Cathy Lodewijckx RN, MSc, PhD cand University Hospitals Leuven, Belgium Catholic University Leuven, Belgium European Pathway Association Belgian Society for Respiratory Nurses DISCHARGE MANAGEMENT AND EDUCATION IN HOME OXYGEN THERAPY

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Content Background Non compliance in current home oxygen care Challenges for future home oxygen therapy

Background (1) Goal: –PaO2 > 7.98 kPa or SaO2 > 90% –↑↑ quality of life and survival Broad application: –Chronic lung diseases e.g. COPD, cystic fibrosis –Cardiac diseases –Palliative care – … Kampelmacher, 2001; Lodewijckx, 2008; Mitrouska, 2006

Critical issue: non compliance (1) What? 1.Non compliance to medical prescription LTOT: ≥ 16 hours a day / continous therapy COPD and LTOT: Compliance = 17 to 45% Short term oxygen therapy Oxygen use during ADL = low Increasing oxygen flow: Carbonarcosis 2.Non compliance to precautions: burns Smoking Incorrect manipulation Cullen, 2009; Cullen 2006; Edelman, 2008; Duck, 2004; Kampelmacher, 2001; Lodewijckx, 2008; Pfister, 1995; Smith, 2004

Critical issue: non compliance (2) Important Issue? –Insufficient effect of oxygen therapy Condition, ADL, Quality of life, Prognosis –Hazardous effects Carbonarcosis or burns Adequate home oxygen therapy: –Effective therapy –Safe administration of oxygen –comfortable administration of oxygen

Determinants (1) Patients: –Insufficient knowledge Medical, practical, technical –Impact on daily living (type of oxygen source!) –Negative views and anxiety –Shame and fear for social stigma –Active smokers –Financial factors Cullen, 2009; Cullen 2006; Duck, 2004; Kampelmacher, 2001; Lodewijckx, 2008; Pfister, 1995; Smith, 2004

Determinants (2) Carers: Lack of education and knowledge Medical, practical, technical, patient impact Lack of coordination between primary and secondary care –Poor discharge management –Insufficient follow-up => Changing care context: ↑↑ need home oxygen therapy –↑↑ prevalence COPD –Aging population –Shift secondary care to primary care Cullen, 2009; Cullen 2006; Duck, 2004; Kampelmacher, 2001; Lodewijckx, 2008; Lodewijckx, 2009; Pfister, 1995; Smith, 2004

Challenge 1: Patient education (1) Who: Patient AND Family / home carer When and who? –At hospital: medical doctor, nurse, physiotherapists Contact with health Care professionals –At Home: Pharmacist & Supplier, nurse & General practitioner Content? –Medical information –Practical information –Technical information Cullen, 2009; Cullen 2006; Kampelmacher, 2001; Pfister, 1995; Smith, 2004

Challenge 1: Patient education (2) Medical information (medical doctor, …) Aim of oxygen therapy Effects Advantages Possible disadvantages Technical information (supplier, …) Correct use and maintenance of the oxygen source Precautions Contact information for questions and technical problems

Challenge 1: Patient education (3) Practical information (medical doctor, nurse, …) Medical prescription Precautions Use of oxygen source and equipment Use of oxygen during transport, air travel and holiday Smoking cessation Financial aspects Flow: ____ L/min Daily use: Continously; only at night, only during exercise, if short of breath Oxygen can be increased during exercise, if short of breath (No/Yes: untill ____ L/min)

Challenge 1: Patient education (4) How to educate? (1) Oral information; (2) Demonstration on correct use of oxygen source and equipment; (3) Evaluation of understanding (checklist); (4) Written information: Patient leaflet Cullen, 2009; Cullen 2006; Kampelmacher, 2001; Pfister, 1995

Challenge 2: EB Practice & uniformity What? Best practice; Uniformity How? EB Guidelines; national, regional level (uniformity) 1.Development: Literature review & Experts & Congresses 2. Dessimination: National book; national journals National professional organizations (lectures) 3. Implementation: Local application in different settings Organization tools (ie transmural care pathway) Continous follow-up of processes, outcomes Lodewijckx, 2008; Van Haecht et al. 2006

Challenge 3: Education of carers Who? All carers involved in oxygen therapy –At hospital: medical doctor, nurse, physiotherapists –At Home: Pharmacist, Provider, General practitioner Content? Medical, practical and technical information How? –Access to electronic databases, websites of (inter)national societies (search strategy) –Training by experts: national courses – local!

Challenge 4: Discharge management Inform patient and family at need for home oxygen therapy Medical prescription of pulmonologist Education: patient, family, home care staf (nursing home) Arrangement of home oxygen therapy Contact with oxygen suppier: social worker / family Home delivery: Pharmacist / supplier Check on readiness of oxygen equipment BEFORE discharge Arrange oxygen therapy during transport if necessary

Challenge 5: Follow-up Re-evaluation by pulmonologist within 1-2 months after start Effect of therapy: Clinical condition, arterial blood gases Need for further therapy / adjustment of therapy Correct use of oxygen therapy Motivation & compliance Ongoing follow-up by GP and home care nurse Systematical assessment: detect problems; refer patients Re-evaluation by pulmonologist every 6 months / ↓ condition Compliance to prescription, motivation, effect Short-oxygen therapy: re-evaluation 3-4 months after start Cullen, 2009; Cullen 2006; Edelman, 2008; Duck, 2004; Kampelmacher, 2001; Lodewijckx, 2008; Pfister, 1995; Smith, 2004 >>ADL, quality of life, readmission, suvival<<

Challenge 6: Research What do we need to know? –What & where is need for interventions? –What are (cost)-effective and feasable interventions? What is impact on outcomes? => Gouvernment: sensibilisation; financial resources? Indicators? –Actual prevalence / compliance in patients –Process outcomes: actual performance of health carers –Patient outcomes: clinical, service –Financial outcomes (cost-effectiveness) –Impact of specific interventions: Education, follow-up

Challenges for future Home oxygen therapy Safe, comfortable and effective Home oxygen therapy Adequate patient & family education EB Practice & uniformity: EB Guidelines: development, dessimination, local implementation (care pathways) Adequate education of carers Organization of care: –Discharge management –Follow-up Research: need & effectiveness of interventions