Improved recognition of lung function decline as signal of cystic fibrosis pulmonary exacerbation: a Cystic Fibrosis Learning Network Innovation Laboratory quality improvement initiative

Abstract

Introduction: Cystic fibrosis (CF) is a systemic autosomal recessive condition characterised by progressive lung disease. CF pulmonary exacerbations (PEx) are episodes of worsening respiratory status, and frequent PEx are a risk factor for accelerated lung function decline, yet many people with CF (PwCF) go untreated at the time of decline. The goal of this quality improvement (QI) initiative was to improve recognition, treatment and follow-up of PEx in PwCF.

Methods: Using the Model for Improvement, the Cystic Fibrosis Learning Network (CFLN) initiated a QI innovation laboratory (iLab) with a global aim to decrease the rate of lung function decline in PwCF. The iLab standardised definitions for signals of PEx using a threshold for decline in forced expiratory volume in one second (FEV₁) and/or changes in symptoms. The FEV₁ decline signal was termed FIES (FEV₁-indicated exacerbation signal). Processes for screening and recognition of FIES and/or symptom changes, a treatment algorithm and follow-up in the presence of a signal were tested concurrently in multiple settings.

Specific aims: The specific aim is to increase the per cent of PwCF assessed for a PEx signal at ambulatory encounters and to increase the per cent of recommendations to follow-up within 6 weeks for PwCF experiencing a PEx signal.

Results: FIES recognition increased from 18.6% to 73.4% across all teams during the iLab, and every team showed an improvement. Of PwCF assessed, 15.8% experienced an FIES event (>10% decline in FEV₁ per cent predicted (FEV₁pp)). Follow-up within 6 weeks was recommended for an average of 70.5% of those assessed for FIES and had an FEV₁pp decline greater than 5%.

Conclusion: The CFLN iLab successfully defined and implemented a process to recognise and follow-up PEx signals. This process has the potential to be spread to the larger CF community. Further studies are needed to assess the impact of these processes on PwCF outcomes.

Keywords: Ambulatory care; Chronic disease management; Collaborative, breakthrough groups; Healthcare quality improvement; PDSA.

Figure 1

Timeline of FIES innovation laboratory

Figure 2

Percentage of eligible encounters with people with cystic fibrosis assessed for forced expiratory volume in one second indicated exacerbation signal (FIES).

Figure 3

Percentage of people with cystic fibrosis who experienced forced expiratory volume in one second (FEV₁) per cent predicted decline outside of the green zone of the FEV₁-indicated exacerbation signal algorithm with a 6-week follow-up recommendation.