| Home | E-Submission | Sitemap | Contact Us |  
Search
Clin Exp Emerg Med Search

CLOSE

Clin Exp Emerg Med > Volume 11(3); 2024 > Article
King, Ramic, Wilson, Aaron, and Stiell: Evaluation of the quality of emergency department management for patients with chronic obstructive pulmonary disease

Abstract

Objective

Chronic obstructive pulmonary disease (COPD) is associated with exacerbations and high risk of serious outcomes. Our goal was to determine the appropriateness of the emergency department (ED) management of COPD exacerbations.

Methods

This observational cohort study incorporated a health records review and included COPD exacerbation cases seen at two large academic EDs. We included all patients with the primary diagnosis of COPD exacerbation. From the electronic medical record, demographic and clinical data were abstracted, and the Ottawa COPD Risk Score (OCRS) was calculated for each. Short-term serious outcomes included intensive care unit admission, intubation, myocardial infarction, noninvasive positive pressure ventilation (NIV), and death at 30 days. Cases were judged for appropriateness of treatment according to explicit indications and standards developed a priori.

Results

We enrolled 500 cases with mean age of 71.9 years, 51.2% female patients, 50.2% admitted, and 4.4% death. The calculated OCRS score was ≥2 for 70.8% of patients. The treatments provided were inhaled β-agonists (82.6%), inhaled anticholinergics (76.6%), corticosteroids (75.2%), antibiotics (71.0%), oxygen (63.8%), NIV (8.8%), and intubation (0.6%). Overall, 50.0% of cases were judged to have had inadequate management due to missing treatments. Specifically, the proportion of missing treatments were inhaled β-agonist (17.0%), inhaled anticholinergic (22.6%), corticosteroids (24.4%), antibiotics (12.8%), and NIV (2.0%).

Conclusion

Adequate treatment of COPD exacerbation was lacking in 50.0% of patients in these two large academic EDs. Concerning were the number of patients not receiving corticosteroids or antibiotics. Implementation of explicit treatment standards should lead to improved patient care of this common and serious condition.

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a chronic lung disease secondary to inflammation and narrowing of the airways, parenchymal destruction, mucous hypersecretion, and hypoxic vasoconstriction [1]. COPD leads to frequent hospitalizations due to infectious and noninfectious acute exacerbations with a mix of viral and bacterial aetiologies [2]. COPD exacerbations account for 1% of all emergency department (ED) visits [3]. Those who experience frequent exacerbations of disease are at risk of serious outcomes including death and endotracheal intubation. Evidence-based therapies currently recommended for optimization of bronchodilation and reduction of inflammation during COPD exacerbations including inhaled short-acting β-agonists or short-acting anticholinergics, long-acting anticholinergics, systemic corticosteroids, and antibiotics [4].
In 2014, ED researchers developed the Ottawa COPD Risk Scale (OCRS) which includes 10 highly predictive signs of serious adverse events in patients with COPD [5]. When validated in 2018, it was determined that a score of ≥2 was an indication for hospitalization to reduce short-term serious outcomes at 30 days [6]. In the study, it was estimated that an 11.6% increase in admission to hospital of patients with COPD exacerbations would be necessary to diminish the rate of secondary serious outcomes by 1.2%. Following the introduction of the OCRS, physicians at Canadian EDs described it as useful and likely to be applied [7].
The goal of this study was to determine the appropriateness of treatment of COPD exacerbations in the ED. We also investigated the OCRS, patient disposition, and the rate of serious short-term outcomes.

METHODS

Ethics statement

The study was approved by the Ottawa Health Sciences Network Research Ethics Board (No. 20200554-01H). Informed consent was waived because this was a simple health records review.

Study design

We conducted an observational cohort study by reviewing the health records of a consecutive sample of COPD patients seen over a 36-month period from June 30, 2017, to July 1, 2020 at the two Ottawa Hospital (Ottawa, ON, Canada) EDs. The Ottawa Hospital Hospital is a large academic health care center with 1,200 beds. The two EDs see 160,000 patients annually and are staffed by 95 certified attending physicians and 55 residents. We included all patients with the primary diagnosis of COPD exacerbation on their initial visits and return visits within 2 months to the ED.

