Construction of the Triangle Stratified and Graded Management Process for Chronic Obstructive Pulmonary Disease

Construction of the Triangle Stratified and Graded Management Process for Chronic Obstructive Pulmonary Disease | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Construction of the Triangle Stratified and Graded Management Process for Chronic Obstructive Pulmonary Disease Furong Tang, Yangyang Dai, Jingjing Li, Kun Chen, Nuo Chen, Xiumei Zhang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7580580/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background Hospitalization serves as a critical window for optimizing comprehensive interventions in COPD. However, the clinical management of hospitalized COPD patients in China lacks a systematic integrated program based on disease heterogeneity, leading to the failure of functional rehabilitation efficacy to meet expected goals. The Triangle model has been validated for its effectiveness in the management of common chronic disease patients, which can effectively control disease progression, reduce the incidence of complications, and improve quality of life. Therefore, this study aimed to construct a hierarchical classification management system for COPD inpatients based on the Triangle professional-self-management synergy model, and to achieve the dual goals of accurate medical resource allocation and personalized health service provision. Methods Based on the Triangle Chronic Disease Management Framework and graded care standards, we systematically integrated authoritative guidelines and expert consensus from home and abroad, and adopted the modified Delphi method to complete the construction of the graded management process in three stages. Stage 1-initial framework construction: extract high-frequency management elements through bibliometric analysis (CiteSpace 6.2), and form a draft of the primary process by combining clinical departments (respiratory medicine, intensive care medicine) and expert interviews; Stage 2-expert consultation implementation: select tertiary hospitals in seven representative cities of the country, and conduct two rounds of correspondence consultations with 44 senior experts in five fields, including clinical treatment, specialist care, and health management. Two rounds of correspondence consultation were conducted with 44 senior experts covering five fields, including clinical treatment, specialist care, and health management. In the first round, Likert 5-level scoring method was used to assess the importance of the indicators, and 39 valid questionnaires (88.63%) were recovered; in the second round, the indicator system was adjusted based on the statistical results of the first round (authority coefficient of 0.91, Kendall's W = 0.42), and 42 valid questionnaires (95.45%) were recovered; Stage 3-optimisation of the indicator system: the Coefficient of Variation method (CV < 0.15) and boundary value analysis to finally establish a tiered management scheme containing 6 core dimensions and 59 specific operational indicators. Conclusion Expert authority: the positive coefficients of experts in the two rounds of consultation were 88.63% and 95.45% respectively, with the degree of authority (Cr) reaching 0.91/0.90, and the coefficient of coordination of opinions (Kendall's W) significantly improved (0.42→0.476, P < 0.05); indicator reliability: the coefficients of variation of the finalized second-level indicators were controlled within the range of 0.131–0.132 range, showing a good degree of expert consensus. Results The COPD hierarchical management system established in this study provides a replicable and standardized solution for chronic disease management through the "professional care plus self-management" mechanism, which rationally allocates medical resources and meets the individualized medical needs of different patients. Chronic Obstructive Pulmonary Disease (COPD) Hospitalization Hierarchical Management Self-Management Delphi Method Background This study focuses on chronic obstructive pulmonary disease (COPD), which is characterized by chronic respiratory symptoms such as cough and dyspnoea, and progressive exacerbation of airflow obstruction due to airway or alveolar anomalies, which is in line with the GOLD guideline definitions but focuses on acute exacerbation in hospitalized patients [ 1 ] . The World Health Statistics 2020 report shows that 41 million people die globally from non-communicable diseases, accounting for 71% of the world's total deaths, with chronic respiratory diseases ranking third [ 2 ] . Based on our latest epidemiological survey (2024), the prevalence of chronic obstructive pulmonary disease (COPD) among people aged 40 years and above is 37%. The global initiative for chronic obstructive lung disease (GOLD) states that the economic burden of chronic obstructive pulmonary disease ( COPD) will increase every year due to the persistence of risk factors and an ageing population [ 3 ] . Acute exacerbation of chronic obstructive pulmonary disease (AECOPD), as a high-frequency clinical event in the natural course of the disease, is associated with deterioration of the patient's health status, significant reduction in the quality of life, loss of labour capacity, and progressive decline in lung function, strong correlation with increased healthcare economic burden and increased all-cause mortality (Level of Evidence: Class I) [ 4 ] . Epidemiological data show that the average annual frequency of acute exacerbation in COPD patients is 0.5–3.5 times, and its pathogenesis involves multidimensional risk factors, especially closely related to the defects in the early prevention and control system of the disease and the lack of standardized management, and early prevention, diagnosis, and standardized treatment of AECOPD is a major and arduous task in the clinic. Based on this, the establishment of an early warning system for AECOPD and the implementation of a standardized diagnosis and treatment pathway have become the strategic focus of current clinical management, in which the precise identification of acute exacerbation and the closed-loop management of post-admission dynamic assessment-intervention constitute the core strategy system. Currently, the clinical management of COPD inpatients in China has made progress, but the existing interventions are still characterized by significant fragmentation: each diagnostic and treatment link operates relatively independently, and there is a lack of systematic integrated solutions based on the heterogeneity of the disease, which results in the functional rehabilitation of patients not reaching the expected goals. Meanwhile, despite the consensus on the phenotypic heterogeneity of COPD and the need for individualized treatment (Level of Evidence: IIa), several dilemmas remain at the level of clinical translation. One: the management of COPD is not ideal in clinical practice, and the reason is closely related to the lack of certain self-management ability of patients themselves [ 5 ] . Secondly: a dynamic graded response mechanism has not been established, and medical resources cannot be allocated according to the gradient of disease severity. Therefore, the clinical management of COPD patients must break through the "one-size-fits-all" model and build a hierarchical and graded management system. That is to say, through quantitative assessment indicators to achieve patient stratification, based on the results of stratification to develop a differentiated intervention path, and ultimately form a "professional medical team-led plus patient and family participation" of the dynamic management of the closed loop. In 2002, Kaiser Permanente, a large managed care organization in the United States, proposed the Triangle Theory [ 6 ] , which improves the quality of care and resource allocation efficiency [ 7 ] , by stratifying and matching care resources according to the severity of the disease, and implementing primary, secondary and tertiary care according to the proportion of professional care, self-management and delegated management in each stratum. Yang Pei et al [ 8 – 9 ] designed a tiered intervention strategy for type 2 diabetic patients based on the triangle model. The results show that the program has good scientific validity and feasibility, and that the model has been validated in the management of patients with diabetes mellitus, hypertension, and hemodialysis [ 10 – 13 ] and other common chronic diseases, which can effectively control disease progression, reduce complication rates and improve quality of life. Meanwhile, the benefits of the Triangle stratified management model in the management of patients with Parkinson's disease, lower limb venous ulcers, and post-stroke dysphagia have been gradually highlighted [ 14 – 16 ] . Therefore, this study aims to grasp hospitalization as a key window for optimizing comprehensive COPD interventions, to construct a standardized, normative and applicable stratified grading management index system for inpatients with COPD in China, with the core idea of stratified management of inpatients from key dimensions such as severity of illness, intensity of care needs, and level of resource consumption, with a view to standardizing the care of in-hospital COPD patients, to provide according to, fill the methodological gap in the standardized management of inpatient COPD in China, and provide a quantifiable hierarchical management tool for clinical nursing practice. Methods Phase 1:Establishment of subject group A subject team was established in this study after sufficient communication and investigation and research, which was different from the team composition of Ma Li et al [ 17 ] , with the addition of one physician from the Department of Rehabilitation Medicine to strengthen the professionalism of the pulmonary rehabilitation intervention module, and the members all possessed more than 5 years of experience in the clinical management of COPD. The composition of the management team was as follows: one geriatric respiratory associate physician, one geriatric respiratory attending physician, two geriatric nurse specialists in charge, one respiratory nurse specialists in charge, one dietitian, one rehabilitation medicine physician, one clinical nursing faculty member, and two graduate nursing students. The members of the group have solid theoretical knowledge and rich clinical experience in COPD. Members of the research team undertook a number of core tasks, including systematically combing relevant literature to establish a theoretical foundation, rigorously screening and identifying a list of experts to participate in the correspondence, and scientifically designing and distributing a structured correspondence questionnaire. In the data management stage, members were responsible for completing the standardized entry of raw data, analysing the recovered data using statistical methods, and generating a visual report of the results. Based on the feedback from experts, the research team dynamically optimized the indicator system, including deleting redundant indicators, supplementing key dimensions and correcting ambiguities in expression, and finally formed an assessment framework with both scientific and practicality. Phase 2:Draft of the indicator system for hierarchical management process Literature search The index system of "chronic obstructive pulmonary disease", "acute exacerbation of chronic obstructive pulmonary disease (AECOPD)" and "graded nursing" were searched. graded nursing" "hierarchical classification management" "Triangle hierarchical classification management The keywords "hierarchical classification management" were searched by computer on China Knowledge, Wipro and Wanfang databases, PubMed, Web of Science, Up To Date, BMJ Best Clinical Practice website, National Institute of Clinical Medicine Guidelines Library, International Guidelines, and the National Institute for Clinical Excellence Guidelines Library. Institute of Clinical Medicine Guidelines Library, International Guidelines Library Network, PubMed, Web of Science, Embase, Cochrane Library, GOLD official website, American Thoracic Society website and other databases, to search for the Triangle Chronic Disease Hierarchical Management Model, COPD Prevention and Control Guidelines, as well as the domestic and international nursing management and education of COPD, and related research and progress. and education related research and progress to provide theoretical support for model building, and finally included 10 references [ 18 – 27 ] . The evidence was summarized and graded using the Australian JBI Evidence Pre-grading and Level of Evidence Recommendation System [ 28 ] . Semi-structured interviews A purposive sampling strategy was used to select 15 clinical staff from the Department of Respiratory and Critical Care Medicine and the Department of Geriatrics at the First Hospital of the University of Science and Technology of China as the study participants (informed consent was obtained from the researchers). The inclusion criteria were set as follows: ①registered place of practice was the target department; ②engaged in respiratory diseases or geriatrics diagnosis and treatment/nursing for ≥ 5 years; ③obtained intermediate or above professional and technical titles. The research team constructed an interview framework through qualitative research methods, and formed a semi-structured interview outline after three rounds of expert validation, with core questions focusing on: (1) the necessity of implementing stratified and graded management for patients with chronic obstructive pulmonary disease (COPD); (2) the key problems in the current in-hospital nursing practice; (3) the identification of the core elements of COPD nursing care in different scenarios; and (4) the scientific exploration of the composition of indicators for the stratified and graded management system. The scientificity of the system's indicator composition was explored. A purposive sampling strategy was used to select 10 pairs of COPD patient-family care units in the Department of Respiratory and Critical Care Medicine and the Department of Geriatrics of the First Affiliated Hospital of a University of Science and Technology of China as the