. 2022 Jan 10;15:47–79. doi: 10.2147/JMDH.S343277

Table 2.

Included Studies Demographics, Barriers, Potential Solutions/Recommendations

Included Studies References	Title	Aims	Methods	Country	Sample Size	Barriers	Solutions/Research Recommendations
1) Smallwood 2018⁶⁰	Attitudes to specialist palliative care and advance care planning in people with COPD: a multi-national survey of palliative and respiratory medicine specialists	To explore the approaches of respiratory and palliative medicine specialists to palliative care and advance care planning (ACP) in advanced COPD	Cohort study	Australia, New Zealand, and UK	N=440 Respiratory-117 clinicians Palliative- 263 clinicians	Difficulty in prognosis of COPD^a due to the variable disease trajectory. Clinicians lacking time to discuss palliative care or being fearful of taking away hope palliative specialist availability Current health care models with insufficient communication and collaboration Poor access, lack of palliative care service capacity	Patient led Advanced Care Planning discussions Respiratory doctors to initiate the conversation and refer to palliative specialist for individualised planning Integrated multidisciplinary services to address fragmented care
2) Lipari 2018¹⁸	Adherence to GOLD Guidelines in the Inpatient COPD^a Population	Assessed the management of inpatient COPD^a exacerbations at an urban teaching hospital	Cohort study (Retrospective)	United States	N=94 patients	Consistent variation in provider guideline adherence. Variability in dosing schedule and duration of corticosteroids Vaccination document lower in summer months (10%) Approximately half of COPD^a readmissions in this hospital did not receive steroids during their first admission	Electronic care order sets for consistent steroid prescription. Improve documentation during hospital admission utilising electronic medical record. Quality improvement projects to improve guideline adherence utilising clinical bundle services
3) Marcos 2017⁴⁴	Treatment with Systemic Steroids in Severe Chronic Obstructive Pulmonary Disease Exacerbations: Use of Short Regimens in Routine Clinical Practice and Their Impact on Hospital Stay	Explore short courses of systemic corticosteroids are followed in clinical practice	Cohort study (Prospective observational)	Spain	N=158 patients	Real world practices vary from guidelines and impact hospital stay Delayed switch to oral treatment Doses of corticosteroid use in asthma being transferred to COPD^a Risk of adrenal crisis due to abrupt withdrawal of prescribed dose Despite the evidence oral steroids are not inferior to intravenous steroids usage of IV^a steroids Recommended duration is tripled as to 5 days in practice	Factors such as social considerations, hospital inefficiencies and continued care after discharge needs to be further researched
4) Masoompour 2016⁵⁸	Adherence to the Global Initiative for Chronic Obstructive Lung Disease guidelines for management of COPD^a: a hospital-based study	To determine the level of adherence to the GOLD^a guidelines, we compared our inpatient management o COPD to these guidelines	Cross sectional study	Iran	N=96 patients admission	No local standard guidelines for managing COPD in Iran	Develop targeted interventions aimed at improving the implementation of guidelines Further research to determine the efficacy of this new interventions
5) Melani 2016⁴⁹	Maintaining Control of Chronic Obstructive Airway Disease: Adherence to Inhaled Therapy and Risks and Benefits of Switching Devices	To evaluate the issues involved in maintaining control of COPD^a, predominantly related to adherence to prescribed inhaled medications, and the potential benefit and risks of switching devices	Critical review	Italy	Search strategy not mentioned	Lack of awareness of the consequences of poorly controlled disease Concerns about drug side effects, or loss of efficacy, or development of addiction Poor medical-patient communication; poor medical-other health caregivers’ partnership in patient’s education. Lack of continuity of care, no written plan; physician’s underestimation of disease control; poor supervision, training, or follow-up of patients; and poor education to inhaler training	Easier-to-use devices and educational strategies on proper inhaler use from health caregivers can improve inhaler technique. Switching to a more appropriate patient centred inhaled therapy is recommended. A comprehensive list including all inhalers in the market, edited by scientific societies face-to-face practical instruction of proper inhaler use at prescription, and regular checks at follow-up visits. Training other staff other than physicians to provide inhaler technique education
