1

Rehab

Management

Strategies in

SNF

REDUCING HOSPITAL

READMISSIONS WITH

COPD

LISA ALEXANDER, PT, DPT, CCI, GCS

RHONDA SCHNABL, PT, DPT, CCI, GCS

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• Allied Health Education and the presenter of this

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views and opinions of the presenter.

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information contained in this presentation.

INTRODUCTIONS

2

E d u cat io n

Bachelor of Science in Education

The U n i ve rsity o f Kansas - Lawr ence , Kansas - 1 994

Bachelor of Science with Honours in Physiotherap y

The R o b ert G ord on U n ive rsit y - A be rd een, S c otland - 1 9 98

Doctor of Physical Therapy with Distincti on

No r t he rn A r izona U n iver sity - F l agsta ff, A r izo na - 2 0 08

Cert if ica t io ns

Credentia l ed Clinical Instructor

A me r i c an P hysi cal The rapy A sso cia tion, 2 0 08, 2 01 5

Board Certifi ed Clinical Specialis t in Geriatri c Physical Therapy

A me r i c an Board o f P hysica l Ther apy S p ecia lists , 2 016

Cu rren t E m p lo ym ent

Director of Rehab for a high-volum e SNF in Western Arizona.

Has worked in the SNF setting since 2007 as a director, supervisin g therapist, or evaluatin g therapist .

Clin ica l Fo cu s

Health policy and administrat i on , physical therapy for cogniti vel y impaired individuals, and quality

assurance.

Academic Appo in tments

Associate and Clinical Faculty for Mohave Community College Physical Therapist Assistant Program.

Clinical Faculty for The University of Missouri Doctor of Physical Therapy Program.

Clinical Faculty for Midwestern Universi ty Doctor of Physical Therapy Program.

Clinical Faculty for University of Findlay Doctor of Physical Therapy Program.

Profess i on al Advisory Committee Member for Mohave Community College Physical Therapist Assistant

Program.

LISA ALEXANDER, PT, DPT, CCI, GCS

E d u cat io n Bachelor of Science in Health Promoti on and Wellness

U n i v er sity o f Wi sc onsin - S te vens P o in t, S teve ns P o int, Wi sc onsi n - 1 98 9

Master of Education in Exercise Science

U n i v er sity o f G e orgia - A t hens, G eor gia – 1 9 91

Master of Physical Therapy

M e d i ca l C olle ge o f G eo rgia - A u gusta , G eor gia – 1 9 98

Doctor of Physical Therapy

A . T . S ti l l U n ivers ity - M e sa, A r izona – 2 012

Cert if ica t io ns Credentia l ed Clinical Instructor

A me r i c an P hysi cal The rapy A sso cia tion, 2 0 08

Board Certifi ed Clinical Specialis t in Geriatri c Physical Therapy

A me r i c an Board o f P hysica l Ther apy S p ecia lists , 2 016

Cu rren t E m p lo ym ent Clinical Supervisor for a high-volu m e SNF in Western Arizona.

Clin ica l Fo cu s Staff and program developm en t for patients with cardiac and pulmonary dysfuncti on

Academic Appo in tments Adjunct Faculty for Brenau Universi ty Doctor of Physical Therapy Program.

Clinical Faculty for Mohave Community College Physical Therapist Assistan t Program.

Clinical Faculty for The University of Missouri Doctor of Physical Therapy Program.

Clinical Faculty for Midwestern Universi ty Doctor of Physical Therapy Program .

Clinical Faculty for University of Findlay Doctor of Physical Therapy Program.

Profess i on al Advisory Committee Member for Mohave Community College Physical Therapist Assistant Program.

RHONDA SCHNABL, PT, DPT, CCI, GCS

Discuss the pathology and stages of COPD.

Stratify SNF residents based on level of

function, and identify treatment strategies for

these patients.

Identify the clinimetric properties of selected

outcome measures.

Discuss selected case studies.

OBJECTIVES

3

Background and Anatomy and Physiology Review

Pathology and Stages of COPD

Patient Stratification and Treatment Strategies

Clinimetric Properties of Selected Outcome

Measures

COPD Education Series

Case Studies

Questions – throughout and at end

AGENDA

BACKGROUND

AND REVIEW

HRRP requires Centers for Medicare and

Medicaid Services (CMS) to reduce payments

to hospitals within 30 days of discharge for

certain conditions.

“What Every Health Care Provider Should

Know About Health Care Reform” webinar by

Elizabeth Koyle.

HOSPITAL READMISSION REDUCTION PROGRAM

(HRRP)

4

In 2008, COPD was one of the top 20 most

expensive conditions treated in hospitals.

