Morning Report is an occasional feature in ACP Hospitalist that will analyze the clinical and administrative aspects of a fictional but realistic hospital case from admission to discharge. Authors of this feature will discuss the patient's clinical course and will also provide a brief overview of background, diagnosis, and management, emphasizing whether the case was optimally managed and whether the patient was appropriately discharged with efforts to prevent readmission. Tips on effective documentation will also be reviewed.
Chief symptoms: Progressive shortness of breath, cough, and wheezing for 4 days
History: A 67-year-old man with a history of chronic obstructive pulmonary disease (COPD), hypertension, and dyslipidemia was brought into the ED by his daughter with 4-day history of worsening shortness of breath, wheezing, and increased productive cough with change in color of sputum from clear tan to greenish. He was experiencing dyspnea on exertion. He did not report fever, night sweats, chest pain, or palpitations. He had had multiple hospitalizations for COPD exacerbations due to nonadherence to medications. The most recent admission was a month previously.
He reported no other pertinent medical or surgical history. He had a family history of hypertension and diabetes in his mother and hypertension and myocardial infarction in his father. He had a 40-pack-year smoking history but did not report using alcohol or illicit drugs. He retired 2 years ago and lived alone. He had no known drug allergies. His medications were lisinopril, 20 mg/d; atorvastatin, 20 mg/d; fluticasone propionate/salmeterol, 250/50 inhaler, 1 puff twice daily; tiotropium inhaler, 18 µg, 1 cap daily; ipratropium bromide/albuterol, inhaled 0.5 mg/2.5 mg/3 mL nebulizer every 6 hours as needed; and levalbuterol, inhaled 0.63 mg/3 mL nebulizer every 8 hours as needed.
His most recent spirometry results, from a month ago, showed an FEV1 of 1.56 L, 30% of predicted (predicted FEV1, 3.07 L), FVC of 2.28 L, and FEV1/FVC ratio of 0.68 (68%).
Physical examination: Vital signs were as follows: blood pressure, 110/60 mm Hg; heart rate, 110/min; temperature, 98.7 °F; respiratory rate, 34/min; oxygen saturation, 81% on room air.
The patient was a thin man who appeared awake and alert but in moderate respiratory distress, using accessory muscles. On cardiac examination, he was tachycardic with regular rhythm and normal S1, S2 heart sounds with audible S3 gallop. Auscultation of the lungs revealed coarse rhonchi and diffuse wheezing. He had no cyanosis or lower-extremity pitting edema. The rest of the examination was unremarkable.
Labs: Arterial blood gases showed a pH of 7.20, a Paco2 of 67 mmHg, a Pao2 of 61 mmHg, and an HCO3 of 30 mmol/L on nasal cannula at 2 L/min. White blood cell count was 14,000 cells/µL, hemoglobin level was 15.1 g/dL, and hematocrit was 48%. Comprehensive metabolic panel was within normal limits.
Imaging: Electrocardiogram revealed sinus tachycardia (heart rate, 115/min) with a normal interval and no ST, T-wave changes. Chest X-ray revealed lung hyperinflation and flattened diaphragm. No acute infiltrates were seen.
The patient was admitted to the inpatient unit with the diagnosis of COPD exacerbation. He was treated with oxygen therapy by nasal cannula, 6 L/min. He was also given inhaled albuterol, 2.5 mg, by nebulizer every 2 to 4 hours, together with oral prednisone, 60 mg/d. On day 2 of admission, the patient's clinical state deteriorated with severe hypoxemia and increasing respiratory fatigue. He required endotracheal intubation and was transferred to the ICU. Levofloxacin, 500 mg, and a systemic corticosteroid were started intravenously along with frequent albuterol/ipratropium nebulization. After daily weaning trials, he was successfully liberated from invasive mechanical ventilation on day 8. His antibiotic course was completed, and he was subsequently discharged on day 10 with a taper course of oral corticosteroids. He was advised to go to the nearest ED if the symptoms developed again.
Q: Was our patient diagnosed correctly?
A: Yes. The diagnosis of COPD exacerbation is based on the clinical presentation (acute change in symptoms from baseline dyspnea, cough and/or sputum production, that is beyond normal day-to-day variation) (11. Global Strategy for the Diagnosis, Management, and Prevention of COPD: Revised 2014. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Updated 2014. Accessed online on Aug. 14, 2015. ). Our patient had an extensive smoking history along with multiple admissions for COPD exacerbation. The worsening of his respiratory symptoms (dyspnea, cough, and/or sputum production) along with his medical history pointed toward COPD exacerbation. However, the severity of his COPD exacerbation was not identified at the time of admission. Our patient had respiratory failure based on his difficulty breathing and abnormal arterial blood gas values, so hypoxic hypercapnic respiratory failure should have been documented. This improper documentation would have resulted in inappropriate coding of the diagnosis-related group (DRG), leading to lower than expected geometric mean length of stay and lower reimbursement to the hospital.