6) Menzella 2012¹⁹	Clinical audit on diagnostic accuracy and management of respiratory failure in COPD^a	The aim of the study was to evaluate the adequacy of diagnosis and management of respiratory failure (RF) in COPD^a	Quantitative (Retrospective clinical audit)	Canada	N=130 patients	Accurate diagnosis and categorisation are essential in implementing quality improvement measures based on clinical audits	Clinical pathways for uniform oxygen management
7) Migone 2015²⁰	Patients Hospitalised with an Acute Exacerbation of COPD^a: Is There a Need for a Discharge Bundle of Care	Identify the proportion of those patients admitted with AECOPD who had received a number of recommended interventions by the time of discharge. A secondary aim of the study was to examine the association between the delivery of recommended interventions and care under a respiratory physician and a respiratory clinical nurse specialist (RCNS)	Quantitative (Retrospective chart audit)	Ireland	N=174 patients	Lack of knowledge of the benefits of some interventions (pulmonary rehabilitation particularly for non-respiratory physicians) Difficulty in implementing recommendations from guidelines where complex behaviour change is required (written self-management plans, may be a barrier) Perception amongst hospital doctors that some interventions are the responsibility of general practitioners. This has been reported in the literature in relation to smoking cessation and vaccination	Electronic reminders & bundles of care. Discharge bundle of care reduced readmissions for COPD and increased adherence to guidelines bundle of care. Discharge bundle improved referral for smoking cessation assistance from 18.2% to 100% and review of inhaler technique increased from 59.1% to 91.2% of admissions. Care bundle impact on pulmonary rehabilitation referral rates rose from 13.6% to 68%. Similar improvements were seen in administration of self-management plans Training of medical staff of the benefits of interventions for patients with COPD^a is also important
8) Overington 2014¹²	Implementing clinical guidelines for chronic obstructive pulmonary disease: barriers and solutions	This review explores these critical issues, gaining insight from efforts in clinical guidelines for other chronic diseases, and applying these principles to improving uptake of the COPD^a guidelines amongst clinicians	Literature Review	Australia	N=5 studies	Low awareness Clinician knowledge of COPD^a management is low worldwide Time constraints Disparity in guideline awareness	Targeted health professional education Clinical decision-making algorithms Electronic reminders at clinical points Continuous quality assurance projects Supportive clinical behavior enablers Brief summaries of guideline in clinical areas Direct mailing guidelines to Clinicians Education sessions with didactic and interactive content Electronic health records Readily accessible guidelines Multifaceted implementation programmes (pamphlets, reminders and meetings) Point of care checklists (electronic)
9) Pozo-RodrÃ-guez 2012⁵⁴	Clinical audit of COPD patients requiring hospital admissions in Spain: AUDIPOC^a study	AUDIPOC is a nationwide clinical audit that describes the characteristics, interventions and outcomes of patients admitted to Spanish hospitals because of an acute exacerbation of chronic obstructive pulmonary disease (AECOPD), assessing the compliance of these parameters with current international guidelines	Prospective cross-sectional study	Spain	N=5178 patients (225 participating hospitals in a national audit)	Variability of care at the hospital level and non-compliance with recommendations regarding diagnosis or in-hospital treatment Level of information included in the final discharge report did not include recommendations related to general health practices and lifestyle improvements and were provided to only 50% patients Minimal interventions aimed at promoting smoking cessation, an active lifestyle (including rehabilitation prescription) and/influenzas or pneumococcal vaccination	The association of access to electronic/digital information with the number of interim and definite cases suggests that the use of information technologies may increase the identification of cases and, possibly, improve the audit process
10) Pretto 2012⁵²	Multicenter audit of inpatient management of acute exacerbations of chronic obstructive pulmonary disease: comparison with clinical guidelines	Document variability and identify gaps from guidelines in management practices to allow targeted interventions to be developed to improve quality of care	Retrospective medical record audit	Australia	N=221 patients	Non provision of non-invasive ventilation (NIV), due to medical decision to not escalate treatment, patient responding well to medical treatment or patient refusal Low respiratory specialist referral and pulmonary rehabilitation referrals Low level of support to implement smoking cessation in public hospitals Lack of standard communication regarding pulmonary function testing Low utilisation of ABG^a data to utilise NIV^a Lack of previous experience with NIV^a initiation. Lack of staff education on NIV ^a More than quarter discharged patient from rural hospital were readmitted within 28 days Low concordance to COPD^a management guidelines	Targeted educational intervention for utilisation of NIV^a Target specific practices in the development of AECOPD^a management policies