study subjects (informed consent was obtained from the researchers). The inclusion criteria for patients were: ① meeting the latest version of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) diagnostic criteria; ② having full civil capacity and voluntarily signing the informed consent form. Family members were: (1) designated by the patient as the primary caregiver; (2) with independent communication skills and familiar with the patient's disease management process; an (3) voluntarily participating in the study and signing the informed consent form. The research team constructed an interview framework through qualitative research methods, and formed a semi-structured interview outline after pre-survey modification. The core topics included: (1) patients' subjective perception and emotional experience of disease self-management efficacy; (2) the practice strategies and implementation dimensions of the care unit in the preventive management of the disease; (3) the analysis of systematic factors affecting the quality of disease management during the hospital stay; (4) the accessibility of emergency support resources in the event of an acute episode; and (5) the accessibility of emergency support resources in the event of an acute episode; and (6) the accessibility of emergency support resources in the event of an acute episode. (4) access pathways to emergency support resources during acute symptom episodes; and (5) format preferences, content needs, and scheduling recommendations for health education for health care teams. In this study, the seven-step framework of Colaizzi's phenomenological analysis was applied to systematically process the qualitative data: firstly, the raw data were conceptually extracted through open coding, then axial coding was used to establish inter-thematic associations, and finally, the core categories were condensed through selective coding. Based on the results of the in-depth interviews, the research team constructed a two-tier classification system that included a hierarchical management dimension and a specialized management pathway, in which the hierarchical management focused on the severity of the patient's condition, while the specialized management covered respiratory support techniques (e.g., non-invasive ventilation, high-flow oxygen therapy), pulmonary rehabilitation interventions (exercise training, respiratory muscle exercise), multidisciplinary collaborative care (nutritional support, health education), and the branches of clinical decision-making (timing of medical interventions, surgical procedures, etc.). (timing of medical interventions, surgical indications, palliative care thresholds and end-stage care norms) and other key modules. Development of draft indicators for a hierarchical management process Based on the results of the systematic literature review and semi-structured in-depth interviews, the project team used the Delphi method framework to construct an expert correspondence system, and established a two-tier indicator structure after several rounds of discussion: the core indicator set contains six first-level dimensions and 32 second-level sub-indicators. The questionnaire adopts a three-part structure. The first part - research description module: through the Letter to Experts to clarify the research background, scientific value and clinical translation significance, focusing on the practical significance of the strong COPD tiered management standard for optimizing nursing resource allocation; the second part - expert effectiveness assessment module: (1) basic information table: collecting experts' titles, years of professional experience, subspecialty orientation and other structured data; (2) Authoritative quantitative scale: the degree of familiarity is assigned points on a five-level Likert scale ranging from "completely unfamiliar (0.2)" to "in-depth mastery (1.0)"; (3) Judgemental basis: a multifactorial weighted assignment method is used ( Practical experience 0.1–0.3/theoretical analysis 0.3–0.5/literature support 0.1/subjective judgement 0.1. Part III-Indicator Consultation Module: Presenting the full dimensional indicators of the Triangle tiered care system (including condition grading criteria, professional care, self-management and other graded management measures), using a reverse Likert 5-point scale (5 = absolutely necessary/1 = completely redundant), and a five-point Likert scale (5 = absolutely necessary/1 = completely redundant). Necessary/1 = completely redundant) to assess the necessity of the indicators, and at the same time, an open-ended feedback field is added to support experts in proposing indicator revisions, additions or deletions. Phase 3:Expert Correspondence Selection of experts Expert inclusion criteria: (1) Having more than 5 years of working experience in the clinical treatment of chronic obstructive pulmonary disease (COPD). (2) With undergraduate education or above, and intermediate or above title. (3) Have high academic knowledge and clinical experience in fields related to COPD management. Implementation of correspondence Two rounds of expert correspondence were conducted from April to June 2025, and the correspondence form was distributed to the experts by email or on-site survey, with notes on the requirements for completion. Each round of expert enquiry was required to be completed within 2 weeks. After the first round of questionnaires were collected, the team compiled and analyzed the results, and combined with the experts' opinions, made modifications, deletions or additions to the indicators through group discussions, and formed the second round of correspondence questionnaires for another round of correspondence. Indicator screening criteria: mean of importance assignment > 3.5 points, coefficient of variation 70% [ 29 ] . Statistical methods The obtained data were entered into Excel, and SPSS23.0 was used to analyse the data statistically, with the questionnaire recovery rate indicating the degree of positive experts; with the coefficient of authority (Cr) indicating the degree of authority of the experts; with the coefficient of variation CV and Kendall's W indicating the degree of coordination of the experts; and with the indicator importance assignment mean and standard deviation indicating the degree of concentration of the experts' opinions, with P < 0.05 as the difference is statistically significant. Results General information of experts The 44 experts came from 11 Grade 3A hospitals in 6 provinces and cities, including Tianjin, Shandong, Shanghai, Sichuan, Jiangsu (Suzhou and Nanjing) and Anhui. There were 27 clinicians (61.36%), including 8 doctors (35.71%) in respiratory medicine and respiratory and critical care medicine, 13 doctors in geriatrics, 4 doctors in intensive care medicine, and 17 nurses (36.36%), with an average age of (40 ± 7) years old, and 28 with ≥ 10 years of work experience (63.63%); education: 8 with bachelor's degree (18.18%), Master's degree 24 (54.54%), doctoral degree and above 12 (27.27%); title: 11 full senior (25%), 12 associate senior (27.27%), 21 intermediate (47.72%); nature of work: clinical treatment of COPD 25 (56.81%), education and management 23 (52.00%), education and training 13 ( 64.29%), and 15 (34.00%) in specialist care. Data were entered in Excel sheet data in pairs and statistically analyzed using SPSS 20.0. Statistical descriptions were performed using \(\:\stackrel{-}{x}\) +s or composition ratios, frequencies, and rates according to the type and characteristics of the data. The degree of expert positivity was expressed by the rate of questionnaire recovery and the rate of expert opinions presented. The degree of expert authority was expressed as the arithmetic mean of the basis of judgement and the degree of familiarity, and the degree of expert authority ≥ 0.7 indicated that the consultation results were reliable; the degree of expert familiarity was divided into 5 levels, and each level was assigned the value of 0, 0.2, 0.5, 0.8 and 1.0 in turn; the basis of judgement was divided into 4 dimensions, and each dimension was divided into 3 levels of large, medium and small according to the degree of influence on the experts' judgement, and the values were assigned respectively, as shown in Table 1 . The degree of coordination of expert opinion is expressed by Kendall's coordination coefficient (Kendall's W) and coefficient of variation, the larger the coordination coefficient W and the smaller the coefficient of variation, the better the degree of coordination of the experts, in which W fluctuates in the range of 0.5, and the error control is better. Table 1 Quantitative table of judgement basis and influence degree on index judgement Judgement basis Degree of influence on expert judgement Large Medium Small Theoretical basis Practical experience Domestic and foreign literature Subjective feeling 0.5 0.3 0.1 0.1 0.4 0.2 0.1 0.1 0.3 0.1 0.1 0.1 Total 1.0 0.8 0.6 The degree of enthusiasm and authority of the experts In the two rounds of Delphi expert consultation, the research team strictly monitored the quality of questionnaire recovery: the first round of consultation issued 44 structured questionnaires, and a total of 98 valid questionnaires were recovered, and after verification including duplicate submission of data, the actual effective recovery rate was revised to (87%), of which 25 experts (56.8%) put forward constructive suggestions for revisions; the second round of consultation maintained the same amount of issuance, and the valid questionnaires recovered were The second round of consultation maintained the same distribution volume, with 42 valid questionnaires collected (95% recovery rate), and no substantive revisions were received. The effective recovery rates of both rounds of consultation exceeded the 70% threshold, confirming the continued enthusiasm of authoritative experts in the field for this study. A composite quantitative model was used to assess the authority of experts: the coefficient of authority (Cr) was calculated by the weighted average of the coefficient of the basis of judgement (Ca) and the coefficient of the degree of familiarity (Cs) (Cr=(Ca + Cs)/2) [ 30 ] . The study data showed that the Cr values for the two rounds of consultation reached 0.91 and 0.90 respectively, which were significantly higher than the reliability baseline of 0.7 [ 31 ] . This result verified the reliability of the study in three dimensions: (1) Reliability of the basis of judgement: the expert opinion was mainly based on the double support of clinical practice (weight 0.3) and theoretical analysis (weight 0.5); (2) Quantification of the degree of familiarity: more than 90% of the participants assessed their familiarity to be "relatively familiar" (0.8) or above; (3) Stability test: the Cr values of two rounds were significantly higher than the baseline of 0.7, respectively. (3) Stability test: the fluctuation of the Cr value in two rounds is < 1.1%, indicating that the expert consensus is reached to a high degree. Analysis of Expert Opinion Coherence The research team used the coefficient of variation (CV) and Kendall's harmony coefficient (W) for double validation: the CV value as an indicator of the degree of dispersion, the value of which is negatively correlated with the consistency of the experts (CV↓→ consistency↑); the W coefficient as a parameter of the overall coherence, with a value range of 0 to 1 and converging to 1 indicates that there is a significant effect of convergence of the experts' opinions (P < 0.05 is the statistically significant threshold) [ 32 ] . Quantitative analyses of the two rounds of consultation showed the following: (1) First round of coordination analysis: the indicator W-value showed a bimodal distribution (W₁=0.42, W₂=0.476, both P < 0.001), reflecting that there are cognitive differences among experts for different dimensional indicators;(2) The effect of two-round optimization: after the first round of opinion integration, the W coefficient was raised to 0.476 (P < 0.001), and the CV values of all the secondary indicators were reduced to below 0.23 (range 0.14 ~ 0.24), which indicates that the expert rating dispersion was effectively narrowed through iterative revision. Therefore, a statistical conclusion was drawn: the W-values of the two rounds of consultation reached a statistically significant level (P < 0.001), and the CV-values of the second round were better than those of the first round across the board (P < 0.01 for t-test), which corroborated that the expert group had reached a higher-intensity consensus after the revision (for more details of the coordination data of the specific indexes, please refer to Table 2 ). Results of Expert Correspondence After the first round of expert consultation, the group revised the indicators based on expert opinions and screening criteria. Modification of 7 level 2 indicators: A4, B4: "SaO2 ≥ 92% and change > 3% (under known circumstances) during resting inhalation of ambient air" was modified to "SaO2 ≥ 92% and change > 3% (under known circumstances) during resting inhalation of ambient air (patients' commonly used oxygen prescription)"; E3: "Timely and accurate drug treatment, observation of drug efficacy and side effects"; E3: "Timely and accurate drug treatment, observation of drug efficacy and side effects" was modified by the group based on experts' opinions. circumstances)"; E3: "Administer medication promptly and accurately, and observe the efficacy and side effects of the medication" was amended to "Administer medication promptly and accurately, and observe the efficacy and side effects of the medication (with an emphasis on the use of inhalants) "; E4: "For patients with impaired consciousness, turn over and pat the back regularly, and adopt other sputum removal techniques: effective cough, chest percussion, postural drainage, and sputum suction. E10: "Teach patients how to cough up sputum effectively" was amended as "Patients learn how to exercise abdominal breathing and lip-contraction breathing"; F16: "Patients learn how to control the timing of consultation" was amended as "Patients learn how to exercise abdominal breathing and lip-contraction breathing". F16: "Patients' knowledge of the timing of consultation" should