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Innovative Care for the COPD Patient in a Rural Community Hospital

Submitted by:  E. Annette Stuart, RRT, CRE, CTE, Lennox & Addington County General Hospital

BREATHE….it sounds so simple.  In the respiratory profession, we know that the mechanics and the execution of breathing is a big challenge for our patients with Chronic Obstructive Pulmonary Disease (COPD).  With increasing focus on COPD and the associated costs of managing this disease in health care, the South East Local Health Integration Network (SELHIN) organized a regional respiratory focus group comprised of community agencies, patient advocate representatives, hospital staff and physicians to address the gaps associated with the care of a COPD patient.  This “think tank” aimed to identify ways to reduce hospital readmission rates, frequent emergency room (ER) visits and the incidence of respiratory exacerbations associated with COPD.  Using the lessons learned at the regional level, the Lennox & Addington County General Hospital (LACGH) in Napanee implemented its own innovative program for COPD patients in the local community.  As a result, our program goals have been met while helping patients dealing with COPD achieve improved quality of life, greater independence and an increase in self-confidence.  I would like to introduce our BREATHE program.

In an effort to model the excellent work already done in Canada, such as that of Dr. Graeme Rocker in Halifax with the INSPIRED project, we examined our hospital’s discharge strategy for COPD patients exhibiting a level of 4 or 5 on the Medical Research Council (MRC) dyspnea scale and identified an opportunity to improve the inpatient education and discharge process.  We developed a Pre-Discharge COPD Order Set to address care delivery process issues in areas such as spirometry, medication optimization and inhaler technique, COPD action plans, weight management and exercise, smoking cessation, support for difficult emotions related to chronic disease, advanced care planning and ongoing support after discharge from hospital.   Each patient receives a checklist to ensure all aspects related to COPD management are addressed prior to discharge.  A drop in Breathe Clinic was established for those instances where patients were unable to receive all the necessary information prior to discharge due to short admission times or even the patient’s ability to cope with influx of information.  The Breathe Clinic is staffed by a Registered Respiratory Therapist (RRT) and a Nurse Practitioner (NP) on a regular basis and an Internal Medicine Specialist on an as needed basis.

Pulmonary rehabilitation was another challenge that needed to be addressed for all COPD patients as the two available programs in the area had extensive wait lists.  The Quality Based Procedures for COPD, as set out by Health Quality Ontario, indicates that access to an exercise program within 4-6 weeks of discharge from hospital due to an acute exacerbation of COPD is one of the key components to ensure respiratory health success.  To pool our resources, we aligned with our Cardiac Rehabilitation program since many cardiac patients have co-morbid respiratory disease and assimilated COPD patients into the existing exercise program to enable our hospital to offer Respiratory Rehabilitation. With that need addressed, the last piece of the puzzle required for a successful comprehensive program was access to care after discharge through community outreach. Although a BREATHE Help Line existed, the benefit of a physical visit to assess the patient could not be fully achieved within the confines of a phone call.

In our geographical area many patients live in remote communities and are isolated due to limited access to transportation, financial constraints or minimal family support.  For various reasons, many of our patients are unable to accommodate frequent travel to hospital or clinic follow-up visits.  Even those patients that are not geographically isolated may have limited access to services simply based on the extreme challenges associated with shortness of breath.

Our Chief of Staff at LACGH found a possible solution for this problem when she attended the e-Health conference in 2017, where she connected with a virtual health program provider.  The possibility of doing follow-up clinic visits and monitoring through technology that could break down the barrier of access for many of our patients was realized.  LACGH invested in the virtual health technology and began using it with discharged COPD patients in the BREATHE program in January 2018. The virtual health program allows us to monitor oxygen saturations, heart rate, blood pressure and weight remotely and visualize trends over time.  It also allows us to “push” information to patients through reminders regarding medication adherence, signs of a lung flare-up, shortness of breath levels, and breathing techniques to name a few.  The patient is able to call the RRT or NP during regular work hours to address any questions they might have regarding management of their COPD.  No longer will the patient be required to travel to the BREATHE clinic appointments at the hospital. Clinic visits are scheduled via the virtual health program.  This provides the health-care professional a visual of how the patient is doing, their respiratory pattern, use of accessory muscles, skin colour and also opportunity of ongoing education as it provides ability to assess patient management.  We can also determine if the patient is experiencing the symptoms of an exacerbation and educate them to refer to their COPD action plan and provide guidance to access their primary care provider(PCP) for management. If the PCP is not available, the NP or Internal Medicine Specialist will provide the prescriptions necessary to manage and control the exacerbation. The other significant benefit from this virtual program is the involvement of family and caregivers.  They can participate in the virtual monitoring with their loved one and also connect with the BREATHE program team should they have concerns.  It provides a continuum in the circle of care for the patient.

Twenty-three patients have been enrolled since the inception of the BREATHE program. We have prevented 13 re-admissions to hospital by helping the patient manage their symptoms at home.  Although not all re-admissions can be prevented, we have seen a decrease in frequency from those enrolled in the program. Patients enrolled in the virtual program have saved the time and cost associated with more than 4,000 km’s in travel to attend the hospital, clinic or ER.  Typically, patients stay connected through the virtual program for about three months and once they are well established in the management of their COPD, they rely less on the program and more on their own newly developed self-management skills.  They have ongoing access to the BREATHE clinic and the BREATHE Help Line.  Patients are also regularly participating in respiratory rehabilitation or an exercise program in their community.  Patient and family feedback has been positive and has encouraged LACGH to continue with all aspects of the BREATHE program.

To improve the lives of patients living with COPD in our area we implemented 3 innovative strategies, a Pre-Discharge COPD Order Set, a combined Cardiac-Pulmonary Rehabilitation Program and a virtual health technology service to link the Breathe Clinic to the patient’s home. Ultimately, our goal was to ensure patients received the knowledge and COPD management skills to permit a reduction in our hospital readmission rate. In the end we also gained an appreciation for the benefits of creating a system where the patient feels they can control their COPD rather than being at the mercy of their symptoms, be more confident in their ability to manage their condition and enjoy an improved quality of life.

The Respiratory Health Education Interest Group (RHEIG) is a multi-disciplinary group of ORCS members who promote and advance the field of respiratory education, with a specific interest in applying theory in a practical way.