11) Roberts 2013²²	European hospital adherence to GOLD^a recommendations for chronic obstructive pulmonary disease (COPD) exacerbation admissions	Understanding how European care of chronic obstructive pulmonary disease (COPD) admissions vary against guideline standards provide an opportunity to target appropriate quality improvement interventions	Retrospective case note audit	Austria, Belgium, Croatia, Greece, Malta, Poland, Republic of Ireland, Romania, Spain, Switzerland Turkey and the United Kingdom	N=16018 patients (384 hospitals)	Unavailability of spirometry test results despite previous admissions patients not having an ABG test documented also received Oxygen. Inappropriate antibiotic prescription	Primary and secondary care spirometry results access Understanding care quality and deficiencies provide opportunities for targeted interventions that could produce significant patient benefits
12) Sandhu 2013⁵⁰	Variations in the management of acute exacerbations of chronic obstructive pulmonary disease	Evaluate adherence to current guidelines across different physician groups and patient outcomes were assessed	A retrospective chart review	Canada	N=293 patients	Lack of physician awareness of guidelines Care gaps between general internists, respiratory physicians and hospitals	Risk stratification and appropriate optimization of maintenance therapy at the time of discharge Cross fertilisation of knowledge by respiratory physicians to other departments
13) Seys 2017⁶⁵	An International Study of Adherence to Guidelines for Patients Hospitalised with a COPD^a Exacerbation	The aim of this study is to perform an importance-performance analysis as an approach for prioritisation of interventions by linking guideline adherence rates to expert consensus on the importance for follow /through in hospital management of COPD^a exacerbation	Cluster randomised controlled trial	Belgium	N=378 patients	Lowest adherence to guidelines can mainly be seen for indicators related to patient education (such as oxygen therapy), nutritional assessment, pulmonary rehabilitation and discharge management. Managerial issues, eg, communication gap between management and prescribers lack of persuasion from the administration, and scientific issues, eg, faulty guideline development Process or guideline is not-up-to-date, relevant or disagreement with the guideline Guideline is too complicated and difference in clinical scenario to the ones mentioned in guidelines	Performance analysis to develop quality framework for systematic follow up of guideline recommendations Care pathways can be used as a framework for clinical interventions as they are based on evidence
14) Seys 2018⁵³	Teamwork and Adherence to Recommendations Explain the Effect of a Care Pathway on Reduced 30-day Readmission for Patients with a COPD^a Exacerbation	This study aimed to increase our understanding of processes that underlie the effect of care pathway implementation on reduced 30-day readmission rate.	Cluster randomised trial	Belgium Italy Portugal	N=257 patients (19 hospitals)	Staff burn out Team climate for innovation	Care pathway implementation was significantly associated with better guideline adherence and reduced 30-day readmission. Clinical interventions Priority indicators for departments
15) Sha 2019¹⁰	Hospitalised exacerbations of chronic obstructive pulmonary disease: adherence to guideline recommendations in an Australian teaching hospital	To examine current practice in management of COPD^a exacerbations at an Australian teaching hospital and to compare with COPD-X Plan recommendations	Retrospective chart audit	Australia	N=134 patients	Reduced awareness of guidelines especially among junior doctors Venous blood gas (VBG) being an unreliable substitute for arterial blood gas (ABG) assessing presence of hypercapneic respiratory failure may be due to patient refusal, clinician concern about patient tolerability and easier technique for clinicians Time poor clinicians may overlook smoking and immunisation history NIV^a provided unnecessarily to patients with adequate oxygenation Antibiotics administration despite normal white cell count Use of corticosteroids without indication Underutilisation of pulmonary rehab Reduced vaccination recommendations	Electronic alerts and care sets
