Post on 26-Mar-2016
description
COPDin Primary CareCOPD in Primary Careseeing the opportunity
Context
More long term conditions, which aredisabling: COPD, Heart failure, Diabetes, …
More people, and living longer
More work outside hospitals: early dischargeschemes & reduced length of stay,alternatives to admission.
No change,and see what happens …
“The definition of insanity is doing the same thingover and over again and expecting differentresults.” Albert Einstein
Invest in more people and things: morehospitals, nurses and doctors, drugs, more …
Even if there was more money, just addingmore people and things doesn’t improveresults
Health care systems have evolved around the conceptof infectious diseases, and they perform best whenaddressing patients’ episodic and urgent concerns.
However, the acute care paradigm is no longeradequate for the changing health problems in today’sworld. Both high and low-income countries spendbillions of dollars on unnecessary hospital admissions,expensive technologies, and the collection of uselessclinical information.
As long as the acute care model dominates health caresystems, health care expenditure will continue toescalate, but improvements in populations’ healthstatus will not. ”
WHO, Innovative care for chronic conditions, 2002
“
Oh, nice! Questions and answers!
larger than the moon
4some meetings …
3some meetings …
Not important
2Planning & prevention,
education &relationship building,recreation, proactive
1Crisis, deadlines, …,
putting out fires,reactive, stress, costly
Important
Not urgentUrgent
Question 1 (easy): Which two are not so important?Question 2: Which square is the good one?Question 3: Which square is the bad one?
* to change the nature of
Shifting stuff from square 1 to square 2
from acute care → Preventionfrom hospital → Community & Primary care
Working differently, and better together
transforming* the services we offerdifferent, not more
“a shift from seeing a world that is made ofthings to seeing a world that’s open and
primarily made up of relationships”
P. Senge & J. Jaworski
Crisis - maybeOpportunity - definitely
to improve the quality of servicesand the experience for patients
to develop alternatives in the community andprimary care, reducing admissions
affordable, without spending more money (butspending it differently)
PBC’s agenda:– Empowering frontline staff
– Empowering patients
– Integrated Care Pathways for COPD, Heartfailure & Diabetes
– Single point of contact for Community Services
– Primary & Community Care Teams
– Hospital-at-home schemes– Community Hospitals
– Prevention & early intervention
– Telehealth
What is COPD?
caused by inhaled toxinschronic inflammation, irreversibly damaging
peripheral airways and alveolesairflow obstruction (reduced FEV1)which is poorly reversible, and progressivewhat it means: breathlessness & cough &
disablity & poor quality of life & early death
Smoking causesongoing inflammation:
(1) Proteases destroying small
airways: repair with scar-tissue
(2) Proteases destroying
alveoles: emphysema
(3) Mucus and cough
small airways & alveoli:irreversible damage, irreversible airflow obstruction
Prevalence
2% in Yorkshire and the HumberTrue prevalence probably 3 to 5% or more
Patients are often diagnosed late, in their fifties
* per 100,000
Mortality
5th leading cause ofdeath now
3rd leading cause ofdeath in 2030
In YH 31, vs. 25 forAMI
In YH 31, vs. 26 forEngland
Numbers are /100,000
YH = Yorkshire and the Humber
Causes &Risk factors
Smoking– active
– passive
Other inhaled toxinsSocioeconomic (manual workers), nutritional
factors, childhood infections
Diagnosis
Symptoms:• Dyspnoea• Cough / Sputum• ‘Acute bronchitis’
Risk factors:• Smoking• Occup / Envir Inhalation
SpirometryFEV1 <80% of predicted
FEV1 / FVC <0.7
Age 35+
Spirometry
Is easy, and easy to get wrong
Needs vigorous encouragementMaximal in- to maximal exspiration, 6 secNo coughs or hesitations3 measurements, 2 within 5%
Step 1: FEV1 measured / predicted
Find the measured FEV1 and divide it by the
FEV1 predictedfor this patient.
Example: FEV1 % of predicted
= FEV1 meas / FEV1 pred
= 2 litres / 4 litres = 50%
Step 2: FEV1 / FVC
Again start with the measured FEV1, but this
time divide it by the measured FVC.
Example: FEV1 / FVC (or FEV1 ratio)
= 2 litres / 3 litres
= 66% (or 0.66)
Reduced Volumes (litres)
FVC (FEV)FEV1
Step 3: FEV1 - SeverityFind a copy of the new NICE guideline and
determine the severity of airflow obstruction:
Step 4: FVC Obstruction or Restriction?
FEV1 / FVC <0.7 (or <70%) indicates COPD
A reduced FEV1 in the presence of a normal orincreased Vital Capacity suggests COPD.
A reduced Vital Capacity increases this ratio(>0.7) and suggests a restrictive disorder.
Step 5: FEV1-Reversibility, ? Asthma
Airflow obstruction (FEV1-reduction) in COPD isnot or poorly reversible, but in Asthma it is.
