Impact of Goal-Directed COPD Care Model on Clinical and Patient-Reported Outcomes : A Pilot Feasibility Study
Conditions: COPD Exacerbation
Sponsor: Ottawa Hospital Research Institute

Correspondence Address:       
               
The Ottawa Hospital, General Campus, 501 Smyth Road, Box 211 Ottawa, ON K1H 8L6 
Impact of a Goal-Directed COPD Care Model on Clinical and Patient-Reported Outcomes: A Pilot Feasibility 
Study 
Study Protocol 
 
PI’s: Sunita Mulpuru, Alan Forster 
Co-I’s: Justin Presseau, Jacqueline Sandoz, Wendy Laframboise, Caroline Tessier, Barbara d’Entremont, Jan 
Leahy, Nha Voduc, Aaron Leblanc 
 
 
July 05, 2018 
 
REB Correspondence: 
 
Dr. Sunita Mulpuru 
 
The Ottawa Hospital – General Campus 
 
Division of Respirology 
 
501 Smyth Rd, Room 6356, Box 211 
 
Ottawa, ON K1H 8L6 
 
smulpuru@toh.ca 
 
 
 
 
 
 
 
 

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1.0 PROJECT SUMMARY 
Chronic obstructive pulmonary disease (COPD) is an incurable and progressive lung disease associated with 
poor quality of life (1).  At The Ottawa Hospital (TOH), 20% of patients with COPD are readmitted to hospital 
within 30-days after discharge, and COPD is responsible for the highest 30-day readmission rate to the 
emergency room in Ontario when compared to other chronic diseases (2).   
Integrated COPD care programs (ICPs) are promising interventions that have been shown to improve quality of 
life and readmission rates in the COPD patient population (3).  ICPs are disease management programs which 
aim to systematically reduce fragmented patient care; a central problem in today’s health system.  ICPs often 
include patient education, self-management, access to a case manager, and care interventions that address 
the psychological and rehabilitative aspects of the disease (e.g. pulmonary rehabilitation) (4). Studies of 
integrated care program effectiveness have yielded conflicting results with respect to clinical outcomes.  The 
interventions within the care programs are not often explicitly reported in a way that would allow for 
replication in other sites. Further, cost effectiveness of ICPs has not been well studied, and the most-
appropriate target patient population which could benefit most from these care interventions has not been 
identified.  Most ICPs were also designed as a ‘one-size-fits-all’ model, where all enrolled COPD patients would 
receive similar care.  Lastly, patient reported outcome data in these studies is notably absent. (4,5).  
To address these stated shortcomings, we developed a unique goal-directed COPD care program which 
streamlines most appropriate care and health resources based on the degree of frailty of a patient.  This care 
model begins at the onset of a hospitalization and integrates ongoing disease management services and 
programs in the community after hospital discharge.  Using this goal-directed frailty-based integrated system 
of care, we aim to improve the confidence of patients to cope with health challenges, improve health system 
outcomes, and reduce costs of care.  In this preliminary study, we will determine whether it is feasible to 
implement our goal-directed, frailty-based COPD care pathway in a large hospital setting.  We will also 
evaluate our ability to measure patient reported and important health service outcomes. 
2.0 BACKGROUND 
COPD is an incurable and debilitating lung disease that causes progressive breathlessness, disability, poor 
quality of life, and premature death (1).  COPD is characterized by progressive airflow obstruction and 
recurring `flare-up's' (also known an exacerbations) that often require patients to seek medical attention in an 
emergency department (1).  Most cases of COPD are caused by long-term tobacco use and exposure to 
biomass fuels (1).  

