Do Guidelines Influence Emergency Department Staff Behaviours and Improve Patient Outcomes? Evaluation of a Multifaceted Intervention for the Implementation of Local Acute Exacerbations of Chronic Obstructive Pulmonary Disease Guidelines

Introduction Published national guidelines on chronic obstructive pulmonary disease (COPD) highlight the importance of oxygen therapy, bronchodilators, corticosteroids, and appropriate antibiotics during acute exacerbations of COPD (AECOPD). We wished to assess how the implementation of local COPD guidelines affects emergency department (ED) staff awareness, knowledge, the use of such guidelines, and patient outcomes, including treatment failure and rates of return to the ED. Methods This study was conducted at a tertiary hospital ED. Local COPD guidelines were developed by a quality improvement group. Guidelines were posted in the department, and educational sessions were provided for staff. We conducted a retrospective chart review and looked at 1849 patient visits before and after COPD guideline implementation. All visits with a diagnosis of COPD or AECOPD were included in the study (for a total of 130 patient visits), and data were collected using a standardized abstraction tool. For non-admitted patients, we recorded 30-day return rates and treatment failures occurring within 30 days of presenting to the ED. Pre- and post-implementation outcomes were analyzed with Fisher's exact tests. We also assessed ED staff awareness, knowledge, and use of COPD guidelines through surveys given out before implementation, and both one and 10 months after the implementation. We calculated proportions and 95% confidence intervals (CI) for our surveys. Pre- and post-implementation survey responses were compared with Fisher's exact tests. Results For ED physicians, the survey response rate was 78%, 79%, and 58% at pre-implementation, one-month follow-up, and 10-month follow-up, respectively. Prior to implementation, 14.3% (95% CI 4.1%-35.5%) were aware and 0% (0%-18.2%) reported using guidelines. One month after implementation, 90.9% (71.0%-98.7%) were aware and 81.8% (60.9%-93.3%) reported using guidelines. At 10 months, 100% (76.1%-100%) were aware and 100% (82%-100%) reported using local guidelines. Similar trends were seen among nurses and respiratory therapists. To assess actual guideline use, 130 visits were evaluated (51 visits prior to implementation and 79 post-implementation). Prior to implementation, 57% (43%-70%) received bronchodilators, systemic steroids, and antibiotics appropriately. Following guideline implementation, 57% (46%-67%) received the respective treatments (p=1.0). For patient-related outcomes, 86 non-admission patient visits were evaluated (35 visits prior to implementation and 51 post-implementation). Prior to guideline implementation, 17% (8%-33%) failed their initial AECOPD treatment, compared to 10% (4%-21%) following guideline implementation (p=0.34). Prior to guideline implementation, 23% (12%-39%) returned to the ED within 30 days in the pre-implementation period while 14% (7%-26%) returned post-implementation (p=0.39). Conclusion Our introduction of local COPD guidelines was successful at increasing self-reported awareness, knowledge, and the use of best practice guidelines among ED staff. At the 10-month follow-up, increased awareness, knowledge, and use of COPD guidelines among ED staff was maintained. However, in practice, guideline adherence, treatment failure, and return rates did not improve significantly after the implementation of local guidelines.

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