Data collection procedures

A list from the National Ambulatory Care Reporting System was obtained from the data warehouse on all included patients. The inclusion criteria were diagnosis of COPD (confirmed with a previous pulmonary function test, verified by consultant, or significant cigarette smoking history), charted past medical history, charted vital signs, and completed investigations during ED visit to permit calculation of the OCRS score (urea, hemoglobin, serum CO2, electrocardiogram [ECG], and chest x-ray). We excluded patients with an unclear diagnosis (i.e., mixed COPD exacerbation and acute pulmonary edema), patients with incomplete charting and insufficient investigations. All potentials cases were reviewed by the first author (PJK) and two medical students (LR, JW) and further reviewed by a staff emergency physician (IGS). All pertinent information was entered into an electronic database for statistical analysis.

Measures

The demographic data collected during chart review included age, sex, data of visit, number of visits, and follow-up visits to the ED. The clinical presentation including the patient’s presenting symptoms, past medical history, current prescribed outpatient medications, triage vital signs, blood work results, chest x-ray, and ECG interpretations and walk test results were recorded. The OCRS score was calculated for each patient utilizing the required data if not already completed by the attending physician. Supplementary Material 1 outlines the OCRS with a breakdown of each criterion. Information on the patient’s disposition was also collected; admission to the ward, to a monitored unit (including the intensive care unit [ICU] or discharge home). We identified short-term serious outcomes (SSO) including time spent in the ICU or other monitored care settings, endotracheal intubation, myocardial infarction, use of noninvasive positive pressure ventilation (NIV), return visits to the ED within 30 days, and death at 30 days. The SSO were also noted for any patients discharged home with return visits to the ED within 30 days.

Appropriateness of treatment

Cases were judged for appropriateness of treatment according to explicit indications and standards developed by a senior respirology physician and ED physician (Figs. 1, 2). The development of the treatment standards of care was based on the most recent GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines for acute COPD exacerbation management [1]. The recent 2023 update included no substantive changes to the management of COPD exacerbation [8].
Fig. 1 outlines the algorithm for oxygen therapy with a target saturation of 88% to 92% with either a venturi mask or nasal prongs. NIV is required if patients have any signs of respiratory failure. Invasive mechanical ventilation is indicated for any signs of life-threatening respiratory failure, contraindications to NIV, or failed NIV.
Fig. 2 displays the algorithm for pharmacotherapy, giving the standard for administration of inhaled short-acting β2-agonists, inhaled anticholinergics, and systemic corticosteroids. Indications for antibiotics administration are signs of bacterial infection: fever, increased sputum production or purulence, opacity on chest x-ray, or sepsis. The recommended antibiotic regimens differed on risk factors for pseudomonas infection.
Determination of appropriateness of treatments was made by the senior authors (PJK, IGS) according to the explicit criteria outlined in Figs. 1 and 2. In all cases, consensus was reached by discussion.

Sample size

Based on feasibility for this unfunded study, we aimed to include 500 patients seen over 36 months. We believed this number of cases would provide sufficient variety in presentations to allow us to adequately evaluate management. The same patient was not counted for two visits unless they presented more than 2 months after the initial visit.

Statistical analysis

A simple frequency report was conducted with 95% confidence intervals.

