June 20, 2013 Heading Towards a COPD Care Pathway Dr Luc Van Zandweghe Pulmonologist Head Nurse AZ Sint-Blasius Dendermonde Belgium 1
AZ Sint-Blasius Where We Are Located Dendermonde Zele AZ Sint-Blasius is a merger of five local hospitals established between 1976 and 1999 in East Flanders, Belgium, consisting of two campuses.. 2
AZ Sint-Blasius Basic Figures Beds: 440 Staff: 1,268 (in 2012) Turnover: 125,000,000 Euros in 2012 Hospitalization: 17,380 in 2012 Consultations: 18,096 in 2012 3
Matrix structure AZ Sint-Blasius Organization Care Units (eg. abdominal, thoracic,..) Care Supporting Services (eg. labo, medical imaging,..) Organisation Supporting Services (eg. HR, ICT,..) Focus on process management (eg. clinical pathways, SLA s) 4
Carepathways in AZ Sint-Blasius History Since 2003 member of Belgian Dutch Clinical Pathway Network Hospital wide implementation ( each ward >= 1 careplan) 2003-2009 : focus on development and implementation 2010-2012: focus on follow-up,analyzing,keeping alive. Evolution Evolution from central ( staff member) to decentral follow- up- evaluation Participation Network workgroups ( COPD, PFF) 5
Composition Multidisciplinary Treatment Team COPD 3 pulmonologists 2 fysiotherapists 1 occupational therapist 1 psychologist/ tobaccologist 1 dietitian 1 social worker headnurse and nursing staff weekly multidisciplinary consultation on thursday 6
7
Thoracic Care Unit hospitalization ward : 34 beds 16 FTE nurses, 3 nurses specially trained in pulmonology; main responsibles for patient education mostly lung patients combination of both internal and surgical pathology 21 rooms from which 4 negative pressure isolation rooms 1,863 admissions in 2012 average LOS: 5 days 8
What s in a word? Chronic Obstructive Pulmonary Disease Global Initiative for Chronic Obstructive Lung Disease 9
What is COPD? Risk Factors Food Habits Infections Socio-Economical Status Aging Global Initiative for Chronic Obstructive Lung Disease 10
What is COPD? Epidemiology COPD is considered one of the leading causes of death world wide and in the coming years will become increasingly more important. The current anti-smoking campaigns will pass within decades which governed. In Belgium, the number of COPD patients is estimated at 680,000. Less than half of those have been diagnosed. 2009: 190 admissions in AZSB 2010: 141 admissions in AZSB Global Initiative for Chronic Obstructive Lung Disease 11
What is COPD? Epidemiology COPD is one of the six leading causes of death in the U.S. with an increasing trend since 1970! COPD Source: US Centers for Disease Control and Prevention, 2011 12
What s the effect of COPD? 13
What is COPD? Pathogenesis INFLAMMATION Small airway disease Airwayinflammation Airway-remodeling Lung tissue damage Loss of alveoli Decreased elasticity AIRWAY LIMITATION 14
What is COPD? Symptoms cough over production of mucus dyspnea: exercise-induced exacerbation during surge wheezing typically, slowly progressive symptoms 15
What is COPD? Treatment Aimed At : prevention of disease progression relief of symptoms improve exercise tolerance improving the general health status prevention and treatment of exacerbation prevention and treatment of complications prevention of mortality 16
Occupational therapy and COPD COPD influence on daily life tasks and Q.o.L. Occupational therapist part of the multidisciplinary team Education (patient and family) Identify the limitations in ADL tasks (interview, home evaluation scale, AMPS,...) Skills training (attention for breath control and energy efficiency) If needed the OT gives information to adapt the environment or advises device assistance to increase participation in everyday life to increase performance of daily activities 17
Progress Of The Path: May 2009: participation EQCP study baseline inclusion of 20 COPD patiënts survey on team-collaboration and group-dynamics Spring 2010: developement and testing pathway September 2010: official pathway kick off meeting with all stakeholders October 2010: start hospital COPD pathway follow-up database at the ward November 2010: EQCP post-test Summer 2011: start tobaccologist activity May 2012: COPD symposium presenting achieved goals Spring 2013: start free information sessions for ambulatory COPD patients and carers and start focus group 18
The COPD Pathway Concept Checklist: control and communication tool for the team base for systematic quality analysis Education plan: methodology used evaluation of results: often repetition needed 19
The COPD Pathway Concept Patiënt Folder: a patient version of the pathway: patient is informed of the who, when and what planned examinations/interventions information leaflets cover letter: what we aim our approach? 20
The COPD Pathway Scientific Key Interventions Designed as a checklist, which includes five sections, with all key interventions during hospitalization that certainly need to be addressed. Medical eg. the pulmonologist systematically examines whether there is an indication for start of chronic oxygen therapy at home Education eg. the physical therapist teaches the patient a correct inhalation technique and sees to it daily eg. professional smoking cessation counseling by an approved tobaccologist 21