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COPD affects over 300 million people worldwide and accounts for 5% of global deaths (10).  It is the only 
chronic disease in which the mortality rate is still rising (11,12).  COPD is also a leading cause for hospital 
admission and the number one reason for hospital readmissions among chronic illnesses in Canada (13).  
COPD is estimated to exceed 700 million dollars annually to the Canadian health system (14).  The majority of 
this cost is related to the hospitalizations and readmissions of COPD patients 14).  The highest in-hospital costs 
are borne by patients with COPD who are frail and those with increased physical care needs (15,16). 
A recent evidence synthesis performed by Health Quality Ontario (HQO) aimed to answer important questions 
relating to patient and caregiver experiences over the course of illness for patients with COPD (17).  The 
authors reviewed and summarized a decade worth of qualitative evidence to understand the daily life 
experiences of patients with COPD.  The resulting information offers valuable insights on the types of 
interventions that could have a substantial impact on the experiences of patients with COPD (17).  
Below is a summary of several important themes identified by HQO in their knowledge synthesis of patients’ 
experiences with COPD. 
• Patients may not realize that COPD is incurable and fatal; some physicians themselves do not consider 
early COPD to be a fatal disease. 
• Patients may not attribute repeated exacerbations to advancing disease, seeing them as temporary 
setbacks instead. 
• Economic hardship, co-morbidities, language barriers, low health literacy can make coping difficult. 
• Many factors that isolate COPD patients from social contact also isolate them from health care 
professionals (or seeking out health care). 
• Lack of confidence in community -based services leads some patients to seek hospital admission, but 
patients also feel vulnerable when hospitalized. 
• Patients feel dependent on others for care or traumatized by hospital care routines 
• Upon discharge following an exacerbation, patients may face new levels of uncertainty about their 
illness, prognosis, care providers, and supports. 
• Patients tend to be poorly informed about the long-term prognosis of COPD, and what to expect 
toward the end of life; lack of understanding impairs quality of life as disease progresses. 
• A palliative care referral can convey the demoralizing message that care providers have “given up”. 

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These valuable insights from patients and their caregivers underscore the need for improved disease-specific 
education, the nature of symptoms and prognosis, re-enforcement around the use of pharmacologic and non-
pharmacologic treatments over time, and readily available access to a health care professional who could 
connect the patient to the most appropriate health services. 
Studies have demonstrated that Integrated COPD care models are associated with reduced readmission rates 
and improved quality of life in single center studies (3, 4, 19).  However, studies of integrated care models 
make it difficult to discern which aspect of the care programs can be replicated and scaled in other sites and 
settings.  It is also unclear which COPD patients derive most benefit from these programs, what effect there is 
on patient reported outcomes, and what resources are required to effectively run and scale these programs. 
As a result, the American Thoracic Society (ATS) has highlighted the need for further studies to evaluate 
components of care models on patient centered outcomes and to better define sub-types of COPD patients 
who might benefit from integrative care models (4). 
Previous care models have used a `one-size-fits-all' approach to care, in which all-comers with COPD are 
offered the same set of interventions and treatment.  However, all COPD patients are not alike.  Simply 
classifying patients by their lung function or age does not correlate with symptoms or outcomes (20). Patients 
with COPD are often managing multiple comorbidities, mental health conditions, addictions, and social factors 
that contribute to their overall health care utilization.  These factors underscore the need to have a more 
personalized and multidisciplinary care-delivery approach in this patient population.   
Based on our knowledge of existing integrated care programs, we developed a unique integrated care 
program specifically for COPD patients.  This care model begins in the hospital setting when a patient is 
admitted with an acute COPD exacerbation.  Evidence based care including disease-specific education is 
provided and a safe transition after discharge is planned by integrating the patient with a variety of 
community services (education, rehabilitation, home care, disease-specific outreach, etc.).  Continuity of care 
for the patient is provided through healthcare providers who straddle both the community and hospital 
settings.   
Our integrated care model is unique as it groups hospitalized patients with COPD into functional health states 
using a validated clinical frailty indicator (8).  Specific health goals are correlated with each health state and 
recommendations are made to involve various care providers to meet these goals (see Appendix B).  
The following are additional unique features of the proposed care model: 