RESULTS

Of 2,696 COPD exacerbation patient visits between July 1, 2017, to June 30, 2020, 745 visits were reviewed. Of these 745 patient visits, 245 were excluded due to incorrect diagnosis, inadequate documentation of the patient’s presenting symptoms, and missing investigative clinical data (ECG, chest x-ray, and blood work) (Fig. 3).
Table 1 displays the patient characteristics for the 500 patient visits: mean age (71.9 years), female sex (51.2%), mean heart rate (97.7 beats/min), mean respiratory rate (23.1 breaths/min), mean oxygen saturation (93%), and mean temperature (36.7 °C). Most patients were currently smoking tobacco or had a history of tobacco use (95.6%). Many had a listed diagnosis of COPD in their medical chart (94.8%). We confirmed the diagnosis of the remaining 4.2% with a reported pulmonary function test (forced expiratory volume in the first second of expiration to forced vital capacity ratio, <0.7) or presumed by a chronic smoking history (>40 years). Many patients had other comorbidities including hypertension (57.8%), cancer (27.0%), diabetes (24.8%), myocardial infarction or angina (21.0%), heart failure (19.4%), atrial fibrillation (18.0%), and chronic renal failure (10.8%). Most had prescribed outpatient medications for COPD including inhaled β-agonist (70.2%), inhaled anticholinergic (57.4%), and inhaled corticosteroids (51.4%). Home oxygen was prescribed for 12.6% of patients. Worsening cough was the most common presenting symptom (94.8%), followed by dyspnea (74.4%), increased sputum production (56.0%), and sputum purulence (42.8%).
The calculated OCRS results of these patients varied from 1 to 10 on a maximum scale of 16 (Table 2). Of note, the OCRS was only calculated on one of the 500 patient visits (0.002%). A minority of patients had a score of <2 (29.8%) which is associated with a risk of SSO <4%. Most had scores of ≥2 (70.8%). These higher scores reflect a risk of SSO >7.2%. The OCRS scores and risk categories for SSO is displayed in Supplementary Material 1.
Table 3 outlines the frequency of treatments provided for 500 patient visits: inhaled β-agonist (82.6%), inhaled anticholinergic (76.6%), corticosteroids (intravenous or per oral, 75.2%), antibiotics (intravenous or per oral, 71.0%), oxygen therapy (63.8%), NIV (8.8%), and endotracheal intubation (0.6%). Disposition of patients included: ward (42.0%), monitored setting (9.6%), and discharge home (48.4%). Of those admitted to hospital, 92 patients had a serious short-term outcome: transfer to a monitored setting (12.5%), endotracheal intubation (1.6%), myocardial infarction (4.3%), and NIV (17.4%). Of the 242 patients discharged home, 58 returned to the ED within 30 days for COPD-related reasons. The SSO of the discharged patients upon return included the following: admission to monitored setting (2.1%), endotracheal intubation (0.8%), and NIV (0.8%). Death at 30 days occurred in 22 patients (4.4%). These deaths were most associated with acute hypoxemic respiratory failure (50.0%), followed by cancer (22.7%), gastrointestinal causes (13.6%), and infection (13.6%).
Table 4 displays the appropriateness of treatments given. The treatment was determined to be appropriate in half of the patients (50.0%). The frequency of the missing treatments are as follows: corticosteroids (24.4%), inhaled anticholinergic (22.6%), inhaled β-agonist (17.0%), antibiotics (12.8%), and NIV (2.0%).

DISCUSSION

This study sought to seek how appropriately patients with COPD exacerbations were being treated in the ED. Overall, 50% of cases were judged to have had suboptimal treatment. Notably, corticosteroids and antibiotics were often missed. This raises concern for how these patients may fare without the needed therapy in avoiding complications. Of all included patients, two-thirds were admitted. A considerable number of discharged patients returned to the ED for treatment within 30 days. With appropriate treatment, we may decrease the number of returning patients to the ED. This entails the benefits of decreased ED volumes and health care expenditure. The returning patient may be having similar or unchanged symptoms, seeking more treatment that may have been missed from their first encounter.
