PURPOSE:To determine if a delay in presentation to the emergency department (ED) after the onset of symptoms of an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) affects the risk of hospital admission.
METHODS:A prospective cohort study utilizing data from 396 patient visits to 29 North American EDs. Inclusion criteria were physician diagnosis of COPD; age ≥ 55 years; and presentation to the ED for treatment of AECOPD (increasing shortness-of-breath, worsening cough, or change in sputum production). “Early-presenters” were those presenting <24 hours after symptom onset, while “late-presenters” were those presenting after ≥24 hours.
RESULTS:The median age of the cohort was 69 years and 54% were female. Most patients (61%) were admitted overnight to the hospital. Likewise, most patients (70%) presented to the ED more than 24 hours after symptom onset. Compared to early-presenters, late-presenters reported significantly worse respiratory symptoms on ED arrival. On multivariate logistic regression analysis, after adjusting for 12 potential confounders (see Table), a delay in presentation of 24 hours or more was associated with a 2.20 fold increase in the odds of admission (95% confidence interval [CI] 1.11–4.76). Further adjustment for respiratory infection as the trigger of exacerbation did not materially change these results (OR 2.08, 95% CI, 0.98–4.41). Late presentation remained significantly associated with increased hospitalization after restricting the analysis to patients admitted to non-ICU beds, those reporting the ED as their usual site of care, and by using 12 hours as the cutoff for defining early vs. late presentation (Table).
CONCLUSION:Almost two-thirds of patients with AECOPD waited for more than a day after onset of increased symptoms to present to the ED for treatment. At presentation, late-presenters’ symptoms were significantly worse than those of early-presenters, and they were more likely to be admitted to the hospital.
CLINICAL IMPLICATIONS:Although early presentation after symptom onset should be emphasized to patients and caregivers, future studies are needed to confirm if early therapy actually reduces the risk of hospitalization for AECOPD.
DISCLOSURE:Divay Chandra, University grant monies n/a; Grant monies (from sources other than industry) NIH; Grant monies (from industry related sources) AstraZeneca, Critical Therapeutics, Dey, GlaxoSmithKline, Merck, Novartis, and Respironics.; Shareholder n/a; Employee Massachusetts General Hospital, Brigham & Women’s Hospital; Fiduciary position (of any organization, association, society, etc, other than ACCP n/a; Consultant fee, speaker bureau, advisory committee, etc. AstraZeneca, Critical Therapeutics, Dey, GlaxoSmithKline, Merck, Novartis, and Schering-Plough.; Other n/a; No Product/Research Disclosure Information