If history makes you think of Asthma, then also doa post-bronchodilator FEV1, after 4 puffsSalbutamol via spacer.
If FEV1 increases by 400ml (0.4l) or more afterSalbutamol, the patient has reversible airflowobstruction and probably asthma.
Consider asthma if: early onset, atopy (hay fever,eczema), wheezing and coughing, symptoms areepisodic, varying from day to day, at night andearly mornings, or exercise-induced
To confirm asthma do:
• Peak flow diary: diurnal or exercise-relatedchanges, improvement with Salbutamol
• Post-bronchodilator spirometry• Post-10days-30mg-Prednisolone spirometry
FEV1: reduction indicates COPD or (ifreversible) Asthma
FVC (FEV): reduction indicates restriction
Symptoms
Which is the least relevant typical for COPDA WheezeB BreathlessnessC CoughD Sputum
Severity
A VCB FVCC FEV1
D PEF
DD Asthma
A FVCB Reversibility of FVCC Reversibility of FEV1
D PEF
DD Restriction
A FVCB Reversibility of FVCC Reversibility of FEV1
D PEF
Moderate COPD
A FEV1 50-80%B FEV1 ratio <0.7C FEV1 ratio 30-50%D FEV1 30-50%
Severe COPD
A FEV1 50-80%B FEV1 ratio <0.7C FEV1 ratio 30-50%D FEV1 30-50%
Breathlessness / Dyspnoea
The main COPD symptom, next to coughThe disabling factor of COPD, next to
exacerbations, affects quality of life, stopspeople going out, or on holidays
Causes panic, which makes people dial 999Improves with Bronchodilators & Pulmonary
RehabilitationGraded with MRC Dyspnoea score
Too breathless to leave the house, or breathlesswhen dressing or undressing
5
Stops for a breath after walking about 100m ora few minutes on a level
4
Walks slower than most people on a level, stopsafter a mile or 15min walking at own pace
3
Short of breath when hurrying on level, orwalking up a slight hill
2
Not troubled by breathlessness except onstrenuous exertion
1
MRC Breathlessness Scale
Mr Smith still picks up a newspaper at thenewsagents every morning, which is just 200or 300 metres down the road, level ground.He has to take his time and stops severaltimes to get his breath.
His MRC dyspnoea score is …
Mrs Miller enjoys a long walk on weekends.She can walk for miles, although when shewalks up a slight hill or walks a bit faster, shehas to stop for a breath from time to time.
Her MRC dyspnoea score is …
Mrs Green goes walking with Mrs Smith, butfinds it a bit frustrating now as she has towalk slower and has to stop for a breathevery ten minutes or so.
Her MRC dyspnoea score is …
Breathlessness, Air trapping & Bronchodilators
COPD patients have pulmonary hyperinflation (air trapping, red) and smaller inspiratory capacity(blue). Hyperinflation worsens with exercise which reduces exercise tolerance (MRC score).
Inhaled bronchodilators improve dynamic hyperinflation, as well as hyperinflation at rest,which improves dyspnoea, reduces the work of breathing and increases exercise tolerance.
Breathlessnes
Anxiety &
Pulmonary Rehabilitation
Empowering
Here’s a little story …
The doctor has his annual appraisal. During themeeting he is given his patient-survey results, and istold that he needs to increase his appointmentlength by a 3 min to address the problem.
- yeah!
Next year, he hasn’t changed a bit. His appraiser hasan idea. The doctor is given some time to mullover the results beforehand, and is asked whatchange he regards as important and achievable …
He now feels so empowerd he starts to empower hispatients, asking them what affects them most,exploring with them …
He even starts to empower nurses and otherfrontline staff, asking them what changes couldmake a real difference to the service …
Elements of empowerment
Provide information, education
Encourage people to take control, make own decisions
or anybody else
“Do you agree or disagreethat the majority of your team possess far more talent,intelligence, capability and creativity
than their present jobs require, or even allow them to use?”
S. Covey
patients & service users(patient perspective)
practitioners & partners(social movement)
managers & leaders(transformational leadership)
Stable COPD
Improve breathlessness with Bronchodilators: short-,long-acting, combined (Salbutamol, Terbutaline,Ipratropium; Salmeterol, Fenoterol, Tiotropium)
Improve breathlessness, fitness, quality of life with regularExercise and Pulmonary rehabilitation
Empower patients, support self managementFor productive cough consider Carbocisteine
No treatment can slow down the decline in FEV1 - onlySmoking cessation can !
Cont.