(NQMC, 2015)

In 2009, the 30-day readmission rate was

22.6%, which accounted for 4% of all 30-day

readmissions. (Jencks, et al., 2009)

In 2010, direct and indirect projected care

costs were nearly $50 billion. (NQMC, 2015)

PROBLEM

Unresolved exacerbations at time of discharge

Disjointed patient management across the

continuum of care

Inadequate patient training

Lack of follow-up care

Inadequate home equipment

Lack of Rapid Action Plan

Tiep, et al., 2015

CAUSES OF HIGH READMISSION RATE

Twenty-five percent of patients take at

least 35 days to to recover.

Shah, et al., 2015.

EXACERBATION RESOLUTION TAKES TIME

5

“… the exacerbation has a substantial negative

effect on physical activity … from which it takes

weeks to recover.”

Chawla, et al., 2014

EXACERBATION AFFECTS MORE THAN

THE LUNGS

Ambulatory-care-sensitive condition

A need for developing strategies to reduce

readmissions exists

A need to reduce subsequent costs associated with

COPD readmissions exists

In general, readmission rates in the geriatric

population can be reduced through interventions

after a hospitalization

NQMC, 2015

COPD REHOSPITALIZATION

CALL TO ACTION

Resolve exacerbations by discharge

Cross-continuum of care delivery

Adequate patient training

Follow-up by next level of care

Proper equipment

Rapid Action Plan

Tiep, et al., 2015

COPD REHOSPITALIZATION

SOLUTION

6

ANATOMY OF THE LUNGS

ANATOMY CONT’D

PHYSIOLOGY

7

PHYSIOLOGY CONT’D

PHYSIOLOGY CONT’D

PHYSIOLOGY CONT’D

8

PATHOLOGY AND

STAGES OF COPD

Chronic and progressive lung disease

Acute exacerbations (flare-ups) that occur with

increasing frequency and intensity

Chronic airflow limitation, and not fully reversible

Asthma, chronic bronchitis, emphysema, and

obstructive bronchiolitis

Almost always caused by exposure to environmental

irritants

Usually manifests at age 55 to 60 years

Physical exam and PFT.

WHAT IS COPD?

Goodman, et al.,

2012

CHRONIC BRONCHITIS

9

EMPHYSEMA

ACUTE EXACERBATION CYCLE

Acute

Exacerbation

Cycle

Tiep, et al 2015

Stage 1

Very mild COPD with FEV1 about 80% or more of normal

Stage 2

Moderate COPD with FEV1 between 50-80% of normal.

Stage 3

Severe COPD with FEV1 30-50% of normal.

Stage 4

Very severe COPD with a lower FEV1 than Stage 3, or

Those with with Stage 3 FEV1 and low blood oxygen levels.

Goldcopd.org

GOLD STAGING SYSTEM

10

PATIENT

STRATIFICATION

Systemic Effects

Weakness in BUE and BLE

Change in muscle fiber type from I to IIb

Reduced muscle mass

Decreased capillary density of muscle

Jewell and Schworm, 2015

APTA CLINICAL SUMMARY

Muscle Strength

Quadriceps

Surrogate marker for reduced generalized performance status.

Handgrip

Functional Capacity

2-minute step-in-place test

Useful alternative to 6-minute walk test

Postural Steadiness

One-leg stance

Torres-Sánchez, et al., 2017

HOSPITALIZATION LEADS TO

IMPAIRMENTS

11

Patients with COPD who were non-ambulatory within

24 hours of discharge were twice as likely to be

readmitted within 30 days compared to patients who

were able to walk 50 feet.

Nguyen, et al., 2014

AMBULATION DISTANCE IS KEY!

Functional status should be used to risk stratify patients for more intensive supportive interventions after discharge.

Current Level of Function

Level I: bed bound

Level II: able to sit

Level III: can stand

Level IV: walks less than 50 feet

Level V: walks more than 50 feet

Nguyen, et al., 2014

FUNCTIONAL STATUS TO STRATIFY

Level 1: Hemodynamically Intolerant

Level 2: Bed bound

Level 3: Chair bound

Level 4: Walks less than 50 feet

Level 5: Walks 50+ feet

ALEXANDER-SCHNABL LEVELS

12

A. SUPINE INTERVENTION1. OK - go to B

2. Not OK go - to E

B. STATIC SITTING INTERVENTION1. OK - go to C

2. Not OK go - to E

C. SEATED THER EX INTERVENTION1. OK - go to D

2. Not OK go - to E

D. STANDING INTERVENTION1. OK – proceed to level ____

2. Not OK go - to E

E. RECOVER/RECHECK1. OK – proceed to level ____

2. Not OK – Proceed with HITS Protocol

F. RECOVER / RECHECK AFTER HITS PROTOCOL1. OK – break up t reatments, promote OOB, advance as tolerated

2. Not OK – Report to appropriate provider

LEVEL 1:

