Definition: › Process › Facilitates moving patients from one level of health care setting to another The process of discharge planning begins the moment

Module I - Discharge Planning, Smoking Cessation,& Pulmonary Rehabilitation

CRC 431

Special Procedures

Discharge Planning

Definition: › Process› Facilitates moving patients from one level of

health care setting to another

The process of discharge planning begins the moment a person (patient) enters a particular health care setting.

Discharge Planning

Provides the foundation for quality post-acute (subacute) care.

Guides multidisciplinary team in transferring patient from health care facility to alternative care site.

Ensures safety and efficacy of continued patient care.

Aims to contain health care costs & improve patient outcomes.

Discharge Planning

Attempts to reduce hospital length of stay (LOS).

Attempts to reduce unplanned readmission to hospital.

Improves coordination of services following discharge from hospital.

Discharge Planning

Discharge planning should ensure that patients are discharged from hospitals at an appropriate time in the course of their care.

Discharge Planning

Indications:› For all respiratory patients being considered for

discharge or transfer to alternative health care settings.

Contraindications:› NONE

Discharge Planning Websites

http://www.respiratoryupdate.com/members/AARC-CPG-Discharge-Planning-for-the-Respiratory-Care-Patient.cfm






What do discharge planners do?

Discharge Planning

Arrange services: Home care Nursing home Rehabilitative care Out-patient medical

treatment Hospice

Hospital discharge planning is usually conducted by the hospital’s Social Services Department.

Discharge PlanningCAVEATS and PROVISOS

Facilities with the most vacancies may

not be desirable.

Facilities located too far from family home

should not be recommended.

Patient/legal representative must consent to

placement.

Discharge Planning Multidisciplinary Team

› Utilization review› MD› Discharge planning (social service)› Respiratory therapy› Nursing› Dietary/nutrition› Physical/occupational therapy› Psychiatry/psychology› DME/home care company

Discharge Planning

MULTIDISCIPLINARY TEAM Utilization review: recommends consideration

of patient discharge, & documents patient’s in-hospital care

MD: writes order for discharge Discharge planning: ensures that patient can

be discharged to subacute care setting RT: provides respiratory care plan and follow-

up

Discharge Planning

MULTIDISCIPLINARY TEAM Nursing: composes nursing plan ; assesses

patient status; provides follow-up Dietary: assesses & determines nutritional

needs PT/OT: recommends modalities/procedures Psychiatry/psychology: emotional

status/counseling/support DME/home care:

equipment/supplies/emergencies RE: equipment

Discharge Planning

Site & Support Service Goals & needs of patient determine

appropriate site for discharge. Resources at proposed site must meet

patient needs.› Competent staff› Respiratory/ventilatory needs› Other health care services

Discharge Planning

Home discharge:› Caregivers’ abilities to learn/perform must be

evaluated.› Caregivers’ competencies must be documented.› Caregivers must provide 24-hour coverage.› Multiple caregivers (professional & non-

professional) required.

Discharge Planning

Confirmation of Skills among Nonprofessionals

verbal communication

demonstration

return-demonstration

Discharge PlanningQualities Required of DME

company’s accreditation status

cost & scope of services

dependability/location/availability (24/7)

Discharge Planning

HOME ENVIRONMENT

no fire, health, or safety hazards

adequate heating, cooling, & ventilation

adequate electrical supply

capable of supporting RT & ancillary equipment

Discharge PlanningRT HOME EQUIPMENT CONSIDERATIONS

available space

electrical power supply

amperage/grounded outlets

absence of hazardous appliances

Discharge Planning

Possible Complications of Discharge Planning:

Patient discharged before full implementation of plan

Natural course of the disease (e.g., patient dies)

Factors beyond control of discharge planners

SMOKING CESSATION

Smoking Cessation

About 46 million American adults smoke cigarettes, but most smokers are either actively trying to quit or want to quit.

Nicotine content in cigarettes has slowly increased over the years.

One study found an average increase of 1.6% per year between the years of 1998 and 2005.

Smoking Cessation

Why encourage people to quit smoking?

Smoking Cessation

CAD/CV disease

atherosclerosis

MI

COPD

lung CA

Smoking Cessation

After 1 year off cigarettes, the risk of CAD is reduced by half.

After 15 years of abstinence, the risk is similar to that for people who've never smoked.

In 5 to 15 years, the risk of stroke for ex-smokers returns to the level of those who've never smoked.

Smoking Cessation

Male smokers who quit between ages 35 to 39 add an average of 5 years to their lives.