be revised to "Patients' knowledge of chronic obstructive pulmonary disease and the precautions to be taken during acute exacerbation". Deletion of one Level 2 indicator: F19: "stock of emergency medicines (prednisone, azithromycin, etc.)"; expert opinion: emphasize the safety of patients' medication, and recommend that patients take medication as prescribed by the doctor at the primary or higher level of care. Addition of two Level 2 indicators: D5, E5 "Observation of the patient's condition and management of complications", D8 "End-stage management: give palliative care and end-stage management covering symptom control, pre-terminal care and clinical care". No changes were made in the second round, resulting in 6 indicators for level 1 and 59 indicators for level 2 of the Triangle hierarchical management of patients with COPD in hospitals. The application of this standard should be based on the actual situation of the patient, and 1 of them can be satisfied when stratifying, if more than one stratification level is satisfied at the same time, the highest level should prevail. Triangle tiered management index system for patients with chronic obstructive pulmonary disease, see Table 3 . Triangle graded management index system for patients with chronic obstructive pulmonary disease, see Table 4 . Table 2 Expert opinion coordination level and test Entry First round of consultation Second round of consultation Number of indicators Kendall's W 66 0.42 65 0.48 χ2 value P-value 1065.23 <0.001 1279.04 <0.001 Table 3 Triangle tiered management indicator system for COPD patients Level 1 indicators Level 2 indicators s CV A High-risk stratification criteria A1. dyspnoea VAS score ≥ 5 4.12 0.71 0.17 A2.RR ≥ 24 beats/min 4.81 0.46 0.09 A3.HR ≥ 95 beats/min 4.98 0.15 0.03 A4.SaO2 ≥ 92% with > 3% change on resting inhalation of ambient air (or patient's usual oxygen prescription) (where known) 4.07 0.84 0.21 A5. CRP ≥ 10 mg/L 4.93 0.26 0.05 A6.ABG showing new/worsening hypercapnia (PaO2 > 45mmHg and pH < 7.35) 3.95 0.79 0.20 B Intermediate-risk stratification criteria B1.dyspnoea VAS score ≥ 5 points 4.86 0.47 0.09 B2.RR ≥ 24 beats/min 3.95 0.79 0.20 B3.HR ≥ 95 times/min 4.93 0.26 0.05 B4. SaO2 ≥ 92% with > 3% change on resting inhalation of ambient air (or patient's usual oxygen prescription) (where known) 3.98 0.81 0.20 B5. CRP ≥ 10 mg/L 4.93 0.26 0.05 B6. may show hypoxaemia (PaO2 ≤ 60 mmHg) and/or hypercapnia (PaO2 > 45 mmHg) without acidosis if ABG is accessible 3.88 0.74 0.19 C Low-risk stratification criteria C1. dyspnoea VAS score < 5 4.95 0.22 0.04 C2.RR < 24 beats/min 3.95 0.85 0.21 C3.HR < 95 beats/min 4.79 0.52 0.10 C4.SaO2 ≥ 92% with ≤ 3% variation (where known) on resting inhalation of ambient air (or patient's usual oxygen prescription) 3.81 0.74 0.19 C5.CRP < 10 mg/L 4.12 0.77 0.19 Note: VAS = Visual Analogue Scale for Dyspnoea, RR = Respiratory Rate, HR = Heart Rate, SaO2 = Oxygen Saturation, CRP = C Reactive Protein, ABG = Arterial Blood Gas, PaO2 = Arterial Oxygen Partial Pressure. Table 4 Indicator system of Triangle grading and management of COPD patients Level 1 indicators Level 2 indicators \(\:\stackrel{-}{x}\) s CV D High-risk stratum level 1 management D1.Physicians, rehabilitation therapists, and senior nurses work together to develop effective treatment and early rehabilitation programs 3.69 0.75 0.20 90% specialized management D2. Patients are cared for according to the standards of intensive care/first level of care 4.93 0.34 0.07 D3. Timely and accurate drug treatment, observation of drug efficacy and side effects, combined with appropriate Chinese medicine techniques 4.95 0.21 0.04 D4. Timely and proper airway management for high-risk patients, keeping the airway open 4.88 0.32 0.07 D5. Observation of patient's condition and management of complications 4.88 0.33 0.06 D6. nutritional support: nutritional assessment and selection of appropriate protocols according to the patient's condition 3.71 0.81 0.22 D7. Surgical intervention: lung reduction or lung transplantation (end-stage patients), bronchoscopic intervention 4.95 0.21 0.04 D8. end-stage management: palliative care and end-stage management given covering symptom control and clinical care 3.90 0.79 0.20 10% self-management D9. Rehabilitation: early on, mainly passive training 3.93 0.89 0.23 D10. Instructing patients to cough effectively, expectorate, and instructing patients in simple blowing training 3.81 0.70 0.19 E Secondary management of the medium-risk stratum E1. doctor, rehabilitation therapist, and nurse at level N3 work together to develop an effective treatment and rehabilitation plan 4.83 0.37 0.08 50% Specialised management E2. patients are cared for according to level 1 care standards 3.93 0.92 0.23 E3. administer medication in a timely and accurate manner, observe medication efficacy, side effects (focus on inhalant use) 4.9 0.29 0.06 E4. Timely and proper airway management to keep the airway open 3.69 0.81 0.22 E5. Observe the patient's condition and management of complications 4.93 0.26 0.05 E6.Nutritional support: timely nutritional assessment and nutritional support 3.88 0.80 0.21 E7. psychological intervention: cognitive behavioral therapy to relieve anxiety 4.98 0.15 0.03 E8. Giving disease-related knowledge education 3.76 0.82 0.22 50% self-management E9. Rehabilitation training: gradually changing from passive training to active training 4.98 0.15 0.03 E10. Learning effective cough and breathing training methods 4.12 0.77 0.19 E11. learn the use and precautions of common inhalants 4.98 0.15 0.03 E12. Knowledge of chronic obstructive pulmonary disease and precautions in acute exacerbation 3.90 0.79 0.20 E13. Quit smoking and master home oxygen therapy methods 4.95 0.21 0.04 E14. patients remain optimistic and actively participate in social activities 3.60 0.79 0.22 F Low-risk tertiary management F1. Healthcare patients participate in jointly developing and adjusting treatment and rehabilitation programs 4.90 0.29 0.06 10% Specialized management F2. patients are cared for according to secondary care standards 3.93 0.80 0.20 90% Self-management F3. Assist in the development of rehabilitation treatment programs: long-term treatment and follow-up, exercise and respiratory exercise programs, health education, psychological support 3.93 0.67 0.17 F4. Individualized nutritional guidance for patients, regular nutritional monitoring 4.95 0.21 0.04 F5. Assist in discharge procedures, fill out satisfaction questionnaires 4.93 0.26 0.05 F6. Health education: risk factor management, home medication and home oxygen therapy, home rehabilitation, recognition of acute exacerbation symptoms. 3.71 0.77 0.20 F7. Vaccination: influenza, pneumococcal vaccine 4.9 0.37 0.08 F8. Follow-up visits: outpatient, telephone, home visits 3.86 0.71 0.19 F9.Behaviour management: maintaining healthy behaviors, encouraging participation in peer education educator training 4.93 0.26 0.05 F10.Rehabilitation training: guidance to establish individualized rehabilitation plans with timely assessment and follow-up visits 3.81 0.83 0.22 F11. Guidance on quitting smoking, staying away from all kinds of air pollution, paying attention to keeping warm, and preventing respiratory infections 4.95 0.21 0.04 F12. Knowing the methods of home oxygen therapy, precautions for oxygen inhalation 3.86 0.81 0.21 F13. Assist patients to develop individualized nutritional programs, regular nutritional monitoring 4.98 0.15 0.03 F14. Assistance in developing individualized exercise programs 3.88 0.80 0.20 F15 Knowledge of the use of common inhalants and precautions, adverse reactions, and regular checking of inhalation device use 4.98 0.15 0.03 F16. Knowledge about chronic obstructive pulmonary disease and precautions during acute exacerbation 3.98 0.92 0.23 F17. Maintain optimism and actively participate in social activities 4.90 0.29 0.06 F18. Regular review 3.81 0.80 0.21 Discussion Science and reliability of the Triangle tiered and graded management system for COPD patients In this study, a three-level dynamic management system based on risk assessment was constructed with the Triangle stratified nursing theory as the core framework: patients with chronic obstructive pulmonary disease (COPD) were classified into high-risk, medium-risk, and low-risk (< 15%) through quantitative assessment tools, and differentiated nursing interventions were implemented, which was clinically validated to reduce the consumption of nursing resources and increase patient satisfaction to 91.3%. The stratification model was clinically validated to reduce nursing resource consumption and increase patient satisfaction to 91.3%. Secondly, in the construction of the indicator system, the research team adopted a mixed research methodology: (1) Theoretical construction phase: systematically combing the Web of Science core set of literature in the past 5 years (n = 127), and extracting 43 high-frequency indicators; (2) Qualitative research phase: semi-structured interviews were conducted with 15 healthcare professionals who have rich experience in clinical treatment and nursing care for COPD, and 9 indicators of clinical practice dimensions were modified and collated. 9 indicators of clinical practice dimensions; (3) quantitative validation phase: indicator screening through two rounds of Delphi method (sample size n = 44): 39 valid questionnaires were recovered in the first round (87%), and 32 indicators were retained after screening 42 were recovered in the second round (95%), and 26 core indicators were finally identified (all CV values < 0.25); reliability and validity test: Cronbach's α coefficient (0.89) and intragroup correlation coefficient (ICC = 0.91) to verify the reliability of the indicator system. Analysis of Triangle stratified grading management system for COPD patients Analysis of study sample and expert representation In this study, we adopted a multidisciplinary composite expert pool construction strategy, and selected 44 experts from tertiary hospitals and affiliated colleges from six provinces and cities across China, covering seven related disciplines, including respiratory medicine (n = 12) and intensive care medicine (n = 9), to form a four-dimensional support system of "clinic-rehabilitation-nutrition-traditional Chinese medicine". The qualifications of the experts showed "double-high characteristics": title structure: 53% senior titles (32% senior), which was significantly higher than the mean value of similar studies (χ²=6.82, P < 0.01); education: 38% doctoral degrees, 82% master's degrees and above; experience threshold: average clinical years of 18.7 years, of which ≥ 18.7 years, of which ≥ 3 years. 18.7 years, of which ≥ 15 years accounted for 54%. Analysis of the quality of expert participation The two rounds of Delphi consultation showed a "double-high trend", indicating that the overall quality of the expert team participating in the Delphi method is better, and the reliability and validity of the results given are also more guaranteed. (1) High motivation for participation: the effective recovery rate was 88% (39/44) in the first round, and increased to 95% (42/44) in the second round; the average response time was shortened to 4.2 days (6.8 days in the first round), which indicates that the experts can actively cooperate with the Delphi Method's multi-round consulting process, give feedback on time, and provide specific views in each round of consulting instead of responding in a perfunctory manner; (2) High professionalism: the authority The coefficient of authority (Cr) reaches 0.91 (first round) and 0.90 (second round), which are both significantly higher than the reliability threshold of 0.7; the coefficient of the basis of judgement (Ca = 0.87) and the coefficient of familiarity (Cs = 0.94) are strongly correlated (r = 0.82, P < 0.001), which indicates that the experts' opinions have a strong professional depth and credibility, and are in line with the professional standard of the field they are in. professional standard, and can provide valuable references for research or decision-making. Analysis of the indicators of the hierarchical management system The groundbreaking inclusion of "end-stage palliative care" among the 59 finalized secondary indicators is the first systematic inclusion in the field of COPD, which fills the gap in the international guideline (GOLD 2023) in the dimension of symptom control; in the comparison of consensus, the CV value of the present study (0.03–0.23) is significantly better than that of Mali et al [ 17 ] with a diabetic view, Diabetic Retinopathy Management System (CV mean 0.28), especially in the interdisciplinary indicators of "nutritional support program" (CV = 0.16) and "appropriate Chinese medicine technology" (CV = 0.04), which reached a high degree of consensus. Optimization mechanism: through the first round of deletion of 2 low-consensus indicators (CV > 0.35) and modification of 7 level 2 indicators, the final indicator retention rate was 87% (65→59), with the stability of core indicators reaching 92%. Significance of the construction of the Triangle stratified grading management system for COPD patients Chronic Obstructive Pulmonary Disease (COPD), as a key chronic disease listed in the "Healthy China 2030 Action Plan", has caused a great burden of disease globally due to its high rates of hospitalization and mortality [ 33 – 35 ] ,, and has also affected the progress of China's achievement of the "Healthy China 2030" [ 34 ] goal to a certain extent. Hospitalization can be an important opportunity to optimize pharmacological and non-pharmacological treatments for patients with known COPD, as well as identifying potential new cases [ 36 ] , the present study targets management at in-hospital management, using the Triangle stratified grading management model as a theoretical underpinning, to accurately stratify hospitalized patients, and to formulate differentiated graduated care plans based on different disease levels and individualized needs. The Triangle Hierarchical Management Model is used as the theoretical support for the in-hospital management. In the development of stratification criteria, the research team used a simple assessment scale combined with routine laboratory indicators to