discharge management (vienna 09)
DESCRIPTION
Presentation Post-graduate Course ERS Vienna Seotember 12th 2009TRANSCRIPT
1
Joan Escarrabill MDDirector of Master Plan for Respiratory Diseases
Institut d’Estudis de la SalutBarcelona
How to organize teaching and
discharge management
Vienna. September 12th 2009
Agenda
Introduction Health professionals and team-working Discharge planning Follow-up and risk management Networks
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3
Lassen. Lancet 1953;i:37-41. Bag ventilation
4
of cases of polio that needed ventilation during the acute phase required long term ventilatory support
10%
Kinnear Br J Dis Chest 1985;79:313-51.
5Bertoye. Lyon Médical 1965;38:389-410.
HMV is not a simple acute discharge.
Agreement between doctors, patients and caregivers
Caregiver involvement is essential
Patient confidence is crucial
Meet the technical needs
Minimization risk strategies
6
Eur Respir J 2002; 20: 1343–1350
Discharge at different levels
ICU
Home
Outpatientclinic
Generalward
RICUHigh-dependency unit
Hospice
Agenda
Introduction Health professionals and team-working Discharge planning Follow-up and risk management Networks
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9
Team Expertise+
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Effective team It has a range of individuals who contribute in different ways. Clear goals. Everyone understands the tasks they have to do. Coordinator There is a supportive, informal atmosphere. Comfortable with disagreement. A lot of discussion (Group members listen to each other) Feel free to criticise Learns from experience.
www.kent.ac.uk/careers/sk/teamwork.htm
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The team produces more than the individual contributions of members.
Patient care team
Wagner. BMJ 2000;320:569-72.
R. Casas & P Romeu (1897)
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Aiken L. NEJM 2003;348:164-6
Holistic vision
Better care related to coordination
Increasing role of non-physcian health professionals.
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Skills related to home mechanical ventilation (HMV) technology and home care
Ability to assess the adequacy of caregivers
Knowledge of community resources
Capacity to integrate home, outpatient, and hospital care
Designing of guideline-based care plans that integrate the clinical needs and preferences of the patient
Behavioral counseling and teaching of self-management
Expertise in group consultations
Learning curve
The amount of clinical exposure and levels of self-reported competence, not years after graduation, were positively associated with quality of care
Hayashino Y. BMC Medical Education 2006, 6:33
Hasan A. BMJ 2000;320:171-3
We can minimise the learning curve
Formal training courses
Simulation
Assistance from expert
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Qual Saf Health Care 2009;18:63–68.
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Acad. Med. 2003;78:783–788.
Low-tech simulators (mannequins)
Simulated/standardized patients
Screen-based computer simulators
Complex task trainers
Realistic patient simulators
team training and integration of multiple simulation devices
ultrasound, bronchoscopy, cardiology, laparoscopic surgery, arthroscopy, sigmoidoscopy, dentistry
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Actors of discharge
Health Service Health professionals
SupplierCaregiver
Home
Patient
Financial issues
Public/Private
Discharge teamCase manager
Risk management
Education
Experience
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Actors of discharge: Health professionals
Health professionals
Discharge teamCase manager
Risk management
Experience
Chest physicians Nurses Respiratory therapists Speech therapists Nutricionists Social workers ....
Hospital
Primary care
Resources in the community
Non-profitPrivateVolunteers
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Key elements in discharge
Multidisciplinary effort
ComprehensiveIntegrated
Starts earlierOver time
Process
Harmonic
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J Nurs Care Qual 2004;19:67-73
Case manager coordinates the discharge plan
Patient and caregiver Confidence & competence
Nurses & RRT Understanding of what is needed
PhysicianConfidence that the patient’s needs are being met
Agenda
Introduction Health professionals and team-working Discharge planning Follow-up and risk management Networks
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Discharge planning
Discharge planning is defined as the development of an individualised discharge plan for the patient prior to them leaving hospital for home
Definition
The discharge planning includes the multidisciplinary effort for the
transition between the hospital and the home (or the facility where
we transfer the patient).
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Aims of discharge planning
SAFETY & EFFICACY
O’Donohue W. Chest 1986;90(suppl):1S-37S.
To prepare patients and carers...
...physiologically and psychologically for transfer home, with the highest level of independence that is feasible.
To provide continuity of care...
Bertoye A. Lyon Médical 1965;38:389-410.
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Monaldi Arch Chest Dis 2003; 59: 2, 119-122.