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• The care model is organized into 3 phases of hospital care relevant to the rescue, optimization, and 
safe transition.   
• Hospital care delivery will be integrated with community care delivery through the pre-existing COPD 
Outreach program for frail individuals with most severe disease (i.e. those most likely to benefit from 
close follow up and management).  The outreach program consists of follow up phone calls at 3 and 12 
months, a home visit, ongoing education, and a hotline that patients may call if they have concerns. 
Individuals with less severe disease will be linked to existing COPD education and maintenance 
pulmonary rehabilitation programs in the community to ensure ongoing support and follow up. 
• The care model also incorporates testing to confirm the COPD diagnosis and reinforces the importance 
of performing spirometry to confirm the diagnosis.  This is a `real world' issue, as many patients 
presenting to hospital with “COPD” have never actually been formally diagnosed (20).  Confirmation of 
diagnosis offers an opportunity to intervene with treatments to improve quality of life in the long term. 
We will use a patient reported outcome measure engagement called `Health Confidence' as an outcome 
for this care model.  Health confidence has not traditionally been a patient reported outcome in COPD, but 
patients consistently indicate it to be an important issue (17). Improving the health confidence of patients 
can contribute to improved health outcomes, better care experiences, and likely fewer health care services 
with less cost (27).   
3.0 OBJECTIVES 
The objectives of this study are to:  
a) Determine the feasibility of implementing a novel COPD care model on a respiratory ward in a 
tertiary care hospital using quantitative and qualitative implementation metrics.  
b) Determine the process measures and personnel required for successful replication of this care 
model intervention at other sites. 
c) Use the results of this pilot feasibility study to determine the optimal study design and plan for 
a larger scale analysis to study the effect of this care model on health system and patient-
reported outcomes. 
4.0 HYPOTHESIS 
We hypothesize that goal-directed care delivery which is tailored to the functional health status of patients 
will improve patient engagement (health confidence) and translate into improved health service and clinical 

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outcomes in the short and long term. To rigorously test this hypothesis, we must first demonstrate feasibility 
of this complex intervention. 
 
5.0 MULTI-DISCIPLINARY STUDY AND CLINICAL CARE TEAM  
• Sunita Mulpuru, MD FRCPC MSc (Project Lead):  Dr. Sunita Mulpuru in a full-time respirologist in the 
Department of Medicine, Associate Scientist at the OHRI, and the clinical quality lead in the Division of 
Respirology.  She has 70% protected time for clinical research activities, will supervise the project 
team, and contribute 0.2 FTE per week to this project.  
• Alan J. Forster, MD FRPCP MSc (Project Co-Lead):  Dr. Alan Forster is a full-time internist in the 
Department of Medicine and the Vice President of Quality, Performance and Population Health at The 
Ottawa Hospital.  He will facilitate the involvement of important stakeholders and provide oversight to 
scale the implementation of the care model.    
• Justin Presseau, PhD: Dr. Justin Presseau is an associate scientist at the Ottawa Hospital Research 
Institute (OHRI) with expertise in implementation science and use of audit/feedback research 
techniques.  He will provide methodological and analytical guidance for the implementation of the care 
model.  He will contribute approximately 20 hours of time. 
• Jacqueline Sandoz, MD FRCPC and Wendy Laframboise, APN:  Dr. Sandoz and Ms. Laframboise are co-
leads of the INSPIRED-COPD Outreach team at TOH.  This innovative program is fully operational with 
permanent funding and will integrate with the hospital care model to ensure long term follow up for 
patients in the community. Dr. Sandoz and Ms. Laframboise will participate in the data acquisition, 
analysis, and contribute approximately 40 hours of time. 
• Barbara d'Entremont RN:  Barbara d'Entremont is the corporate coordinator for clinical pathways at 
TOH and facilitated the initial development of the COPD care pathway and order set. She will assist 
with ongoing pathway production.   
• Caroline Tessier RRT & Nha Voduc MD FRCPC:  Caroline Tessier is the lead respiratory therapist in the 
Pulmonary Function Test (PFT) laboratory at TOH.  She will coordinate and supervise the involvement 
of certified respiratory educators on the respiratory ward and ensure delivery of standardized 
education.  Dr. Voduc is a staff respirologist at TOH and medical director of the PFT laboratory.  He was 
an author on the Canadian COPD Guidelines and will provide guidance to the project from a clinical 
perspective. 
• Jan Leahy RN:  Jan Leahy is the nurse manager on the 6NW ward at TOH.  She is responsible for the 
nursing staff on the ward, and for coordinating hospital-based clinical care in Respirology, Thoracics, 

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and Otorhinolaryngology (ENT).  She will assist with nursing staff engagement throughout the project 
and the development and revisions of care processes related to the care model. 
• Aaron Leblanc, MD, PGY-5 Respirology Resident:  Dr. Leblanc is a senior Respirology trainee who will 
participate in aspects of the study, including calibration of frailty ratings by nursing staff, data 
collection in focus groups, and manuscript writing. 
 