16) Wijayaratne 2013³⁶	Differences in care between general medicine and respiratory specialists in the management of patients hospitalised for acute exacerbations of chronic obstructive pulmonary disease	The aims of this study were to firstly examine the differences in AECOPD^a management of general medicine practitioners (GMP) and Respiratory specialist (RS) and secondly compare their care to national COPD guidelines	A retrospective review	Australia	N=169 patients	Inadequate utilisation of NIV despite meeting guideline criteria Differences in medication prescription between general medicine physicians and Respiratory specialist GMP performed fewer investigations and provided less pharmacological management while in hospital compared to RS Lower rates of referral to pulmonary rehabilitation s low awareness, low support for rehabilitation at multiple levels, lack of time and a perceived difficult referral process GMP did not prescribe short‑acting beta‑agonists (SABA^a), long‑acting anti‑cholinergic, combination LABA^a/ICS^a and systemic steroids as frequently as RS and instead prescribed short‑acting anti‑cholinergic more frequently.	Further research to understand reasons behind poor prescription of NIV^a for eligible patients
17) Vanhaecht 2016³⁴	Impact of a care pathway for COPD^a on adherence to guidelines and hospital readmission: a cluster randomized trial	The primary aim of this study was to evaluate whether implementation of a care pathway (CP) for COPD improves the 6 months readmission rate	Pragmatic cluster randomised controlled trial	Belgium, Ireland, Italy and Portugal	N=174 patients (11 hospitals)	Nonpharmacological management observed to be suboptimal particularly education required care recommendations such as smoking cessation, inhaler technique and pulmonary rehab	Care pathway implementation significantly lowered 30-day readmission rate and improved performance on process indicators Clinical audits and continuous quality improvements to target and improve low performing indicators
18) Susanto 2015³²	Assessing the use of initial oxygen therapy in chronic obstructive pulmonary disease patients: a retrospective audit of pre-hospital and hospital emergency management	Assess the use of O₂ therapy and FiO₂ in the emergency management of patients with a known diagnosis of COPD^a	Retrospective audit	Australia	N=150 patients	High-flow oxygen is used for the initial treatment of COPD exacerbations when only 53% patients were recognised to have COPD A lack of recognition of COPD high flow oxygen initiated in ambulances continued in ED^a in spite of down titration Blood gas measurements were performed, but there was a high proportion of VBG measurements rather than the recommended arterial analysis	Larger, prospective studies would be required to confirm the possible harm of un-titrated oxygen approach in COPD^a Patients The implementation of current oxygen guidelines for use in the pre-hospital setting and education of those who are involved in treating COPD patients in emergency care and other situations may reduce the risk of complications in COPD patients. Developing oxygen administration guidelines depending on the initial SpO2 would be useful as this could potentially prevent administration of high– flow Oxygen as first line treatment. Education of patients regarding their diagnosis of COPD^a, the importance of alerting ambulance and medical personnel to the diagnosis and the provision of a medical alert bracelet or oxygen alert card, especially in those with known hypercapnia. The utilisation of a dedicated oxygen prescription chart, which has been used in some hospitals, may also be of some benefit.
19) Brownridge 2017⁴⁷	Retrospective audit of antimicrobial prescribing practices for acute exacerbations of chronic obstructive pulmonary diseases in a large regional hospital	Evaluate the antibiotic prescribing practices in acute exacerbations of chronic obstructive pulmonary disease (AECOPD^a) patients, and to compare the differences in clinical outcomes (primarily mean length of stay and the rate of unplanned readmissions) between patients who received broad vs narrow-spectrum antibiotic	Implementation audit	Australia	N=130 patients	Inappropriate use of antimicrobial agents representing a modifiable factor responsible for driving antimicrobial resistance Only Ten per cent of patients received guideline concordant antimicrobial therapy The single most common reason for non-compliance with current guidelines was the use of dual antibiotic therapy	AECOPD pathway may improve antibiotic selection and help to drive compliance with guidelines. Dedicated and holistic bundles of care for AECOPD^a have been implemented in the United Kingdom and have been demonstrated to improve patient management. Future antimicrobial stewardship initiatives should target inappropriate use of antibiotics in AECOPD^a.