Q: Was our patient managed and discharged appropriately?
A: No. Our patient had COPD exacerbation with respiratory failure from the time of admission. Signs of severity for diagnosis of a COPD exacerbation consist of accessory respiratory muscles usage, worsening or new-onset central cyanosis, development of peripheral edema, hemodynamic instability, and deteriorated mental status (11. Global Strategy for the Diagnosis, Management, and Prevention of COPD: Revised 2014. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Updated 2014. Accessed online on Aug. 14, 2015. ). The need for noninvasive positive-pressure ventilation and antibiotics should have been addressed from the time of admission given his degree of gas exchange impairment. Based on guidelines (22. Woodhead M, Blasi F, Ewig S, Huchon G, Ieven M, Leven M, et al; European Respiratory Society. Guidelines for the management of adult lower respiratory tract infections. Eur Respir J. 2005;26:1138-80. [PMID: 16319346], 33. 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. [PMID: 10858396]), antibiotics should be given to patients with COPD exacerbation who have worsening dyspnea, increased sputum volume, and purulent sputum. In the GOLD (Global Initiative for Chronic Obstructive Lung Disease) classification, our patient fits the criteria for stage D COPD. Therefore, he should have been on a short- and long-acting bronchodilator, inhaled corticosteroid, and oxygen therapy (11. Global Strategy for the Diagnosis, Management, and Prevention of COPD: Revised 2014. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Updated 2014. Accessed online on Aug. 14, 2015. ). Our patient was not on oxygen therapy at home, and the requirement for oxygen therapy was not assessed upon discharge. His home medications should have also been reviewed and reconciled upon discharge. Influenza and pneumococcal vaccinations should have been given. He should also have been educated on inhaler technique and medication adherence, as well as being offered smoking cessation counseling.
Q: Was the transition of care properly handled at the time of discharge?
A: No. Poor coordination of the transition and communication with the patient increased his risk of recurrent COPD exacerbation. Home oxygen therapy requirements should have been assessed and arranged prior to discharge. Follow-up within 4 to 6 weeks should have been scheduled. Case management should ensure adequate social support and follow-up adherence. A referral for pulmonary rehabilitation should have been provided to promote long-term adherence to health-enhancing behaviors, since research has shown that pulmonary rehabilitation referral within 28 days of discharge from an acute exacerbation of COPD decreased the chance of readmissions (44. Man WD, Polkey MI, Donaldson N, Gray BJ, Moxham J. Community pulmonary rehabilitation after hospitalisation for acute exacerbations of chronic obstructive pulmonary disease: randomised controlled study. BMJ. 2004;329:1209. [PMID: 15504763]).
Acute exacerbation of COPD is defined by worsening of the patient's respiratory symptoms (baseline dyspnea, cough, and/or sputum production) that is beyond normal day-to-day variations and leads to a change in medication (11. Global Strategy for the Diagnosis, Management, and Prevention of COPD: Revised 2014. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Updated 2014. Accessed online on Aug. 14, 2015. , 55. Rodriguez-Roisin R. Toward a consensus definition for COPD exacerbations. Chest. 2000;117:398S-401S. [PMID: 10843984], 66. Celli BR, Barnes PJ. Exacerbations of chronic obstructive pulmonary disease. Eur Respir J. 2007;29:1224-38. [PMID: 17540785]). There are several precipitating factors for COPD exacerbation—70% of exacerbations are due to either viral or bacterial respiratory infections (77. Sethi S, Murphy TF. Infection in the pathogenesis and course of chronic obstructive pulmonary disease. N Engl J Med. 2008;359:2355-65. [PMID: 19038881] doi:10.1056/NEJMra0800353), whereas the rest are due to pollution, pulmonary embolism, or unknown cause (88. Gan WQ, FitzGerald JM, Carlsten C, Sadatsafavi M, Brauer M. Associations of ambient air pollution with chronic obstructive pulmonary disease hospitalization and mortality. Am J Respir Crit Care Med. 2013;187:721-7. [PMID: 23392442] doi:10.1164/rccm.201211-2004OC).
