthine			50 (13)	243 (26)
Antibiotic			63 (16)	190 (21)

Data presented as n (%), mean±sd and mean (interquartile range)
2% were unknown
6% admission details were unknown
Of the 302 cases in which oxygen was reported, the type was stated as oxygen concentrator in 90 cases, and as a cylinder in 110 cases.

Table 2

Assessments and measurements on admission

Assessment or measurement made on admission		Interhospital variation		Overall summary statistics for patients
	n (%)	IQR %	range %	Mean	sd	Median	IQR	Range
Increased breathlessness	96% (1347)	93–100	83–100	Symptom present in 96% (1299)
Increased sputum volume	70% (987)	52–85	12–100	Symptom present in 58% (574)
Change in colour of sputum	68% (948)	53–82	9–100	Symptom present in 53% (502)
Bilateral leg oedema	66% (923)	52–77	9–97	Present in 38% (348)
Comment on the chest radiograph	65% (916)	53–78	0–98	Infiltrates reported in 26% (242)
Respiratory rate bpm	70% (982)	60–86	27–100	27	7	26	22–30	10–60
Temperature ^oC	86% (1209)	85–97	37–100	36.7	0.8	36.6	26.2–37.2	34.0–40.0
Peak flow l·min⁻¹	46% (648)	30–55	0–88	47	71	140	100–185	10–460
S_a,_O₂ %	75% (1061)	65–91	5–100	91	8	94	89–96	46–100
pH	79% (1109)	73–90	40–100	7.39	0.9	7.40	7.36–7.45	6.89–7.80
P_a,_O₂ kPa				6.21	2.18	5.70	4.81–6.91	1.56–21.88
P_a,_O₂ kPa				10.31	5.0	9.01	7.50–11.32	3.30–48.40

IQR: interquartile range
bpm: beats per minute
S_a,_O₂: arterial oxygen saturation
P_a,_CO₂: arterial carbon dioxide tension
P_a,_O₂: arterial oxygen tension
114 of these the actual value was marked “unrecordable”. Statistical summary is for the 534 with values.

Table 3

Initial management within 24 h of admission

Formal prescription of level of inspired oxygen
Overall		64 (886/1375 known)
S_a,_O₂	≤92	75 (328/439)
	>92	62 (377/613)
P_a,_O₂	<8 kPa	76 (269/355)
	8–9.99 kPa	71 (231/326)
	10+ kPa	68 (282/417)
Repeat arterial blood gases
Overall		34 (371/1109 done on admission)
P_a,_CO₂	>6.0 kPa	49 (225/456)
	≤6.0 kPa	22 (144/642)
pH	<7.35	63 (141/224)
	7.35+	26 (224/861)
P_a,_CO₂>6.0 kPa & pH<7.35		65 (128/197)
Assisted ventilation IPPV NIPPV
Overall		3 (40/1400)
First COPD		3 (23/919)
Re-admission		3 (10/400)
P_a,_CO₂	>6.0 kPa	7 (34/456)
	≤6.0 kPa	1 (4/642)
PH	<7.26	15 (11/72)
	7.26–7.34	11 (16/152)
	7.35+	1 (11/861)
P_a,_CO₂>6.0 kPa & pH<7.35		13 (25/197)
Medication
Nebulized bronchodilator		91 (1267/1400)
Steroids		85 (1183/1400)
Antibiotics		80 (115/1400)

Data presented as % (absolute fraction)
S_a,_O₂: arterial oxygen saturation
P_a,_O₂: arterial oxygen tension
P_a,_CO₂: arterial carbon dioxide tension
IPPV: invasive positive pressure ventilation
NIPPV: noninvasive positive pressure ventilation.

Table 4

Continuing management

			Hospital Variation
	n (%)		IQR %	Range %
PEF chart record	51	(710)	28–68	5–93
FEV₁ or PEF recorded	71	(988)	58–84	26–93
Inhaler technique assessed	20	(241/1218)	4–26	0–90
Smoking cessation advice given:
to smokers	30	(134/445)	14–45	0–75
to exsmokers in last months	11	(7/64)	0–0	0–50
P_a,_O₂>7.3 kPa on air at any time	33	(455)	18–48	0–78
OP follow-up	63	(797/1272)	50–80	22–94
Vaccination advice given	5	(65)	0–7	0–21
Pulmonary rehabilitation recommended	3	(39)	0–3	0–39
Reversibility to bronchodilator	27	(378)	6–38	0–86
Steroid reversibility tested	7	(96)	0–11	0–44
Discharge medication
Inhaled bronchodilator	64	(899)	48–80	28–100
Long-acting bronchodilator	15	(209)	5–18	0–69
Inhaled steroid	56	(779)	45–68	14–84
Oral steroid	57	(803)	47–71	7–80
Home nebuliser	38	(536)	30–48	0–86
Home oxygen	18	(254)	10–25	3–40
Theophylline	24	(340)	15–35	0–50
Antibiotics	35	(493)	29–40	5–78

Stated as concentrator in 105 cases and as cylinder in 90
PEF: peak expiratory flow
FEV₁: forced expiratory volume in one second
P_a,_O₂: arterial oxygen tension
OP: outpatient.

Table 5

Differences in the management of patients under the care of Respiratory Physicians (n=602) and nonrespiratory specialists (n=759) at the time of discharge

Comparison made	Chest Physician %	Non-specialist %	Chi-squared*	P‐value	95% CI
Inpatient Care
FEV₁ recorded	70	40	127.4	<0.001	26–36
FEV₁ %pred.	49	27	69.2	<0.001	17–27
PEF chart	61	44	35.8	<0.001	6–17
Inhaler technique	21	14	12.1	<0.001	4–13
Smoking advice to current smokers	36	26	4.6	0.03	1–18
Discharge Medications Prescribed
Inhaled bronchodilator	66	65	0.2	0.64	−4–6
Inhaled long acting β‐agonist	20	12	16.1	<0.001	4–12
Inhaled steroid	61	53	7.8	0.005	2–13
Oral steroid	61	56	4.3	0.04	0–11
Home nebuliser	49	31	43.1	<0.001	12–23
Home oxygen	24	14	20.9	<0.001	6–14
Theophylline	28	22	7.0	0.008	2–11
Antibiotics	36	36	0.06	0.81	−5–6
Discharge plans
Follow up arranged	73	46	0.06	<0.001	22–33
Reversibility to BD	33	23	14.4	<0.001	4–14
Reversibility to steroids	10	4	19.2	<0.001	3–9
Vaccination advice	5	4	1.2	0.27	−1–4
Pulmonary rehabilitation	5	1	23.3	<0.001	3–6

Comparisons made using the chi-squared test for 2×2 tables. Case numbers for inhaler technique and for smoking advice were lower due to exclusions
95% CI: 95% confidence intervals
FEV₁: forced expiratory volume in one second
PEF: peak expiratory flow
BD: bronchodilator.