20) Kim 2019³⁰	Adherence to the GOLD Guideline in COPD^a management of South Korea: Findings from KOCOSS Study 2011–2018	Examine the adherence to the GOLD^a guidelines, we examined the patterns of prescribed medication in COPD^a patients from 2011 to 2018.	Cohort study	Korea	N=1818 patients	The common type of inappropriate COPD^a treatment is overtreatment, with inhaled corticosteroid (ICS^a) containing regimens Low rate of guideline adherence with 61.5% for 2011 and 49.6% for 2017	Standardization of COPD pharmacological treatment utilising GOLD^a guidelines Better implementation strategy to optimize the use of these guidelines a
21) Kelly 2019¹¹	Get with the guidelines: management of chronic obstructive pulmonary disease in emergency departments in Europe and Australasia is sub-optimal	To determine compliance with guideline recommendations for patients treated for COPD in ED in Europe (EUR) and South East Asia/Australasia (SEA) and to compare management and outcome	Prospective cohort study	Australia Europe South-east Asia	N=801 patients	Compliance with guideline recommended treatments, in particular administration of corticosteroids and NIV^a, was sub-optimal in both regions The proportion of patients with acidosis who received treatment with NIV^a was also lower than expected, despite level 1 evidence that it improves outcome.1 lack of awareness of the evidence, lack of availability of the required equipment in ED and lack of appropriately trained staff to undertake this therapy safely in ED^a. Patient declining NIV or clinician underestimating severity of COPD^a The evidence suggests there may be a disjunct between ward-based pathways and ED^a pathways for this patient group, a gap that should be closed lack of awareness of the evidence, the cognitive overload associated with ED^a practice, time constraints in ED^a, distraction and competing patient priorities as several patients, high turnover of ED^a staff making it difficult to ensure that all staff are educated in evidence-based recommendations and recent change	Individual health services local audit to inform individual health services and hopefully encourage them to audit their own practice and implement quality improvement activities with an emphasis on the identified gaps COPD^a proforma or checklist use of clinical informatics systems, computer-assisted decision support Disease specific ED^a short stay unit pathways and access to appropriate follow-up care (such as primary care or specialist clinics, disease specific outreach services, encourage smoking cessation
22) Harrison 2017³⁷	Inappropriate inhaled corticosteroid prescribing in chronic obstructive pulmonary disease patients	This study quantified the proportion of patients with COPD^a on ICS^a treatment despite a post-bronchodilator FEV1^a ≥ 50%.	Retrospective medical audit	Australia	N=707 patients	Significant discordance exists between guideline recommendations and inhaler prescription over-prescription of ICS^a in COPD^a.	COPD-X and the Pharmaceutical Benefit Scheme recommend that the introduction of inhaled corticosteroid (ICS) and long-acting beta-agonist combinations (LABA) should be reserved for patients with a post bronchodilator FEV1^a less than 50% predicted and those who experience more than two exacerbations in 12 months Encourage guideline education and prescribing within guidelines
23) Jouleh 2018⁵⁵	Guideline adherence in hospital recruited and population based COPD^a patients	Estimate and compare the guideline adherence to COPD^a treatment in general population-based and hospital-recruited COPD^a patients, and find possible predictors of guideline adherence	Prospective observational cohort study	Norway	N= (cohort 1–90) N= (cohort-2-245)	Adherence to guidelines were significantly lower in cohort treated by general physicians in diagnostic, pharmacological and non-pharmacological management Educational institutions not utilising COPD^a guidelines particularly with nurses and physiotherapists	Reliable and regularly updated guidelines are therefore, very valuable for clinicians, and help them provide the best care for their patients at any time. Possible establishment of incentives for the health care personnel who do adhere to the guidelines Accessible guidelines for healthcare workers, drug devises that facilitates compliance, accessible rehabilitation facilities, and vaccination programmes to ensure that COPD^a patients are offered the best care available.
24) Desalu 2013²⁹	Guideline adherence in hospital recruited and population based COPD^a patients	To assess physicians’ understanding, adherence, and barriers to implementation of GOLD guidelines in Nigeria	Cross-sectional study	Nigeria	N=156 physicians	Lack of familiarity was cited as the most common barrier to adherence to the guidelines Lack of awareness, non-familiarity, outcome of expectancy, time constraints, and non-agreement with recommendation. Environmental, and guideline-related factors which are beyond the control of physicians Lack of knowledge of spirometry interpretation may also be associated with the low utilisation as only one-quarter (26.9%) of the respondents could correctly make a spirometric diagnosis of COPD^a Health facilities (specialist and medical equipment) are inadequate in Nigeria, especially in rural areas. Most of the tertiary hospitals are located in the urban areas, of which only 29.4% have a spirometer Political commitment and resources are also lacking, and the allocation of a budget and human resources for the prevention and management of COPD^a is not a priority Low utilisation of pulmonary rehabilitation may be attributed to lack of human resources including specialists in pulmonary rehabilitation, infrastructure, and establishment of a well-equipped pulmonary rehabilitation unit in most hospitals in Nigeria. Poor awareness of its impact on the outcome of management, non-availability, and affordability of the vaccines	Frequent exposure of more senior doctors to the recommendations of the guidelines from several sources of continuing medical education (CME) and publications. World Spirometry Day should be used to increase the awareness and use of Spirometry Continuing medical education (CME) on these modalities of therapy. Physicians should collaborate with hospital authorities to establish smoking cessation teams and pulmonary rehabilitation units. The pharmaceutical industry can also contribute by making available cheaper vaccines for COPD^a patients Educational interventions are required to achieve optimal care for COPD^a patients.
