Regional COPD Pre-printed Orders & Discharge Plan Standardizing Improved COPD Management Across the...
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Transcript of Regional COPD Pre-printed Orders & Discharge Plan Standardizing Improved COPD Management Across the...
Regional COPD Pre-printed Orders & Discharge Plan
Standardizing Improved COPD Management Across
the Lower Mainland
Learning ObjectivesCOPD prevalence, admission rates, and
economic burden in Canada & BCWhat COPD management looked like in
2009How to improve COPD care in hospitalFactors affecting QOL, morbidity, and
mortality of COPD patientsHow to better link your patient to
community support programs and servicesHow to use the Regional COPD Care
Planning & Discharge Plan
COPD facts:4th leading cause of death in Canada (2004)COPD prevalence is on the rise, especially in
womenEstimated 1.5 million Canadians have been
diagnosed, another 1.6 million report symptoms but have not been tested (spirometry)
COPD exacerbations (aka “Lung Attacks”) have the same consequences as a heart attack in terms of the patient’s quality of life, future hospital admissions, and mortality
Trends in age-standardized death rates(Percent change between 1970 and 2002)
- 63.1% - 52.1% - 41.0% -32.0% -2.7%
+3.2% +102.8%
COPD [#4]
Diabetes [#6]
Cancer [#2]
All causesAccidents
[#5]Heart disease
[#1]Stroke
[#3]
0
-60%
-30%-40%
-50%
-20%
-10%
COPD: greatest increase in death rate amongst the 6 leading causes
10%
40%
30%20%
50%60%
70%
100%90%
80%
Adapted from Jamal A, et al. JAMA 2005; 294:1255-1259Adapted from Jamal A, et al. JAMA 2005; 294:1255-1259
The Human & Economic Burden of COPDCOPD now accounts for the highest rate of hospital admissions among major chronic illnesses in Canada (CIHI – 2008) – CTS report Feb 2010
Feb 2010 CTS Report (con’t)Hospital admissions for COPD average
10-day LOS at cost of $10,000 per stayTotal annual cost estimated at $1.5
billion per yearCOPD is frequently not diagnosed,
even when patients are hospitalized for an exacerbation – COPD can contribute to other issues (ex. CHF, pneumonia)
Vancouver Snapshot:Study comparing 3 hospitals in
Vancouver (Apr 2001 – Dec 2002)Variations in care59% patients received oral or parenteral
corticosteroids in first 24 hoursVariable re-admission rates38% of patients had at least one
subsequent hospital readmission (within 5 (+/-4.08) month period)
Can Respir J Vol 16 No 4 July/August
Existing Barriers Identified (2009)PPO existing at most sites but all differed
from each other (no standard of care)No COPD discharge planLow awareness – both physicians and staffClinical Pathway resulted in redundant
charting
Goals for COPD In-hospital ManagementReduce Length of Stay (LOS)Reduce Readmission ratesMinimize impact of exacerbation on overall
disease progression Improve overall management of AECOPD
according to best practice guidelines (CTS, GOLD)
Create links between acute and primary careCreate links with community programs and
follow-up post dischargeImprove patient quality of life (QOL)
In-Hospital Documents Regional documents assure
streamlined care according to evidence based best practice guidelines1. COPD Exacerbation Admission Order set (PPO) for admitted patients
3. COPD Discharge Plan Documents tie into one another and
attempt to fill gaps in care
Links to Programs & SupportSmoking cessation:
QuitNow programLinks to COPD Discharge
Plan Referral to Spirometry and
COPD Management Services (through COPD Discharge Plan)
List of patient education materials on back of care planning pathway
Links to GP
Co-morbidities Associated with COPD
Ischemic Heart DiseaseCongestive Heart FailureArrhythmiasPulmonary HypertentionLung CancerOsteoporosis and FracturesSkeletal Muscle DysfunctionCachexia and MalnutritionGlaucoma and CataractsDepressionAnxiety and Panic DisordersMetabolic Disorders
Can Respr J 2008;15(Suppl A):1A-8A
Predictors of Survival (BODE)BMIDegree of ObstructionDyspnea (MRC Scale)Exercise capacity
Other risk factors for increase mortality:Presence of co-morbiditiesHistory of repeat ED or hospital admissionAgeLow PaO2
Improving Predictors of Survival
BMI: DietObstruction: PhamacotherapyDyspnea: Pulmonary Rehab, Self Management Education Exercise capacity: Mobility, Pulmonary Rehab
Smoking cessation supportCo-morbidities: reduce risk of developing, management of
existing co-morbiditiesRepeat admission: Adequate follow up and referral post
dischargeAge: no cure!Low PaO2: Home O2 for those who qualify
COPD Plan of Care:Indicators for improving LOS OxygenationState of inflammation/infection (measured by
temperature, sputum production)Dyspnea (compared to patient baseline)Activities of Daily Living/Mobility (compared to
patient baseline)DietCheck box if indicator is met, or an “X” if
indicator does not apply to the patient. Initial and date only if you sign off on the indicator
NOTE:It’s important to remember to compare patient
symptoms and activity tolerance to what was normal for them (baseline) prior to exacerbation
A patient’s baseline shortness of breath, mobility, diet tolerance, and sputum production will be unique in each patient
Pre-Discharge Phase: TeachingTeaching from the acute and transition phases
should be reviewed and re-enforcedIntroduce exercise and strength building
exercisesInhaler technique should be reviewed and
checkedSmoking cessation strategies and post-
discharge plan should be reviewedReview the COPD Discharge Plan with the
patient (copy will go with the patient)
Pre-Discharge Phase: Discharge Planning
Complete the COPD Discharge Plan & fax COPD to Spirometry clinic/lab and COPD community program if referred
Home O2 assessment if you suspect they may need itPatient vaccinations should be up to date (Influenza and
pneumoccocal)Links to follow up support in the community are made at
this time Notify the GP of discharge (fax/send discharge summary
and COPD Discharge Plan)Fax QuitNow referral (if applicable)
COPD Discharge PlanGuides patient with post-discharge
directionsImproves gap between acute and primary
careServes as a referral to spirometry,
pulmonary rehab, and/or COPD ClinicPhysician to fill out and sign page 1If referred for spirometry or rehab, tick
the location referred to on page 2Fax as per booking directionsCopy of all 3 pages will go home with the
patient, original stays in patient chart
COPD Pre-Printed Order (PPO)A Regional COPD Exacerbation Admission PPO
has been approved across 3 health Authorities (VCH, PHC, and FHA)
There are areas of the PPO that can be modified as per site policy or resources
PPO should be initiated in the ED when the patient is admitted.
The PPO ties into the Care Planning Pathway – part of admission instructions is to initiate clinical pathway. Which we are not trialing at this time.