Female quitters in this age group add 3 years.

Men and women who quit at ages 65 to 69 increase their life expectancy by 1 year.

Nicotine Addiction

Crosses BBB in 10-20 seconds after inhalation. Induces euphoria & acts as its own reinforcer. Leads to nicotine withdrawal syndrome when

absent. It’s a stimulant and it’s a depressant. Elimination half-life is about 2 hours. Metabolized by liver by P450 enzyme system.

Nicotine Addiction

Increases levels of dopamine (relaxation & reward) & norepinephrine in brain.

These levels drop when smoker quits. Body reacts by having nicotine withdrawal

› Edginess› Hunger

Nicotine Replacement Therapy

Reduces nicotine withdrawal & craving by supplying small amounts of nicotine.

Contains about ⅓ to ½ the amount of nicotine found in cigarettes.


Forms of NRT:› Nicotine gum › Nicotine patch › Nicotine nasal spray › Nicotine inhaler


Nicotine patches & nicotine gum are available over-the-counter.

Nicotine nasal spray & nicotine inhaler are currently available only by prescription.

Provide a small amount of nicotine to relieve withdrawal symptoms when quitting.

No smoking while using NRT. Goal is to be free of cigarettes and nicotine substitutes

within 3 to 6 months.


NICOTINE GUM Releases small amounts of nicotine,

absorbed into the body through the mucous membranes of the mouth.

Chew 10 to 15 pieces of gum a day; some chew 30.

Nicotine Replacement Therapy 1 piece at a time. Chew slowly. Sense peppery taste &

feel tingle in mouth. Park between cheek &

gum of mouth. Tingle gone. Resume chewing until

tingle returns. Park gum in different

area in mouth.

These steps repeated for 30 minutes.

Chewing NOT to be continuous.

NO swallowing saliva while chewing.

Nicotine NOT absorbed by GI system.

Chew daily for 2 to 3 months.

NO drinking fluids while or just after chewing.


NICOTINE PATCH Applied to skin for about 24 hours. No smoking while wearing patch. May cause:

› Headaches› Dizziness› Blurred vision diarrhea› Upset stomach


NICOTINE PATCH Apply to clean, dry, non-hairy part of upper

arm. Avoid using creams & lotions. Showering is permissible.


NICOTINE SPRAY Prescription required. No smoking while using spray. Delivers nicotine through nose. Dosage is flexible. Nicotine cravings eliminated quickly. Nicotine absorbed through mucous

membranes in nasal cavity.


NICOTINE INHALER Prescription required. No smoking while using spray. Delivers nicotine through mouth & throat. Dosage is flexible. 10 puffs = 1 cigarette.

Zyban

Zyban (Wellbutrin) = bupropion hydrochloride Non-nicotine prescription drug. Increases level of dopamine & norepinephrine. Zyban + NRT = more effective than either alone. Taken BID (AM and PM). 1 week needed to reach therapeutic dose. Set Quit Date 1 to 2 weeks after starting Zyban. Average length of use: 7 to 12 weeks.

Chantix

Chantix = varenicline Blocks pleasant effects of nicotine in brain. Taken PO (per os) QD or BID with food & water. Begin Chantix 1 week before Quit Date. Taken for 12 weeks:

› If smoking stopped after 12 weeks, another 12 weeks prescribed.

› If smoking continues after 12 weeks, consult with MD for another plan.

Five A’s

Ask: patient’s tobacco use & record response. Assess: willingness & readiness to attempt

quitting. Advise: clear, nonjudgmental, and suggestions

for quitting. Assist: provide cessation plan to patient. Arrange: schedule follow-up visits for

discussion.

THE END

Pulmonary Rehabilitation

Goals› Maximize patient’s functional ability› Minimize impact in

Patient Family Community

› Improve quality of life› Control & alleviate symptoms


Historical Perspective› 1951: Dr Barach recommended physical

reconditioning for COPD patients Walk without becoming dyspneic

› Barach was ignored; O2 therapy & bed rest prescribed Skeletal muscle deterioration Fatigue & weakness Increased dyspnea Homebound, room bound, bed bound


Historical Perspective› 1962: Pierce confirmed Barach› Pierce found that exercising COPD patients

Decreased pulse Decreased respiratory rates Decreased minute ventilation Decreased CO2 production