25) Tang 2014³⁸	Level of adherence to the GOLD^a strategy document for management of patients admitted to hospital with an acute exacerbation of COPD^a	Evaluate the level of adherence among health professionals to GOLD^a	Retrospective audit	Australia	N=240 patients	Over prescription of antibiotics and oxygen therapy Poor adherence to steroids and antibiotics Non-pharmacological management such pulmonary rehabilitation and smoking cessation Factors such as time constraints and lack of awareness about resources may be the reasons for the poor adherence. Reduction in hospital beds puts pressure to provide suboptimal treatment Lack of clinical advocacy by senior clinicians Ambiguity in recommendations from GOLD^a recommendations	Clinical practice review to improve nonpharmacological management Improving environmental resources, promotion campaigns Targeted educational sessions specialised to each discipline Interactive educational tools, specific cue cards in clinical practice and presence of hospital clinical champions Improved communication between hospitals and primary care practitioners Clarity and communication by senior clinicians to address ambiguity to choose of evidence-based practice
26) Ta 2011⁴³	Management of chronic obstructive pulmonary disease in Australia after the publication of national guidelines	To evaluate COPD^a patient adherence to treatment recommendations and healthcare provider adherence to the COPD^a-X Plan	Cross-sectional study	Australia	N=45 patients	Patient self-reported medication non-adherence Suboptimal Inhaler technique Lack of self-management of exacerbations plan or teaching by clinicians Long-term steroid and prophylactic antibiotic prescription. Over-prescription of ICS^a and under prescription of tiotropium	Appropriating grading of severity of COPD^a and use of spirometry to distinguish COPD^a from other respiratory conditions like Asthma
27) Fanning 2014⁴⁸	Adherence to guideline-based antibiotic treatment for acute exacerbations of chronic obstructive pulmonary disease in an Australian tertiary hospital	This study aimed to (1) define antibiotic prescribing practice in patients admitted to a tertiary hospital with AECOPD^a and compare this with current locally and nationally recognised antibiotic prescribing guidelines and (2) correlate variations in guideline concordant antibiotic prescribing with mean length of stay (LOS) and rates of unplanned readmission to hospital	Retrospective case series	Australia	N=84 patients	Guideline discordant antibiotic therapy leading to increased length of stay	Regular clinical audits Clinical pharmacists should question the indication for IV^a antibiotics in AECOPD in association with educational campaigns that raise guideline awareness Prescribing restrictions utilising technology and policies
28) Au 2013⁴⁶	Severity of airflow limitation, co-morbidities and management of chronic obstructive pulmonary disease patients acutely admitted to hospital	To assess the disease spectrum, severity of airflow limitation, admission pattern, co-morbidities, and management of patients admitted for acute exacerbations of chronic obstructive pulmonary disease	Retrospective Case series	Hong Kong	N=253 patients	A low prescription rate of long-acting bronchodilators Low utilisation of NIV^a	Management by a designated multidisciplinary team is recommended COPD patients with hypercapnic respiratory failure are at risk of mortality, and if feasible, should be managed by trained staff in a dedicated team
29) Markun 2017³³	Acute exacerbated COPD^a: room for improvement in key elements of care	Measuring the implementation rates of acute and post-acute hospital care interventions for AECOPD^a	Retrospective chart review	Switzerland	N=263 patients	Patient education and self-management advice was low to 2% Over prescription of antibiotics Inhaler technique assessment, influenza vaccination/recommendation and referral for pulmonary rehabilitation	Checklists (also called care bundles) are disease management aids supporting clinicians to implement predefined elements of care in individual patients and improve important outcomes such as rehospitalization rates An automatized linkage between an electronic in-hospital AECOPD care bundle and the discharge letter generation might efficiently contribute to communication and comprehensiveness along the chain of care
