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 prevalence, admission rates, and

economic burden in US, Canada & BC

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)

COPD Management in the Lower mainland, 2007 – 2009

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

Improving In-Hospital Care of the COPD Patient

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

Factors affecting Morbidity, Mortality, and Quality of Life

in COPD Patients

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

Medical Research Council (MRC) Dyspnea Scale

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.

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 it’s management?Who can be called if there are questions?