6.0 METHODS 
6.1 Design: a prospective, mixed-methods, cohort study design at The Ottawa Hospital (TOH) to 
evaluate feasibility of this complex intervention.   
 
6.2 Study population and Inclusion Criteria: We will include adult patients admitted to the 6NW 
(Respirology ward) of the General campus at TOH with a primary diagnosis of acute exacerbation of 
COPD (AECOPD).  The diagnosis is based on the admitting physician’s assessment of the patient in 
the emergency room.  
 
We will also include approximately 26 health care workers (nurses, physicians, and allied health 
professionals) who care for patients on the 6NW of the General campus at TOH who have 
implemented and worked with the COPD care pathway during the study duration.  
 
6.3 Time Frame:  Implementation and feasibility data will be collected for 50 patients who are 
hospitalized for COPD over the course of two flu seasons (2017-2018 and 2018-2019), which 
corresponds to the peak season for COPD-related hospitalizations (22).  
 
6.4 Consent Process: Patients eligible for the study will be approached by the study respiratory nurse 
educator (RT), who is already part of the patients circle of care. The RT will ensure the potential 
participant understands the study and what it would require of them (two questionnaires: one in 
hospital and one during a 3-month post-discharge visit). If the patient accepts, the RT will ask them 
to review the Informed Consent Form and sign if they agree to participate in the study.  
 
A member of the study team will approach Healthcare professionals (HCPs) who work on the 
Respiratory ward (6NW) of TOH, General campus and have used the COPD care pathway to 
participate in the study. The member of the study team will explain the study and ask if they would 

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like to participate. If they agree to participate, they will be given a consent form. The consent form 
requests a consent to complete a questionnaire and participate in the focus group with other HCPs. 
If the HCP chooses to participate, the signed informed consent is placed in one box, while the 
completed questionnaire is placed in another. This is to conserve anonymity of the questionnaire 
responses. Once focus group times and location are set, an email will be sent out by a member of 
the study team to inform those who consented to participate of the focus group time and location.  
 
6.5 Implementation of the Goal-Directed Care Pathway:  Patients enrolled in the study will receive 
standardized treatment using an initial physician order set followed by a clinical care pathway 
(Appendix B).  The order set and care pathway will be physically added to the patient's chart for 
daily reference by the health care team.     
 
The care pathway (see Appendix B) consists of orders to be executed by the nursing staff, attending 
physician, and allied health professionals (respiratory therapy, occupational therapy, and 
physiotherapy, where applicable) while the patient is hospitalized.  None of the components of the 
pathway extend beyond standard care that would be provided at TOH. 
 
To initiate the care pathway, the first nurse to admit the patient will complete a frailty assessment 
and document the patient's clinical frailty score (8).  This validated frailty score is associated with a 
set of expected treatment goals and outcomes for the patient during hospitalization and will serve 
to guide the subsequent care for the patient.    
 
Following the frailty assessment, the care pathway is divided into three phases: rescue, 
optimization, and safe transition.  The interventions in each phase are tailored to the COPD patient 
based upon their frailty rating.  Evidence-based pharmacologic treatments, consultations with 
allied health professionals, medical services (e.g. Palliative care), and multidisciplinary educational 
interventions (Appendix A) are ordered in each phase where appropriate.  In the safe transition 
phase, follow up with primary care, and referrals to pulmonary rehabilitation and the COPD 
outreach program will be arranged where appropriate.  
 
6.6 Sample Size:   
6.6.1 Patients: We aim to recruit 50 unique patients over an 18-month period to use the 
care pathway.  The Ottawa Hospital admits over 500 patients with acute exacerbations 

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of COPD annually and approximately 30% of these patients are admitted to the 
respiratory inpatient service (150 patients).  Given that COPD exacerbations are twice 
as common in the winter months (22), we feel our recruitment target of 50 patients is 
feasible between November 2017 and May 2019.  
6.6.2 Health Care Professionals (HCPs):  We aim to recruit approximately 26 HCPs, 2 groups 
of 13 participants, to discuss of their personal experiences with the COPD care Pathway 
after an evaluation of the pathway.   
6.7 Outcomes 
6.7.1 Primary: The primary outcome is the feasibility of using this COPD care model in a 
hospital setting.  In this practical experiment, feasibility will be defined by recruitment 
of 50 patients (3-4 per month x 18 months) to the care pathway, with an 85% 
completion rate (care model completion). This will be calculated using the number of 
completed pathway documents divided by the total number of care pathways initiated 
at the time of admission. We will critically review each document for completion. 
 
