Walden University ScholarWorks Walden Dissertations and Doctoral Studies Walden Dissertations and Doctoral Studies Collection 2020 Clinical Practice Guideline for Transitions of Patients with Chronic Obstructive Pulmonary Disease Thomas Stewart Walden University Follow this and additional works at: https://scholarworks.edu/dissertations Part of the Nursing Commons This Dissertation is brought to you for free and open access by the Walden Dissertations and Doctoral Studies Collection at ScholarWorks. It has been accepted for inclusion in Walden Dissertations and Doctoral Studies by an authorized administrator of ScholarWorks. For more information, please contact ScholarWorks@waldenu. Walden University College of Health Sciences This is to certify that the doctoral study by Thomas Stewart has been found to be complete and satisfactory in all respects, and that any and all revisions required by the review committee have been made.
Review Committee Dr. Mary Catherine Garner, Committee Chairperson, Nursing Faculty Dr. Sue Bell, Committee Member, Nursing Faculty Dr. Jonas Nguh, University Reviewer, Nursing Faculty Chief Academic Officer and Provost Sue Subocz, Ph.
Walden University 2020 Abstract Clinical Practice Guideline for Transitions of Patients with Chronic Obstructive Pulmonary Disease by Thomas Stewart MS, Walden University, 2015 BS, Tuskegee University, 1995 Project Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Nursing Practice Walden University August 2020 Abstract Chronic obstructive pulmonary disease (COPD) is a public health challenge and a leading cause of readmissions in the United States. Research suggests that many patient readmissions could be prevented by using a multidisciplinary approach to develop quality, evidence-informed clinical practice guidelines. A retrospective review of the electronic health record by the project site’s quality committee revealed a lack of consistency in adhering to best practice recommendations, as evidenced by increased readmission rates. The purpose of this project was to develop a clinical practice guideline with input from a collaborative expert advisory committee for the discharge care of COPD patients.
The practice-focused question addressed whether a multidisciplinary group could develop evidence-based clinical practice guidelines that meet the AGREE II criteria for the discharge care of COPD patients. The Iowa model of evidence-based practice was used as the conceptual framework to guide this project. Core components of the chronic care model were used as a proactive approach to reducing fragmented care while improving quality outcomes for COPD patients. Five expert advisory members provided feedback on the quality of the guideline using the AGREE II instrument.
The advisory committee agreed to present the guideline as a policy proposal to the local site’s medical executive committee. If implemented, this guideline could affect positive social change through use at other organizations to improve patient outcomes and reduce 30-day readmissions. Clinical Practice Guideline for Transitions of Patients with Chronic Obstructive Pulmonary Disease by Thomas Stewart MS, Walden University, 2015 BS, Tuskegee University, 1995 Project Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Nursing Practice Walden University August 2020 Dedication I would like to dedicate this capstone project to my parents, who taught me as their first-born child to lead by example, never to stop learning, and always set the bar high. Without my mother’s nurturing affection and my father’s tough love and guidance, this achievement would not be possible.
I would not be where I am today or what I am today without both of my amazing parents. So, Mom and Dad—this one is for both of you! Acknowledgments First and foremost, I acknowledge my God Almighty for giving me the opportunity and inner strength to complete this research study satisfactorily. I pray that this project will positively impact those affected by COPD. This achievement could not have been possible without his blessing.
Secondly, I would like to extend my sincere gratitude to my chair for this project, Dr. Catherine Garner, whose insightful guidance, mentorship, encouragement, and support pushed me forward during challenging times to help me successfully achieve this goal. I would also like to thank my committee members for their constructive feedback and guidance. Sue Bell, Dr.
Jonas Fomukong-Nguh, and Dr. Nancy Moss, thank you for your contributions to this project! Last but not least, I want to acknowledge my perseverance to finish what I started. In the words of the great Maya Angelou, “That is what you want to do? Then nothing beats a trial but a failure. Give it everything you have got.
I have told you many times, ‘Cannot do is like Do not Care.’ Neither of them has a home.” Table of Contents List of Tables. iv Section 1: Nature of the Project .4 Nature of the Doctoral Project .7 Section 2: Background and Context .9 Concepts, Models, and Theories. 10 Chronic Care Model. 11 Clinical Practice Guideline Development.
12 Relevance to Nursing Practice .13 Local Background and Context .17 Role of the DNP Student.18 Role of Project Team .20 Section 3: Collection and Analysis of Evidence .21 i Practice-Focused Question(s) .22 Sources of Evidence .23 Analysis and synthesis .25 Section 4: Findings and Recommendations .26 Findings and Implications .27 Domain 1: Scope and Purpose. 28 Domain 2: Stakeholder Involvement. 29 Domain 3: Rigor of Development. 30 Domain 4: Clarity of Presentation.
32 Domain 6: Editorial Independence. 33 Overall Guideline Assessment .34 Contributions of the Doctoral Project Team .35 Strengths and Limitations of Project.35 Section 5: Dissemination Plan .37 Analysis of Self .41 ii Appendix A: Literature Review Matrix .51 Appendix B: Walden IRB Approval Number .55 Appendix C: Clinical Practice Guideline .56 Appendix D: Expert Panels Scoring of Clinical Practice Guideline.62 Appendix F: Disclosure to Expert Panel .67 Appendix G: Permission to use GOLD Description of Levels of Evidence Table .68 iii List of Tables Table 1 Domain 1: Scope and Purpose .29 Table 2 Domain 2: Stakeholder Involvement .30 Table 3 Domain 3: Rigor of Development .31 Table 4 Domain 4: Clarity of Presentation .32 Table 5 Domain 5: Applicability .32 Table 6 Domain 6: Editorial Independence .33 Table 7 Overall Guideline Assessment .34 Table 8 Recommended Use of Guideline .34 iv 1 Section 1: Nature of the Project Introduction The increasing prevalence of chronic obstructive pulmonary disease [COPD] is a public health concern. COPD is the third leading cause of morbidity and mortality in the United States (Guarascio, Ray, Finch, & Self, 2013).7 million people in the United States have been diagnosed with COPD, with millions more people potentially living with the disease undiagnosed (Centers for Disease Control and Prevention [CDC], 2019). According to the CDC, COPD can be defined as a group of progressive respiratory diseases that are characterized by increasing breathlessness.
