Waterloo Wellington Rehabilitative Care System Integrated Care Pathway for COPD Stream of Care (short version)

Transcription

1 Waterloo Wellington Rehabilitative Care System Integrated Care Pathway for COPD Stream of Care (short version) Care Setting ACUTE Activity Confirmation of COPD diagnoses: If time and the patient s condition does not allow for spirometry testing prior to discharge, arrange for testing to be completed as soon as possible after discharge Improve Bronchopulmonary hygiene: Referral for physical therapy Active cycle of breathing Controlled cough Secretion clearing devices Encourage mobility Vibes and percussions are contraindicated Smoking Cessation: Counsel re benefits of quitting Nicotine Replacement Therapies Referral to smokers help line Identify barriers that would impact self-management: Depression, anxiety Sleep disorders, Cognition Should barriers be identified, referrals are made to the appropriate specialty. Improved knowledge and skill to self manage their disease: Development and use of a COPD Action Plan Disease self-management should include components of the following: 1. Smoking cessation counseling 2. Effective inhaler techniques 3. Early recognition and treatment of acute exacerbations 4. Identification of community resources and 5. End of life care issues Increased activity tolerance: Maintain an active lifestyle. Mobility, strengthening (upper body and lower body), endurance Early ambulation - Promote independence with frequent short walks. Document baseline distance, and frequency. Progress patient by increasing frequency and distance walked with shorter breaks in between walks Ensure adequate oxygen needs are met to participate in an activity program: Assess for continuous oxygen (15 hr./day or more to achieve a saturation of 90% or greater) offered to clients with stable COPD and sever hypoxemia, or when PaO 2 is less the 60 mmhg in the presence of bilateral ankle edema, corpulmonale or hematocrit of greater than 56%. Medical directives may be required (goal: maintain an SpO 2 sats >88) 1

2 IN-PATIENT REHAB Early supported discharge as determined by the needs of the patient: Arrangements are made for a follow up appointment with a health care provider post discharge. The dates/times are included in the discharge information. 1. Communication with the patient s primary care physician or other care providers to promote continuity. 2. Patient centered discharge instructions. And, 3. Potentially, a transition coach to ensure seamless delivery of care. Transition of care to an inpatient rehab facility if one or more of the following exists: 1. Frequent readmission or frequent ER visits 2. Rehab needs cannot be met in an outpatient rehab facility or through home care services Transition of care to CCAC services could include: 1. Patients with moderate, severe and very severe COPD participate in an in-home pulmonary rehabilitation program 2. Occupational therapy for energy conservation, assessment of home or living situation. 3. Physical Therapy for Bronchopulmonary hygiene, activity program. Transition to outpatient pulmonary rehab Return home to community/independent living must include at least one of the following 1. Follow up with a respirologist, 2. Nurse Practitioner, 3. Primary Care Provider and/or 4. a COPD clinic. Patient demonstrates confidence and a sense of hope for the future: Assess motivational level, emotional distress, cognitive impairment, Failure to detect and address the presence of significant psychosocial pathology may result in poor prognosis. Refer to appropriate health care provider for further evaluation and counseling. Confirmation of COPD diagnoses: Confirm spirometry testing has been completed if not make arrangements for the test. Improve Bronchopulmonary hygiene: Referral for physical therapy Bronchopulmonary hygiene techniques are reviewed -patient demonstrates ability to self-manage Active cycle of breathing Controlled cough Secretion clearing devices Encourage mobility Vibes and percussions are contraindicated Smoking Cessation: Counsel re benefits of quitting Nicotine Replacement Therapies Referral to smokers help line Improved knowledge and skill to self manage their disease: Develop the Action Plan if none exists Review and provide education in regards to the plan with a focus on specific interventions for disease specific management. The plan should include components of the following: 1. Smoking cessation 2. Effective inhaler technique 2

3 IN-HOMECARE 3. Early recognition and treatment of acute exacerbations 4. Identify community resources 5. Address any end-of-life care issues Ensure adequate oxygen needs are met to participate in an activity program: Assess for continuous oxygen Increase activity tolerance: Encourage patient to maintain an active lifestyle Define an exercise program based on mobility, strengthening (upper body and lower body), and endurance Early ambulation - Promote independence with frequent short walks. Progress patient by increasing frequency and distance walked with shorter breaks in between walks. The patient demonstrates confidence and a sense of hope for the future: Psychosocial If significant psychosocial problems are identified the patient is referred for further evaluation and appropriate counseling clinical social worker, psychiatrist, psychologist, palliative care specialist, family MD. Supported discharge as determined by the needs of the patient: Transition of care home with CCAC supports Transition to outpatient pulmonary rehab program Transition of care home to independent living/community with follow up with a health cares provider post discharge. Improved knowledge or skills to self manage their disease: Assess patients understanding and compliance with self-management principles. Review of the COPD Action Plan. Early recognition and self treatment of COPD exacerbation Self management 1. Medications 2. Breathing strategies (pursed-lip breathing and active expiration) 3. Secretion clearance (coughing, use of medications, postural drainage, percussion, and forced expiration) Use of medications, postural drainage, percussion, and forced expiration. Risk behavior modification smoking cessation, proper nutrition, activities of daily living should be reviewed and assist the patient in defining strategies to promote healthy behaviors. Identification of community resources to support the self-management Action Plan. The patient demonstrates confidence and a sense of hope for the future: Psychosocial If significant psychosocial problems are identified the patient is referred for further evaluation and appropriate counseling clinical social worker, psychiatrist, psychologist, palliative care specialist, family MD. Ensure oxygen needs are met to participate in an ADLs/IADLs and physical activity program. Timely access to Respiratory Therapy for re/assessment of oxygen. Improved independence in home environment: Occupational Therapy referral Basic ADL s such s dressing, bathing, walking, eating Household chores 3

