Decision tool identifies which patients with COPD are at risk of death, serious complications

December 3, 2018

Le Dr Ian StiellA made-in-Ottawa decision tool can help emergency physicians identify which patients with chronic obstructive pulmonary disease are at high risk of serious complications including death. The Ottawa COPD Risk Scale is better than current practice at predicting these short-term risks, according to a validation study published in CMAJ.

“Before this tool, there was no way to know if a patient who came to the emergency department with a COPD flare-up was going to have serious complications,” said Dr. Ian Stiell, lead author of the paper and an emergency physician and senior scientist at The Ottawa Hospital and distinguished professor at the University of Ottawa. “This new information can help doctors decide whether to admit a patient or send them home.”

COPD is a group of diseases that block airways and affects 11 percent of Canadians over age 35. Flare-ups of the disease make it harder to breathe and can lead to complications like needing a breathing machine, heart attack or death. Patients are told to seek emergency care during flare-ups in case they need to be hospitalized.

Many patients respond well to treatment in the emergency department and can be safely sent home several hours later. Others suffer serious complications and need to be admitted to hospital, but identifying these patients is challenging. Dr. Stiell’s team previously found that about half of patients with COPD who suffer adverse events in Canada do so after being sent home. Until now, there has been little evidence to help prevent this.

“This tool will improve care for patients with COPD by helping ensure that those at high-risk of serious complications are admitted to hospital, and those at low risk are sent home,” said Dr. Stiell.

Dr. Stiell notes that physicians consider many factors when deciding whether to admit a patient, including how much support they have at home and whether they can see a doctor within a week of their visit. The Ottawa COPD Risk Scale does not replace these considerations, but provides additional information to help doctors make a decision.

Dr. Stiell’s research team developed the tool based on data from 945 patients from Canadian hospitals. The 10-point scale includes elements from a patient’s history, examination or tests conducted during their visit. These risk factors are easy to determine and do not need expensive testing.

In this validation study, the researchers tested whether the tool could accurately predict the outcomes of 1415 Canadian patients who arrived at the emergency department with COPD flare-ups. It correctly predicted that 135 patients would suffer serious complications after 30 days.

The risk scale is better than current practice, and if used will likely increase COPD admissions for higher-risk patients while decreasing admissions of low-risk patients. Researchers don’t expect this tool to cause a net increase in COPD admissions overall.

“There’s no question that this tool can be used today,” said Dr. Stiell. “While designed for emergency physicians, it could also help others who serve patients with COPD, including respirologists, general internists and family doctors.”

Dr. Stiell is known around the world for creating decision rules that improve patient care, such as the Ottawa Ankle Rules and the Canadian C-Spine Rule. These rules are now available on a mobile app.

This study was funded by the Canadian Institutes of Health Research. Research like this is possible because of generous support for research to improve patient care at The Ottawa Hospital.

Full reference: Clinical validation of a risk scale for serious outcomes among patients with chronic obstructive pulmonary disease managed in the emergency department. Ian G. Stiell, Jeffrey J. Perry Catherine M. Clement, Robert J. Brison, Brian H. Rowe, Shawn D. Aaron, Andrew D. McRae, Bjug Borgundvaag, Lisa A. Calder, Alan J. Forster, Jennifer Brinkhurst, George A. Wells. Canadian Association Medical Journal. December 3, 2018. doi: 10.1503/cmaj.180232

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