The result of this increasing breathlessness over time leads to respiratory failure, which often results in excessive hospital readmissions, long-term disability, and early death (Kumbhare, Beiko, Wilcox, & Strange, 2016). Nearly one out of five patients diagnosed with COPD are readmitted back to the hospital within 30 days of discharge (Krishnan et al. The slow progression of COPD potentially contributes to these excessive readmissions, as many people are unaware of the early warning signs associated with this chronic disease and are frequently diagnosed in the later stages of the disease (Krishnan et al. As a result of these late diagnoses, more than 800,000 people aged 40 years or older in 2008 were hospitalized with a primary diagnosis of COPD (Wier, Elixhauser, Pfuntner, & Au, 2011).8 million people hospitalized that same year aged 40 years or older had a secondary diagnosis of COPD, costing a total of $6.1 billion in direct care costs for that year alone (Wier et al.
In 2010, the projected cost of COPD was nearly $50 billion, with 70% of this cost being attributed to longer than average 2 hospital stays, excessive 30-day readmission rates, and lost workdays (Guarascio et al., 2013; Kumbhare et al. Clinical practice guidelines aim to improve the quality of care and patient outcomes by using evidence-based research to inform clinical decisions. Despite the available COPD guidelines and the abundance of published evidence on reducing excessive readmissions, the gap in practice was the poor implementation of evidence- based recommendations at this acute care facility, which may potentially contribute to excessive readmission rates. The effective management of COPD requires adherence to best practice guidelines.
DNP-prepared nurses can help promote adherence to best practice guidelines by identifying gaps in knowledge and then translating the best available evidence from clinical practice guidelines into clinical practice. Problem Statement COPD is a significant cause of morbidity and mortality and is one of the leading causes of hospitalization in the United States (Guarascio et al. Each year, over 700,000 hospitalizations and 1.5 million emergency room visits are the result of COPD (Sullivan et al. The projected costs of these hospitalizations and emergency department visits, as well as readmissions and indirect costs such as days of work lost, are estimated to be about $32 billion (Sullivan et al.
Additionally, nearly one out of five (19.2%) COPD admissions discharged from the hospital will be readmitted within 30 days, and more than half (58%) of these patients are readmitted within 15 days (Jacobs et al., 2018; Krishnan et al. By the year 2020, the economic burden of COPD is projected to be approximately $50 billion annually (Sullivan et al. As mortality 3 rates for other leading causes of death such as heart disease and stroke steadily decline, mortality rates for COPD continue to increase (May & Li, 2015). Based on this growing prevalence, the increasing clinical, financial, and societal burden of COPD implies that there is a gap in the quality of care delivered to this population.
The Global Initiative for Chronic Obstructive Lung Disease (GOLD; Mirza, Clay, Koslow, & Scanlon, 2018), which was established by the National Heart, Lung, and Blood Institute in 1998, offers guidance on the diagnosis, management, and prevention of COPD. Despite the available COPD guidelines and the abundance of published evidence to reduce readmissions after acute exacerbations, the gap in implementation of evidence- based guidelines may potentially contribute to excessive readmission rates. The effective management of COPD to reduce hospital readmissions would require adherence to best practice guidelines. The development and implementation of a COPD clinical guideline for discharge care planning promoted evidence-based recommendations that can potentially be useful in reducing 30-day readmissions while concurrently improving patient outcomes.
In comparison to national benchmark data, hospital readmissions for this acute care project site are 21.9%, which is above the national average at 20. A retrospective review of the electronic health records by the project site's quality committee found a lack of consistency in adhering to best practice recommendations. For example, evidence-based core interventions recommended by the GOLD guidelines, such as demonstration of proper inhaler technique, smoking cessation counseling, and referrals to pulmonary rehabilitation frequently lacked in patient records. Other core 4 interventions recommended by the GOLD guidelines, like self-management education and scheduling outpatient follow-up visits before discharge was also found to be inconsistent.
The gap in practice was the lack of using consistent, evidence-based clinical practice guidelines to deliver optimal discharge care to COPD patients and to prevent premature readmissions. Purpose Statement The purpose of this scholarly project was to develop a clinical practice guideline with input from a collaborative expert advisory committee for the discharge care of COPD patients. The practice-focused question was: Can a multidisciplinary group develop evidence-based clinical practice guidelines that meet the AGREE II criteria for the discharge care of COPD patients? The overall aim of this project was to improve the quality of life for people with COPD by reducing excessive hospital readmissions through the development and implementation of an evidence-based COPD clinical practice guideline for discharge care planning that aligns with national guideline recommendations. Baseline data from the quality department indicated that evidence- based practices were not consistently followed.
Frequent failures in care found lacking in the electronic health record included return demonstration of proper inhaler technique, smoking cessation counseling, referrals to pulmonary rehabilitation, disease-specific patient education, and a lack of follow-up appointments scheduled before discharge. This gap in evidence implementation may have potentially contributed to excessive readmission rates.