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COPD Care Program

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Dr Yuk Lung KWOK. Division of Respiratory Medicine, Department of Medicine & Geriatrics, ... All COPD exacerbations were managed by the general team. ... – PowerPoint PPT presentation

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Title: COPD Care Program


1
COPD Care Program
  • Dr Yuk Lung KWOK
  • Division of Respiratory Medicine, Department of
    Medicine Geriatrics,
  • Tuen Mun Hospital, Hong Kong
  • Clinical Audit Conference
  • NTWC, Hospital Authority
  • February 2005

2
Characteristics of COPD management in NTWC before
start of CCP
  • All COPD exacerbations were managed by the
    general team.
  • Aim at solving the acute problems for that
    particular admission and discharge ASAP.
  • Usually no specific probing into the reasons for
    repeated admissions and blame the natural
    deterioration of the disease (which in fact is
    not true).

3
Characteristics of COPD management in NTWC before
start of CCP
  • No Chest Hospital in the region.
  • No existing structured convalescent care.
  • Lack of organization of all the work and inputs
    from the paramedical teams in POH.
  • In-patient pulmonary rehabilitation in TMH since
    2002 can only accommodate a small volume of
    highly selected patients.

4
COPD hospitalization episodes in HA Hospitals
(2002)
NTWC ?1.06 million
5
COPD Hospital Outcomes 2002
6
COPD Care Program (CCP TMH/POH)
  • Q3 2003

7
COPD Care Program - Essence
  • COPD Care Program (CCP) Respiratory
    physicians-led multidisciplinary disease
    management program for managing hospitalized COPD
    exacerbations in the NTWC of HA.
  • Acute phase in Respirology Cubicle, TMH
  • Extended-care phase Integrated Patient Care
    Pathway (IPCP) in POH

8
COPD Care Program (CCP TMH/POH)
  • To deliver specialists-directed, effective and
    comprehensive COPD management
  • COPD exacerbations are perceived as a window of
    opportunity for holistic evaluation.
  • Protocol/management model ? comprehensiveness.
  • Respiratory physicians-directed ? specialized
    care.
  • Standardize investigations and treatments.
  • Optimize recovery time.
  • Improve patient outcomes/satisfaction.
  • Utilize resources effectively and reduce hospital
    costs while maintaining care quality.
  • Evidence-based local practicability.

9
COPD Care Program (CCP TMH/POH)
  • Acute phase/TMH
  • Collection of patients in a Sub-specialty ward
    cubicle for focused care and expertise
    development among nursing staff.
  • 10 beds for male patients from Sep 03 Jun 04
    increase to 14 beds from Jul 04 onwards (3-4 all
    acute medical beds).
  • Recruit all COPD new admissions within 24 hours
    (by a random process) until beds are fully
    occupied.

10
COPD Care Program (CCP TMH/POH)
  • Acute phase/TMH
  • A team of Respirology physicians directed all
    medical treatment.
  • Nurse specialists assessment/education.
  • Physiotherapists and occupational therapists
    referral.
  • Smoking cessation program referral.
  • Nutritional scoring and refer to dietitian for
    supplements
  • CCP Booklet and standardized education materials.
  • A single CCP booklet for each patient.
  • Review and update progress by all disciplines,
    during each subsequent admissions and by
    community nurses.

11
COPD Care Program (CCP TMH/POH)
  • Indications for referral to POH Extended-care
    Phase high risk for early readmission
  • Slow symptom resolution after initial treatment.
  • Multiple social domestic disabilities/handicaps
    due to physiological impairment.
  • Repeated unplanned re-admissions (gt2 in 12
    months) due to exacerbations for further
    exploration by a multidisciplinary approach.
  • Other clinical situations that make a
    multi-disciplinary management program likely to
    be beneficial, as assessed by Respirology
    specialists.

12
COPD Care Program (CCP TMH/POH)
  • Extended-care phase/POH
  • Collaboration between Divisions of Respiratory
    Medicine and Rehabilitation Medicine
  • 15-20 beds assigned for CCP Extended-care Phase
    in POH.
  • Weekly re-assessment of the extended-care phase
    COPD patients in POH by the TMH CCP Respiratory
    physicians.
  • Multidisciplinary protocol-based evaluation and
    intervention of disease-related medical,
    physical, and psychosocial handicaps.
  • Walking exercise program interval exercise
    capacity assessment (6MWT).
  • ADL training and assessment.
  • Comprehensive education.
  • Interface with community services.

13
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14
COPD Care Program (CCP TMH/POH)
  • Outcomes measurements
  • Hospital outcomes
  • LOS, morbidity, mortality
  • Physiological outcomes
  • Lung function tests, exercise capacities
  • Clinical outcomes
  • Dyspnoea, ADL, social function, leisure
    activities
  • Health care resources utilization
  • AED visits, unplanned readmissions

Clinical Management System (CMS)
15
COPD Care Program (CCP TMH/POH)
  • Auditing standards
  • NTWC historical data
  • Outcomes data from other HA clusters/hospitals
  • Re-audit cycle annually

16
COPD Care Program Outcomes Audit at 1 year
17
CCP Outcomes (Acute Phase/TMH Sep 03 Sep 04)
18
CCP Outcomes(Acute Phase/TMH Sep 03 Apr 04)
  • Distribution of GOLD Staging for PFT Impairment