Another surprising finding was the lack of calculation of the OCRS by ED providers. We found only one chart with the calculated score in the 500 reviewed. The OCRS is a clinical decision tool that may alter our disposition for patients as it permits calculation of a risk for SSO in 30 days. It appears that most patients that warranted an admission considering a calculated score of ≥2 were admitted. This may indicate that ED providers may already be aware of the clinical findings that increase the risk of SSO. It could be that ED providers are also relying heavily on the walk test for oxygenation to determine admission versus discharge for patients. As we know, a failure walk test alone scores 2 on the OCRS, warranting admission due to increased risk of SSO.
There are many publications that review management [9,10] or predict outcomes of patients with COPD exacerbations [11,12]. There are only a few, however, that discuss optimal management in the ED, through use of treatment bundles in observation units [13,14]. No previous studies have evaluated the appropriateness of ED management of COPD exacerbations and tied this to the use of the OCRS in the ED. The rate of admission was comparable to a previous study by Garcia-Sanz et al. [3] quoting a 57% admission rate. In fact, a considerable number of patients admitted to hospital had short-term complications with admission to ICU and use of NIV being the most common. Although complications occur in a minority of patients, these events significantly increase health care expenses [15]. Admittedly, the complications of ICU admission and NIV use were often combined as a negative pressure room was necessary due to concerns from aerosol generating procedures since the COVID-19 pandemic. Perhaps with appropriate treatment in the ED, the patients could anticipate an admission to hospital with less or no complications. Our recorded 30-day mortality of 4.4% was lower than described in previous data. In fact, Roche et al. [16]. in 2008 had a 7.4% mortality at 90 days. Our rate of patients returning to the ED after discharge home is comparable to previous quoted return rates of one in five patients [17].
This study had some limitations. Firstly, a total of 134 patients were excluded as shown in Fig. 3, due to lack of blood work or investigations such as ECG and chest x-ray. This represents approximately 5.6% of the total 745 patients visits reviewed prior to exclusion. These patients were likely low-risk patients who may not warrant further investigations and who were more likely to have been dispositioned home with less risk of SSO. Second, some patients may have had withheld treatments due to a pending admission. We did note that many of the missing treatments were later provided by the consulting service. However, we would argue that effective treatments should not be delayed for the admission of a consultant as these medications are readily available in the ED. Third, we did not follow patients to determine if outcomes varied by appropriateness of ED treatment.
Overall, this study clarified the current management of COPD exacerbations in the ED. Certainly, our findings have the potential of improving patient care by making ED providers aware of the pitfalls of current management. Implementation of explicit treatment standards should lead to improved patient care of this common and serious respiratory condition. A method which may directly affect patient care would be the building of integrated COPD exacerbation order sets on electronic medical systems based on our predetermined treatment standards. This may lead to increased rates of indicated antibiotics and corticosteroids which were the two therapies most missed. Certainly, it appears that clinicians were utilizing adverse event predictors from the OCRS without necessarily calculating the score. Perhaps physician gestalt is performing similarly to the explicit calculation of the score. This resulted in admission and monitoring of patients who had the highest rates of adverse events. An integrated treatment algorithm or pathway may decrease the number of missed indicated therapies.
Further evaluation of the role of brief smoking cessation counselling in the ED as part of the management standard of COPD exacerbations may be interesting in pursuing as it is the only reversible cause to this chronic pulmonary disease. An evaluation of the impact of introducing an ED COPD exacerbation treatment algorithm may also help identify if it is an appropriate quality improvement strategy. Finally, future studies could evaluate the impact of appropriateness of ED treatment on 30-days outcomes.
In conclusion, adequate treatment of COPD exacerbation was lacking in 50% of patients in these two large academic EDs. Concerning were the number of patients not receiving corticosteroids or antibiotics. Implementation of explicit treatment standards should lead to improved patient care of this common and serious respiratory condition.