No treatment can slow downthe decline in FEV1 …
… only early diagnosis & smokingcessation can
Why COPD deaths are still increasing
Diagnose & stop smoking early to slowthe decline of FEV1
COPD exacerbations
Change: sustained worsening from what isnormal for patient
Increase in sputum and darker colour suggestinfection → antibiotics
Increase in breathlessness and cough suggestinflammation and bronchospasm →bronchodilators and steroids
Caused by bacteria, viruses, both, or pollutants
Self-management / GP Visit:– Increase dose and frequency of Bronchodilators
(spacer/neb) +/- add oral Prednisolone 30-40mg
– Add oral Antibiotics for purulent sputum
Hospital-at-home:Hospital admission: if marked dyspnoea,
cyanosis, confusion, high fever, new oedema
Prednisolone30-40mg for 7-14dImproves dyspnoeaand ABGsReduces relapse
Amoxicillin, a Macrolide, Tet or DoxyHalf exacerbations are bacterial (half not)Cochrane: antibiotics reduce deaths by 75% and treatment
failure by 50% in moderate or severe (not in mild)exacerbations
Exacerbation Self Management Plan
Cough and Sputumincrease and
colour dark / green
Start standby course ofAntibiotics
Breathlessnessand Cough
worse than usual
Breathlessnessand Cough
much worse than usual,or worse for over 2 days
Increase your Relieverdose and use it more
often
Increase your Relieverand start standbycourse of Steroid
tablets
Very unwell: If you arereally struggling to
breathe and speak, havechest pain, high fever, orare becoming agitated,
confused or drowsy
Emergency callfor doctor (surgerynumber at any time)
or if necessarycall an ambulance
(999)
Pulse Oximetry (SpO2)
Exacerbation or LRTI: >95% in air is reassuring;if <90% consider admission
?PE: if SpO2 drops after going up flight of stairs,increases chance it is a PE
Spot check models areViamed MD300-D for £70Nonin 9500 for £160Nonin 9550 for £220at bmamedicalsupplies
After exacerbations
Review within 6 weeks:Self management plan (SMP), consider stand-by
boxes of antibiotics and steroids
Optimise management: all Bronchodilators, ICS,mucolytics, theophylline reduce exacerb.
Refer for Pulmonary rehabilitation (PR) if MRC3 or more
Consider for MDT and Telehealth
Consider Inhaled corticosteroids (ICS)
If recurrent exacerbations & FEV1 <50%They improve FEV1 and health status, and reduce
exacerbations by 25%Slightly increased risk of pneunomia
Use high dose & combination with bronchodilatorSeretide Accuhaler 500mcg BDSymbicort Turbohaler 400mcg BDSeretide Evohaler 250mcg
with spacer 2 puffs BD
Acute COPD admissions to Scarborough Hospital 2009/10:• Reduction in admissions compared to predictions• Encouraging results for primary care and community basedinterventions: Local enhanced service, Pulmonary rehabilitation,Training in COPD / Spirometry, Specialist nurse etc.
COPD LES
To improve the diagnosis and management of peopleespecially with more severe COPD, to reduceadmissions
1. Offer spirometry from 35 years onwards withsymptoms and risk factors
2. Code as mild, moderate or severe airflowobstruction based on FEV1.
3. More frequent and structured reviews for thosewith moderate or severe obstruction.
4. All COPD patients: Self Management Plan (SMP)e.g. “COPD and me”
5. Refer to Pulmonary Rehabilitation those whosuffer from breathlessness i.e. MRC score 3 ormore
Why finding alternatives to admissionis such a good thing
Hospitals are not patients’ preferred place of care
Risk of delirium, confusion, nosocomial infections,pressure sores, falls, …
Loss of independence, ‘worse on discharge’, …Poor discharge management causing re-admissions
Hospital care is terribly expensive
And maybe we can prevent the crisis, the patientgetting so unwell in the first place …
Primary & CommunityCare Teams
Shifting stuff from square 1 to 2
Preventing the crisis, and planning for it
Works like the Gold Standards Framework (GSF)
For older and vulnerable people on a practice’s list
Regular meetings of primary care and community staff- GP, PN, Case manager, …
Encourages Community and Primary care workingcloser together
Applying the GSF principles– Identify vulnerable & older patients
– Ask them how they are affected, record theirpreferences, empowerment approach
– Assess management along relevant CarePathway, and do what’s missing
– Plan, what to do if things get worse (COPDexacerbation) and make sure SMP, contacts etcare in place
Estimating the risk of admission in COPD• Previous admissions
• Worsening airflow obstruction (FEV1)
• Worsening breathlessness (MRC score)
• Low BMI
• Increasing age
• Social factors
Hospital-at-home
“ We need to get the skillmix right. “
Work is being shifted into the community. Do theyhave the capacity? They will need more staff, andempowered staff.
Telehealth
Helps clinicians with relevant measurements,does not replace clinician
Informs and reassures patientsUsing the tool markedly reduces admissions,
more phonecalls, ? visits
Tunstall “my medic”
New technology - initial scepticism
“We need assistive technology now”Say the experts - Alan Hansen, Alan Shearer, Gary Lineker, …
Technologycan be fun …
“Nantendo”
… and intuitive.
Integrated Care Pathways
Pulling all the above together
Locally agreed standards, national guidelinesIntegrate care across boundaries of primary,
secondary and community care
Make care predictable for patients and clinicians,
which helps shifting stuff from square …