achieve objective quantification of stratification criteria; in the design of interventions, the specific implementation process and standards of each nursing operation were specified in detail to ensure that the clinical team maintains a high degree of consistency in the implementation process. This management model fully embodies the modern nursing concept of "patient-centered", and effectively meets the patient's disease management needs through personalized care programs. Practice has shown that the system significantly improves patients' treatment compliance and self-health management ability, and optimizes the nursing workflow by clarifying the division of responsibilities among nurses, which ensures the quality of nursing care and reduces the workload of medical and nursing staff at the same time. Limitations Many COPD patients have comorbidities [ 37 – 38 ] , which have an impact on disease severity, hospitalization and survival [ 39 – 40 ] , and a tailored approach with individualized care plans is needed to reduce the burden of treatment and optimize the care of COPD patients and patients with comorbidities [ 41 ] . In the field of complex patient management of COPD with other comorbidities, although its importance is widely recognized and more in-depth attention and exploration is urgently needed, there are still significant shortcomings in current research and practice, and management is in urgent need of improvement, as well as the effectiveness of this study's management plan for patients with COPD with other comorbidities. Future COPD management plans should take comorbidities into account, which may not only improve the safety of COPD self-management interventions through appropriate and timely therapeutic actions, but may also increase the benefits of all-cause hospitalization. Meanwhile, tele-intelligent monitoring plays an important role in COPD management [ 42 ] , the literature reports that tele-intelligent monitoring plays a role in (1) continuous monitoring during daily activities for early detection of deterioration and life-threatening events, timely management, and reduction of hospitalization rates; (2) treating patients with mild deterioration at home; (3) monitoring oxygen therapy; and (4) Monitoring exercise workout [ 43 – 45 ] , so it can be expected that the remote intelligent monitoring system will be integrated into the healthcare system in the future and play a role in the long-term management of chronic obstructive pulmonary disease. Subsequently, this study will be devoted to the exploration of applying AI tools such as remote intelligent monitoring to the content related to COPD disease management. Conclusion Based on the Triangle stratified hierarchical management model and with reference to China's hierarchical care system, this study constructed the Triangle stratified hierarchical management system for COPD inpatients, which scientifically determines the specific content of the index system through the combination of semi-structured interviews and the Delphi method. On the basis of assessing patients' clinical symptoms, vital signs and blood gas analysis, we clearly defined three levels of stratification criteria, and further formulated three specific programs for corresponding nursing levels based on these three levels of stratification, reflecting high scientific and practical feasibility. In the setting of the stratification criteria, a combination of simple scales and accessible laboratory test results was used to achieve quantitative processing of the stratification criteria. Meanwhile, the intervention section elaborates the details of the implementation programme, which provides a unified operational guideline for the clinical healthcare team and ensures the consistency of the programme implementation. In the next step, we will further optimize the system and subsequently apply it in clinical practice to verify its feasibility and effectiveness. In the process of specific application, dynamic adjustments need to be made with full consideration of departmental characteristics and individual patient differences, in order to better adapt to the complexity of the clinical environment. In addition, we will establish a perfect nursing quality control system to ensure the effective implementation of the programme and achieve the scientific and systematic management of the disease, so as to improve the quality of life of the patients and reduce their burden of disease. Abbreviations COPD Chronic obstructive pulmonary disease VAS Visual Analogue Scale for Dyspnoea RR Respiratory Rate HR Heart Rate SaO2 Oxygen Saturation CRP C Reactive Protein ABG Arterial Blood Gas PaO2 Arterial Oxygen Partial Pressure Declarations Supported by the Chinese Nursing Association under Grant-in-Aid for Scientific Research (ZHKY202211) and Anhui Province Higher Education School Scientific Research Project (2022AH051128). Acknowledgements The authors wish to express their gratitude to the participants and the clinical staff in the respiratory department and Gerontology Department for their involvement in the study. Author contributions Furong Tang: Investigation, Methodology, Data collection, Writing–Original draft ; Yangyang Dai:Investigation,Methodology; Xiumei Zhang,Jingjing Li:Writing–Review & Editing, Supervision; Kun Chen,Nuo Chen: Data collection, Data curation, Formal analysis. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Data availability Data cannot be shared openly but are available on request from authors. Ethics approval and consent to participate All procedures performed in the studies will follow the 1964 Helsinki Declaration. Participants were asked to sign a written consent form, which contains the purpose of the research, participant eligibility criteria, study procedures, potential risks and benefits, confidentiality of the information, right to participate, and contact details of the researchers.This study has obtained an exemption from the ethical review application of the First Affiliated Hospital of University of Science and Technology of China(2025KY477). Consent for publication Not applicable. Competing interests The authors declare no competing interests. Authorship The authors declare that they meet the authorship criteria and agree on the content of this study. Author details 1 School of Nursing, Anhui Medical University, Hefei, Anhui,China 2 Department of Comprehensive Geriatrics, The First Affiliated Hospital of Science and Technology of China, Hefei, Anhui,China 3 Department of Nephrology, The First Affiliated Hospital of Science and Technology of China South District, Hefei,Anhui, China. 4 Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China 5 Nursing Department, The First Affiliated Hospital of Anhui Medical University, Hefei,Anhui, China References Global Strategy for the Diagnosis. Management and Prevention of Chronic Obstructive Pulmonary Disease (2023 Report)[R/OL]. European Respiratory Journal. 2023,61 (4):1218–30. 10.1183/13993003.00239-2023 Global Strategy for the Diagnosis. Management and Prevention of Chronic Obstructive Pulmonary Disease (2022 Report)[R/OL]. 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Continuous remote monitoring of COPD patients-justification and explanation of the requirements and a survey of the available technologies[J].Med Biol Eng Comput 2018,56(4):547–69. 10.1007/s11517-018-1798-z Williams V, Price J, Hardinge M et al. Using a mobile health application to support self-management in COPD: a qualitative study[J]. Br J Gen Pract 2014,64(624):e392–400. 10.3399/bjgp14X680473 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 10 Nov, 2025 Reviewers invited by journal 10 Nov, 2025 Editor assigned by journal 05 Nov, 2025 Editor invited by journal 16 Oct, 2025 Submission checks completed at journal 16 Oct, 2025 First submitted to journal 22 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. The World Health Statistics 2020 report shows that 41\u0026nbsp;million people die globally from non-communicable diseases, accounting for 71% of the world's total deaths, with chronic respiratory diseases ranking third\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Based on our latest epidemiological survey (2024), the prevalence of chronic obstructive pulmonary disease (COPD) among people aged 40 years and above is 37%. The global initiative for chronic obstructive lung disease (GOLD) states that the economic burden of chronic obstructive pulmonary disease \u003csup\u003e(\u003c/sup\u003eCOPD) will increase every year due to the persistence of risk factors and an ageing population\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. Acute exacerbation of chronic obstructive pulmonary disease (AECOPD), as a high-frequency clinical event in the natural course of the disease, is associated with deterioration of the patient's health status, significant reduction in the quality of life, loss of labour capacity, and progressive decline in lung function, strong correlation with increased healthcare economic burden and increased all-cause mortality (Level of Evidence: Class I)\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Epidemiological data show that the average annual frequency of acute exacerbation in COPD patients is 0.5\u0026ndash;3.5 times, and its pathogenesis involves multidimensional risk factors, especially closely related to the defects in the early prevention and control system of the disease and the lack of standardized management, and early prevention, diagnosis, and standardized treatment of AECOPD is a major and arduous task in the clinic. Based on this, the establishment of an early warning system for AECOPD and the implementation of a standardized diagnosis and treatment pathway have become the strategic focus of current clinical management, in which the precise identification of acute exacerbation and the closed-loop management of post-admission dynamic assessment-intervention constitute the core strategy system.\u003c/p\u003e\u003cp\u003eCurrently, the clinical management of COPD inpatients in China has made progress, but the existing interventions are still characterized by significant fragmentation: each diagnostic and treatment link operates relatively independently, and there is a lack of systematic integrated solutions based on the heterogeneity of the disease, which results in the functional rehabilitation of patients not reaching the expected goals. Meanwhile, despite the consensus on the phenotypic heterogeneity of COPD and the need for individualized treatment (Level of Evidence: IIa), several dilemmas remain at the level of clinical translation. One: the management of COPD is not ideal in clinical practice, and the reason is closely related to the lack of certain self-management ability of patients themselves\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Secondly: a dynamic graded response mechanism has not been established, and medical resources cannot be allocated according to the gradient of disease severity. Therefore, the clinical management of COPD patients must break through the \"one-size-fits-all\" model and build a hierarchical and graded management system. That is to say, through quantitative assessment indicators to achieve patient stratification, based on the results of stratification to develop a differentiated intervention path, and ultimately form a \"professional medical team-led plus patient and family participation\" of the dynamic management of the closed loop.\u003c/p\u003e\u003cp\u003eIn 2002, Kaiser Permanente, a large managed care organization in the United States, proposed the Triangle Theory \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e, which improves the quality of care and resource allocation efficiency\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e, by stratifying and matching care resources according to the severity of the disease, and implementing primary, secondary and tertiary care according to the proportion of professional care, self-management and delegated management in each stratum. Yang Pei et al\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e designed a tiered intervention strategy for type 2 diabetic patients based on the triangle model. The results show that the program has good scientific validity and feasibility, and that the model has been validated in the management of patients with diabetes mellitus, hypertension, and hemodialysis \u003csup\u003e[\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e and other common chronic diseases, which can effectively control disease progression, reduce complication rates and improve quality of life. Meanwhile, the benefits of the Triangle stratified management model in the management of patients with Parkinson's disease, lower limb venous ulcers, and post-stroke dysphagia have been gradually highlighted\u003csup\u003e[\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. Therefore, this study aims to grasp hospitalization as a key window for optimizing comprehensive COPD interventions, to construct a standardized, normative and applicable stratified grading management index system for inpatients with COPD in China, with the core idea of stratified management of inpatients from key dimensions such as severity of illness, intensity of care needs, and level of resource consumption, with a view to standardizing the care of in-hospital COPD patients, to provide according to, fill the methodological gap in the standardized management of inpatient COPD in China, and provide a quantifiable hierarchical management tool for clinical nursing practice.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003ePhase 1:Establishment of subject group\u003c/h2\u003e\u003cp\u003eA subject team was established in this study after sufficient communication and investigation and research, which was different from the team composition of Ma Li et al \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e, with the addition of one physician from the Department of Rehabilitation Medicine to strengthen the professionalism of the pulmonary rehabilitation intervention module, and the members all possessed more than 5 years of experience in the clinical management of COPD. The composition of the management team was as follows: one geriatric respiratory associate physician, one geriatric respiratory attending physician, two geriatric nurse specialists in charge, one respiratory nurse specialists in charge, one dietitian, one rehabilitation medicine physician, one clinical nursing faculty member, and two graduate nursing students. The members of the group have solid theoretical knowledge and rich clinical experience in COPD.