Improved pulmonary function


Historical Perspective› Paez demonstrated

Efficiency of motion Decreased O2 consumption

› Smoking cessation included› Education added

Pathophysiology Equipment Medications


Scientific Basis› Focus on patient› Include clinical sciences

Quantify degree of physiologic impairment Establish outcomes for reconditioning

› Include social sciences Psychological Social Vocational


Physical Reconditioning› Exercise increases energy demands

Increased circulation Increased ventilation Increased O2 deliver Increase CO2 elimination

› If O2 demands NOT met Blood lactate level increases CO2 increases as lactic acid buffered Increased stimulus to breathe


This point is called the “onset of blood lactate accumulation,” or OBLA

Abrupt rise in PaCO2 & minute ventilation: called “ventilatory threshold”

Beyond VT, metabolism = anaerobic respiration (decreased NRG production efficiency, lactic acid rise, fatigue)


Physical Reconditioning› MVV index of respiratory system’s ability to

handle increased physical activity› MVV = FEV1 x 35› Normal: 60% to 70% of predicted MVV during

max exercise› Indicates adequate respiratory reserve› Indicates ventilation NOT primary limiting factor

for ending exercise


Physical Reconditioning› MVV decreased with COPD› COPDs have limited exercise ability

Increased CO2 production

Respiratory acidosis SOB O2 consumption increases faster than normal


Physical Reconditioning› Rehab programs must:

Physically recondition Increase exercise tolerance


Psychosocial Support› Indicators bettor predictors of frequency & LOS

for COPD patients compared to PFTs› Psychosocial indicators better determine rehab

program completion than physical reconditioning› COPD negatively affects person’s outlook on life› Can reduce motivation


Psychosocial Support› Depression/hostility occur with acute & chronic

disease› Economic loss & fear of death produce hostility › Interaction among patients is beneficial› Patient’s lacking social support at higher risk for

re-hospitalization› Intolerance for physical exertion lessens social

activity


Psychosocial Support› Physical reconditioning & psychosocial support

linked› Reducing exercise intolerance & improving

cardiovascular response to exercise = independent, active lifestyle

› Improve social importance & self-worth› Occupational training & job placement important


Program Goals› Control respiratory infection› Basic airway management› Improve ventilation & cardiac status› Improve ambulation & other physical activities› Reduce medical costs› Reduce hospitalizations


Program Goals› Reduce LOS when hospitalized› Reduce # of MD office visits› Provide psychosocial support› Occupational training/job placement› Family education, counseling, support› Patient education, counseling, support


PROGRAM OBJECTIVES› Development of diaphragmatic breathing skills› Development of stress management and relaxation techniques› Involvement in a daily physical exercise regimen to condition

both skeletal and respiratory-related muscles› Adherence to proper hygiene, diet, and nutrition› Proper use of medications, oxygen, and breathing equipment (if

applicable)› Application of airway clearance techniques (when indicated)› Focus on group support› Provisions for individual and family counseling


Chronic lung disease progressive & irreversible

Rehabilitation slows progressive deterioration Rehabilitation does NOT alter progressive

deterioration Rehabilitation improves tissue utilization of O2

by:› Increasing muscle use effectiveness› Promoting effective breathing techniques


O2 cost for given amount of ventilation is excessive

Training skeletal muscle groups alone NOT beneficial

Training respiratory related muscles improves exercise tolerance


Evaluation of Rehabilitation Program Outcomes› Changes in exercise tolerance› Before and after 6 minute walking distance› Review of patient home exercise logs› Strength measurement› Flexibility and posture› Performance on specific exercises (e.g., ventilatory muscle,

upper extremity)› Changes in symptoms› Dyspnea measurement comparison› Frequency of cough, sputum production, or wheezing› Weight loss or gain› Psychological test instruments


Evaluation of Rehabilitation Program Outcomes› Other changes› Activities of daily living (ADL) changes› Postprogram follow-up questionnaires› Preprogram and postprogram knowledge tests› Compliance improvement with pulmonary rehabilitation

medical regimen› Frequency and duration of respiratory exacerbations› Frequency and duration of hospitalizations› Frequency of emergency department visits› Return to productive employment


Program Results› Evaluate

Patient Program outcomes

› Preprogram/current program status› Data

Physiological Psychological Sociological


Potential Hazards› Cardiovascular abnormalities

Cardiac arrhythmias (can be reduced with supplemental O2 during exercise)

Systemic hypotension› Blood gas abnormalities

Arterial desaturation Hypercapnia Acidosis

› Muscular abnormalities Functional or structural injuries Diaphragmatic fatigue and failure Exercise-induced muscle contracture


Potential Hazards› Miscellaneous

Exercise-induced asthma (more common in young patients with asthma than in patients with COPD)

