1

Joan Escarrabill MDDirector of Master Plan for Respiratory Diseases

Institut d’Estudis de la SalutBarcelona

jescarrabill@gencat.cat

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

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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

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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

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Alarm malfunction

0,9% Power off

n = 300

18,6% Disconnection

5,1% Obstruction

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13 %

4 %

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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

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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

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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

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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

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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

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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

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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