6.7.2 Secondary: There are four secondary outcomes for this study. 
 
6.7.2.1 Qualitative Implementation Metrics:  Implementation of the care pathway will 
be evaluated by HCPs (nursing staff and allied health professionals). Participants 
are asked to complete a questionnaire and participate in a focus group with 
other HCPs.  During focus groups, common themes for barriers to 
implementation will be identified using a-priori selected questions.  We will 
consider success of implementation if no significant barriers are identified 
through group consensus in the focus groups and if 80% of questionnaire 
responses in each category fall into the “agree” or “strongly agree” responses.  
 
6.7.2.2 Knowledge Translation Metrics:  We will measure success in knowledge 
translation with achievement of 80% adherence to basic COPD care guideline 
standards including use of appropriate antibiotics, systemic steroids, 
bronchodilators, venous thromboembolism prophylaxis, and advanced directives 
documentation.  Adherence will be calculated from direct review of the care 
pathway documents after completion. 

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6.7.2.3 Patient Reported `Health Confidence':  Health confidence is a measure of the 
engagement of a patient in his or her own health (24).  Greater health 
confidence is associated with improved outcomes, better experiences with care, 
and improved health resource utilization and cost (24,25).  Health confidence 
will be measured using a four-item scaled survey: 1) I know enough about my 
health, 2) I can look after my health, 3) I can get the right help if I need it, and 4) I 
am involved in decisions about me. Participants answer each of the statements 
with the following scale: strongly agree, agree, not sure, or disagree. Patients 
who report 'strongly agree' for each of the above-mentioned statements are 
considered to have a higher level of health confidence than participants who 
report 'disagree'. These statements have demonstrated adequate psychometric 
properties and construct validity in preliminary testing (26).  Formal permission 
for utilization of this tool in this study was obtained from the developer (T. 
Benson, R-Outcomes Ltd., Bristol, UK).  The health confidence survey will be 
administered at the start of the education session in hospital, and repeated at 3 
months, during a follow-up visit in the Pulmonary Function Test laboratory of the 
Ottawa Hospital, General campus.  We aim for 80% completion of the “Health 
Confidence Score” among patients using the care model.  
6.7.2.4 Patient Reported ‘Quality of life’: Patients quality of life can be measured with 
the “Health Related Quality of Life Score”, or 'howRu' tool which has been 
validated against other quality of life tools. This tool is a four-item scaled survey: 
1) Pain or discomfort, 2) feeling low or worried, 3) Limited in what I can do, and 
4) require help from others. Participants answer each of the statements with the 
following scale: none, a little, quite a lot, or extreme. Those who report 'none' 
for each of the above-mentioned statements are considered to have a better 
quality of life than those who respond 'extreme'. These statements have 
demonstrated adequate psychometric properties and construct validity in 
preliminary testing (26). Formal permission for utilization of this tool in this study 
was obtained from the developer (T. Benson, R-Outcomes Ltd., Bristol, UK).  This 
survey will be administered at the start of the education session in hospital, and 
repeated at 3 months, during a follow-up visit in the PFT laboratory. We aim for 

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80% completion of the “Quality of Life Score” among patients using the care 
model 
6.7.2.5 Health Service Metrics:  We will use the Ottawa Hospital Data Warehouse 
(TOHDW) to measure length of stay, cost per weighted case, 30-day readmission, 
mortality, intensive care unit admission, intensive care unit length of stay, and 
number of hospitalizations in the 2-year window prior to the current admission. 
TOHDW is a relational database that captures clinical and administrative data for 
unique hospital encounters.  
 