Hypoglycemia Dehydration


Patient Selection› Evaluation› Testing

Patient Evaluation› History (medical, psychological, vocational,

social)› Questionnaire/interview form› Physical exam› CXR


Patient Evaluation› CBC› Electrolytes› Urinalysis› PFTs (pre/post spirometry, volumes, DLCO)› Cardiopulmonary exercise evaluation

Quantifies initial exercise capacity Provides basis for exercise prescription Renders baseline data for assessing progress Shows degree of hypoxemia/desaturation

during exercise


Patient Selection› Ex-smokers› Smoking cessation program for smokers

Patients Excluded› Concurrent problems limiting or precluding

exercising› Condition complicated by malignant neoplasms,

e.g., bronchogenic carcinoma


Common Physiological Measurements Obtained before Rehab Program› Blood pressure› Heart rate› ECG› Respiratory rate› Arterial blood gases (ABGs)/O2 saturation› Maximum ventilation (max)› O2 consumption (either absolute O2 or METS, the metabolic

equivalent of energy expenditure)› CO2 production (CO2)› Respiratory quotient (RQ)› O2 pulse



Relative Contraindications to Exercise Testing› Patients who cannot or will not perform the test› Severe pulmonary hypertension/cor pulmonale› Known electrolyte disturbances (hypokalemia, hypomagnesemia)› Resting diastolic blood pressure > 110 mm Hg or resting systolic

blood pressure > 200 mm Hg› Neuromuscular, musculoskeletal, or rheumatoid disorders

exacerbated by exercise› Uncontrolled metabolic disease (e.g., diabetes)› SaO2 or SpO2 < 85% with the subject breathing room air› Untreated or unstable asthma


Indications for Pulmonary Rehabilitation› Symptomatic patients with COPD› Patients with bronchial asthma and associated

bronchitis (asthmatic bronchitis)› Patients with combined obstructive and restrictive

respiratory defects› Patients with chronic mucociliary clearance problems

(Kartagener’s syndrome, PCD, immotile cilia syndrome)

› Patients having exercise limitations caused by severe dyspnea


Situs Solitus

Situs Inversus


Program Design› Open-ended format

Participate until predetermined objectives achieved

No set timeframe Completed at patient’s pace Good format for self-directed patients Good format for schedule difficulties Good format for individual attention Lack group support/involvement


Program Design› Closed design

Set timeframe (8 to 16 weeks; 1 to 3 sessions/wk)

Sessions last 1 to 3 hours Presentations formal Offer group support/involvement Schedule determines program completion Insurance coverage may dictate length for

which person qualifies


Session Example: Closed Design (1 day)

Component Focus Time FrameEducation Welcome (group interaction) 5 min

Review of program diaries (past week’s activities) 20 minPresentation of education topic 20 minQuestions, answers, groupdiscussion 15 min

Physical Physical activity/reconditioning 45 minReconditioning Individual goal-setting/session

summary 15 min

Total: 120 minutes (2 hours)


Physical Reconditioning› Exercise prescription with target HR based on

initial exercise evaluation› Target HR set using Karvonen’s formula› THR = [(MHR-RHR) x (50% to 70%)] + RHR

› THR = target heart rate› MHR = maximum heart rate› RHR = resting heart rate


Physical Reconditioning

MHR = 150 bpm

RHR = 90 bpm

THR = [(150 – 90) x (0.60)]+ 90 = 126 bpm


Exercise Prescription› Lower extremity aerobic exercises› Timed walking› Upper extremity aerobic exercises› Respiratory muscle training

Monitoring during Exercise› Pulse oximetry› Blood pressure› Heart rate


Lower Extremity› Walking (treadmill/flat surface)

Goals for distance, time, grade on treadmill 6 minute / flat surface / increase distance

› Bicycling (stationary) Upper Extremity

› Arm ergometers› Rowing machines


Inspiratory resistance breathing device› Adjustable flow resistor› One-way valve› Inhale through restricted orifice (variable size)› Change inspiratory load› Exhalation through one-way valve

Inspiratory Resistance Breathing Device

Pulmonary Rehabilitation Instruction

› Sit upright› Breathe slowly through device (10 to 12 bpm)› MIP < 30% of measured Pimax, use next smaller

orifice› Repeat effort until 30% is consistently achieved› 1 or 2 daily sessions for 10 to 15 minutes/session› When 30% is consistently achieved, increase

resistance› Increase session time to 30 minutes

Documents

Definition: › Process › Facilitates moving patients from one level of health care setting to another The process of discharge planning begins the moment