The development of a bundle checklist for patients with chronic obstructive pulmonary disease (COPD) has helped a Maryland hospital sharply reduce its readmission rates for these patients. Overall care quality improved for these patients while admitted.

The effort was spurred by a hospitalwide effort to improve processes and identify gaps in care, says Vanessa Piñeiro, BA, RRT-NPS, RRT-ACCS, manager of respiratory care services, PFT Lab & EEG, at Adventist HealthCare Shady Grove Medical Center in Rockville, MD.

“Our chronic obstructive pulmonary disease patients were readmitted at a very high rate, sometimes as high as 30%. Of course, the hospital is not reimbursed if you are readmitted for something that was not adequately treated during admission, so that had a big impact on the hospital overall,” Piñeiro reports. “We respiratory therapists looked at that and thought there must be ways we can improve those rates.”

At that time, the hospital’s COPD readmission average rate was 16.09%, an all-time high for the facility. Reimbursement for hospitals in Maryland was determined in part by the state’s Health Services Cost Review Commission. COPD readmission rates higher than 10.8% resulted in a penalty.

The penalty, in addition to the other negative effects of readmission, inspired the hospital to set a target goal of 10.7%, and a stretch goal of 10.2%, Piñeiro explains. The hospital would surpass both goals within a year.

Task Force Studies Processes

The hospital established a task force that met monthly to study processes, people, and how the hospital’s electronic medical record (EMR) affected readmissions or could be used to reduce them. In addition, respiratory care specialists studied the patient education process at discharge to look for possible improvements.

Others contributing to the project were the medical director of pulmonary services, case management professionals, discharge nurses, hospitalists, and home health nurses. The informatics department assisted with data collection and analysis. “One of the first things we did was to flag the patients who were diagnosed with COPD and who were readmitted. We looked at each case, tried to peel the onion and see why these patients were readmitted to the hospital,” Piñeiro says. “We actually did a small case study of about 28 patients and monitored them for readmissions for about three or four months. We ... [tried] to identify gaps in care and potential reasons for readmission.”

In some cases, the task force found the patients were readmitted for a comorbidity. Many COPD patients experience comorbidities such as diabetes, high blood pressure, and uncontrolled infections.

“Once we identified why these patients were coming back to the hospital, we tried to identify what we as respiratory therapists can control. We don’t treat them for diabetes, but from a respiratory viewpoint we wanted to identify all the points of care that might be improved,” Piñeiro says. “There were multiple factors related to the readmissions, but we wanted to see what we could influence as respiratory therapists.”

Piñeiro and task force members from several departments used the Lean Six Sigma approach to tackle the problem, including the DMAIC methodology, which stands for Define (the problem), Measure (the gaps in the problem), Analyze (the problem), Improve (the problem), and Control (how do we maintain the process).

That prompted a wider investigation into how the hospital could address issues such as comorbidities and noncompliance with COPD patients.

For example, some COPD patients continued to smoke. Other patients would feel worse after they returned home, in part because they did not comply with instructions for medication and monitoring. This could lead to a trip to the emergency department.

“From the time they came in the door, we had to educate them on the things that would make their treatment successful and avoid coming back,” Piñeiro says. “That meant educating them on their medications, whether they knew what the medications were for and how to use them. A lot of these patients knew what COPD was, but never really understood the medications and why their conditions had to be carefully monitored, even after they went home.”

The task force created a COPD bundle, addressing issues such as the signs and symptoms of infection, education, inhaler management, and smoking cessation. A new patient education plan was integrated into the EMR. “It was a huge undertaking to revise the education process, and that took about six months,” Piñeiro says. “But immediately after we implemented that education, we saw a dramatic drop in readmissions.”

Many Touchpoints for Patients

A significant revelation for the task force was understanding how many touchpoints were involved with a COPD patient. A single patient might be treated by a physician for diabetes, an infection specialist, a respiratory therapist, and others.

“None of us were really collaborating. We all worked in our own little silos,” Piñeiro says. “The patient heard different things from different providers, and that left the patient overwhelmed and a little lost.”

To help clinicians implement the COPD bundle, the task force created a “swim lane” process map that shows the various roles involved with the bundle so each clinician could clearly see what he or she was responsible for completing with the patient.

The Shady Grove facility also collaborated with an Adventist team that was working systemwide to improve aftercare for COPD patients at home, helping ensure the education provided to COPD patients in the hospital was consistent with and reinforced by the education provided at home.

Sharp Reduction in Readmissions

After the plan was implemented, the COPD readmission rate decreased from an average rate of 16.09% in 2017 to an average rate of 14.62% in early 2018. By June 2018, the rate was down to 9.54%, surpassing the hospital’s stretch goal.

Those results have been sustained since then, and the COPD task force still meets monthly. New staff are onboarded to the bundle, and Shady Grove is working with other Adventist hospitals interested in adopting the same approach.

“We’ve been under 10% for two and half years. We have never gone back up to 30%,” Piñeiro says. “The task force and all the others involved in the care of these patients feel like we’ve made a real difference for them. When a patient does come back now, we are very interested in looking back at their experience and trying to see if there was a gap in care that could have prevented that readmission.”

Piñeiro says she and her fellow task force members did not realize the enormity of the problem until they were deep into the analysis of COPD readmissions.

“That’s when we realized we needed collaborations with the nurses, discharge nurses, home health, so many people,” she says. “If you think you can do this by yourself and you don’t need anybody, you’re very mistaken. When you’re implementing an idea, it’s very important that you have all the stakeholders at the table to share their input. You have to consider how all of these different people affect the patient’s experience before you try to implement change.”

She recalls one example involving patient education about COPD. The task force originally developed a three-page patient education document, but then others pointed out that patients are unlikely to read such lengthy material. It was revised to a one-page document that included the most important information.

“You have to be willing to ask for help and be vulnerable, to say you’re trying to do something but it’s not working out,” Piñeiro says. “As respiratory therapists, we can focus so much on our part of the patient care that we don’t realize there are others we can reach out to who have the same goal of improving the quality of care. It takes a village.”


  • Vanessa Piñeiro, BA, RRT-NPS, RRT-ACCS, Manager, Respiratory Care Services, Adventist HealthCare Shady Grove Medical Center, Rockville, MD. Phone: (240) 826-6407.