COPD exacerbation can be diagnosed on the basis of a patient's medical history, clinical signs of severity, and laboratory tests. Relevant medical history includes severity of COPD based on degree of airflow limitation, duration of worsening or new symptoms, and number of previous episodes (including whether hospital or ICU admission resulted). The best predictor of future exacerbations is past exacerbations. Signs of severity for diagnosis of COPD exacerbation include use of accessory respiratory muscles, paradoxical chest wall movements, worsening or new-onset central cyanosis, development of peripheral edema, hemodynamic instability, and deteriorated mental status (11. Global Strategy for the Diagnosis, Management, and Prevention of COPD: Revised 2014. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Updated 2014. Accessed online on Aug. 14, 2015. ).
The goals of treatment in COPD exacerbation are to minimize the impact of the current exacerbation and prevent subsequent exacerbations (99. Martinez FJ, Han MK, Flaherty K, Curtis J. Role of infection and antimicrobial therapy in acute exacerbations of chronic obstructive pulmonary disease. Expert Rev Anti Infect Ther. 2006;4:101-24. [PMID: 16441213]). Depending on the severity of an exacerbation and/or severity of underlying disease, COPD exacerbation can be managed in an outpatient or inpatient setting. More than 80% of exacerbations can be treated on an outpatient basis.
The decision to hospitalize is based on a marked increase in intensity of symptoms, such as sudden development of resting dyspnea, severe underlying COPD, onset of new physical signs such as cyanosis or peripheral edema, failure of exacerbation to respond to medical management, presence of serious comorbidities (e.g., heart failure or newly occurring arrhythmias), frequent exacerbations, older age, and insufficient home support.
In the ED, physicians should assess the patient's ability to protect his airway, his hemodynamic stability, and the need for respiratory support. If needed, the patient should be admitted to the ICU immediately based on the following criteria: severe dyspnea that responds inadequately to initial emergency therapy; changes in mental status (confusion, lethargy, coma); persistent or worsening hypoxemia (Pao2 <40 mm Hg); and/or severe respiratory acidosis (pH <7.25) despite supplemental oxygen and noninvasive ventilation, need for invasive mechanical ventilation, and hemodynamic instability (including need for vasopressors) (11. Global Strategy for the Diagnosis, Management, and Prevention of COPD: Revised 2014. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Updated 2014. Accessed online on Aug. 14, 2015. ).
Inpatient management of a COPD exacerbation includes pharmacologic therapy (bronchodilators, corticosteroids, antibiotics, other adjunct therapies) and respiratory support (oxygen therapy, mechanical ventilation).
A bronchodilator, such as an inhaled short-acting beta-agonist (albuterol, 2.5 mg diluted to 3 mL via nebulizer or 4 to 8 inhalations from a metered-dose inhaler [MDI]), is typically given every hour. Increasing the nebulized albuterol dose to 5 mg does not have a significant impact on spirometry or clinical outcomes (1010. Nair S, Thomas E, Pearson SB, Henry MT. A randomized controlled trial to assess the optimal dose and effect of nebulized albuterol in acute exacerbations of COPD. Chest. 2005;128:48-54. [PMID: 16002915]), and a meta-analysis showed no significant difference in FEV1 between the routes of delivery (nebulizers versus MDI with or without a spacer device) (1111. Turner MO, Patel A, Ginsburg S, FitzGerald JM. Bronchodilator delivery in acute airflow obstruction. A meta-analysis. Arch Intern Med. 1997;157:1736-44. [PMID: 9250235]). Because of significant side effects, IV methylxanthines (theophylline or aminophylline) should be considered as second-line therapy only in selected cases, including insufficient response to short-acting bronchodilators (1212. Mahon JL, Laupacis A, Hodder RV, McKim DA, Paterson NA, Wood TE, et al. Theophylline for irreversible chronic airflow limitation: a randomized study comparing n of 1 trials to standard practice. Chest. 1999;115:38-48. [PMID: 9925061]).
