Predicting safe discharge from emergency department observation unit in copd exacerbation: Resting borg progression as indicator of safe discharge.

Background COPD exacerbations (eCOPD) can be life threatening and costly. ED observation units (ED-Obs) offer short-term care to safely reduce preventable hospitalizations. Accurately identifying eCOPD patients who can be discharged safely will improve outcomes. Objectives I) Evaluate utility of conventional clinical variables as predictors of safe discharge. II) Assess utility of serial resting-Borg score and novel Dyspnea Assessment Score (DAS) for identifying eCOPD patients who can be safely discharged from ED-Obs. Setting A 680-bed tertiary, academic hospital with >700 annual eCOPD ED encounters and a 16-bed ED-Obs. Methods Two-phase study of eCOPD patients admitted to ED-Obs. Objective I: Retrospective study including all eCOPD admits from 4/2016-5/2017. Predictor variables (demographics, COPD severity, comorbid conditions, exacerbation severity, clinical care in ED) and outcome variables (ED-Obs disposition, ED revisits) were obtained through electronic medical records. Safe discharge was defined as home disposition from ED-Obs without 7-day revisit. A stepwise regression was performed for predictors of safe discharge. Objective II: Prospective observation study for change in every 4-hour serial resting Borg and DAS scores as identifiers of safe discharge. Comparative and ROC analyses were performed. P Results Objective I: 171 patients with age, FEV1% and BMI of 59.8(±9.5) years, 35(+24)% and 28.8(+8) m2/kg were included. After ED-Obs treatment 78(45.6%) were hospitalized and 93(54.4%) were discharged home, of which 11(6.4%) had 7-day ED-revisit. Safe discharge occurred in 82(48%). None of the predictor variables correlated with safe discharge. Objective II: Of 38 patients included, 20(52.6%) had safe discharge. Among others, 16(42%) were hospitalized and 2(5.2%) had 7-day ED revisit. The admission Borg and DAS scores were similar in both groups. The pre-disposition BORG score was significantly lower in patients with safe discharge (2.75 vs 5.28, p Conclusions Routine clinical variables do not identify eCOPD patients who can be safely discharged from ED-Obs. Change in resting-Borg during the course of ED-Obs treatment safely identifies patients for discharge. Prospective, external validation is needed to incorporate serial Borg scores in ED-Obs disposition decision for improved safety.