19
CCP Outcomes(Acute Phase/TMH Sep 03 Aug 04)
Average length of stay in TMH (Days)
(SARS in 2003)
20
CCP Outcomes(Acute Phase/TMH 2002-2004)
Monthly COPD emergency hospitalizations TMH
(Number of episodes)
Start of CCP ?
?SARS?
21
COPD hospitalization episodes in HA Hospitals
(2002 2004)
Projected from data of Jan to Sep 2004
22
CCP Outcomes(Acute Phase/TMH Sep 03 Sep 04)
  • 28-day COPD Re-admission Rate in TMH ()

()
Start of CCP ?
?SARS?
23
COPD 28-day readmission rate () in HA Hospitals
(2002 2004)
()
24
Percentage change of COPD 28-day readmission rate
in HA hospitals from 2002 to 2004
()
25
CCP Outcomes(Acute Phase/TMH Sep 03 Sep 04)
  • TMH COPD In-patient Mortality

26
COPD Care Program Retrospective case-controlled
cohort analysis
27
COPD Care Program Retrospective case-controlled
cohort analysis
28
COPD Care Program Retrospective case-controlled
cohort analysis
Exacerbation pattern (AED visits,
hospitalizations, acute hospital days)
6 months before
29
COPD Care Program Retrospective case-controlled
cohort analysis
Exacerbation pattern (AED visits,
hospitalizations, acute hospital days)
6 months before
6 months after
Exacerbation pattern, morbidity, mortality
30
COPD Care Program Oct to Dec 03 cohort analysis
31
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32
COPD Care Program Oct to Dec 03 cohort analysis
33
COPD Care Program Oct to Dec 03 cohort analysis
(p0.10)
(p0.76)
(p0.27)
34
Exacerbation pattern among 6-month survivors in
the CCP and non-CCP groups
24.6 ?
(p0.03)
(p0.63)
AED visits 6 months before and after index
admission (episode/patient/six months)
(p0.45)
(p0.001)
(p0.06)
(plt0.001)
Total number of exacerbations 6 months before
and after index admission (episode/patient/six
months)
Emergency hospitalizations 6 months before and
after index admission (episode/patient/six
months)
35
Acute hospital days among 6-month survivors in
the CCP and non-CCP groups
38.4 ?
(plt0.001)
(p0.08)
Acute hospital days 6 months before and after
index admission (days/patient/six months)
36
Infrequent exacerbators 2 or less exacerbations
in 6 months Frequent exacerbators 3 or more
exacerbations in 6 months
Statistically Significant
37
Infrequent exacerbators 2 or less exacerbations
in 6 months Frequent exacerbators 3 or more
exacerbations in 6 months
Statistically Significant
38
COPD Care Program Conclusions
39
COPD Care Program
  • Improve quality
  • When compared with non-CCP management
  • No change in hospital as well as 6-month
    mortality rates.
  • CCP recruitment ? 24.6 reduction in exacerbation
    frequency within 6 months.
  • TMH 28-day readmission rate for COPD dropped from
    an average of 39.2 in 2002 to 24.1 in 2004.

40
COPD Care Program
  • Reduce healthcare cost
  • Estimated cost of a Medical Ward hospital day in
    2002/03
  • TMH Medical Ward 2400
  • POH 1300
  • After commencement of COPD Care program
  • CCP recruitment ? 38.4 reduction in acute
    hospital days within 6 months.
  • Average monthly reduction of 90.5 episodes
    (?38.4) of COPD admission comparing with
    historical data of similar months in TMH.
  • Involves re-organization of existing manpower.
  • Only took up 3-4 of all acute medical beds.
  • No sacrifice in average LOS in the participating
    acute and convalescent hospitals.

41
Members of CCP/IPCP TMH/POH
Project Leader Dr YL Kwok, Respirologist,
TMH Core Members Dr CY Tam, CONS, Respirologist,
TMH Dr KM Sin, SMO, Respirologist, TMH
Dr SL Chow, A/C, Rehabilitation Director,
NTWC Miss Hilda Li, Respirology Nursing
Specialist, TMH
Other Members Dr JS Lee, MO, TMH Dr CL Lau, MO,
TMH Dr CC Leung, MO, TMH Dr KY Ng, MO, TMH Dr KC
Leung, MO, TMH Mr. Aaron Kwok, DOM, TMH Ms SC
Cheung, NO, TMH Mr. Sammyy Sun, WM, TMH
Ms YM Chan, WM, TMH Ms YL Fong, RN, TMH Ms WL
Law, WM, POH Mr. Charles Cheung, Physiotherapist,
TMH Mr. Manfield Chan, Physiotherapist, POH Ms.
Peg Cheung, Occ Therapist, TMH Ms. Pinkie Cheung,
Occ Therapist, POH Ms. Sally Ng, Dietitian, TMH
Ms. Vivian Wong, Dietitian, POH. Ms. Connie
Chan, MSW, TMH. Ms. KY Pang, MSW, POH. Ms. YW
Tang, Smoking Cessation Counselor Ms. Fanny
Wong, Community Rehab Network Ms. Fonny Ng,
Health Resource Center.
Coordinators Miss Betty Au, IPCP Subject Officer,
NTWC Miss Vivian Chan, IPCP Coordinator, NTWC.
Miss PF Tang, IPCP Facilitators, NTWC.
42
  • Dr Yuk Lung Kwok
  • CCP (TMH/POH)
  • Clinical Audit Conference
  • NTWC, Hospital Authority
  • February 2005
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