Butler M W, O'Mahony M J, Donnelly S C, McDonnell T J
Department of Respiratory Medicine, St. Vincent's University Hospital, Elm Park, Dublin 4.
Ir Med J. 2004 Apr;97(4):108-10.
Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a major cause of hospital admissions. Because of the consequent morbidity, mortality and burden on hospital resources, COPD management guidelines have been formulated. We reviewed 62 consecutive patients with AECOPD admitted from September 1st to December 18th 2000 in St. Vincents University Hospital, Ireland, including 3 months follow-up data, to evaluate the quality of care and in particular to assess the care of such patients by respiratory and non-respiratory physicians. There was a frequent failure to objectively confirm the diagnosis of COPD by spirometry (completed in 39 of the 51 patients who, at admission, had been previously labelled with COPD (76%), and in 53 out of 62 patients (85%) at the end of the study period), or to estimate severity by quantifying the FEV1 as a percentage of the normal predicted range (estimated in only 21 of the 39 patients who had spirometry previously performed (53%)). Those patients managed with input from respiratory physicians were more likely to have their diagnosis of COPD confirmed with spirometry (p < 0.05). They were also more likely to have out-patient follow-up arranged at discharge (p < 0.05). There was a trend towards the more frequent prescribing of oxygen to hypoxic patients in "respiratory" than in "non-respiratory" managed cases (p = 0.182) and a shorter hospital stay (0.1 < p < 0.5). 4 out of 11 severely hypoxaemic patients at admission (PO2 < 7.3kPa) were not screened at discharge for possible long term oxygen therapy (36%). 20 patients received combination antibiotic therapy with no infiltrate on CXR (32%). Pulmonary rehabilitation was offered to 12 patients (19%). 5 out of 18 current smokers had documented smoking cessation advice (28%) and none received smoking cessation pharmacotherapy. Finally we noted that the Hospital In-Patient Enquiry (HIPE) data and casualty department admission books were frequently misleading or medical records unlocatable (in 30 out of 92 cases (33%)). We conclude that the management of AECOPD at St. Vincent's University Hospital is frequently suboptimal, and may be managed better with respiratory physician involvement. In particular, there could be more frequent spirometric confirmation of the diagnosis of COPD, better screening for long term oxygen therapy and more conservative use of antibiotics. Audit is complicated by difficulty accessing relevant data.
慢性阻塞性肺疾病急性加重（AECOPD）是住院的主要原因。由于其导致的发病率、死亡率以及对医院资源的负担，已制定了慢性阻塞性肺疾病管理指南。我们回顾了2000年9月1日至12月18日期间连续收治于爱尔兰圣文森特大学医院的62例AECOPD患者，包括3个月的随访数据，以评估医疗质量，特别是评估呼吸内科和非呼吸内科医生对此类患者的治疗情况。通过肺功能测定客观确诊慢性阻塞性肺疾病的情况经常出现缺失（在入院时曾被诊断为慢性阻塞性肺疾病的51例患者中，有39例（76%）完成了肺功能测定，在研究期末的62例患者中有53例（85%）完成了测定），或者未能通过将第一秒用力呼气容积（FEV1）量化为正常预测范围的百分比来评估严重程度（在之前进行过肺功能测定的39例患者中，只有21例（53%）进行了评估）。那些在呼吸内科医生参与下接受治疗的患者更有可能通过肺功能测定确诊慢性阻塞性肺疾病（p < 0.05）。他们在出院时也更有可能安排门诊随访（p < 0.05）。与“非呼吸内科”管理的病例相比，“呼吸内科”管理的低氧患者更频繁地接受吸氧治疗（p = 0.182），且住院时间更短（0.1 < p < 0.5）。入院时11例严重低氧血症患者（动脉血氧分压<7.3kPa）中有4例（36%）在出院时未接受长期氧疗筛查。20例患者接受了联合抗生素治疗，胸部X线检查无浸润影（32%）。12例患者（19%）接受了肺康复治疗。18例现吸烟者中有5例（28%）有戒烟建议的记录，且无人接受戒烟药物治疗。最后，我们注意到医院住院患者查询（HIPE）数据和急诊科入院记录经常产生误导，或者病历难以找到（92例中有30例（33%））。我们得出结论，圣文森特大学医院对AECOPD的治疗经常未达到最佳水平，呼吸内科医生参与可能会改善治疗。特别是，对慢性阻塞性肺疾病的诊断可以更频繁地通过肺功能测定来确认，对长期氧疗进行更好的筛查，以及更保守地使用抗生素。获取相关数据的困难使审计工作变得复杂。
