Regional COPD Pre-printed Orders

1
Regional COPD Pre-printed Orders Discharge Plan

• Standardizing Improved COPD Management Across the
  Lower Mainland

2
Learning Objectives

• COPD prevalence, admission rates, and economic
  burden in Canada BC
• What COPD management looked like in 2009
• How to improve COPD care in hospital
• Factors affecting QOL, morbidity, and mortality
  of COPD patients
• How to better link your patient to community
  support programs and services
• How to use the Regional COPD Care Planning
  Discharge Plan

3
COPD prevalence, admission rates, and economic
burden in US, Canada BC
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COPD facts

• 4th leading cause of death in Canada (2004)
• COPD prevalence is on the rise, especially in
  women
• Estimated 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 patients quality of life, future hospital
  admissions, and mortality

5
Trends in age-standardized death rates (Percent
change between 1970 and 2002)
100
90
COPD 4
80
COPD greatest increase in death rate amongst the
6 leading causes
70
60
50
40
30
20
102.8
3.2
10
0
Diabetes 6
- 63.1
-2.7
- 52.1
- 41.0
-32.0
-10
Cancer 2
-20
-30
All causes
-40
Accidents 5
-50
Heart disease 1
-60
Stroke 3
Adapted from Jamal A, et al. JAMA 2005
2941255-1259
Adapted from Jamal A, et al. JAMA 2005
2941255-1259
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The Human Economic Burden of COPD
COPD now accounts for the highest rate of
hospital admissions among major chronic
illnesses in Canada (CIHI 2008) CTS report
Feb 2010
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Feb 2010 CTS Report (cont)

• Hospital admissions for COPD average 10-day LOS
  at cost of 10,000 per stay
• Total annual cost estimated at 1.5 billion per
  year
• COPD is frequently not diagnosed, even when
  patients are hospitalized for an exacerbation
  COPD can contribute to other issues (ex. CHF,
  pneumonia)

8
COPD Management in the Lower mainland, 2007 2009
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Vancouver Snapshot

• Study comparing 3 hospitals in Vancouver (Apr
  2001 Dec 2002)
• Variations in care
• 59 patients received oral or parenteral
  corticosteroids in first 24 hours
• Variable re-admission rates
• 38 of patients had at least one subsequent
  hospital readmission (within 5 (/-4.08) month
  period)

Can Respir J Vol 16 No 4 July/August
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Existing Barriers Identified (2009)

• PPO existing at most sites but all differed from
  each other (no standard of care)
• No COPD discharge plan
• Low awareness both physicians and staff
• Clinical Pathway resulted in redundant charting

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Improving In-Hospital Care of the COPD Patient
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Goals for COPD In-hospital Management

• Reduce Length of Stay (LOS)
• Reduce Readmission rates
• Minimize 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 care
• Create links with community programs and
  follow-up post discharge
• Improve patient quality of life (QOL)

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In-Hospital Documents

• Regional documents assure streamlined care
  according to evidence based best practice
  guidelines
• 1. 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

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Links to Programs Support

• Smoking cessation QuitNow program
• Links 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

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Factors affecting Morbidity, Mortality, and
Quality of Life in COPD Patients
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Co-morbidities Associated with COPD

• Ischemic Heart Disease
• Congestive Heart Failure
• Arrhythmias
• Pulmonary Hypertention
• Lung Cancer
• Osteoporosis and Fractures
• Skeletal Muscle Dysfunction
• Cachexia and Malnutrition
• Glaucoma and Cataracts
• Depression
• Anxiety and Panic Disorders
• Metabolic Disorders

Can Respr J 200815(Suppl A)1A-8A
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Predictors of Survival (BODE)

• BMI
• Degree of Obstruction
• Dyspnea (MRC Scale)
• Exercise capacity
• Other risk factors for increase mortality
• Presence of co-morbidities
• History of repeat ED or hospital admission
• Age
• Low PaO2

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Improving Predictors of Survival

• BMI Diet
• Obstruction Phamacotherapy
• Dyspnea Pulmonary Rehab, Self Management
  Education
• Exercise capacity Mobility, Pulmonary Rehab
• Smoking cessation support
• Co-morbidities reduce risk of developing,
  management of existing co-morbidities
• Repeat admission Adequate follow up and referral
  post discharge
• Age no cure!
• Low PaO2 Home O2 for those who qualify

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COPD Plan of CareIndicators for improving LOS

• Oxygenation
• State of inflammation/infection (measured by
  temperature, sputum production)
• Dyspnea (compared to patient baseline)
• Activities of Daily Living/Mobility (compared to
  patient baseline)
• Diet
• Check 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

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NOTE

• Its important to remember to compare patient
  symptoms and activity tolerance to what was
  normal for them (baseline) prior to exacerbation
• A patients baseline shortness of breath,
  mobility, diet tolerance, and sputum production
  will be unique in each patient

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Medical Research Council (MRC) Dyspnea Scale
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Pre-Discharge Phase Teaching

• Teaching from the acute and transition phases
  should be reviewed and re-enforced
• Introduce exercise and strength building
  exercises
• Inhaler technique should be reviewed and checked
• Smoking cessation strategies and post-discharge
  plan should be reviewed
• Review the COPD Discharge Plan with the patient
  (copy will go with the patient)

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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
  it
• Patient 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)

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COPD Discharge Plan

• Guides patient with post-discharge directions
• Improves gap between acute and primary care
• Serves as a referral to spirometry, pulmonary
  rehab, and/or COPD Clinic
• Physician to fill out and sign page 1
• If referred for spirometry or rehab, tick the
  location referred to on page 2
• Fax as per booking directions
• Copy of all 3 pages will go home with the
  patient, original stays in patient chart

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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.

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Discussion

• Where will these documents be kept on your ward?
• Who (if anyone) will take ownership of ensuring
  these documents are completed?
• What tools are available to learn more about COPD
  and its management?
• Who can be called if there are questions?