Diurnal adaptation
Efficacy of nocturnal ventilation
Hospital training: caregiver & patient
Follow-up plan
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Initiation of NIV
28 patients
DMDSpinal musc atrophyOld polioScoliosisThoracoplasty
Stable nocturnal hypoventilation
OUT INn 14 14age 12 - 65 14 - 73stay IN (days) 3,8 + 1,5Sessions 1,2 + 0,4Technician contact 177 + 99 188 + 60Compliance (hrs/night) 3,9 + 2,8 4,3 + 2,7
IN group may be more effectively ventilated (al least in the first 2-3 months)
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Respir Med 2007;101:1177-82
5.5 + 1.3 sessions
7 + 1.1 LOS (days)
16 patients
6.8 + 1 hours/day
6.6 + 1.3 hours/day
Compliance
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Outpatient vs inpatient initiation of NIV
Small impact in the hospital resources consoumption (availability of beds)
Outpatient initiation of NIV
It’s feasible and safe
Not better than inpatient
In some cases inpatient initiation is mandatory
Social factors encourage inpatient initiation (distance, caregiver...)
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NIV: Feasibility
Indication
Feasibility
Characteristics of the respiratory failure
Home conditions
Patients preferences
Discharge
NON YESAlternatives
HospiceLow tech hospitals
Practicability of a proposed project
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NIV: Feasibility
Indication
Feasibility
Characteristics of the respiratory failure
Home conditions
Patients preferences
Discharge
NON YESAlternatives
HospiceLow tech hospitals
Technical criteria
Social criteria
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High dependency or high risk
Respir Care 2007;52:1056-62
Invasive home ventilation
Impaired self-care
Free time out ventilator < 10 hrs Dependency
AccessibilityLiving far from the hospital
Comorbidity Non respiratory clinical condicionts
Home and caregiver conditions
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Respir Med 2007;101:1068-1073
A = AcuteE = Elective
n = 43Age = 77 + 1.9 yrsCompliance: 8.3 + 3.1 hrs/day
Dropout 11%
Patients < 75 yrs: 2%
0
2
4
6
8
10
12
> 75 yrs < 75 yrs
9% 4,8%
Compliance < 4 h/day
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MESES
12010896847260483624120
SU
PE
RV
IVE
NC
IA
1,0
,8
,6
,4
,2
0,0
6 yrs
HMV in patients > 75 yrs oldSurvival
Farrero et al. Respir Med 2007;101:1068-1073
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Chest 2004;126:1583-91
15%
Octogenarians
of ICU Admissions
35% Discharge to care facility
17 %
31 %
0
5
10
15
20
25
30
35
Discharge home Discharge care facility
Mortality
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Ventilation and oxygen needs stable or palliative care plan.
Cardiovascular stability or palliative care plan.
Patient and family motivated to achieve discharge.
Feeding established.
Manageable secretions.
Technical resources can be managed at home.
Organization of care in the community can be achieved.
Funding can be gained for home care package.
No change expected in the management of the disease
Criteria for discharge
Addapted from Pratt P & Escarrabill J (2008)Kinnear (1994)
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Discharge in practice
Timing Discharge process starts as soon as possible
Feasibility
Identify the competent caregiver
Education
Analize practical issues
Take your time
Home visit
DischargeAvoid the weekend
Case manager
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Practical tools
Health professionals
Checklist
Patients & caregivers
Written information
Phone numbers
Ventilator settings
Especific recommendations
38
Equipment needs for NIV
Schönhofer B, Sortor-Leger S. Eur Respir J 2002;20:1029-38
Respiratory accessorie
s
• Humidification• Oxygen supplementation• Drugs nebulisation• Power supply: battery power source, backup ventilator
Secretions management
Daily living activities
Communication
Nutrition
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Secretions management
Hanayama. Am J Phys Med Rehab 1997;76:338-9Seong-Wong. Chest 2000;118:61-5
Eductional programme
Clearance secretions Manually assisted coughing
Hyperinsufflations
Insufflation-exuflation cycles
Mechanically assisted coughing
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Manually assisted cough
Ambu bag Volume ventilator
Air stacking
Deliver volumes of air that the patient retained to the deepest volume possible with a closed glottis
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Daily living activities Mobility
– Strollers.– Standard Wheelchairs.– Rigid Frame Weelchairs.– Nonrigid Frame Weelchairs.– Seating Systems.– Motorized Weelchairs
Transfer and lifting systems
Transportation
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Daily living activities
www.mobilityexpress.com/
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Room setting
Accessibility– Doors– Elevators– Alternative systems (volunteers)
Bed and mattressses
Bathing and toileting
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Room setting
www.medame.com
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Technological support Architectural Elements Communication Computers Home Management Personal Care: eating, personal
higyene Orthotics & Prosthetics Recreation Seating Sensory Disabilities Therapeutic Aids Transportation Vocational Management Walking Wheeled Mobility
Patients will need a wide range of assistive devices, in some
cases for a short period of time
Support groups may help provide short term use devices
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Nutritional status
Difficulties in chewing and swallowing Factors triggering or aggravating
eating problems:– Food textures– States / consistences– Bolus size
Associated difficulties wuth salivation Breathing disorders while eating
Proactive approach to anticipate dysphagia
symptoms
The BMI should be used with caution for the evaluation of the nutritional status of patients with ALS and Duchenne muscular dystrophy
Pessolano FA et al. Am J Phys Med Rehabil 2003;82:182-185.