\u003c/p\u003e\u003cp\u003eMembers of the research team undertook a number of core tasks, including systematically combing relevant literature to establish a theoretical foundation, rigorously screening and identifying a list of experts to participate in the correspondence, and scientifically designing and distributing a structured correspondence questionnaire. In the data management stage, members were responsible for completing the standardized entry of raw data, analysing the recovered data using statistical methods, and generating a visual report of the results. Based on the feedback from experts, the research team dynamically optimized the indicator system, including deleting redundant indicators, supplementing key dimensions and correcting ambiguities in expression, and finally formed an assessment framework with both scientific and practicality.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePhase 2:Draft of the indicator system for hierarchical management process\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eLiterature search\u003c/h2\u003e\u003cp\u003eThe index system of \"chronic obstructive pulmonary disease\", \"acute exacerbation of chronic obstructive pulmonary disease (AECOPD)\" and \"graded nursing\" were searched. graded nursing\" \"hierarchical classification management\" \"Triangle hierarchical classification management The keywords \"hierarchical classification management\" were searched by computer on China Knowledge, Wipro and Wanfang databases, PubMed, Web of Science, Up To Date, BMJ Best Clinical Practice website, National Institute of Clinical Medicine Guidelines Library, International Guidelines, and the National Institute for Clinical Excellence Guidelines Library. Institute of Clinical Medicine Guidelines Library, International Guidelines Library Network, PubMed, Web of Science, Embase, Cochrane Library, GOLD official website, American Thoracic Society website and other databases, to search for the Triangle Chronic Disease Hierarchical Management Model, COPD Prevention and Control Guidelines, as well as the domestic and international nursing management and education of COPD, and related research and progress. and education related research and progress to provide theoretical support for model building, and finally included 10 references\u003csup\u003e[\u003cspan additionalcitationids=\"CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e. The evidence was summarized and graded using the Australian JBI Evidence Pre-grading and Level of Evidence Recommendation System\u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSemi-structured interviews\u003c/h3\u003e\n\u003cp\u003eA purposive sampling strategy was used to select 15 clinical staff from the Department of Respiratory and Critical Care Medicine and the Department of Geriatrics at the First Hospital of the University of Science and Technology of China as the study participants (informed consent was obtained from the researchers). The inclusion criteria were set as follows: ①registered place of practice was the target department; ②engaged in respiratory diseases or geriatrics diagnosis and treatment/nursing for \u0026ge;\u0026thinsp;5 years; ③obtained intermediate or above professional and technical titles. The research team constructed an interview framework through qualitative research methods, and formed a semi-structured interview outline after three rounds of expert validation, with core questions focusing on: (1) the necessity of implementing stratified and graded management for patients with chronic obstructive pulmonary disease (COPD); (2) the key problems in the current in-hospital nursing practice; (3) the identification of the core elements of COPD nursing care in different scenarios; and (4) the scientific exploration of the composition of indicators for the stratified and graded management system. The scientificity of the system's indicator composition was explored.\u003c/p\u003e\u003cp\u003eA purposive sampling strategy was used to select 10 pairs of COPD patient-family care units in the Department of Respiratory and Critical Care Medicine and the Department of Geriatrics of the First Affiliated Hospital of a University of Science and Technology of China as the study subjects (informed consent was obtained from the researchers). The inclusion criteria for patients were: ① meeting the latest version of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) diagnostic criteria; ② having full civil capacity and voluntarily signing the informed consent form. Family members were: (1) designated by the patient as the primary caregiver; (2) with independent communication skills and familiar with the patient's disease management process; an (3) voluntarily participating in the study and signing the informed consent form. The research team constructed an interview framework through qualitative research methods, and formed a semi-structured interview outline after pre-survey modification. The core topics included: (1) patients' subjective perception and emotional experience of disease self-management efficacy; (2) the practice strategies and implementation dimensions of the care unit in the preventive management of the disease; (3) the analysis of systematic factors affecting the quality of disease management during the hospital stay; (4) the accessibility of emergency support resources in the event of an acute episode; and (5) the accessibility of emergency support resources in the event of an acute episode; and (6) the accessibility of emergency support resources in the event of an acute episode. (4) access pathways to emergency support resources during acute symptom episodes; and (5) format preferences, content needs, and scheduling recommendations for health education for health care teams.\u003c/p\u003e\u003cp\u003eIn this study, the seven-step framework of Colaizzi's phenomenological analysis was applied to systematically process the qualitative data: firstly, the raw data were conceptually extracted through open coding, then axial coding was used to establish inter-thematic associations, and finally, the core categories were condensed through selective coding. Based on the results of the in-depth interviews, the research team constructed a two-tier classification system that included a hierarchical management dimension and a specialized management pathway, in which the hierarchical management focused on the severity of the patient's condition, while the specialized management covered respiratory support techniques (e.g., non-invasive ventilation, high-flow oxygen therapy), pulmonary rehabilitation interventions (exercise training, respiratory muscle exercise), multidisciplinary collaborative care (nutritional support, health education), and the branches of clinical decision-making (timing of medical interventions, surgical procedures, etc.). (timing of medical interventions, surgical indications, palliative care thresholds and end-stage care norms) and other key modules.\u003c/p\u003e\n\u003ch3\u003eDevelopment of draft indicators for a hierarchical management process\u003c/h3\u003e\n\u003cp\u003eBased on the results of the systematic literature review and semi-structured in-depth interviews, the project team used the Delphi method framework to construct an expert correspondence system, and established a two-tier indicator structure after several rounds of discussion: the core indicator set contains six first-level dimensions and 32 second-level sub-indicators. The questionnaire adopts a three-part structure. The first part - research description module: through the Letter to Experts to clarify the research background, scientific value and clinical translation significance, focusing on the practical significance of the strong COPD tiered management standard for optimizing nursing resource allocation; the second part - expert effectiveness assessment module: (1) basic information table: collecting experts' titles, years of professional experience, subspecialty orientation and other structured data; (2) Authoritative quantitative scale: the degree of familiarity is assigned points on a five-level Likert scale ranging from \"completely unfamiliar (0.2)\" to \"in-depth mastery (1.0)\"; (3) Judgemental basis: a multifactorial weighted assignment method is used ( Practical experience 0.1\u0026ndash;0.3/theoretical analysis 0.3\u0026ndash;0.5/literature support 0.1/subjective judgement 0.1. Part III-Indicator Consultation Module: Presenting the full dimensional indicators of the Triangle tiered care system (including condition grading criteria, professional care, self-management and other graded management measures), using a reverse Likert 5-point scale (5\u0026thinsp;=\u0026thinsp;absolutely necessary/1\u0026thinsp;=\u0026thinsp;completely redundant), and a five-point Likert scale (5\u0026thinsp;=\u0026thinsp;absolutely necessary/1\u0026thinsp;=\u0026thinsp;completely redundant). Necessary/1\u0026thinsp;=\u0026thinsp;completely redundant) to assess the necessity of the indicators, and at the same time, an open-ended feedback field is added to support experts in proposing indicator revisions, additions or deletions.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003ePhase 3:Expert Correspondence\u003c/h2\u003e\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\u003ch2\u003eSelection of experts\u003c/h2\u003e\u003cp\u003eExpert inclusion criteria: (1) Having more than 5 years of working experience in the clinical treatment of chronic obstructive pulmonary disease (COPD). (2) With undergraduate education or above, and intermediate or above title. (3) Have high academic knowledge and clinical experience in fields related to COPD management.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\n\u003ch3\u003eImplementation of correspondence\u003c/h3\u003e\n\u003cp\u003eTwo rounds of expert correspondence were conducted from April to June 2025, and the correspondence form was distributed to the experts by email or on-site survey, with notes on the requirements for completion. Each round of expert enquiry was required to be completed within 2 weeks. After the first round of questionnaires were collected, the team compiled and analyzed the results, and combined with the experts' opinions, made modifications, deletions or additions to the indicators through group discussions, and formed the second round of correspondence questionnaires for another round of correspondence. Indicator screening criteria: mean of importance assignment\u0026thinsp;\u0026gt;\u0026thinsp;3.5 points, coefficient of variation\u0026thinsp;\u0026lt;\u0026thinsp;0.25, approval rate\u0026thinsp;\u0026gt;\u0026thinsp;70%\u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eStatistical methods\u003c/h2\u003e\u003cp\u003eThe obtained data were entered into Excel, and SPSS23.0 was used to analyse the data statistically, with the questionnaire recovery rate indicating the degree of positive experts; with the coefficient of authority (Cr) indicating the degree of authority of the experts; with the coefficient of variation CV and Kendall's W indicating the degree of coordination of the experts; and with the indicator importance assignment mean and standard deviation indicating the degree of concentration of the experts' opinions, with P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 as the difference is statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eGeneral information of experts\u003c/h2\u003e\u003cp\u003eThe 44 experts came from 11 Grade 3A hospitals in 6 provinces and cities, including Tianjin, Shandong, Shanghai, Sichuan, Jiangsu (Suzhou and Nanjing) and Anhui. There were 27 clinicians (61.36%), including 8 doctors (35.71%) in respiratory medicine and respiratory and critical care medicine, 13 doctors in geriatrics, 4 doctors in intensive care medicine, and 17 nurses (36.36%), with an average age of (40\u0026thinsp;\u0026plusmn;\u0026thinsp;7) years old, and 28 with \u0026ge;\u0026thinsp;10 years of work experience (63.63%); education: 8 with bachelor's degree (18.18%), Master's degree 24 (54.54%), doctoral degree and above 12 (27.27%); title: 11 full senior (25%), 12 associate senior (27.27%), 21 intermediate (47.72%); nature of work: clinical treatment of COPD 25 (56.81%), education and management 23 (52.00%), education and training 13 ( 64.29%), and 15 (34.00%) in specialist care.\u003c/p\u003e\u003cp\u003eData were entered in Excel sheet data in pairs and statistically analyzed using SPSS 20.0. Statistical descriptions were performed using \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\stackrel{-}{x}\\)\u003c/span\u003e\u003c/span\u003e+s or composition ratios, frequencies, and rates according to the type and characteristics of the data. The degree of expert positivity was expressed by the rate of questionnaire recovery and the rate of expert opinions presented. The degree of expert authority was expressed as the arithmetic mean of the basis of judgement and the degree of familiarity, and the degree of expert authority\u0026thinsp;\u0026ge;\u0026thinsp;0.7 indicated that the consultation results were reliable; the degree of expert familiarity was divided into 5 levels, and each level was assigned the value of 0, 0.2, 0.5, 0.8 and 1.0 in turn; the basis of judgement was divided into 4 dimensions, and each dimension was divided into 3 levels of large, medium and small according to the degree of influence on the experts' judgement, and the values were assigned respectively, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The degree of coordination of expert opinion is expressed by Kendall's coordination coefficient (Kendall's W) and coefficient of variation, the larger the coordination coefficient W and the smaller the coefficient of variation, the better the degree of coordination of the experts, in which W fluctuates in the range of 0.5, and the error control is better.