NOTES

Author contributions
Conceptualization: SA, IGS; Data curation: PJK, LR, JW; Supervision: IGS; Writing–original draft: PJK; Writing–review & editing: all authors. All authors read and approved the final manuscript.
Conflicts of interest
Ian G. Stiell is an Editorial Board member of Clinical and Experimental Emergency Medicine, but was not involved in the peer reviewer selection, evaluation, or decision process of this article. The authors have no other conflicts of interest to declare.
Funding
The authors received no financial support for this study.
Data availability
Data analyzed in this study are available from the corresponding author upon reasonable request.

Supplementary materials

Supplementary materials are available from https://doi.org/10.15441/ceem.24.197.

Supplementary Material 1.

Ottawa COPD Risk Scale to identify emergency department patients with acute COPD at high risk for serious short-term outcomes.
ceem-24-197-supplementary-Material-1.pdf

REFERENCES

1. Singh D, Agusti A, Anzueto A, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease: the GOLD science committee report 2019. Eur Respir J 2019; 53:1900164.
crossref pmid
2. Stockley RA, O'Brien C, Pye A, Hill SL. Relationship of sputum color to nature and outpatient management of acute exacerbations of COPD. Chest 2000; 117:1638-45.
crossref pmid
3. Garcia-Sanz MT, Pol-Balado C, Abellas C, Canive-Gomez JC, Anton-Sanmartin D, Gonzalez-Barcala FJ. Factors associated with hospital admission in patients reaching the emergency department with COPD exacerbation. Multidiscip Respir Med 2012; 7:6.
pmid pmc
4. Dobler CC, Morrow AS, Beuschel B, et al. Pharmacologic therapies in patients with exacerbation of chronic obstructive pulmonary disease: a systematic review with meta-analysis. Ann Intern Med 2020; 172:413-22.
crossref pmid
5. Stiell IG, Clement CM, Aaron SD, et al. Clinical characteristics associated with adverse events in patients with exacerbation of chronic obstructive pulmonary disease: a prospective cohort study. CMAJ 2014; 186:E193-204.
crossref pmid pmc
6. Stiell IG, Perry JJ, Clement CM, et al. Clinical validation of a risk scale for serious outcomes among patients with chronic obstructive pulmonary disease managed in the emergency department. CMAJ 2018; 190:E1406-13.
crossref pmid pmc
7. Hale MK, Stiell IG, Clement CM. Emergency department management of heart failure and COPD: a national survey of attitudes and practice. CJEM 2016; 18:429-36.
crossref pmid
8. Agusti A, Celli BR, Criner GJ, et al. Global initiative for chronic obstructive lung disease 2023 report: GOLD executive summary. Am J Respir Crit Care Med 2023; 207:819-37.
crossref pmid pmc
9. Long B, Rezaie SR. Evaluation and management of asthma and chronic obstructive pulmonary disease exacerbation in the emergency department. Emerg Med Clin North Am 2022; 40:539-63.
crossref pmid
10. Phillips TM, Moloney C, Sneath E, et al. Associated factors, assessment, management, and outcomes of patients who present to the emergency department for acute exacerbation of chronic obstructive pulmonary disease: a scoping review. Respir Med 2022; 193:106747.
crossref pmid
11. Rezaee ME, Ward CE, Nuanez B, Rezaee DA, Ditkoff J, Halalau A. Examining 30-day COPD readmissions through the emergency department. Int J Chron Obstruct Pulmon Dis 2018; 13:109-20.
crossref pmid pdf
12. Doers ME, Zafar MA, Stolz U, Eckman MH, Panos RJ, Loftus TM. Predicting adverse events among patients with COPD exacerbations in the emergency department. Respir Care 2022; 67:56-65.
crossref pmid
13. Zafar MA, Loftus TM, Palmer JP, et al. COPD care bundle in emergency department observation unit reduces emergency department revisits. Respir Care 2020; 65:1-10.
crossref pmid
14. Budde J, Agarwal P, Mazumdar M, Yeo J, Braman SS. Can an emergency department observation unit reduce hospital admissions for COPD exacerbation? Lung 2018; 196:267-70.
crossref pmid pdf
15. Dalal AA, Shah M, D'Souza AO, Rane P. Costs of COPD exacerbations in the emergency department and inpatient setting. Respir Med 2011; 105:454-60.
crossref pmid
16. Roche N, Zureik M, Soussan D, Neukirch F, Perrotin D; Urgence BPCO (COPD Emergency) Scientific Committee. Predictors of outcomes in COPD exacerbation cases presenting to the emergency department. Eur Respir J 2008; 32:953-61.
crossref pmid
17. Kim S, Emerman CL, Cydulka RK, et al. Prospective multicenter study of relapse following emergency department treatment of COPD exacerbation. Chest 2004; 125:473-81.
crossref pmid

Fig. 1.
Emergency department chronic obstructive pulmonary disease exacerbation treatment standard (oxygen therapy). SaO2, oxygen saturation; NIV, noninvasive positive pressure ventilation.
ceem-24-197f1.jpg
Fig. 2.
Emergency department chronic obstructive pulmonary disease (COPD) exacerbation treatment standard (pharmacotherapy). PO, per oral; PRN, as needed; IV, intravenous.
ceem-24-197f2.jpg
Fig. 3.
Inclusion and exclusion of patients visits. ECG, electrocardiogram; AMA, acute medical assessment.
ceem-24-197f3.jpg
Table 1.
Characteristics of patients with COPD exacerbations
Characteristic Value (n=500)
Age (yr) 71.9±11.7 (39–101)
Sex
 Female 256 (51.2)
 Male 244 (48.8)
Vital sign at triage
 Heart rate (beats/min) 97.7±20.9
 Systolic blood pressure (mmHg) 138.5±24.7
 Diastolic blood pressure (mmHg) 77.5±15.0
 Respiratory rate (breaths/min) 23.1±6.1
 Oxygen saturation (%) 93.0±5.7
 Temperature (°C) 36.7±0.8
Past medical history
 Current or former smoker 478 (95.6)
 Chronic obstructive pulmonary disease 474 (94.8)
 Hypertension 289 (57.8)
 Cancer 135 (27.0)
 Diabetes 124 (24.8)
 Myocardial infarction or angina 105 (21.0)
 Heart failure 97 (19.4)
 Atrial fibrillation 90 (18.0)
 Chronic renal failure 54 (10.8)
 Valvular heart disease 44 (8.8)
 Peripheral vascular disease 37 (7.4)
 Dementia 36 (7.2)
 Pacemaker 21 (4.2)
Current prescribed outpatient medications
 Inhaled β-agonist 394 (78.8)
 Inhaled anticholinergic 287 (57.4)
 Inhaled corticosteroid 257 (51.4)
 Antibiotic 78 (15.6)
 Home oxygen 63 (12.6)
 Oral corticosteroid 62 (12.4)
Presenting symptom
 Worsening cough 474 (94.8)
 Dyspnea 372 (74.4)
 Increased sputum production 280 (56.0)
 Sputum purulence 214 (42.8)
 Chest pain 123 (24.6)
 Fever 106 (21.2)

Values are presented as mean±standard deviation (range), number (%), or mean±standard deviation.

