A decision model for the management of acute exacerbation chronic obstructive pulmonary disease in the emergency department: flowchart for treatment allocation.

In patients with an acute exacerbation of chronic obstructive pulmonary disease
(AECOPD), no objective criteria are validated to decide which patient should be
hospitalized or which can be treated at home. In the light of increasing
healthcare costs together with the high prevalence of this condition, treatment
of AECOPD should be restructured and optimized.

The primary objective is to validate a previously established prognostic
instrument in the form of an algorithm (flowchart) in patients that present
with AECOPD to the department of emergency medicine for classifying for out- or
inpatient treatment leading to less hospital admissions. The secondary
objectives are demonstrating that this stratification also leads to less
readmissions, shorter length of stay when admitted to the medical ward and
efficient, cost-effective care without thereby adversely affecting health
status and 30-day mortality rate.

Firstly the algorithm is validated in a prospective cohort. Secondly, a
retrospective control group is compared to this prospective group stratified
for treatment category by applying this flowchart. The primary endpoint is the
admission rate, adjusted for health status and 30-days mortality. The
secondary study endpoints are readmission rate, the average length of stay when
admitted and healthcare costs.

The algorithm is applied in all patients presenting to the emergency department
with an acute exacerbation of COPD. It is divided into four categories based on
clinical criteria and arterial blood gas values: discharge and treatment at
home, admission to the medical ward, admission to the medical ward and start
non-invasive ventilation or admission to the intensive care unit with or
without (non-)invasive ventilation. All patients are evaluated between 5 to 10
days after inclusion in the outpatient clinic or, if still hospitalized, in the
medical ward. CCQ and MRC questionnaires are carried out.

Participation in this study leads to therapeutic decision making based on
objective parameters instead of a subjective funded decision. It is important
to note that there is no actual difference between the nature of care provided
in the medical ward and the care that could be provided at home. Therefore
there is no increased risk in participation in this study. The expected benefit
is avoidance of unnecessary admissions and in case of admission a shorter
length of stay in the hospital.