6.8 Data Sources: 
6.8.1 Electronic Health Record, COPD Pathway Documents:  We will collect patient-related 
data using and some feasibility data using a combination of vOacis and the COPD care 
model document.  These data points are detailed in the case report forms.  
6.8.2 Focus Groups and Questionnaires:  We will gather data from focus groups of HCPs to 
assess our implementation outcomes, and questionnaires provided to the HCPs who 
use the care models. 
6.8.3 Patient Questionnaires:  We will gather data from the COPD Assessment Test (CAT) 
and Health Confidence scores (HCS) to assess the symptom burden and engagement of 
patients. 
6.8.4 TOH Data Warehouse (TOHDW):  Health service metrics including length of stay, cost 
per weighted case, readmissions, mortality, and ICU admissions will be ascertained 
from the Data Warehouse.  A separate Data Specification Form (DSF) has been initiated 
for this data request.  
 
6.9 Data Collection: The following figure illustrates when data will be collected for participant during 
the study.  The two focus groups will be conducted during the pilot in March 2018 with HCPs 
(nurses, physiotherapists, occupational therapists, and dieticians) who have used the pathway. 
Questionnaires of HCPs will be gathered prior focus groups. 
 
Patient data will be collected at three time-points:  
1) 
During hospitalization: Includes COPD Pathway Phases 1 to 3. Patient data relating to 
demographics, frailty rating, COPD diagnosis, lung function, oxygen use, smoking status, 

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and symptom burden will be collected from the hospital chart. The study respiratory 
therapist will enter this data in a Case Report Form for Respiratory Therapists.  Patient 
participants are asked to complete a baseline health confidence and quality of life 
questionnaire at the beginning of hospitalization (Part A – Patient In-Hospital 
Questionnaire). 
2) 
 3-Months Post-Discharge: Includes COPD Pathway Phase 4. During a post-discharge visit 
in the PFT laboratory of the General Campus at TOH, patient participants will be asked to 
complete a follow up questionnaire (Part B – Patient Post-Discharge Questionnaire). 
During this visit, a review will be undertaken of community services accessed by the 
patients, and any referral issues will be rectified if needed. 
3) 
At Study Conclusion: Data collection in this phase will be from TOHDW.  We will collect 
all health service outcome data up to 6 months post-discharge from the TOHDW. This will 
include initial hospital length of stay, mortality, ICU admission, 30-day readmission, and 
cost per weighted case.   
 
 
 
 

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Figure 1 – Details for each point of data collection * As part of the study, patient participants are invited for a 3month follow-up in the PFT 
laboratory. 
7.0 STUDY TIMELINE 
There are 5 distinct phases to the study: 1) pre-implementation, 2) hire, 3) educate, 4) implementation and 
data collection, and 5) finalize results and plan for next steps.  
Figure 2 - Study Timeline 
Pre-implementation:  Finalize the COPD pathway documents, engage the nursing staff in initial 
education, trial the pathway on 5 patients, and conduct 2 PDSA (Plan, Do, Study, Act) cycles with 
subsequent pathway revisions, based upon preliminary nursing and physician recommendations. 
Hire: Hire clinical research assistant and submit research ethics board application 
Educate: Clinical care team regarding individual components and application of the care model (nurses, 
physicians, respiratory therapists, allied health).  Create secure database to store study data.  
Implementation and data collection: Implementation of the care model on the respiratory warddata 
collection and organization, education sessions and post-rotation focus groups with each new group of 
physician trainees on the ward (once per month), focus groups (March 2018), and questionnaires with 
nursing and allied health staff. 
Finalize results and plan for next steps: Write manuscript, plan the design of next steps (cluster 
randomized trial). 
8.0 DATA MANAGEMENT 
The data collected will be password protected and will not leave TOH.  Only study personnel will have 
access to the study data.  A study master list (containing MRN’s) will be linked to a study ID.  This master 
linking file will be kept separate from the main study dataset in a protected folder on a secure TOH sever.   

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Only the unique study ID will be used on the patient questionnaires and study case report forms.  The 
study files will not be stored on the hard drives of portable devices or on USB keys. 
9.0 FUNDING & COLLABORATION 
The Ottawa Hospital Academic Medical Organization (TOHAMO) has awarded a $100,000 grant to conduct 
this pilot project. The Lung Association and Ontario Thoracic Society has also awarded $47,000 for this 
pilot project. 
The Ottawa Hospital has provided in-kind resources for development of this project, via specific 
commitments from individuals in clinical nursing, nursing professional practice, respiratory therapy, 
pharmacy, senior management, and allied health care.   
The Department of Medicine Patient Safety and Quality Committee has also provided in-kind support and 
resources for this project.  
The Canadian Foundation for Healthcare Improvement (CFHI) has also provided in-kind support to this 
project to assist with scaling and promotion of the care pathway concept in COPD care. 
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17.  Giacomini M, DeJean D, Simeonov D SA. Experiences of Living and Dying With COPD: A Systematic 
Review and Synthesis of the Qualitative Empirical Literature. 2012. Available 