Table 2.
OCRS criteria and calculated score of 500 patients with COPD (n=500)
Variable No. of patients (%)
OCRS criteria
 History of CABG 21 (4.2)
 History of intervention for PVD 37 (7.4)
 History of intubation for respiratory distress 15 (3.0)
 Heart rate >110 beats/min 130 (26.0)
 Hemoglobin <100 g/L 52 (10.4)
 Urea >12 mmol/L 54 (10.8)
 Serum CO2 >35 mEq/L 124 (24.8)
 Pulmonary congestion on chest x-ray 103 (20.6)
 Acute ischemic changes on ECG 49 (9.8)
 Walk testa) 266 (53.2)
Calculated OCRS on chart review
 0 104 (20.8)
 1 45 (9.0)
 2 106 (21.2)
 3 67 (13.4)
 4 80 (16.0)
 5 44 (8.8)
 6 15 (3.0)
 7 18 (3.6)
 8 12 (2.4)
 9 5 (1.0)
 10 4 (0.8)
 >10 0 (0)

OCRS, Ottawa COPD Risk Score; COPD, chronic obstructive pulmonary disease; CABG, coronary artery bypass graft; PVD, peripheral vascular disease; ECG, electrocardiogram.

a)Oxygen saturation <90% or heart rate >120 beats/min after 3 minutes of walking.

Table 3.
Disposition and treatments in the ED
Variable No. of patients (%) (n=500)
Treatment
 Inhaled β-agonist 413 (82.6)
 Inhaled anticholinergic 383 (76.6)
 Corticosteroid (IV or PO) 376 (75.2)
 Antibiotics (IV or PO) 355 (71.0)
 Oxygen therapy 319 (63.8)
 Noninvasive positive pressure ventilation 44 (8.8)
 Intubation 3 (0.6)
Disposition
 Home 242 (48.4)
 Admission to monitored setting (AMA/ICU) 48 (9.6)
 Admission to ward 210 (42.0)
Complication during admission to hospital (n=258)
 Admission to monitored setting (AMA/ICU) 32 (12.4)
 Endotracheal intubation 4 (1.6)
 Myocardial infarction 11 (4.3)
 Noninvasive positive pressure ventilation 45 (17.4)
Return to ED visits within 30 days if discharged home (n=242) 58 (24.0)
Complication during return to ED visit (n=58)
  Admission to ICU/monitored setting 2 (3.4)
  Endotracheal intubation 1 (0.8)
  Myocardial infarction 0 (0)
  Noninvasive positive pressure ventilation 1 (0.8)
Death at 30 days 22 (4.4)
Cause of death (n=22)
  Acute hypoxemic respiratory failure 11 (50.0)
  Cancer 5 (22.7)
  Gastrointestinal complication (perforation/obstruction) 3 (13.6)
  Infection 3 (13.6)

entages may not total 100 due to rounding.

ED, emergency department; IV, intravenous; PO, per oral; AMA, acute medical assessment; ICU, intensive care unit.

Table 4.
Appropriate treatments not given when indicated in 500 COPD patient visits in the emergency department
Variable No. of patients (%)
Treatment appropriateness (as per predetermined goal standard)
 Yes 250 (50.0)
 No 250 (50.0)
Missing treatmenta)
 Corticosteroids (IV or PO) 122 (24.4)
 Inhaled anticholinergic 113 (22.6)
 Inhaled β-agonist 85 (17.0)
 Antibiotics (IV or PO) 64 (12.8)
 Noninvasive positive pressure ventilation 10 (2.0)
 Oxygen therapy 0 (0)
 Endotracheal intubation 0 (0)

COPD, chronic obstructive pulmonary disease; IV, intravenous; PO, per oral.

a)Patients may have had more than one missing treatments.

Editorial Office
The Korean Society of Emergency Medicine
101-3104, Brownstone Seoul, 464 Cheongpa-ro, Jung-gu, Seoul 04510, Korea
TEL: +82-31-709-0918   E-mail: office@ceemjournal.org
About |  Browse Articles |  Current Issue |  For Authors and Reviewers
Copyright © by The Korean Society of Emergency Medicine.                 Developed in M2PI