Research has shown that systemic corticosteroids can shorten recovery time; improve FEV1 and arterial hypoxemia (PaO2); and reduce the risk of early relapse, treatment failure, and length of hospital stay (1313. Maltais F, Ostinelli J, Bourbeau J, Tonnel AB, Jacquemet N, Haddon J, et al. Comparison of nebulized budesonide and oral prednisolone with placebo in the treatment of acute exacerbations of chronic obstructive pulmonary disease: a randomized controlled trial. Am J Respir Crit Care Med. 2002;165:698-703. [PMID: 11874817]-1515. Alía I, de la Cal MA, Esteban A, Abella A, Ferrer R, Molina FJ, et al. Efficacy of corticosteroid therapy in patients with an acute exacerbation of chronic obstructive pulmonary disease receiving ventilatory support. Arch Intern Med. 2011;171:1939-46. [PMID: 22123804] doi:10.1001/archinternmed.2011.530). A daily dose of prednisone, 40 mg, for 5 days is recommended (1616. Leuppi JD, Schuetz P, Bingisser R, Bodmer M, Briel M, Drescher T, et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial. JAMA. 2013;309:2223-31. [PMID: 23695200] doi:10.1001/jama.2013.5023). Oral therapy appears to be as efficacious as IV glucocorticoids for treating most exacerbations of COPD. A randomized trial found no difference between oral versus IV prednisolone, 60 mg daily for 5 days, in the rate of treatment failure, length of hospital stay, improvement in spirometry, or quality of life (1717. de Jong YP, Uil SM, Grotjohan HP, Postma DS, Kerstjens HA, van den Berg JW. Oral or IV prednisolone in the treatment of COPD exacerbations: a randomized, controlled, double-blind study. Chest. 2007;132:1741-7. [PMID: 17646228]).
Antibiotics should be given to patients who have 3 cardinal symptoms (increase in dyspnea, sputum volume, and sputum purulence); those who have 2 of the cardinal symptoms, 1 being increased sputum purulence; and those who require invasive or noninvasive mechanical ventilation (22. Woodhead M, Blasi F, Ewig S, Huchon G, Ieven M, Leven M, et al; European Respiratory Society. Guidelines for the management of adult lower respiratory tract infections. Eur Respir J. 2005;26:1138-80. [PMID: 16319346], 33. 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. [PMID: 10858396]). Five to 10 days of antibiotic therapy is usually recommended (11. Global Strategy for the Diagnosis, Management, and Prevention of COPD: Revised 2014. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Updated 2014. Accessed online on Aug. 14, 2015. ). Other adjunct therapies such as smoking cessation treatment should also be strongly promoted.
Supplemental oxygen should be titrated to improve hypoxemia with a target saturation of 88% to 92% (1818. Austin MA, Wills KE, Blizzard L, Walters EH, Wood-Baker R. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial. BMJ. 2010;341:c5462. [PMID: 20959284] doi:10.1136/bmj.c5462). Arterial blood gases should be checked 30 to 60 minutes after oxygen is started. Although Venturi masks are less likely to be tolerated by the patient, they offer more accurate and controlled oxygen delivery than nasal prongs (1919. Celli BR, MacNee W; ATS/ERS Task Force. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J. 2004;23:932-46. [PMID: 15219010]).
Noninvasive mechanical ventilation (NIV) is indicated if the patient has respiratory acidosis (arterial pH ≤7.35 and/or PaCO2 ≥45 mm Hg) or severe dyspnea with clinical signs suggestive of respiratory muscle fatigue or increased work of breathing, such as use of respiratory accessory muscles, paradoxical motion of the abdomen, or retraction of the intercostal spaces (2020. International Consensus Conferences in Intensive Care Medicine: noninvasive positive pressure ventilation in acute Respiratory failure. Am J Respir Crit Care Med. 2001;163:283-91. [PMID: 11208659], 2121. Esteban A, Anzueto A, Alía I, Gordo F, Apezteguía C, Pálizas F, et al. How is mechanical ventilation employed in the intensive care unit? An international utilization review. Am J Respir Crit Care Med. 2000;161:1450-8. [PMID: 10806138]).
Invasive mechanical ventilation is indicated for patients who are unable to tolerate NIV or who have NIV failure; in patients with respiratory or cardiac arrest; or in those who have respiratory pauses with loss of consciousness or gasping for air, diminished consciousness, psychomotor agitation inadequately controlled by sedation, massive aspiration, persistent inability to remove respiratory secretions, heart rate below 50/min with loss of alertness, severe hemodynamic instability without response to fluids and vasoactive drugs, or severe ventricular arrhythmias and life-threatening hypoxemia (2222. Conti G, Antonelli M, Navalesi P, Rocco M, Bufi M, Spadetta G, et al. Noninvasive vs. conventional mechanical ventilation in patients with chronic obstructive pulmonary disease after failure of medical treatment in the ward: a randomized trial. Intensive Care Med. 2002;28:1701-7. [PMID: 12447511]).
