A Team Approach to Creating a Seamless COPD clinic in a FHT Setting. Judy Cobus, RN Karen Dubé, PCNP Ellen Holmes, RRT, RCPT(P), CRE
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1 A Team Approach to Creating a Seamless COPD clinic in a FHT Setting Judy Cobus, RN Karen Dubé, PCNP Ellen Holmes, RRT, RCPT(P), CRE January 2015
2 Disclosures:
3 Better Breathing Program Objectives To Overview the ADFHT s approach to COPD Management To review available resources in planning a COPD management program To facilitate group discussion regarding starting a COPD program to discuss perceived and experienced barriers to implementation and exploration of alternatives
4 Before we started: Baseline Data Collection Chart review We surveyed 20% of patients diagnosed with COPD at our FHT Encounters were rated according to the following variables: Diagnosis: bronchitis/emphysema/copd Immunization status (influenza + pneumococcal) Smoking status & whether referred for cessation counseling Hospital admission within previous year Date of last spirometry CAT/MRC scores Referral to Respirologist, Pulmonary Rehabilitation or Maintenance Exercise Program
5 Environmental Scan Available resources within our FHT Community resources OLA Respiratory Health Program CCAC Assessment of current hospital stats and management of COPD Reviewed statistics for admissions/readmissions Informal assessment of nursing continuing education needs
6 Stakeholder Collaboration Formation of Collaborative Hospital Working Group RN- hospital front line staff Hospital discharge planner Family Health Team (FHT) RN Respiratory Therapist Physician Champion (FHT) CCAC representative
7 Educational program for Inpatient Nursing Staff Three hour presentation: NP student and RRT Pathology/ Pathophysiology and Dyspnoea We designed a care map/pathway Inhaler education: Each Nurse was given a placebo inhaler kit RRT created a Quick Guide to Respiratory Medications Practice doing chest and dyspnoea assessments Smoking cessation education COPD Admission orders and Discharge plans
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9 Funding for Program Development Boehringer-Ingelheim (BI) Canada Limited funded: Baseline assessment and environmental scan Resource binder CTS guidelines, MRC/CAT scales, AECOPD, nutrition, home oxygen therapy, MUMS Health Resp. Guidelines, Action Plan, Quick Med Guide Educational leave for RespTrec training, Better Breathing Conference CME events for IHP s and MD s Consultant who assisted with database development Development of our COPD Action Plan Modification of several different Action Plans MUMS Health Respiratory Guidelines for team members and MD s
10 Our team at the Arnprior FHT RRT Ellen Holmes RN Judy Cobus NP Karen Dube Pharmacist Wade Thompson/Israa Rahmaan MD Champion Dr. Jennifer Becker Admin support Colleen Desarmia
11 Evidence Based Resources We used the following Resource tools: COPD Action Plan CTS guidelines CAT/MRC scores OLA and other patient education materials GSK Breathe Essentials Patient Assessment Form Nightingale templates we had to create our own template within our EMR
12 Referral from: MD, IHP, Hospital Intake Visit RN/ Pharmacist Medical & Family History Medication Reconciliation Record Height/Weight & Last Spirometry Date Immunization History + Update Immunizations Nutrition, Exercise & Smoking History CAT/MRC Scores ] classify severity NP Exacerbations Symptom & Symptom Recognition Action Plan: Antibiotic/Steroid Rx Resp. Meds according to CTS Guidelines Physical Assessment Oxygen Saturation Chest Assessment Follow-up Visit Smoking Cessation Counselling RRT Respiratory medications Puffer Education Spirometry Repeat MRC/CAT Breathing/coping Techniques Lifestyle Management Exercise Maintenance Program Respiratory Rehab Respirologist Other Referrals PRN
13 Non-Rostered Patients Discharge planners at the hospital send a referral to the OLA Respiratory Health Center Ellen receives the consult and sees the patient at a local retirement residence to provide education and support
14 EMR Template Flow Diagram of Clinic Roles
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18 Patient Education Plan Inhaler technique Medication compliance Prevention and management of exacerbations: Action Plan Breathing techniques/ coping techniques/ sputum clearance, etc. Immunization update (Influenza & Pneumococcal) Referral to OLA exercise program Daily life self-management Use of home Oxygen Community Resources End of Life Care
19 Community Outreach We have a partnership with a local Retirement Residence to offer monthly community patient and caregiver education sessions Sample Topics Covered: Inhaler technique & introduction to new puffers Nutrition and COPD Exercise and breathing techniques End of Life Issues Evaluation: Approximately 20 attendees per session Positive Feedback
20 Outcomes of our Program: How are we doing? Statistics drawn from patients entered into our new database 25 patients entered into our new database Up to date Influenza immunization: 24/25 (96%) Up to date pneumococcal immunization: 23/25 (92%) Action Plan: 24/25 (92%) Updated spirometry: 16/25 (64%) Respiratory Education 25/25 (100%) Attended the OLA Maintenance Exercise program 12/25 (48%)
21 Outcomes of our Program: Smoking Cessation Total # patients: 53 Non-smokers at time of referral to COPD clinic: 41 (77%) Number of smokers at time of referral: 12 (23%) Offer of help to quit smoking: 12/12 (100%) Accepted referral to OMSC: 5/12 (42%) Declined referral to OMSC: 7/12 (58%)
22 Arnprior Regional Health Statistics for COPD April 1, 2012 to March 31, 2013 April 1, 2013 to March 31, 2014 April 1, 2014 to Sept. 30, Cases Avg. LOS ELOS
23 Future Planning: Dealing with the challenges Statistics : what do we absolutely need? Ministry requirements Program evaluation requirements Capacity to follow up with our patients on an annual basis looking at the logistics of staffing Need to improve our routine spirometry rates Access to quality spirometry an issue Exercise maintenance program: do we have the capacity to expand? Hospital link Improve discharge notification & referrals Referral patterns low referral rates from physicians on our team
24 Question/Discussion Period What is your experience with starting a COPD program at your FHT? What were the barriers/challenges that you encountered & how did you overcome them?
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