The COPD Pathway Examinations eg. ABG and lung function test at fixed intervals Care planning eg. systematic B.M.I. measurement, monitoring weight and oxygen saturation daily patient assesment Medication eg. antibiotics only if strictly necessary based on procalcitonin (= infection marker blood test) eg. AB treatment as short as possible eg. rapid transition to oral therapy eg. reduction schedules for corticoids 22
The COPD Pathway The education plan, where all team members contribute, comprises the following items; disease understanding (terminology, diagnosis, prognosis ) smoking cessation (motivational techniques, tools ) inhalation- and oxygen therapy (inhaler use ) physical exercise/ breathing exercises/rehabilitation (prevent muscle atrophy ) nutritional advice (risk of malnutrition ) prevention (influenza vaccination ) discharge instructions (medication schedule ) 23
Together, with respect, for your wellbeing! Why this care vision? Within the mission statement of the AZ Sint-Blasius, the team developed a shared vision of care. All members of the multidisciplinary treatment team COPD endorse such a vision of care. With this vision, we consider the patient and his relatives as our first partner in the care process. These active partnership that involves mutual commitments finally results in patient empowerment also. 24
Together, with respect, for your wellbeing! "We are committed to work to improve, restore or longer maintain health and well-being. Efficient in respectful partnership with each care recipient and his or her family, We want to achieve this goal together to form a highperformance, multi-disciplinary team of which there is appreciation for the input of all team members. We invest all of our available resources, and our professional expertise in team work. In this way we aim to continuously optimize the quality of our total care. " 25
What makes this project innovative? Fully evidence based Keyinterventions from the European Quality of Care Pathways study conducted by the Centre for Health Services and Nursing Research of the University Leuven commissioned by the European Pathway Association. (Examines the effectiveness of a COPD care pathway in acute hospitals.) Multidisciplinary collaboration from a clearly defined team vision "Together, with respect, for your well-being. Investment in human resources. Team + care recipient = extra value 26
What makes this project innovative? Patient empowerment due to an active partnership with the patient and his relatives. mutual commitment Attention to a large but socially weaker and often unsung, target with a current problem. current prevention (smoking cessation) will affect the incidence only in the longer term 27
What makes this project innovative? Emphasis On Targeted Education encouraging selfmanagement active role for care recipient / relatives Systematic monitoring and improvement of the careproces higher level of care quality. database and clinical performance indicators 28
What makes this project innovative? Positive effects on patient safety: better coordinated care shorter L.O.S. better informed patients and relatives will report (potential) incidents earlier than before rational drug use: oral instead of IV : risks of thrombophlebitis, catheter sepsis AB en corticoïds: risks of AB resitence and side effects 29
What makes this project innovative? Ambulatory Component freely accessible, periodic, information sessions for ambulatory patients and carer givers in collaboration with the primary care (GP s, homecare ) involvement of patients in the organization of the care process through focus groups 30
Facts and figures Baseline october 2009 - march 2010 october 2010 - march 2011 october 2011 - march 2012 october 2012 - march 2013 # Admissions 93 81 89 62 # Readmissions <= 30 days 6 1 5 3 # Patient days 1069 724 806 507 Average length stay hospital (days) 11,49 8,94 9,06 8,2 Average readmissions length stay hospital (days) 21,7 6 10,6 9,3 # Patients with antibiotics 68 49 66 38 % 73,12 60,49 74,16 61,29 # units antibiotics* 1721 1027 1537 851 Antibiotics, DDD* 1185 584 1043 535 # Patients with corticosteroids 88 76 83 59 % 94,62 93,83 93,26 95,16 # mg cortisosteroids/patientday 56,13 23,09 34,84 40,77 *Antibiotics: Augmentin, Avelox, Biclar, Ciproxine, Maxipime, Tazocin (cfr. former studies clinical pathway COPD). 31
Facts and figures Downward trend readmissions within 30 days after discharge. 32
Facts and figures The average LOS currently decreased with 3,29 days since the start of the PW. 33
Facts and figures Reduction in the percentage of patients receiving antibiotics through stricter criteria. 34
Facts and figures Currently the corticosteroid use still almost 28% less than in the baseline, in spite of the re-rising trend. Reduction of the total # mg corticosteroids per patientday steroidrelated side effects Shift from intravenous to oral adminstration safer and more cost efficient. 35
Sincere thanks to the entire team for their daily commitment. Together, with respect, for your wellbeing! 36
Questions? mario.heirewegh@azsintblasius.be It s a matter of breath or death! 37