30) Khialani 2014²³	Emergency department management of acute exacerbations of chronic obstructive pulmonary disease and factors associated with hospitalisation	The aim of this study was to identify biomarkers associated with hospitalisation in AECOPD patients and to determine if the ED^a management was concordant with local COPD^a guidelines	Retrospective audit	Australia	N= 122 patients	Spirometry was performed in 17% of patients and 28% of patients with hypercapnic respiratory failure received non-invasive ventilation (NIV). Poor understanding of the clinical indications for NIV^a Limited experience and/or lack of staff education	Scope for improvement in performing spirometry and provision of NIV to eligible patients. Educational initiatives including checklists have been shown to improve adherence to guidelines in the provision of NIV^a for eligible patients. Further research required to understand why NIV^a provision is low in ED^a (both in Australia and worldwide) and measures that need to be undertaken to improve this practice. An alternative to consider for future studies will be to obtain an accurate assessment of smoking history, and to use this information as a proxy measure of spirometry since pack-years of smoking is a surrogate measure of the severity of COPD^a
31) Meng 2018⁴²	The impact of 2011 and 2017 Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD^a) guidelines on allocation and pharmacological management of patients with COPD^a in Taiwan: Taiwan Obstructive Lung Disease (TOLD) study	Evaluate the evolution of distributions of patients with COPD according to the 2011 and 2017 Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD^a) guidelines and to assess the concordance between the prescribed medications and the pharmacological management recommended by the two distinct classification systems in Taiwan	Retrospective audit observational multicentre	Taiwan	N=1053 patients	Overtreatment was unnecessary inhaled corticosteroids and the main cause of undertreatment was a lack of maintenance long-acting bronchodilators	Physicians should make proper adjustments of the prescriptions according to the updated guidelines to ensure the mostly appropriate treatment for COPD^a patients Promotion of the guidelines might increase the treatment appropriateness and improve the patient outcomes
32. Johnson 2013³¹	Audit of acute exacerbations of chronic obstructive pulmonary disease at Waitemata District Health Board, New Zealand	To examine management and outcome of patients admitted to Waitemata District Health Board (WDHB) with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and determine performance according to evidence-based guidelines	Retrospective chart review	Australia	N=156 patients	Poor utilisation of non-invasive ventilation (NIV), limited use of ABG and spirometry, and referral to pulmonary rehabilitation (PR). Patients with acute respiratory acidosis did not receive NIV^a Spirometry non-utilisation Reasons include patient’s acute respiratory status or lack of knowledge of availability Lack of knowledge of availability or focus being on acute issues PR poor detection of functional impairment	Improvements in admission/ assessment procedures in particular ABG^a measurement, use of spirometry and NIV^a, PR referral, systemic corticosteroid/NRT^a prescription, judicious antibiotic use, and documentation of performance status. Educational sessions have been held for medical staff to raise awareness of the findings
33. Considine 2011⁶⁶	Emergency department management of exacerbation of chronic obstructive pulmonary disease: audit of compliance with evidence-based guidelines	The aim of this study was to examine compliance with high level evidence for management of exacerbation of COPD during the first 4 h of ED^a care	Retrospective audit	Australia	N=273 patients	Only 56.6% of patients in this study received a systemic steroid through either oral or intravenous route Several patients did not receive NIV^a despite clearly meeting the criteria of acidosis and/or hypercapnia Poor uptake of evidence by clinicians	Compliance with treatment recommendations may be improved if guidelines were more specifically targeted to the process of emergency care rather than detailing specific elements of treatment Further research is warranted to understand better the barriers to implementing evidence-based emergency care for exacerbation of COPD^a and inform local guidelines, care processes and education programmes.