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Effective communication
The maintenance of effective communication favors patients remaining in the communitiy
Bach JR. Am J Phys Med Rehabil 1993;72:343-9.
Simple icons
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Augmentative and alternative communication (AAC) devices
Not waiting until speech is affected to start asking around for a AAC
symbol-based,
text-based,
text-to-speech machines, in which you can type a sentence and the computer “speaks it.”
www.als-mda.org/publications/everydaylifeals/ch6/#aac_devices
Eye TrackingHead MouseTrackballsJoysticksTouch Screens
Mouse Alternatives
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Augmentative and alternative communication (AAC) devices
Though handheld or palm computers may be attractive, their small size may soon make them unmanageable to a person with neuro-muscular disease
Agenda
Introduction Health professionals and team-working Discharge planning Follow-up and risk management Networks
52
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Follow-up
Package therapyClinical
follow-up
Caregiver role
Risk management
Respite and Ongoing Support
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Clinical follow-up
Pulsioximetry
Home visits Outpatient clinic Hospital admission Phone call General practitioner Community resources e-mail
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Respir Med 2007;101:62-68
Post-operative intubation time
3,8 + 3,2 h.
Only 1 patient > 12 h.
Stay un postsurgical reanimation unit
19 + 9 h.
19 + 6 h. in the general population
n=16
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www.ventusers.org/vume/HomeVentuserChecklist.pdf
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www.ventusers.org/vume/TreatingNeuroPatients.pdf
1. The patient and designated caregiver are experts. accept the patient's suggestions even if they run contrary to standard
hospital protocols.
2. Communication is critical.
3. Return to the patient’s routine as soon as possible.
4. No oxygen alone.
5. Be careful with anesthesia and sedation
6. Use the patient’s own ventilator
7. Ask the patient or caregiver about acceptable positions.
8. Life continuation/cessation is the patient’s decision
Therapy “package”
Servera E. Sancho S. Lancet Neurol 2006;5:140-7
It’s mandatory to evaluate therapy “package”
Changes over time
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0102030405060708090
100
None Mild Moderate Severe
Discharge6 months
Caregiver depression
Chest 2003;123:1073-81
Caregivers of patients receiving LTV have similar characteristics to other caregiving populations
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Caregiver Strain & Participation
Impact of tracheotomy
Information
Restricted personal life
Rossi Ferrario S. Chest 2001;119:1498-1502
Education and support when approaching terminal issues
Sharing information to formulate life plans
Gilgoff I. Chest 1989;95:519-24
61 Neale G. J R Soc Med 2001;94:322-330.
< 20%
Directly related to surgical operations or invasive procedures
< 10%
General ward care
53%
18%
Misdiagnoses
At the time of discharge
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Ann Intern Med 2005;142:121-8
41% ...test results return after discharge
9.4% of theses results were potentially actionable
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CMAJ 2004;170(3):345-9
…of patients had an adverse event (AE) after hospital discharge 1/4
50% of the AEs werepreventable or ameliorable.
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BMJ 2000;320:791-4
Complex systems involve many gaps between, people, stages, and processes.
Presence of many gaps, yet only rarely do gaps produce accidents.
How practitioners identify and bridge new gaps that occur when systems change?
Nocturnal transfers Admission just before change of shift Patients admited out of their service Weekends
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August 14 2000
Power cut kills man on home ventilator BY SAM TOWLSON
AN INVESTIGATION has been launched into the death of a disabled man whose life-saving equipment failed during a power cut.
Feb 15, 2001A Fatal Complication of Noninvasive VentilationLechtzin N., Weiner C. M., Clawson L.