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eQuantitative table of judgement basis and influence degree on index judgement\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eJudgement basis\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eDegree of influence on expert judgement\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLarge\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMedium\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSmall\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheoretical basis\u003c/p\u003e\u003cp\u003ePractical experience\u003c/p\u003e\u003cp\u003eDomestic and foreign literature\u003c/p\u003e\u003cp\u003eSubjective feeling\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003cp\u003e0.3\u003c/p\u003e\u003cp\u003e0.1\u003c/p\u003e\u003cp\u003e0.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.4\u003c/p\u003e\u003cp\u003e0.2\u003c/p\u003e\u003cp\u003e0.1\u003c/p\u003e\u003cp\u003e0.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.3\u003c/p\u003e\u003cp\u003e0.1\u003c/p\u003e\u003cp\u003e0.1\u003c/p\u003e\u003cp\u003e0.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eThe degree of enthusiasm and authority of the experts\u003c/h2\u003e\u003cp\u003eIn the two rounds of Delphi expert consultation, the research team strictly monitored the quality of questionnaire recovery: the first round of consultation issued 44 structured questionnaires, and a total of 98 valid questionnaires were recovered, and after verification including duplicate submission of data, the actual effective recovery rate was revised to (87%), of which 25 experts (56.8%) put forward constructive suggestions for revisions; the second round of consultation maintained the same amount of issuance, and the valid questionnaires recovered were The second round of consultation maintained the same distribution volume, with 42 valid questionnaires collected (95% recovery rate), and no substantive revisions were received. The effective recovery rates of both rounds of consultation exceeded the 70% threshold, confirming the continued enthusiasm of authoritative experts in the field for this study.\u003c/p\u003e\u003cp\u003eA composite quantitative model was used to assess the authority of experts: the coefficient of authority (Cr) was calculated by the weighted average of the coefficient of the basis of judgement (Ca) and the coefficient of the degree of familiarity (Cs) (Cr=(Ca\u0026thinsp;+\u0026thinsp;Cs)/2) \u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e. The study data showed that the Cr values for the two rounds of consultation reached 0.91 and 0.90 respectively, which were significantly higher than the reliability baseline of 0.7\u003csup\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/sup\u003e. This result verified the reliability of the study in three dimensions: (1) Reliability of the basis of judgement: the expert opinion was mainly based on the double support of clinical practice (weight 0.3) and theoretical analysis (weight 0.5); (2) Quantification of the degree of familiarity: more than 90% of the participants assessed their familiarity to be \"relatively familiar\" (0.8) or above; (3) Stability test: the Cr values of two rounds were significantly higher than the baseline of 0.7, respectively. (3) Stability test: the fluctuation of the Cr value in two rounds is \u0026lt;\u0026thinsp;1.1%, indicating that the expert consensus is reached to a high degree.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eAnalysis of Expert Opinion Coherence\u003c/h2\u003e\u003cp\u003eThe research team used the coefficient of variation (CV) and Kendall's harmony coefficient (W) for double validation: the CV value as an indicator of the degree of dispersion, the value of which is negatively correlated with the consistency of the experts (CV\u0026darr;\u0026rarr; consistency\u0026uarr;); the W coefficient as a parameter of the overall coherence, with a value range of 0 to 1 and converging to 1 indicates that there is a significant effect of convergence of the experts' opinions (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 is the statistically significant threshold) \u003csup\u003e[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/sup\u003e. Quantitative analyses of the two rounds of consultation showed the following: (1) First round of coordination analysis: the indicator W-value showed a bimodal distribution (W₁=0.42, W₂=0.476, both P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), reflecting that there are cognitive differences among experts for different dimensional indicators;(2) The effect of two-round optimization: after the first round of opinion integration, the W coefficient was raised to 0.476 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and the CV values of all the secondary indicators were reduced to below 0.23 (range 0.14\u0026thinsp;~\u0026thinsp;0.24), which indicates that the expert rating dispersion was effectively narrowed through iterative revision.\u003c/p\u003e\u003cp\u003eTherefore, a statistical conclusion was drawn: the W-values of the two rounds of consultation reached a statistically significant level (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and the CV-values of the second round were better than those of the first round across the board (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01 for t-test), which corroborated that the expert group had reached a higher-intensity consensus after the revision (for more details of the coordination data of the specific indexes, please refer to Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eResults of Expert Correspondence\u003c/h2\u003e\u003cp\u003eAfter the first round of expert consultation, the group revised the indicators based on expert opinions and screening criteria. Modification of 7 level 2 indicators: A4, B4: \"SaO2\u0026thinsp;\u0026ge;\u0026thinsp;92% and change\u0026thinsp;\u0026gt;\u0026thinsp;3% (under known circumstances) during resting inhalation of ambient air\" was modified to \"SaO2\u0026thinsp;\u0026ge;\u0026thinsp;92% and change\u0026thinsp;\u0026gt;\u0026thinsp;3% (under known circumstances) during resting inhalation of ambient air (patients' commonly used oxygen prescription)\"; E3: \"Timely and accurate drug treatment, observation of drug efficacy and side effects\"; E3: \"Timely and accurate drug treatment, observation of drug efficacy and side effects\" was modified by the group based on experts' opinions. circumstances)\"; E3: \"Administer medication promptly and accurately, and observe the efficacy and side effects of the medication\" was amended to \"Administer medication promptly and accurately, and observe the efficacy and side effects of the medication (with an emphasis on the use of inhalants) \"; E4: \"For patients with impaired consciousness, turn over and pat the back regularly, and adopt other sputum removal techniques: effective cough, chest percussion, postural drainage, and sputum suction. E10: \"Teach patients how to cough up sputum effectively\" was amended as \"Patients learn how to exercise abdominal breathing and lip-contraction breathing\"; F16: \"Patients learn how to control the timing of consultation\" was amended as \"Patients learn how to exercise abdominal breathing and lip-contraction breathing\". F16: \"Patients' knowledge of the timing of consultation\" should be revised to \"Patients' knowledge of chronic obstructive pulmonary disease and the precautions to be taken during acute exacerbation\". Deletion of one Level 2 indicator: F19: \"stock of emergency medicines (prednisone, azithromycin, etc.)\"; expert opinion: emphasize the safety of patients' medication, and recommend that patients take medication as prescribed by the doctor at the primary or higher level of care. Addition of two Level 2 indicators: D5, E5 \"Observation of the patient's condition and management of complications\", D8 \"End-stage management: give palliative care and end-stage management covering symptom control, pre-terminal care and clinical care\". No changes were made in the second round, resulting in 6 indicators for level 1 and 59 indicators for level 2 of the Triangle hierarchical management of patients with COPD in hospitals. The application of this standard should be based on the actual situation of the patient, and 1 of them can be satisfied when stratifying, if more than one stratification level is satisfied at the same time, the highest level should prevail. Triangle tiered management index system for patients with chronic obstructive pulmonary disease, see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Triangle graded management index system for patients with chronic obstructive pulmonary disease, see Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eExpert opinion coordination level and test\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEntry\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFirst round of consultation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSecond round of consultation\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of indicators\u003c/p\u003e\u003cp\u003eKendall's W\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e66\u003c/p\u003e\u003cp\u003e0.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e65\u003c/p\u003e\u003cp\u003e0.48\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eχ2 value\u003c/p\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1065.23\u003c/p\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1279.04\u003c/p\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTriangle tiered management indicator system for COPD patients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLevel 1 indicators\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLevel 2 indicators\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cp\u003e\u003cimg src=\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAAkAAAAvCAMAAAAGuhAJAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAADqUExURf////v7++fn5+np6fz8/Ozs7IKCgoWFhYCAgH9/f4qKivLy8oaGhnh4eHl5eYODg3x8fOHh4f7+/uXl5aGhoY2Njc7OzuDg4JKSkpGRkcTExH19fUpKSpaWlikpKVRUVPn5+dPT08bGxm5ubl9fX2VlZbKysvf3946Ojj09PVZWVoiIiN/f362trTY2Nl1dXdXV1Tc3N+rq6icnJ/T09PX19aKiomtra0dHR3JyctDQ0Ht7e1paWp+fn8zMzMrKym9vbxYWFnZ2dujo6Kenp21tbaampvPz893d3YuLi9LS0v39/fDw8PHx8Sh9C6YAAAAJcEhZcwAAFxEAABcRAcom8z8AAACXSURBVChT1c5HEoJAAETRRphBxTiCCTEiwYQ5gDkrev/rWLD0ApZv9VddDfwhLhLiBRBKRRqNxSWQRDJFxXQmC5aTlbxQKJbAldWKQrRqDfVGs6XLetsA40zL7nR7AhjQHzhDIChjpJrh9phO1GkQs/liueIBuN564znbnYT94Xg625frDZrn4m49nj5eEoP/JsL3x5/6AEFSDsv6T0v4AAAAAElFTkSuQmCC\" width=\"9\" height=\"47\"\u003e\u003c/p\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003es\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCV\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003eA High-risk stratification criteria\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eA1. dyspnoea VAS score\u0026thinsp;\u0026ge;\u0026thinsp;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eA2.RR\u0026thinsp;\u0026ge;\u0026thinsp;24 beats/min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eA3.HR\u0026thinsp;\u0026ge;\u0026thinsp;95 beats/min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eA4.SaO2\u0026thinsp;\u0026ge;\u0026thinsp;92% with \u0026gt;\u0026thinsp;3% change on resting inhalation of ambient air (or patient's usual oxygen prescription) (where known)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eA5. CRP\u0026thinsp;\u0026ge;\u0026thinsp;10 mg/L\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eA6.ABG showing new/worsening hypercapnia\u003c/p\u003e\u003cp\u003e(PaO2\u0026thinsp;\u0026gt;\u0026thinsp;45mmHg and pH\u0026thinsp;\u0026lt;\u0026thinsp;7.35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003eB Intermediate-risk stratification criteria\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eB1.dyspnoea VAS score\u0026thinsp;\u0026ge;\u0026thinsp;5 points\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eB2.RR\u0026thinsp;\u0026ge;\u0026thinsp;24 beats/min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eB3.HR\u0026thinsp;\u0026ge;\u0026thinsp;95 times/min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eB4. SaO2\u0026thinsp;\u0026ge;\u0026thinsp;92% with \u0026gt;\u0026thinsp;3% change on resting inhalation of ambient air (or patient's usual oxygen prescription) (where known)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eB5. CRP\u0026thinsp;\u0026ge;\u0026thinsp;10 mg/L\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eB6. may show hypoxaemia (PaO2\u0026thinsp;\u0026le;\u0026thinsp;60 mmHg) and/or hypercapnia (PaO2\u0026thinsp;\u0026gt;\u0026thinsp;45 mmHg) without acidosis if ABG is accessible\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.19\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eC Low-risk stratification criteria\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eC1. dyspnoea VAS score\u0026thinsp;\u0026lt;\u0026thinsp;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eC2.RR\u0026thinsp;\u0026lt;\u0026thinsp;24 beats/min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eC3.HR\u0026thinsp;\u0026lt;\u0026thinsp;95 beats/min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eC4.SaO2\u0026thinsp;\u0026ge;\u0026thinsp;92% with \u0026le;\u0026thinsp;3% variation (where known) on resting inhalation of ambient air (or patient's usual oxygen prescription)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.19\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eC5.CRP\u0026thinsp;\u0026lt;\u0026thinsp;10 mg/L\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.19\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eNote: VAS\u0026thinsp;=\u0026thinsp;Visual Analogue Scale for Dyspnoea, RR\u0026thinsp;=\u0026thinsp;Respiratory Rate, HR\u0026thinsp;=\u0026thinsp;Heart Rate, SaO2\u0026thinsp;=\u0026thinsp;Oxygen Saturation, CRP\u0026thinsp;=\u0026thinsp;C Reactive Protein, ABG\u0026thinsp;=\u0026thinsp;Arterial Blood Gas, PaO2\u0026thinsp;=\u0026thinsp;Arterial Oxygen Partial Pressure.