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Reliable adherence to a COPD care bundle mitigates system-level failures and reduces COPD readmissions: a system redesign using improvement science
  1. Muhammad Ahsan Zafar1,2,
  2. Ralph J Panos1,3,
  3. Jonathan Ko4,
  4. Lisa C Otten4,
  5. Anthony Gentene5,6,
  6. Maria Guido5,6,
  7. Katherine Clark7,
  8. Caroline Lee7,
  9. Jamie Robertson8,
  10. Evaline A Alessandrini2
  1. 1 Division of Pulmonary and Critical Care Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
  2. 2 James M. Anderson Center for Health Systems Excellence, Cincinnati, Ohio, USA
  3. 3 Department of Medicine, Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio, USA
  4. 4 Department of Respiratory Care, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
  5. 5 Division of Pharmacy Practice and Administration, University of Cincinnati James L Winkle College of Pharmacy, Cincinnati, Ohio, USA
  6. 6 Department of Pharmacy Services, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
  7. 7 Division of General Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
  8. 8 Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
  1. Correspondence to Dr Muhammad Ahsan Zafar, Division of Pulmonary and Critical Care Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, MSB Room 6053, Cincinnati, Ohio, USA; zafarmd{at}, ahsanzz{at}


Background Readmissions of chronic obstructive pulmonary disease (COPD) have devastating effects on patient quality-of-life, disease progression and healthcare cost. Effective interventions to reduce COPD readmissions are needed.

Objectives Reduce 30-day all-cause readmissions by (1) creating a COPD care bundle that addresses care delivery failures, (2) using improvement science to achieve 90% bundle adherence.

Setting An 800-bed academic hospital in Ohio, USA. The COPD 30-day all-cause readmission rate was 22.7% from August 2013 to September 2015.

Method We performed a cross-sectional study of COPD 30-day readmissions from October 2014 to March 2015 to identify care delivery failures. We interviewed readmitted patients with COPD to identify their needs after discharge. A multidisciplinary team created a care bundle designed to mitigate system failures. Using a quasi-experimental study and ‘Model for Improvement’, we redesigned care delivery to improve bundle adherence. We used statistical process control charts to analyse bundle adherence and all-cause 30-day readmissions.

Results Cross-sectional review of the index (first-time) admissions revealed COPD was the most common readmission diagnosis and identified 42 system-level failures. The most prevalent failures were deficient inhaler regimen at discharge, late or non-existent follow-up appointments, and suboptimal discharge instructions. Patient interviews revealed confusing discharge instructions, especially regarding inhaler use. The COPD care-bundle components were: (1) appropriate inhaler regimen, (2) 30-day inhaler supply, (3) inhaler education on the device available postdischarge, (4) follow-up within 15 days (5) standardised patient-centred discharge instructions. The adherence to completing bundle components reached 90% in 5.5 months and was sustained. The COPD 30-day readmission rate decreased from 22.7% to 14.7%. Patients receiving all bundle components had a readmission rate of 10.9%. As a balancing measure for the targeted reduction in readmission rate, we assessed length of stay, which did not change (4.8 days before vs 4.6 days after; p=0.45).

Conclusion System-level failures and unmet patient needs are modifiable risks for readmissions. Development and reliable implementation of a COPD care bundle that mitigates these failures reduced COPD readmissions.

  • Quality improvement
  • Chronic disease management
  • Teamwork

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  • Twitter ACOPD care bundle designed to mitigate system-level failures & implemented through Model for improvement reduced COPD readmissions by 35%.

  • Competing interests The authors have no conflict of interests.

  • Ethics approval University of Cincinnati Institutional Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.