According to the 2014 GOLD guidelines, discharge criteria for COPD exacerbation include being able to use long-acting bronchodilators, either beta-2 agonists and/or anticholinergics with or without inhaled corticosteroids; requiring inhaled short-acting beta-2 agonist therapy no more than every 4 hours; being able to walk across the room (if previously ambulatory); being able to eat and sleep without frequent awakening by dyspnea; being clinically stable for 12 to 24 hours; and having stable arterial blood gas values for 12 to 24 hours. The patient (or home caregiver) should also fully understand correct use of medications and follow-up and home care arrangements should have been completed (e.g., visiting nurse, oxygen delivery, meal provisions), with the patient, family, and physicians feeling confident that the patient can manage successfully at home (11. Global Strategy for the Diagnosis, Management, and Prevention of COPD: Revised 2014. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Updated 2014. Accessed online on Aug. 14, 2015. ). The GOLD guidelines also provide a checklist to assess patients at the time of discharge (Table 1) (11. Global Strategy for the Diagnosis, Management, and Prevention of COPD: Revised 2014. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Updated 2014. Accessed online on Aug. 14, 2015. ).
Repeated COPD exacerbations and hospitalizations can be minimized by smoking cessation; influenza and pneumococcal vaccines; patient knowledge of current therapy, including inhaler technique; and treatment with long-acting inhaled bronchodilators (with or without inhaled corticosteroids) and possibly phosphodiesterase-4 inhibitors (2323. Decramer M, Celli B, Kesten S, Lystig T, Mehra S, Tashkin DP; UPLIFT investigators. Effect of tiotropium on outcomes in patients with moderate chronic obstructive pulmonary disease (UPLIFT): a prespecified subgroup analysis of a randomised controlled trial. Lancet. 2009;374:1171-8. [PMID: 19716598] doi:10.1016/S0140-6736(09)61298-8-2525. Calverley PM, Rabe KF, Goehring UM, Kristiansen S, Fabbri LM, Martinez FJ; M2-124 and M2-125 study groups. Roflumilast in symptomatic chronic obstructive pulmonary disease: two randomised clinical trials. Lancet. 2009;374:685-94. [PMID: 19716960] doi:10.1016/S0140-6736(09)61255-1). Early outpatient pulmonary rehabilitation after hospitalization for an exacerbation results in clinically significant improvements in exercise capacity and health status at 3 months (44. Man WD, Polkey MI, Donaldson N, Gray BJ, Moxham J. Community pulmonary rehabilitation after hospitalisation for acute exacerbations of chronic obstructive pulmonary disease: randomised controlled study. BMJ. 2004;329:1209. [PMID: 15504763]).
Some predictors of readmission include patient factors such as male sex; history of heart failure; lung cancer; osteoporosis; depression; and care factors such as no prior prescription of statin within 12 months of the index hospitalization and no prescription of short-acting bronchodilator, oral steroid, and antibiotic on discharge. Other factors such as length of stay less than 2 or more than 5 days and lack of follow-up visit after discharge have also been associated with early readmission (2626. Sharif R, Parekh TM, Pierson KS, Kuo YF, Sharma G. Predictors of early readmission among patients 40 to 64 years of age hospitalized for chronic obstructive pulmonary disease. Ann Am Thorac Soc. 2014;11:685-94. [PMID: 24784958] doi:10.1513/AnnalsATS.201310-358OC).
It is crucial to specify the primary diagnosis in COPD exacerbation. For example, one should document an acute exacerbation of COPD or exacerbated COPD or acute on chronic COPD, all of which are equivalent for coding purposes. Clinicians should not document respiratory insufficiency as a diagnosis by itself. Complications and comorbidities should also be documented to allow coding to reflect accurate severity of illness and ensure appropriate DRG classification (Table 2) (2727. Optum Insight, Inc. DRG EXPERT. A comprehensive guidebook to the MS-DRG classification system, 30th ed. 2013., 2828. HC Pro Inc. Clinical Documentation Improvement Boot Camp, Book 1. Resource Material. Marblehead, MA: 2010.).
Improper coding will result in lower reimbursements to hospitals. In the case of our patient, inappropriate coding of the DRG leading to lower reimbursement to the hospital would result from the incomplete documentation of severity (respiratory failure) of the disease.
In conclusion, this case demonstrates potential opportunities for better management of a COPD exacerbation, including adhering to guideline-directed medical therapy, improving transitions of care, and optimizing documentation, which can result in better patient outcomes, lower readmissions, and higher reimbursement.