Why Do Hospitals Struggle With Adhering to National COPD Care Guidelines?

In a recent study, investigators found 8 prominent barriers preventing emergency departments (ED) from adhering to national guidelines for treating, discharging, and referring patients with chronic obstructive pulmonary disease (COPD).

“The contribution of all clinicians towards the preferential implementation of COPD guidelines in practice is indispensable to prevent readmission of patients within the ED,” wrote the authors.

The study, published in the Journal of Multidisciplinary Healthcare, is the first to explore barriers and possible solutions to guideline adherence from an interdisciplinary staff perspective.

The 2003 COPD-X guidelines in Australia pushed for hospitals to pull back on using pharmacological treatments in favor of more holistic multidisciplinary interventions to prevent readmissions and acute exacerbations.

Nonpharmacological interventions for COPD can include pulmonary rehabilitation, smoking cessation programs, increased physical activity, early detection of COPD, and comorbidity treatment.

However, evidence has shown that doctors, nurses, and interdisciplinary health professionals often do not follow the national guidelines consistently and readmission rates have increased over the past decade, raising questions on why hospitals are having trouble adhering to the guidelines.

Additionally, economic research data has shown that 50% of patients with COPD who presented at 3 Southern Queensland Hospitals were discharged within 4 hours without targeted referrals, which can lead to repetitive readmissions and increased economic burden.

The qualitative interpretive study design included individual interviews with 8 participants recruited from a metropolitan, tertiary hospital in Queensland, Australia. The participants included 2 doctors, 2 nurses, 2 physiotherapists, 1 pharmacist, and 1 social worker.

The interviews comprised of questions regarding 14 domains that could be considered barriers to guideline uptake, of which 8 emerged as the most prominent:

• Knowledge
• Skills
• Beliefs about capabilities
• Memory attention and decision process
• Behavior regulation
• Environmental context and resources
• Social professional role identity
• Emotion

“COPD is a multimodal disease that requires a multi-disciplinary involvement of a comprehensive health care team that is skilled, knowledgeable and has the capacity to implement best practice strategies in line with national COPD guidelines,” wrote the investigators.

Participants expressed that a lack of awareness about the national guidelines caused confusion and online resources were not made available to them. They suggested that continuing education programs could boost staff awareness, utilization, and adherence.

There were also reports that participants lacked the skills and experience to aid in respiratory management, patient education, and guideline implementation. Nurses also noted that they are often tasked with teaching inhaler techniques to patients without themselves being trained on the techniques outlined in the guidelines.

The busy nature and time constraints associated with EDs made it difficult to provide appropriate care to the acute emergent needs of patients with COPD. The participants said that time-efficient assessments, referral processes, and easily accessible patient information on smoking cessation and referrals could improve care and prevent COPD complications.

The ability to retain information on many life-threatening conditions and relying on interdisciplinary staff to know and abide by current behavioral regulations were cited as challenges to guideline implementation.

“Multiple staff reiterated the need for point of care clinical cues, prompts, checklist and easier access to resources including patient information as a probable solution to better adherence to COPD guidelines,” noted the investigators.

The participants noted that more funding and staffing was needed during winter months, when there are more COPD-related ED visits. Professional boundaries and lack of role clarification in managing COPD were known challenges, especially regarding whether COPD tests should be conducted by ED staff as opposed to respiratory specialists.

Better communication, delegation, and planning between specialty departments and interdisciplinary staff were mentioned by the investigators as strategies to mitigate staff attitudes that place the responsibility of guideline adherence on primary care teams. Emotional barriers can lead to patients with COPD being discharged without appropriate follow-up.

Limited generalizability due to interviews occurring at only 1 acute care ED and a lack of input from psychologists, respiratory physiotherapists, and respiratory clinical nurses were listed as study limitations.

“Future interventions and implementation strategies should adopt educational training, assistance and resource provision appealable to multidisciplinary teams and in an environment where online resources are readily available and accessible,” wrote the authors.

Reference

Issac H, Taylor M, Moloney C, Lea J. Exploring factors contributing to chronic obstructive pulmonary disease (COPD) guideline non-adherence and potential solutions in the emergency department: Interdisciplinary staff perspective. J Multidiscip Healthc. 2021;14: 767–785. doi: 10.2147/JMDH.S276702