ICU readmission is associated with increased mortality, resource utilisation and hospital expenditure. In the general population, respiratory-related event is one of the most common causes of unexpected ICU readmission. Patients with neurological deficits faced an increased risks of ICU readmissions due to impaired mentation, protective reflexes and other factors. A retrospective review revealed that the leading cause of unexpected ICU readmissions in adult neurovascular patients admitted to our hospital was respiratory related. A respiratory therapists-driven assessment-and-treat protocol was developed for proactively assessing and treating adult neurovascular patients. On-duty respiratory therapists assessed all neurovascular patients on admission, assigned a respiratory severity score to each patient and then recommended interventions based on a standardised algorithm.Our quality improvement initiative had no effect on the rate of unexpected ICU readmissions in adult neurovascular patients. When compared with the baseline population, patients enrolled in the intervention group were significantly older ((79, 68–85 years) vs (71, 56–81 years)), but they spent comparable amount of time in the ICU (4.5 vs 4 days, p=0.42). When the respiratory severity score was trended in the intervention group, patients demonstrated significant improvement in their respiratory function, with a greater proportion of patients scoring in the minimal and mild categories and smaller proportion in the moderate category (p<0.01).

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Rationale Pulmonary Rehabilitation (PR) is an intervention that has proven morbidity and mortality benefits in chronic obstructive pulmonary disease (COPD) patients. It has also been shown to be the most effective therapeutic strategy to improve dyspnea, overall health status and exercise tolerance. The Global Initiative for Chronic Obstructive Disease (GOLD) notes that PR is an essential non-pharmacological intervention in the management of patients with COPD categories B, C, and D. However, we hypothesis that PR is underutilized. The aim of this study assesses the rate of referral to PR in COPD patients at a tertiary center teaching hospital. We also performed a secondary analysis to assess the type of provider referring to PR and whether there is a difference between a teaching outpatient primary care physician (PCP) vs non-teaching PCP. Methods We performed a retrospective observational study of patients seen at the Mercy Health Center (MHC), a multispecialty medical building at a tertiary teaching hospital, from November 2016 to October 2019. We chart audited 526 patients seen at least 3 times at the MHC with a diagnosis of COPD on their electronic medical record. We included only patients with evidence of obstruction on their pulmonary function test and were GOLD category B-D in our analysis. A total of 231 patients were included in our final analysis. We assessed the rates of PR referral and performed secondary analysis to stratify whether referral was made by a PCP or a specialist and whether teaching vs non-teaching PCP had different rates. All analyses were performed using Stata version 15. Results Only 70 patients (30.3%) of the qualified patients were referred at the MHC clinic. After being stratified by PCP vs Pulmonologist care, only 20 patients (28.6%) were referred by a PCP while 50 patients (71.4%) were referred by a Pulmonologist (p<0.001). Of those referred by a PCP, 15 patients (75%) were referred by the resident clinic while only 5 patients (25%) were referred by a non-teaching PCP (p=0.016). Conclusion PR is underutilized at the MHC building, with only 30% of qualified patients being referred. Although this rate is higher than the previously published 10% rate, there appears to be a deficit in the way PR is being used. Pulmonologists appear to have higher referral rates, and teaching PCP has a higher proportion of referrals as compared to a non-teaching PCP. An educational intervention may be necessary to help improve the utilization of PR.