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Application of appropriateness criteria for hospitalization in COPD exacerbation

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Abstract

The IRYSS-COPD appropriateness study was developed in 16 hospitals belonging to the Spanish National Health Service from June 2008 to September 2010 (n = 2,877). The objectives were to apply a set of explicit criteria for the appropriateness of hospital admission created by the RAND/UCLA methodology to patients evaluated in the emergency department (ED) for exacerbations of COPD. This is a prospective cohort study. We explored the relationship between appropriateness of admission as defined by the explicit criteria and the final decision to admit or discharge. A total of 2,877 patients were included for analysis; of these, 1,747 (60.7 %) were admitted and 1,130 (39.3 %) were discharged from the ED to home. Among patients classified by the explicit criteria as appropriate for hospital admission, 81.3 % were admitted, compared with 64.81 % of those classified as uncertain and 48.65 % of those classified as inappropriate for admission. Severity of exacerbation was the most influencing variable in the decision. Application of our explicit criteria for appropriate hospital admission among a large sample of patients experiencing an exacerbation of COPD in the ED setting suggests that these criteria could be used as the basis for clinical decision-making and health-care assessment.

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Conflict of interest

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Author information

Authors and Affiliations

  1. Unidad de Investigación, Hospital Galdakao-Usansolo, Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Barrio Labeaga s/n, 48960, Galdakao, Vizcaya, Spain

    Susana Garcia-Gutierrez, José M. Quintana, Irantzu Barrio, Nerea Gonzalez, Iratxe Lafuente & Edurne Arteta

  2. Departamento de Matemática Aplicada y Estadística e Investigación Operativa, Universidad del País Vasco, Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Leioa, Vizcaya, Spain

    Irantzu Barrio

  3. Unidad de Epidemiología Clínica, CorporacioParcTauli, Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Barcelona, Spain

    Marisa Bare

  4. Agencia LainEntralgo, Madrid, Spain

    Nerea Fernandez

  5. Unidad de Calidad, Hospital Valme, Sevilla, Spain

    Silvia Vidal

  6. Servicio de Respiratorio, Hospital Galdakao-Usansolo, Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Galdakao, Spain

    Cristóbal Esteban

  7. Servicio de urgencias, Hospital Galdakao-Usansolo, Galdakao, Spain

    Esther Pulido

Authors
  1. Susana Garcia-Gutierrez
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  2. José M. Quintana
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  3. Irantzu Barrio
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  4. Marisa Bare
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  5. Nerea Fernandez
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  6. Silvia Vidal
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  7. Nerea Gonzalez
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  8. Iratxe Lafuente
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  9. Edurne Arteta
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  10. Cristóbal Esteban
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  11. Esther Pulido
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Consortia

The IRYSS-COPD Appropriateness Study (IRYSS-CAS) group

Corresponding author

Correspondence to Susana Garcia-Gutierrez.

Additional information

The members of IRYSS-COPD group are listed in Appendix 2.

Appendices

Appendix 1

See Fig. 1

 

Severity of the current COPD exacerbation

Parameters

Mild category I

Moderate category II

Severe category III

Very severe category IV

pH

7.35–7.45

7.35–7.45

7.35–7.45

<7.35

Consciousness level (Glasgow scale)

15

15

15

Altered <15

Hemodynamic stability*

Yes

Yes

Yes

No

Respiratory frequency <30– > 24/min

    

Sat O2/PaO2 (≤90 y/o PaO2 < 60– > 45)

0

1–2

3

Respiratory frequency ≥30

Hypercapnia of recent onset (>45), or significative deterioration, at least on 3 units, on relation to basal values.

Parameter altered

Parameter altered

The 3 parameter altered

ó

PaO2 ≤45

PCO2 >45 and PH altered (<7.35)

  1. * Hemodynamic instability: systolic blood pressure minor to 90 mmHg, or a 40 % reduction of the systolic blood pressure in absence of other stress raisers, and tachycardia or bradycardia (cardiac frequency ≤60 or ≥100)

From these six variables, defined after the meeting of the expert panel, four levels of severity for COPD exacerbation were identified:

  1. 1.