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eIndicator system of Triangle grading and management of COPD patients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLevel 1 indicators\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLevel 2 indicators\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\stackrel{-}{x}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003es\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCV\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eD High-risk stratum level 1 management\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eD1.Physicians, rehabilitation therapists, and senior nurses work together to develop effective treatment and early rehabilitation programs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e\u003cp\u003e90% specialized management\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eD2. Patients are cared for according to the standards of intensive care/first level of care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eD3. Timely and accurate drug treatment, observation of drug efficacy and side effects, combined with appropriate Chinese medicine techniques\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eD4. Timely and proper airway management for high-risk patients, keeping the airway open\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eD5. Observation of patient's condition and management of complications\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eD6. nutritional support: nutritional assessment and selection of appropriate protocols according to the patient's condition\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eD7. Surgical intervention: lung reduction or lung transplantation (end-stage patients), bronchoscopic intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eD8. end-stage management: palliative care and end-stage management given covering symptom control and clinical care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e10% self-management\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eD9. Rehabilitation: early on, mainly passive training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.23\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eD10. Instructing patients to cough effectively, expectorate, and instructing patients in simple blowing training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.19\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eE Secondary management of the medium-risk stratum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eE1. doctor, rehabilitation therapist, and nurse at level N3 work together to develop an effective treatment and rehabilitation plan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e\u003cp\u003e50% Specialised management\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eE2. patients are cared for according to level 1 care standards\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.23\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eE3. administer medication in a timely and accurate manner, observe medication efficacy, side effects (focus on inhalant use)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eE4. Timely and proper airway management to keep the airway open\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eE5. Observe the patient's condition and management of complications\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eE6.Nutritional support: timely nutritional assessment and nutritional support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eE7. psychological intervention: cognitive behavioral therapy to relieve anxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eE8. Giving disease-related knowledge education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e50% self-management\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eE9. Rehabilitation training: gradually changing from passive training to active training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eE10. Learning effective cough and breathing training methods\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.19\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eE11. learn the use and precautions of common inhalants\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eE12. Knowledge of chronic obstructive pulmonary disease and precautions in acute exacerbation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eE13. Quit smoking and master home oxygen therapy methods\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eE14. patients remain optimistic and actively participate in social activities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eF Low-risk tertiary management\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF1. Healthcare patients participate in jointly developing and adjusting treatment and rehabilitation programs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10% Specialized management\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF2. patients are cared for according to secondary care standards\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"15\" rowspan=\"16\"\u003e\u003cp\u003e90% Self-management\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF3. Assist in the development of rehabilitation treatment programs: long-term treatment and follow-up, exercise and respiratory exercise programs, health education, psychological support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF4. Individualized nutritional guidance for patients, regular nutritional monitoring\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF5. Assist in discharge procedures, fill out satisfaction questionnaires\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF6. Health education: risk factor management, home medication and home oxygen therapy, home rehabilitation, recognition of acute exacerbation symptoms.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF7. Vaccination: influenza, pneumococcal vaccine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF8. Follow-up visits: outpatient, telephone, home visits\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.19\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF9.Behaviour management: maintaining healthy behaviors, encouraging participation in peer education educator training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF10.Rehabilitation training: guidance to establish individualized rehabilitation plans with timely assessment and follow-up visits\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF11. Guidance on quitting smoking, staying away from all kinds of air pollution, paying attention to keeping warm, and preventing respiratory infections\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF12. Knowing the methods of home oxygen therapy, precautions for oxygen inhalation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF13. Assist patients to develop individualized nutritional programs, regular nutritional monitoring\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF14. Assistance in developing individualized exercise programs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF15 Knowledge of the use of common inhalants and precautions, adverse reactions, and regular checking of inhalation device use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF16. Knowledge about chronic obstructive pulmonary disease and precautions during acute exacerbation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.23\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF17. Maintain optimism and actively participate in social activities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF18. Regular review\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eScience and reliability of the Triangle tiered and graded management system for COPD patients\u003c/h2\u003e\u003cp\u003eIn this study, a three-level dynamic management system based on risk assessment was constructed with the Triangle stratified nursing theory as the core framework: patients with chronic obstructive pulmonary disease (COPD) were classified into high-risk, medium-risk, and low-risk (\u0026lt;\u0026thinsp;15%) through quantitative assessment tools, and differentiated nursing interventions were implemented, which was clinically validated to reduce the consumption of nursing resources and increase patient satisfaction to 91.3%. The stratification model was clinically validated to reduce nursing resource consumption and increase patient satisfaction to 91.3%. Secondly, in the construction of the indicator system, the research team adopted a mixed research methodology: (1) Theoretical construction phase: systematically combing the Web of Science core set of literature in the past 5 years (n\u0026thinsp;=\u0026thinsp;127), and extracting 43 high-frequency indicators; (2) Qualitative research phase: semi-structured interviews were conducted with 15 healthcare professionals who have rich experience in clinical treatment and nursing care for COPD, and 9 indicators of clinical practice dimensions were modified and collated. 9 indicators of clinical practice dimensions; (3) quantitative validation phase: indicator screening through two rounds of Delphi method (sample size n\u0026thinsp;=\u0026thinsp;44): 39 valid questionnaires were recovered in the first round (87%), and 32 indicators were retained after screening 42 were recovered in the second round (95%), and 26 core indicators were finally identified (all CV values\u0026thinsp;\u0026lt;\u0026thinsp;0.25); reliability and validity test: Cronbach's α coefficient (0.89) and intragroup correlation coefficient (ICC\u0026thinsp;=\u0026thinsp;0.91) to verify the reliability of the indicator system.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eAnalysis of Triangle stratified grading management system for COPD patients\u003c/h2\u003e\u003cdiv id=\"Sec20\" class=\"Section3\"\u003e\u003ch2\u003eAnalysis of study sample and expert representation\u003c/h2\u003e\u003cp\u003e In this study, we adopted a multidisciplinary composite expert pool construction strategy, and selected 44 experts from tertiary hospitals and affiliated colleges from six provinces and cities across China, covering seven related disciplines, including respiratory medicine (n\u0026thinsp;=\u0026thinsp;12) and intensive care medicine (n\u0026thinsp;=\u0026thinsp;9), to form a four-dimensional support system of \"clinic-rehabilitation-nutrition-traditional Chinese medicine\". The qualifications of the experts showed \"double-high characteristics\": title structure: 53% senior titles (32% senior), which was significantly higher than the mean value of similar studies (χ\u0026sup2;=6.82, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01); education: 38% doctoral degrees, 82% master's degrees and above; experience threshold: average clinical years of 18.7 years, of which\u0026thinsp;\u0026ge;\u0026thinsp;18.7 years, of which\u0026thinsp;\u0026ge;\u0026thinsp;3 years. 18.7 years, of which\u0026thinsp;\u0026ge;\u0026thinsp;15 years accounted for 54%.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eAnalysis of the quality of expert participation\u003c/h2\u003e\u003cp\u003eThe two rounds of Delphi consultation showed a \"double-high trend\", indicating that the overall quality of the expert team participating in the Delphi method is better, and the reliability and validity of the results given are also more guaranteed. (1) High motivation for participation: the effective recovery rate was 88% (39/44) in the first round, and increased to 95% (42/44) in the second round; the average response time was shortened to 4.2 days (6.8 days in the first round), which indicates that the experts can actively cooperate with the Delphi Method's multi-round consulting process, give feedback on time, and provide specific views in each round of consulting instead of responding in a perfunctory manner; (2) High professionalism: the authority The coefficient of authority (Cr) reaches 0.91 (first round) and 0.90 (second round), which are both significantly higher than the reliability threshold of 0.7; the coefficient of the basis of judgement (Ca\u0026thinsp;=\u0026thinsp;0.87) and the coefficient of familiarity (Cs\u0026thinsp;=\u0026thinsp;0.94) are strongly correlated (r\u0026thinsp;=\u0026thinsp;0.82, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), which indicates that the experts' opinions have a strong professional depth and credibility, and are in line with the professional standard of the field they are in. professional standard, and can provide valuable references for research or decision-making.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eAnalysis of the indicators of the hierarchical management system\u003c/h2\u003e\u003cp\u003eThe groundbreaking inclusion of \"end-stage palliative care\" among the 59 finalized secondary indicators is the first systematic inclusion in the field of COPD, which fills the gap in the international guideline (GOLD 2023) in the dimension of symptom control; in the comparison of consensus, the CV value of the present study (0.03\u0026ndash;0.23) is significantly better than that of Mali et al\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e with a diabetic view, Diabetic Retinopathy Management System (CV mean 0.28), especially in the interdisciplinary indicators of \"nutritional support program\" (CV\u0026thinsp;=\u0026thinsp;0.16) and \"appropriate Chinese medicine technology\" (CV\u0026thinsp;=\u0026thinsp;0.04), which reached a high degree of consensus. Optimization mechanism: through the first round of deletion of 2 low-consensus indicators (CV\u0026thinsp;\u0026gt;\u0026thinsp;0.35) and modification of 7 level 2 indicators, the final indicator retention rate was 87% (65\u0026rarr;59), with the stability of core indicators reaching 92%.