N Engl J Med 2001;344:533
Safety
66
Alarm malfunction
0,9% Power off
n = 300
18,6% Disconnection
5,1% Obstruction
67
13 %
4 %
68
Power failure Ventilator malfunction Accidental disconnection Circuit obstruction Mask fit Tracheostomy:
Blocked Falls out Cannot be replaced after changing
Medical problems
Thorax 2006;61:369-71
Risk exist
We can prevent risk
Tecnical service
Training (patient and caregiver)
Patient shared records
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Accidental disconnection from ventilator
Risk minimisation (i)
Adapted from AK Simonds, 2001
Power failure
Back-up ventilatorRegular maintenance
BatteryAmbu bag
BlockedHumidificationSuction
Falls out Trained caregiver to change trachSmaller size trach tube available
Technical aspects
The device
Ventilator breakdown
Tracheostomy
70
Adapted from AK Simonds, 2001
Medical and social aspects
Resources in the community Communication
Medical problem
s
Exacerbation alarm signs
Ressucitation
Medical hot-line
Emergency phone numbers
AmbulancesSupplier
Risk minimisation (ii)
Respite and Ongoing Support....
when the burden of home care can be great
Hospice
Palliative care support
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Hospital
Pre-discharge
Patient evaluation Community preparation
Clinical stabilityNutritionSecretion managementCaregiver
Technical supportFinancial issuesHome conditions
Feasible?
Yes NonHome Alternatives
(Hospice?)Discharge Plan
Discharge
Equipment Training
VentilatorHumidificationSuction devicesWheel chair
PatientCaregiverEmergencies
Funding application
Agenda
Introduction Health professionals and team-working Discharge planning Follow-up and risk management Networks
73
74
Some questions
Specific network for each disease?
The needs of each patient are heterogeneous
Patients' needs change through the natural history
Balance between difficulties of accessibility and personal benefits
Answer to problems non directlly related to respiratory failure.
14,19
6,3
32,26
20
12,5
6,5
10
3,9
9,35
5,6
1,320,1
21,11
10
15
4,1
0
5
10
15
20
25
30
35
Catalonia(Spain)
France (*) Germany Italy (North-East)
Netherlands Poland Sweden UK
JIVD 2009Eurovent 2002
Patients on HMV
Prevalence / 100.000 hab
(*) without pediatric patients
Relationship with resources in the community
Very variable34%
Personal contacts
3%Sporadic
33%
Systematic and well
organized30%
Population: 291.500.000
77
Generalists or specialized teams: only?
Generalists Specializedteams
Support network
78
Community nurse
Home care
General practitioner
Resources in the community
RRTSocial worker
Occupational therapist
Multidisciplinary team
79
Escarrabill J. Arch Bronconeumol 2007;43:527-9
Patient-centered care: accessibility vs performance
Network Reference center
General practitioner
Support network
Information technology and communication
80
Support network
Case manager
J Nurs Care Qual 2004;19:67-73
Support team
• Care for patients with different diseases but with common problems• Skills to care patients with HMV (respiratory problems)• Coordination of care: specialized team / generalist• Alternatives to the home (hospice)
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Catalonia WHO Palliative Care Demonstration Project at 15 Years (2005)
X Gómez-Batiste. Journal of Pain and Symptom Management 2007;22:584-590
59%41%
Cancer Non cancer
21,400 patients received palliative carePalliative care networks
95% population coverage
Home care, hospice, social support
82
Monaldi Arch Chest Dis 2007; 67: 3, 142-147.n = 792 patients
16% HMV >12 hours/day
20% Tracheo
45% Mobility / Handicap
36% Living > 30 km far from hospital
Severity of the disease
Accessibility
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The “S. Maugeri” Telepneumology Programm
Pulse oximetry / HRPneumotacograph
Central workstation
on call
Tutor nurse
Vitacca M. Telemed & e-Health 2007;13:1-5
Technical elements
Health professional
access
General support
Nurse solving problems
Access to pneumologist on duty
24 h/day
Educational material Link with GP
Telemetricmonitoring
84
Vitacca M. Breathe 2006;3:149-158
Telemedicine is an innovative medical approach
85
Community nurse
Home care
General practitioner
Resources in the community
RRTSocial worker
Occupational therapist
Multidisciplinary team
Support team Hospice
MJA 2003; 179: 253–256
“more expert” patients To develop common ground. Patient autonomy: “fully informed choice”
...re-organising healthcare systems to maximise the partnerships of patients and doctors in managing chronic disease.
Health care system
Direct access to the team
Waiting time
Fragmentation
Working for patients on home mechanical ventilation
Organized by: With the contribution of:
Welcome Benvinguts Bienvenidos
Technological innovation
Care & organization
Real life
Quality of life
Autonomy: to decide
Mobility
Social networks
Caregiver support