    Mild Patient with normal pH and no alterations in level of consciousness, hemodynamically stable, with respiratory rate ≤24 with O2 saturation >90 or >60 mm PaO2 without hypercapnia.

  2. 2.

    Moderate Patient with normal pH and no alterations in level of consciousness, hemodynamically stable, having one or two of the following altered parameters: increased respiratory rate (>24 cycles/min but <30 cycles/min), or respiratory failure (<60 mmHg PaO2 but >45 mmHg) or hypercapnia, as defined above.

  3. 3.

    Moderate–severe Patient with normal pH, and no alterations in level of consciousness, hemodynamically stable, which has altered the following three parameters: increased respiratory rate (>24 but <29 cycles/min), or respiratory failure, or hypercapnia, as defined above.

  4. 4.

    Grave–fatal Patient with altered pH (<7.35) or has altered level of consciousness (Glasgow <15) or is unstable hemodynamically, based on blood pressure and heart rate as defined above, or has altered respiratory rate (≥30 breaths/min) or hypoxemia (PaO2 ≤45) or its PCO2 is >45 (having, in this case also the altered pH).

Appendix 2

The IRYSS-COPD group included the following investigators: Dr. Jesús Martínez-Tapias (Subdirección de Investigación, Calidad y Docencia, Hospital Universitario Virgen de las Nieves, Granada); Dr. Eduardo Briones, (Unidad de Calidad, Hospital Valme, Sevilla); Dr. Emilio Perea-Milla (Servicio de Epidemiología, Hospital Costa del Sol, Málaga/CIBER Epidemiología y Salud Pública-CIBERESP); Dr. Juan Ramón Lacalle (Unidad de Bioestadística, Dpto. Ciencias Sociosanitarias, Universidad de Sevilla); Dra. Marisa Baré, Dra. Gemma Navarro (Unidad de Epidemiología y Evaluación, Corporació Sanitaria ParcTaulí, Sabadell); Dra. Elena Andradas, Dr. Juan Antonio Blasco, Dra. Nerea Fernández de Larrea (Unidad de Evaluación de Tecnologías Sanitarias, Agencia Laín Entralgo, Madrid); Dr. Luis Alberto Ruiz (Servicio de Neumología, Hospital San Eloy, Bizkaia), Dra. Ane Miren Gastaminza (Servicio de Urgencias, Hospital San Eloy, Bizkaia); Dr. Mikel Sánchez (Servicio de Urgencias, Hospital Alto Deba, Gipuzkoa); Dr. Jose Luis Lobo (Servicio de Neumología, Hospital Txagorritxu, Araba); Dr. Juan Ignacio Larruskain (Servicio de Urgencias, Hospital Basurto, Bizkaia); Dr. Jose Miguel Tirapu (Servicio de Neumología, Hospital Basurto, Bizkaia); Dr. José Mª Beguiristain, Dra. Belén Elizalde (Dirección Territorial de Gipuzkoa); Dra. Idoia Garai (Dirección Territorial de Bizkaia); Dr. Felipe Aizpuru [Unidad de Investigación, Hospital Txagorritxu, Álava/Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC)]; Antonio Escobar, Amaia Bilbao [Unidad de Investigación Hospital Basurto, Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC)]; Dra. Eva Tabernero (Servicio de Neumología Hospital Santa Marina); Dra. Carmen Haro (Servicio de Urgencias Hospital Santa Marina), Inmaculada Arostegui [Departamento de Matemática Aplicada y Estadística e Investigación Operativa, Universidad del País Vasco, Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC),Leioa, Bizkaia].

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Garcia-Gutierrez, S., Quintana, J.M., Barrio, I. et al. Application of appropriateness criteria for hospitalization in COPD exacerbation. Intern Emerg Med 8, 349–357 (2013). https://doi.org/10.1007/s11739-013-0927-9

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