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from:http://www.hqontario.ca/Portals/0/Documents/evidence/reports/rev_COPD_Qualitative_March.
pdf 
18.  Kinsman L, Rotter T, James E, Snow P, Willis J. What is a clinical pathway? Development of a definition 
to inform the debate. BMC Med. 2010 May 27;8:31.  
19.  Rotter T, Kinsman L, James E, Machotta A, Willis J, Snow P, et al. The effects of clinical pathways on 
professional practice, patient outcomes, length of stay, and hospital costs: Cochrane systematic review 
and meta-analysis. Eval Health Prof. 2012 Mar;35(1):3–27.  
20.  Lange P, Halpin DM, O’Donnell DE, MacNee W. Diagnosis, assessment, and phenotyping of COPD: 
beyond FEV₁. Int J Chron Obstruct Pulmon Dis. 2016;11 Spec Is:3–12.  
21.  Jordan RE, Adab P, Sitch A, Enocson A, Blissett D, Jowett S, et al. Targeted case finding for chronic 
obstructive pulmonary disease versus routine practice in primary care (TargetCOPD): a cluster-
randomised controlled trial. Lancet Respir Med. 2016 Sep;4(9):720–30.  
22.  Rabe KF, Fabbri LM, Vogelmeier C, Kögler H, Schmidt H, Beeh KM, et al. Seasonal distribution of COPD 
exacerbations in the Prevention of Exacerbations with Tiotropium in COPD trial. Chest. 2013 
Mar;143(3):711–9. 
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in Focus Group Research. Int J Qual Methods. 2009;8(3). Available from: 
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_Focus_Group_Research.pdf 
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practice. Fam Pract Manag. 21(5):8–12.  
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medication illness, and low health confidence. J Ambul Care Manage. 2013;36(3):245–50.  
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Outcomes and Care Experiences; Fewer Data On Costs. In Health Affairs, 32(2), pp, 207-214. 

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Appendix A - Standard COPD Education Session in Hospital1 
1. Review the definition of COPD, symptoms, and the common causes. 
2. Discuss the concept of ‘COPD Flare-up’s, including a definition, review of common triggers, and early recognition 
of symptoms. 
3. Review strategies to prevent worsening of symptoms (exercise, good nutrition, smoking cessation, medication 
use).  
4. Discuss smoking cessation where applicable and provide relevant community resources for smoking cessation 
(example:  Ottawa MyQuit Program, Heart Institute Smoking Cessation Clinic, etc.)  
5. Review medications used to prevent and relieve symptoms 
6. Demonstrate and confirm inhaler technique with attention to the appropriateness of the inhaler delivery device  
7. Demonstrate and review breathing and cough techniques to clear secretions 
8. Discuss with patient the potential benefit of community COPD education programs for ongoing support, 
pulmonary rehabilitation programs (including maintenance rehabilitation), support from the COPD outreach 
team, and referral to the HealthLinks program offered by the Champlain LHIN 
a. Review the best community program option for individual patients, based on patient preference, 
location, and services provided. 
If appropriate, review and discuss exercise goals to consider once recovered from acute exacerbation.  
 
 
                                                          
1 Kruis, (2013) Adapted from the ‘Living Well with COPD™’ educational materials from the McGill University Health Center, in 
Montreal, Canada. 

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Appendix B - COPD Care Pathway –Order Set (page 1 of 8)
 
 
 

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Appendix B - COPD Care Pathway –Order Set (page 2 of 7) 
 

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Appendix B - COPD Care Pathway –Order Set (page 3 of 7) 
 

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Appendix B - COPD Care Pathway –Order Set (page 4 of 7) 
 

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Appendix B - COPD Care Pathway –Order Set (page 7 of 7) 
 

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Appendix B - COPD Care Pathway –Physician Orders (page1 of 1)