34. Alsubaei 2017³⁹	COPD care in Saudi Arabia: physicians’ awareness and knowledge of guidelines and barriers to implementation	To assess Saudi physicians’ awareness and knowledge about chronic obstructive pulmonary disease (COPD^a) guideline recommendations	Cross-sectional study	Saudi Arabia	N=44 physicians	Awareness of and adherence to COPD guidelines showed that most physicians were not aware of (61.4%) and did not adhere to (63.6%) any of the COPD guidelines in their practice. Lack of educational material/support’ (72.7% of physicians), followed by ‘lack of awareness’ (70.5%) Low levels of confidence in implementing the GOLD^a recommendations in them practice	To develop education and other interventions such as system support aiming to improve physicians’ knowledge of COPD to enhance self-learning among physicians and increase their level of confidence to apply COPD guidelines
35 Sonstein 2014⁴⁵	Improving Adherence for Management of Acute Exacerbation of Chronic Obstructive Pulmonary Disease	To assess evidence-based electronic order sets improve compliance with clinical practice guidelines	Pre and post intervention study (Cohort study)	United States	N=420 patients	Only a one third of the patients hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD) received ideal care	Health information technology offers a unique opportunity to improve compliance with evidence-based medicine Implementation of clinical practice guidelines into the electronic health record reduced variation in care and corticosteroid use by 50%
36. Cousins 2016³⁵	Acute oxygen therapy: a review of prescribing and delivery practices	Identify strategies that have shown promise in facilitating changes to oxygen prescription and delivery practice	Review	Australia	N=17 studies	Insufficient training and education for medical and nursing staff Lack of familiarity with oxygen delivery devices Lack of understanding of the effects, role and dangers of oxygen therapy Staff time constraints Necessity to maintain SpO₂ −94% due to the “between the flags” track and trigger observations charts Practical issues related to space and place for prescribing oxygen Difficulties with changing long established behavior Patients transferred from other wards/departments with oxygen therapy Lack of enthusiasm by senior clinical staff Communication difficulties between doctors and nurses Lack of full-time staff or staff turnover	Introduction of oxygen alert stickers Dedicated oxygen order chart Clearly delineated section on the drug chart or changes to the drug chart to include space for the transcription of oxygen orders Informational posters Email notification/dissemination of information Educational session across various clinical specialities and at various key times Nurse facilitated reminder system Development of hospital guidelines/policy to guide Practice Admission bundle with electronic prescribing system Message alerts on computer login screens
37. Cousins 2020²¹	Management of acute COPD exacerbations in Australia: do we follow the guidelines	To assess adherence to the Australian national guideline (COPD-X) against audited practice, and to document the outcomes of patients hospitalised with an acute exacerbation of chronic obstructive pulmonary disease (COPD) at discharge and 28 days after	Retrospective case audit	Australia	N=171 patients	Spirometry was performed in only 22.7% of admissions Patients with no change in the sputum color (85.7%) or volume (84.9%) were also prescribed antibiotics Reasons for not using non-invasive ventilation (NIV) or invasive ventilation included a documented decision not to escalate to NIV or invasive ventilation (18.2%), “patient responded to medical therapy” (45.6%) and in 36.4%, no reason was listed Referral to pulmonary rehabilitation was low in most centers (mean 32.4%) Lack of spirometry performed during the admission increased the odds of 28-day readmission COPD-X argues that “even the sickest of patients can perform an FEV1^a manoeuvre” the GOLD guidelines do not routinely recommend that sick patients perform spirometry. It is also important to consider the practicality or capacity of emergency department staff to obtain acceptable spirometry traces NIV^a is underutilised. Referral to pulmonary rehabilitation programs is very low	Clinical Care Bundles

Abbreviations: ^aCOPD, chronic obstructive pulmonary disease; ACP, advanced care planning; N, number of; UK, United Kingdom; GOLD, Global Initiative Obstructive Lung Disease; IV, intravenous; RF, respiratory failure; RCNS, respiratory nurse specialist; AUDIPOC, AECOPD (acute exacerbation of COPD); NIV, non-invasive ventilation; ABG, arterial blood gas; GMP, general medicine practitioners; RS, respiratory specialist; SABA, short‑acting beta‑agonists; LABA, long‑acting beta agonist bronchodilators; ICS, inhaled corticosteroids; CP, care pathway; VBG, venous blood gas; FEV1, forced expiratory volume; CME, continuing medical education; LOS, length of stay; PR, pulmonary rehabilitation; NRT, nicotine replacement therapy.