Download - Discharge 03 04 09
![Page 1: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/1.jpg)
11
Protocols for discharge planning.
Neuromuscular disorders – Home mechanical ventilation for patients with neuromuscular disorders
Joan Escarrabill MDMaster Plan of Respiratory Diseases (PDMAR)
Institut d’Estudis de la Salut
Barcelona
Stressa, April 3th 2009
![Page 2: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/2.jpg)
2
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.
![Page 3: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/3.jpg)
3Bertoye. 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
![Page 4: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/4.jpg)
4
Agenda
Agenda
Team training
Discharge
planning
Safety
1 2
3
![Page 5: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/5.jpg)
5
Agenda
Agenda
Team training
Discharge
planning
Safety
1 2
3
![Page 6: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/6.jpg)
6
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
![Page 7: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/7.jpg)
7
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
![Page 8: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/8.jpg)
8
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
![Page 9: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/9.jpg)
9
Key elements in discharge
Multidisciplinary effort
Comprehensive
Integrated
Starts earlierOver time
Process
![Page 10: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/10.jpg)
10
Process
Multidisciplinary effort
Comprehensive
IntegratedHarmonic
Key elements in discharge
![Page 11: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/11.jpg)
11
Agenda
Agenda
Team training
Discharge
planning
Safety
1 2
3
![Page 12: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/12.jpg)
12
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).
![Page 13: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/13.jpg)
13
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.
![Page 14: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/14.jpg)
14
Monaldi Arch Chest Dis 2003; 59: 2, 119-122.
Diurnal adaptation
Efficacy of nocturnal ventilation
Hospital training: caregiver & patient
Follow-up plan
![Page 15: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/15.jpg)
15
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
![Page 16: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/16.jpg)
16
NIV: Feasibility
Indication
Feasibility
Characteristics of the respiratory failure
Home conditions
Patients preferences
Discharge
NON YESAlternatives
HospiceLow tech hospitals
Practicability of a proposed project
![Page 17: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/17.jpg)
17
NIV: Feasibility
Indication
Feasibility
Characteristics of the respiratory failure
Home conditions
Patients preferences
Discharge
NON YESAlternatives
HospiceLow tech hospitals
Technical criteria
Social criteria
![Page 18: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/18.jpg)
18
Actors of discharge
Health ServiceHospital
SupplierCaregiver
Home
Patient
Financial issues
Public/Private
Discharge teamCase manager
Risk management
Education
Experience
![Page 19: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/19.jpg)
19
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
![Page 20: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/20.jpg)
20
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)
![Page 21: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/21.jpg)
21
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
![Page 22: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/22.jpg)
22
Practical tools
Health professionals
Checklist
Patients & caregivers
Written information
Phone numbers
Ventilator settings
Especific recommendations
![Page 23: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/23.jpg)
23
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
![Page 24: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/24.jpg)
24
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
![Page 25: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/25.jpg)
25
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
![Page 26: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/26.jpg)
26
Daily living activities
Mobility– Strollers.– Standard Wheelchairs.– Rigid Frame Weelchairs.– Nonrigid Frame Weelchairs.– Seating Systems.– Motorized Weelchairs
Transfer and lifting systems
Transportation
![Page 27: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/27.jpg)
27
Daily living activities
www.mobilityexpress.com/
![Page 28: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/28.jpg)
28
Room setting
Accessibility– Doors– Elevators– Alternative systems (volunteers)
Bed and mattressses
Bathing and toileting
![Page 29: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/29.jpg)
29
Room setting
www.medame.com
![Page 30: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/30.jpg)
30
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
![Page 31: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/31.jpg)
31
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.
![Page 32: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/32.jpg)
32
![Page 33: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/33.jpg)
33
![Page 34: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/34.jpg)
34
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
![Page 35: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/35.jpg)
35
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
![Page 36: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/36.jpg)
36
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
![Page 37: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/37.jpg)
37
Agenda
Agenda
Team training
Discharge
planning
Safety
1 2
3
![Page 38: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/38.jpg)
38 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
![Page 39: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/39.jpg)
39
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
![Page 40: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/40.jpg)
40
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
![Page 41: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/41.jpg)
41
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
![Page 42: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/42.jpg)
42
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)
![Page 43: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/43.jpg)
43
Follow-up assessment
Pulsioximetry
Home visits Outpatient clinic Hospital admission Phone call General practitioner Community resources e-mail
![Page 44: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/44.jpg)
44
Vitacca M. Breathe 2006;3:149-158Vitacca M. Telemed & e-Health 2007;13:1-5
Telemedicine is an innovative medical approach
![Page 45: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/45.jpg)
45
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
![Page 46: Discharge 03 04 09](https://reader033.vdocuments.site/reader033/viewer/2022061222/54c262984a7959306c8b4583/html5/thumbnails/46.jpg)
46
www.slideshare.net/jescarra