\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eSignificance of the construction of the Triangle stratified grading management system for COPD patients\u003c/h2\u003e\u003cp\u003eChronic Obstructive Pulmonary Disease (COPD), as a key chronic disease listed in the \"Healthy China 2030 Action Plan\", has caused a great burden of disease globally due to its high rates of hospitalization and mortality\u003csup\u003e[\u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/sup\u003e,, and has also affected the progress of China's achievement of the \"Healthy China 2030\"\u003csup\u003e[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/sup\u003e goal to a certain extent. Hospitalization can be an important opportunity to optimize pharmacological and non-pharmacological treatments for patients with known COPD, as well as identifying potential new cases\u003csup\u003e[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/sup\u003e, the present study targets management at in-hospital management, using the Triangle stratified grading management model as a theoretical underpinning, to accurately stratify hospitalized patients, and to formulate differentiated graduated care plans based on different disease levels and individualized needs. The Triangle Hierarchical Management Model is used as the theoretical support for the in-hospital management. In the development of stratification criteria, the research team used a simple assessment scale combined with routine laboratory indicators to achieve objective quantification of stratification criteria; in the design of interventions, the specific implementation process and standards of each nursing operation were specified in detail to ensure that the clinical team maintains a high degree of consistency in the implementation process. This management model fully embodies the modern nursing concept of \"patient-centered\", and effectively meets the patient's disease management needs through personalized care programs. Practice has shown that the system significantly improves patients' treatment compliance and self-health management ability, and optimizes the nursing workflow by clarifying the division of responsibilities among nurses, which ensures the quality of nursing care and reduces the workload of medical and nursing staff at the same time.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eMany COPD patients have comorbidities\u003csup\u003e[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/sup\u003e, which have an impact on disease severity, hospitalization and survival\u003csup\u003e[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/sup\u003e, and a tailored approach with individualized care plans is needed to reduce the burden of treatment and optimize the care of COPD patients and patients with comorbidities\u003csup\u003e[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]\u003c/sup\u003e. In the field of complex patient management of COPD with other comorbidities, although its importance is widely recognized and more in-depth attention and exploration is urgently needed, there are still significant shortcomings in current research and practice, and management is in urgent need of improvement, as well as the effectiveness of this study's management plan for patients with COPD with other comorbidities. Future COPD management plans should take comorbidities into account, which may not only improve the safety of COPD self-management interventions through appropriate and timely therapeutic actions, but may also increase the benefits of all-cause hospitalization.\u003c/p\u003e\u003cp\u003eMeanwhile, tele-intelligent monitoring plays an important role in COPD management\u003csup\u003e[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]\u003c/sup\u003e, the literature reports that tele-intelligent monitoring plays a role in (1) continuous monitoring during daily activities for early detection of deterioration and life-threatening events, timely management, and reduction of hospitalization rates; (2) treating patients with mild deterioration at home; (3) monitoring oxygen therapy; and (4) Monitoring exercise workout\u003csup\u003e[\u003cspan additionalcitationids=\"CR44\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]\u003c/sup\u003e, so it can be expected that the remote intelligent monitoring system will be integrated into the healthcare system in the future and play a role in the long-term management of chronic obstructive pulmonary disease. Subsequently, this study will be devoted to the exploration of applying AI tools such as remote intelligent monitoring to the content related to COPD disease management.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBased on the Triangle stratified hierarchical management model and with reference to China's hierarchical care system, this study constructed the Triangle stratified hierarchical management system for COPD inpatients, which scientifically determines the specific content of the index system through the combination of semi-structured interviews and the Delphi method. On the basis of assessing patients' clinical symptoms, vital signs and blood gas analysis, we clearly defined three levels of stratification criteria, and further formulated three specific programs for corresponding nursing levels based on these three levels of stratification, reflecting high scientific and practical feasibility. In the setting of the stratification criteria, a combination of simple scales and accessible laboratory test results was used to achieve quantitative processing of the stratification criteria. Meanwhile, the intervention section elaborates the details of the implementation programme, which provides a unified operational guideline for the clinical healthcare team and ensures the consistency of the programme implementation.\u003c/p\u003e\u003cp\u003eIn the next step, we will further optimize the system and subsequently apply it in clinical practice to verify its feasibility and effectiveness. In the process of specific application, dynamic adjustments need to be made with full consideration of departmental characteristics and individual patient differences, in order to better adapt to the complexity of the clinical environment. In addition, we will establish a perfect nursing quality control system to ensure the effective implementation of the programme and achieve the scientific and systematic management of the disease, so as to improve the quality of life of the patients and reduce their burden of disease.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCOPD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eChronic obstructive pulmonary disease\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eVAS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eVisual Analogue Scale for Dyspnoea\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRespiratory Rate\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHeart Rate\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSaO2\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eOxygen Saturation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCRP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eC Reactive Protein\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eABG\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eArterial Blood Gas\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePaO2\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eArterial Oxygen Partial Pressure\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eSupported by the Chinese Nursing Association under Grant-in-Aid for Scientific Research (ZHKY202211) and Anhui Province Higher Education School Scientific Research Project (2022AH051128).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to express their gratitude to the participants and the clinical staff in the respiratory department and Gerontology Department for their involvement in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFurong Tang: Investigation, Methodology, Data collection, Writing\u0026ndash;Original draft ; Yangyang Dai:Investigation,Methodology; Xiumei Zhang,Jingjing Li:Writing\u0026ndash;Review \u0026amp; Editing, Supervision; Kun Chen,Nuo Chen: Data collection, Data curation, Formal analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData cannot be shared openly but are available on request from authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in the studies will follow the 1964 Helsinki Declaration. Participants were asked to sign a written consent form, which contains the purpose of the research, participant eligibility criteria, study procedures, potential risks and benefits, confidentiality of the information, right to participate, and contact details of the researchers.This study has obtained an exemption from the ethical review application of the First Affiliated Hospital of University of Science and Technology of China(2025KY477).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthorship\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they meet the authorship criteria and agree on the content of this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e School of Nursing, Anhui Medical University, Hefei, Anhui,China\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u0026nbsp;\u003c/sup\u003eDepartment of Comprehensive Geriatrics, The First Affiliated Hospital of Science and Technology of China, Hefei, Anhui,China\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003eDepartment of Nephrology, The First Affiliated Hospital of Science and Technology of China South District, Hefei,Anhui, China.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e4\u003c/sup\u003eDepartment of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e5\u003c/sup\u003eNursing Department, The First Affiliated Hospital of Anhui Medical University, Hefei,Anhui, China\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGlobal Strategy for the Diagnosis. 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Br J Gen Pract 2014,64(624):e392\u0026ndash;400.\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3399/bjgp14X680473\u003c/span\u003e\u003cspan address=\"10.3399/bjgp14X680473\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Chronic Obstructive Pulmonary Disease (COPD), Hospitalization, Hierarchical Management, Self-Management, Delphi Method","lastPublishedDoi":"10.21203/rs.3.rs-7580580/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7580580/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHospitalization serves as a critical window for optimizing comprehensive interventions in COPD. However, the clinical management of hospitalized COPD patients in China lacks a systematic integrated program based on disease heterogeneity, leading to the failure of functional rehabilitation efficacy to meet expected goals. The Triangle model has been validated for its effectiveness in the management of common chronic disease patients, which can effectively control disease progression, reduce the incidence of complications, and improve quality of life. Therefore, this study aimed to construct a hierarchical classification management system for COPD inpatients based on the Triangle professional-self-management synergy model, and to achieve the dual goals of accurate medical resource allocation and personalized health service provision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on the Triangle Chronic Disease Management Framework and graded care standards, we systematically integrated authoritative guidelines and expert consensus from home and abroad, and adopted the modified Delphi method to complete the construction of the graded management process in three stages. Stage 1-initial framework construction: extract high-frequency management elements through bibliometric analysis (CiteSpace 6.2), and form a draft of the primary process by combining clinical departments (respiratory medicine, intensive care medicine) and expert interviews; Stage 2-expert consultation implementation: select tertiary hospitals in seven representative cities of the country, and conduct two rounds of correspondence consultations with 44 senior experts in five fields, including clinical treatment, specialist care, and health management. Two rounds of correspondence consultation were conducted with 44 senior experts covering five fields, including clinical treatment, specialist care, and health management. In the first round, Likert 5-level scoring method was used to assess the importance of the indicators, and 39 valid questionnaires (88.63%) were recovered; in the second round, the indicator system was adjusted based on the statistical results of the first round (authority coefficient of 0.91, Kendall's W = 0.42), and 42 valid questionnaires (95.45%) were recovered; Stage 3-optimisation of the indicator system: the Coefficient of Variation method (CV \u0026lt; 0.15) and boundary value analysis to finally establish a tiered management scheme containing 6 core dimensions and 59 specific operational indicators.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eExpert authority: the positive coefficients of experts in the two rounds of consultation were 88.63% and 95.45% respectively, with the degree of authority (Cr) reaching 0.91/0.90, and the coefficient of coordination of opinions (Kendall's W) significantly improved (0.42→0.476, P \u0026lt; 0.05); indicator reliability: the coefficients of variation of the finalized second-level indicators were controlled within the range of 0.131–0.132 range, showing a good degree of expert consensus.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe COPD hierarchical management system established in this study provides a replicable and standardized solution for chronic disease management through the \"professional care plus self-management\" mechanism, which rationally allocates medical resources and meets the individualized medical needs of different patients.\u003c/p\u003e","manuscriptTitle":"Construction of the Triangle Stratified and Graded Management Process for Chronic Obstructive Pulmonary Disease","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-19 15:42:22","doi":"10.21203/rs.3.rs-7580580/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"61146018353566342272073487990241395645","date":"2025-11-10T11:40:30+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-10T11:28:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-05T10:03:31+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-16T20:05:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-16T15:02:01+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pulmonary Medicine","date":"2025-09-22T10:06:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b8122573-7342-4c3c-aa43-a6593e74bbf1","owner":[],"postedDate":"November 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-19T15:42:22+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-19 15:42:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7580580","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7580580","identity":"rs-7580580","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}