4 OUT-PATIENT REHAB Leisure activities Sexual activity Improved physical fitness: Examples of an exercise program is outlined, but is not limited to the following: Stationary bike x 15 mins. As RPE and oxygen needs stabilize workloads on the bike may be increased, decrease the duration and number of rest stops. Ambulation x 15 minutes (use of aid i.e. rollator if indicated). Emphasize paced breathing with walking. Progress to increase the amount of time walked; decrease the number and length of rest stops. Strength training using elastic bands, dumbbells, cuff weights for arms and legs, 10 repetitions each. Instruct in paced breathing with exercise. Progress to 20 repetitions, increase resistance, and/or introduce strengthening on weight training machines. As strength improves introduce diaphragmatic, pursed lip and paced breathing during exercise. Stretching for hamstrings, calf muscles and upper body. Supported discharge as determined by the needs of the patient: Transition of care to an outpatient pulmonary rehab program (within 1 month) Transition of care to independent living - home based exercise program, and/or a community based activity program. Patient has timely access to an outpatient pulmonary rehab program: COPD patients should participate inpulmonary rehab within one month following an AECOPD Improved knowledge and skill to self manage their disease: Review/development of the COPD Action Plan. Early recognition and self treatment of COPD exacerbation Self management 1. Medications 2. Breathing strategies (pursed-lip breathing and active expiration) 3. Secretion clearance (coughing, use of medications, postural drainage, percussion, and forced expiration) Risk behavior modification smoking cessation, proper nutrition, activities of daily living. The patient demonstrates confidence and a sense of hope for the future: Psychosocial If significant psychosocial problems are identified the patient is referred for further evaluation and appropriate counseling clinical social worker, psychiatrist, psychologist, palliative care specialist, family MD. Ensure adequate oxygen needs are met to participate in an activity program: Assess for continuous oxygen (15 hr./day or more to achieve a saturation of 90% or greater) offered to clients with stable COPD and severe hypoxemia, or when Pa0 2 is less than 60 mmhg in the presence of bilateral ankle oedema, corpulmonale or hematocrit of greater than 56%. Medical Directives may be required to facilitate appropriate titration of oxygen therapy as per the needs of the patient during an activity program. (Goal: maintain an SpO 2 sats>88) Improved physical fitness: Determine an individualized exercise plan. Ideally a patient should participate in a supervised exercise program at least 3 times per week, when this is not possible, an in home program with specific guidelines and instructions may be an acceptable alternative. Examples of an exercise program is outlined, but is not limited to the following: 4

5 COMMUNITY Stationary bike x 15 mins. As RPE and oxygen needs stabilize workloads on the bike may be increased, decrease the duration and number of rest stops. Ambulation x 15 minutes (use of aid i.e. rollator if indicated). Emphasize paced breathing with walking. Progress to increase the amount of time walked; decrease the number and length of rest stops. Strength training using elastic bands, dumbbells, cuff weights for arms and legs, 10 repetitions each. Instruct in paced breathing with exercise. Progress to 20 repetitions, increase resistance, and/or introduce strengthening on weight training machines. As strength improves introduce diaphragmatic, pursed lip and paced breathing during exercise. Stretching for hamstrings, calf muscles and upper body. Progression is vital in improving the patient s functional capacity and should follow the FITT principles. F=Frequency I=Intensity T=Time T=Type Smoking Cessation: Counsel re benefits of quitting Nicotine Replacement Therapies Referral to smokers help line Supported discharge as determined by the needs of the patient: Transition of care to independent living - home based exercise program, and/or a community based activity program. Link with community resources for activity, psychosocial support, smoking cessation etc., if required. Follow up appointment with a respirologist, Nurse Practitioner, Primary Care provider, and/or COPD clinic. Increased qualities of life, increased motivation with ability and action to self manage their disease: Is the patient aware of the early signs of a COPD exacerbation, and the strategies to manage an exacerbation? Can the patient demonstrate self management strategies? 1. Medication management 2. Breathing strategies (pursed-lip breathing and active expiration) 3. Secretion clearance (coughing, use of medications, postural drainage, percussion, and forced expiration) Reinforce links with resources which support the self-management Action Plan: 1. Smoking cessation strategies 2. Activity 3. Nutrition Support system navigation for prevention o o Vaccinations for influenza, pneumococcal, etc. Inquire whether the patient/client has a follow-up with a Respirologist, Nurse Practitioner, or COPD clinic. 5

6 The patient demonstrates confidence and a sense of hope for the future: Psychosocial If significant psychosocial problems are identified the patient is referred for further evaluation and appropriate counseling clinical social worker, psychiatrist, psychologist, palliative care specialist, family MD. 6