New study shows ‘transition bundle’ helps acute COPD patients following hospital stay

The program is effective at preventing rehospitalization and will soon be part of standard care in Alberta.

Jon Pullin - 08 August 2022

Chronic obstructive pulmonary disease (COPD) is one of the top causes of hospitalizations in Alberta. The lung disease, which makes it difficult to breathe, often gets worse over time. Chronic inflammation restricts airflow from the lungs, and symptoms include difficulty breathing, coughing, mucus production and wheezing. The annual health-care cost of COPD in Alberta is estimated to be $254 million, and COPD patients are at a very high risk of returning to hospital within seven to 30 days following discharge.

A recent study, conducted at five sites and led by Department of Medicine professor Michael Stickland, looked at the effectiveness of using both a “transition bundle” and a care coordinator with hospitalized COPD patients to optimize the outcomes of patients. 

“We had evidence that patients with COPD were being discharged from hospital without appropriate support, which increased their risk of being readmitted later,” says Stickland. “We needed to find ways to better support the transition for these patients.”

The transition bundle consists of making sure patients understand how to properly use their inhalers, sending a discharge summary to the patient’s family doctor and arranging a follow-up visit, optimizing the patient’s medications, providing a care management plan, screening for comorbidities, assessing for smoking and referring patients for pulmonary rehabilitation. 

“The bundle is designed to help patients transition back to the community. We know that if patients see their family physician following discharge from hospital, it helps them manage their condition and keeps them out of hospital,” says Stickland.

Researchers found that when used, the bundle was associated with lower hospital readmissions, increased patient follow-up with a family physician and lower mortality. 

“We found COPD patients were more likely to follow up with their family doctor which reduced the risk of readmission later,” says Stickland.

Care coordinators were introduced as part of the study as well. The coordinators contacted some of the patients shortly after being discharged to ensure they had followed through with their post-discharge care plan. 

Although adding the use of a care coordinator to the transition bundle did not reduce readmissions, it did result in more patients visiting their doctor within 14 days of discharge.

Shelley Vallaire, senior provincial director within the Alberta Health Services (AHS) Strategic Clinical Network, facilitated the rollout.

"We often know which interventions are supported with clinical evidence but determining how to implement them within an operational context is challenging. This study pulled resources and expertise including academic researchers, AHS clinical and operational leadership, including the AHS Strategic Clinical networks, as well as frontline local improvement teams at the five hospitals, to work collaboratively to test the most clinically and cost-effective way to transition patients," says Vallaire.

“We now need to translate the evidence generated by this study into everyday clinical practice to ensure that patients with COPD receive the best care and achieve the best outcomes possible,” adds Louise Morrin, senior provincial director of the AHS Medicine Strategic Clinical Network.  

To that end, the transition bundle developed as part of this study now forms part of the AHS COPD order set and discharge bundle. “Our colleagues have worked to integrate this into Alberta’s new electronic medical system (Connect Care) and this is to be rolled out as part of a larger AHS Acute Care Bundle Initiative, at the 14 largest acute care sites in Alberta,” says Stickland. 

“The transition bundle we developed is now becoming part of the standard of care for hospitalized COPD patients.”

Funding for this study was awarded through the Alberta Innovates Health Solutions (AIHS) Partnership for Research and Innovation in the Health System (PRIHS) Competition. This study was made possible through collaboration with clinical and operational leadership, frontline, and local improvement teams at the five hospitals, as well as with the support of the Respiratory Health Strategic Clinical Network. Hospitals include: Foothills Medical Centre, Red Deer Regional Hospital Centre, Rockyview General Hospital, Royal Alexandra Hospital and University of Alberta Hospital.