Factors influencing the implementation and uptake of a discharge care bundle for patients with acute exacerbation of chronic obstructive pulmonary disease: a qualitative focus group study

Abstract

Background: Chronic obstructive pulmonary disease (COPD) is one of the most common causes of mortality and morbidity in high-income countries. In addition to the high costs of initial hospitalization, COPD patients frequently return to the emergency department (ED) and are readmitted to hospital within 30 days of discharge. A COPD acute care discharge care bundle focused on optimizing care for patients with an acute exacerbation of COPD has been shown to reduce ED revisits and hospital readmissions. The aim of this study was to explore and understand factors influencing implementation and uptake of COPD discharge care bundle items in acute care facilities from the perspective of health care providers and patients. Methods: Qualitative methodology was adopted. Nine focus groups were conducted using a semi-structured guide: seven with acute and primary/community health care providers and two with patients/family members. Focus groups were audiotaped, transcribed verbatim, and coded and analyzed using a thematic approach. Results: Forty-six health care providers and 14 patients/family members participated in the focus groups. Health care providers and patients identified four factors that can challenge the implementation of COPD discharge care bundles: process of care complexities, human capacity in care settings, communication and engagement, and attitudes and perceptions towards change. Both health care providers and patients recognized process of care complexity as the most important determinant of the COPD discharge bundle uptake. Processes of care complexity include patient activities in seeking and receiving care, as well as practitioner activities in making a diagnosis and recommending or implementing treatment. Important issues linked to human capacity in care settings included time constraints, high patient volume, and limited staffing. Communication during transitions in care across settings and patient engagement were also broadly discussed. Other important issues were linked to patients', providers', and system attitudes towards change and level of involvement in COPD discharge bundle implementation.

Optimizing COPD Acute Care Patient Outcomes Using a Standardized Transition Bundle and Care Coordinator

“…This study was novel because it tested the effectiveness of a transition bundle on patient outcomes in a realworld setting. A key strength of this work is the implementation strategy, which included the evaluation of patient and clinician barriers and facilitators to implementation, 28 and then use of these findings to support local improvement teams. Bundle uptake was low, despite the use of clinician engagement meetings and audit and feedback reports.…”

“…The study was not designed to understand the elements of usual care; however, before the study, no formal processes were in place at any of the hospitals to deliver the transition bundle elements listed in Table 1. Physicians are expected to send a discharge summary to the family physician; however, based on previous investigation, 28 it is estimated that other elements would have been delivered infrequently within the usual care group. Transition bundle data were submitted to the study analyst at patient discharge, and patients in the transition bundle group then were randomized to either care coordinator or no care coordinator using a concealed group allocation algorithm and an electronic random-number generator (Fig 1).…”

“…27 Patient and clinician focus groups were held to understand barriers and facilitators for bundle uptake or use in clinical settings. 28 These data contributed to the development and real-world implementation of a COPD transition bundle.…”

Evaluation of an implementation package to deliver the COPD CARE service

“…Similar barriers to implementing COPD care bundles into practice are described in the literature including challenges coordinating service implementation and training across service lines. 36 The INSPIRED COPD Outreach Program, a COPD care transitions programme in Canada, describes lack of clinician training and experience as barriers to implement the programme across Canadian provinces. 37 Furthermore, evaluators describe stakeholder relationships as a barrier when communication challenges existed.…”

Retrospective observational study of asthma and chronic obstructive pulmonary disease prevalence and associated healthcare resource utilization in a large, integrated healthcare system

“…Early engagement of patients and healthcare providers and clear communication to target barriers may facilitate care transitions between the ED and the primary care setting for acute asthma 13 and COPD. 14 …”