Regional COPD Pre-printed
Orders & Discharge Plan
Standardizing Improved COPD
Management Across the Lower
Mainland
Learning Objectives
 COPD prevalence, admission rates, and
economic burden in Canada & BC
 What COPD management looked like in 2009
 How to improve COPD care in hospital
 Factors affecting QOL, morbidity, and
mortality of COPD patients
 How to better link your patient to community
support programs and services
 How to use the Regional COPD Care Planning
& Discharge Plan
COPD prevalence, admission
rates, and economic burden
in US, Canada & BC
COPD facts:
 4th leading cause of death in Canada (2004)
 COPD prevalence is on the rise, especially in
women
 Estimated 1.5 million Canadians have been
diagnosed, another 1.6 million report symptoms
but have not been tested (spirometry)
 COPD exacerbations (aka “Lung Attacks”) have
the same consequences as a heart attack in
terms of the patient’s quality of life, future
hospital admissions, and mortality
Trends in age-standardized death rates
(Percent change between 1970 and 2002)
100%
90%
COPD
[#4]
80%
70%
60%
50%
40%
30%
20%
10%
COPD: greatest increase
in death rate amongst
the 6 leading causes
+3.2%
0
-10%
- 63.1%
- 52.1% - 41.0%
-32.0%
-2.7%
Cancer
-20%
+102.8
%
Diabetes
[#6]
[#2]
-30%
-40%
All causes
Accidents
-50%
-60%
Stroke
Heart
disease
[#3]
[#1]
[#5]
Adapted from Jamal A, et al. JAMA 2005; 294:1255-1259
Adapted from Jamal A, et al. JAMA 2005; 294:1255-1259
The Human & Economic Burden of COPD
COPD now accounts for the highest rate of hospital admissions among major
chronic illnesses in Canada (CIHI – 2008) – CTS report Feb 2010
Feb 2010 CTS Report (con’t)
 Hospital admissions for COPD average 10-day
LOS at cost of $10,000 per stay
 Total annual cost estimated at $1.5 billion per
year
 COPD is frequently not diagnosed, even when
patients are hospitalized for an exacerbation –
COPD can contribute to other issues (ex. CHF,
pneumonia)
COPD Management in the
Lower mainland, 2007 – 2009
Vancouver Snapshot:
 Study comparing 3 hospitals in Vancouver
(Apr 2001 – Dec 2002)
 Variations in care
 59% patients received oral or parenteral
corticosteroids in first 24 hours
 Variable re-admission rates
 38% of patients had at least one subsequent
hospital readmission (within 5 (+/-4.08)
month period)
Can Respir J Vol 16 No 4 July/August
Existing Barriers Identified (2009)
 PPO existing at most sites but all differed from each
other (no standard of care)
 No COPD discharge plan
 Low awareness – both physicians and staff
 Clinical Pathway resulted in redundant charting
Improving In-Hospital Care
of the COPD Patient
Goals for COPD In-hospital Management
 Reduce Length of Stay (LOS)
 Reduce Readmission rates
 Minimize impact of exacerbation on overall
disease progression
 Improve overall management of AECOPD
according to best practice guidelines (CTS,
GOLD)
 Create links between acute and primary care
 Create links with community programs and
follow-up post discharge
 Improve patient quality of life (QOL)
In-Hospital Documents
 Regional documents assure streamlined care
according to evidence based best practice
guidelines
1. COPD Exacerbation Admission Order set
(PPO) for admitted patients
3. COPD Discharge Plan
 Documents tie into one another and attempt
to fill gaps in care
Links to Programs & Support
 Smoking cessation:




QuitNow program
Links to COPD Discharge
Plan
Referral to Spirometry and
COPD Management
Services (through COPD
Discharge Plan)
List of patient education
materials on back of care
planning pathway
Links to GP
Factors affecting Morbidity,
Mortality, and Quality of Life
in COPD Patients
Co-morbidities Associated with COPD












Ischemic Heart Disease
Congestive Heart Failure
Arrhythmias
Pulmonary Hypertention
Lung Cancer
Osteoporosis and Fractures
Skeletal Muscle Dysfunction
Cachexia and Malnutrition
Glaucoma and Cataracts
Depression
Anxiety and Panic Disorders
Metabolic Disorders
Can Respr J 2008;15(Suppl A):1A-8A
Predictors of Survival (BODE)




BMI
Degree of Obstruction
Dyspnea (MRC Scale)
Exercise capacity
Other risk factors for increase mortality:
 Presence of co-morbidities
 History of repeat ED or hospital admission
 Age
 Low PaO2
Improving Predictors of Survival
 BMI: Diet
 Obstruction: Phamacotherapy
 Dyspnea: Pulmonary Rehab, Self Management Education
 Exercise capacity: Mobility, Pulmonary Rehab
 Smoking cessation support
 Co-morbidities: reduce risk of developing, management of
existing co-morbidities
 Repeat admission: Adequate follow up and referral post
discharge
 Age: no cure!
 Low PaO2: Home O2 for those who qualify
COPD Plan of Care:
Indicators for improving LOS
 Oxygenation
 State of inflammation/infection (measured by
temperature, sputum production)
 Dyspnea (compared to patient baseline)
 Activities of Daily Living/Mobility (compared to
patient baseline)
 Diet
 Check box if indicator is met, or an “X” if
indicator does not apply to the patient. Initial and
date only if you sign off on the indicator
NOTE:
 It’s important to remember to compare patient
symptoms and activity tolerance to what was
normal for them (baseline) prior to exacerbation
 A patient’s baseline shortness of breath,
mobility, diet tolerance, and sputum production
will be unique in each patient
Medical Research Council (MRC)
Dyspnea Scale
Pre-Discharge Phase: Teaching
 Teaching from the acute and transition phases
should be reviewed and re-enforced
 Introduce exercise and strength building
exercises
 Inhaler technique should be reviewed and
checked
 Smoking cessation strategies and postdischarge plan should be reviewed
 Review the COPD Discharge Plan with the patient
(copy will go with the patient)
Pre-Discharge Phase:
Discharge Planning
 Complete the COPD Discharge Plan & fax COPD to





Spirometry clinic/lab and COPD community program if
referred
Home O2 assessment if you suspect they may need it
Patient vaccinations should be up to date (Influenza and
pneumoccocal)
Links to follow up support in the community are made at
this time
Notify the GP of discharge (fax/send discharge summary
and COPD Discharge Plan)
Fax QuitNow referral (if applicable)
COPD Discharge Plan
 Guides patient with post-discharge directions
 Improves gap between acute and primary care
 Serves as a referral to spirometry, pulmonary
rehab, and/or COPD Clinic
 Physician to fill out and sign page 1
 If referred for spirometry or rehab, tick the
location referred to on page 2
 Fax as per booking directions
 Copy of all 3 pages will go home with the
patient, original stays in patient chart
COPD Pre-Printed Order (PPO)
 A Regional COPD Exacerbation Admission PPO
has been approved across 3 health Authorities
(VCH, PHC, and FHA)
 There are areas of the PPO that can be modified
as per site policy or resources
 PPO should be initiated in the ED when the
patient is admitted.
 The PPO ties into the Care Planning Pathway –
part of admission instructions is to initiate
clinical pathway. Which we are not trialing at this
time.
Discussion:
 Where will these documents be kept on your ward?
 Who (if anyone) will take ownership of ensuring
these documents are completed?
 What tools are available to learn more about COPD
and it’s management?
 Who can be called if there are questions?