Regional COPD Pre-printed Orders & Discharge Plan Standardizing Improved COPD Management Across the Lower Mainland

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

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

COPD facts: 4 th 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 patient’s quality of life, future hospital admissions, and mortality

Trends in age-standardized death rates (Percent change between 1970 and 2002) % %- 41.0%-32.0% % % % COPD [#4] Diabetes [#6] Cancer [#2] All causes Accidents [#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:

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

Feb 2010 CTS Report (con’t) 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)

COPD Management in the Lower mainland, 2007 – 2009

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

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

Improving In-Hospital Care of the COPD Patient

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)

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

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

Factors affecting Morbidity, Mortality, and Quality of Life in COPD Patients

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 2008;15(Suppl A):1A-8A

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

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

COPD Plan of Care: Indicators 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

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: 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)

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)

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

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?