HEMODYNAMICALLY INTOLERANT

Endurance training

Strength training

Inspiratory muscle training

Airway clearance techniques

Balance training

Prevention and Wellness Strategies

Jewell and Schworm, 2015

APTA CLINICAL SUMMARY

Endurance training

Strength training

Inspiratory muscle training

Airway clearance

techniques

Balance training

Prevention and Wellness

Strategies

OUTCOME MEASURES:

DEMMI

FIST

Functional reach test

KUBS

MMRC Dyspnea Scale

LEVEL 2:

BED BOUND

13

Endurance training

Strength training

Inspiratory muscle

training

Airway clearance

techniques

Balance training

Prevention and

Wellness Strategies

OUTCOME MEASURES:

DEMMI

FIST

FTSST

Functional reach test

KUBS

MMRC Dyspnea Scale

LEVEL 3:

CHAIR BOUND

Endurance training

Strength training

Inspiratory muscle

training

Airway clearance

techniques

Balance training

Prevention and

Wellness Strategies

OUTCOME MEASURES:

2-min step test

Berg

DEMMI

FTSST

MMRC Dyspnea Scale

PAVS

RPE

TUG

LEVEL 4:

WALKS LESS THAN 50 FEET

Endurance training

Strength training

Inspiratory muscle

training

Airway clearance

techniques

Balance training

Prevention and

Wellness Strategies

OUTCOME MEASURES:

6 min walk test / 2

min walk test

Berg

DEMMI

FTSST

MMRC Dyspnea Scale

PAVS

RPE

TUG

LEVEL 5:

WALKS 50+ FEET

14

CLINIMETRIC

PROPERTIES OF

SELECTED

OUTCOME

MEASURES

Has there been exposure to risk factors such as

smoking (PPY), secondhand/passive smoking, other

environmental or occupational exposures?

Is there a history of hospitalizations due to

exacerbation of the disease?

What exacerbates or relieves the symptoms?

Are co-morbidities present?

COPD-SPECIFIC HISTORY QUESTIONS

Jewell and Schworn, 2015

6MWT

Heart failure -100 ft

Obesity -91 ft

Sleep apnea -74 ft

PVD -69 ft

CHD -64 ft

Osteoporosis -45 ft

DM -43 ft

OA -36 ft

DYSPNEA

Heart failure

Obesity

Sleep apnea

Osteoporosis

Stroke

GERD

Stomach ulcers

IMPACT OF COMORBIDITIES ON COPD

Putcha, Han & Martinez, 2014

15

Lung auscultation – abnormal or adventitious breath sounds (wheezing, crackles)

Single expiratory wheeze

Multiple wheezes

Crackles, mid to late inspiratory

Crackles, early inspiratory

Cough – strength of cough and quantity/quality of secretions produced

Lung percussion – tympanic sounds due to hyperinflation of the lungs

Overall breathing pattern, including paradoxical movements of the chest/abdomen, recruitment of accessory muscles, diaphragmatic movement, and chest wall excursion/expansion.

BODY FUNCTIONS AND STRUCTURES

PULMONARY

Jewell and Schworn, 2015

PULMONARY

Modified MRC dyspnea scale

Borg Rating of Perceived Exertion

Visual Analog Scale

CARDIOVASCULAR

6 Minute Walk Test

2 Minute Walk Test**

2 Min Step Test**

MUSCULOSKELETAL

Strength and/or MMT

Sit<>stand test

Chair rise test

BODY FUNCTIONS AND STRUCTURES

Jewell and Schworn, 2015

G r ade 0 – I only get breathless with strenuous exercise.

G r ade 1 – I get shor t of breath when hurr ying on the level or walking up a slight hill.

G r ade 2 – I walk slower than people of the same age on the level because of breathlessness , or I have to stop for breath when walking on my own pace on the level.

G r ade 3 – I stop for breath af ter walking about 100 meters (328 feet) or af ter a few minutes on the level.

G r ade 4 – I am too breathless to leave the house, or I am breathless when dressing or undressing.

Health-related QoL

Assess disability

More relevant to health and psych status than FEV1.

Increased mMRCscore indicates a decline in HRQOL

Better discriminative capacity than GOLD staging and SGRQ in HRQoL

MODIFIED MEDICAL RESEARCH COUNCIL

(MMRC) DYSPNEA SCALE

Hsu, Lin, Lin, et al., 2013

16

BORG RATE OF PERCEIVED EXERTION

10 cm line

Horizontal vs vertical

Level indicated by marking the line at the level of dyspnea

Anchors to indicate extremes of a sensation

No breathlessness

Intolerable breathlessness

PULMONARY VISUAL ANALOG SCALE

Submaximal test of aerobic capacity/endurance

MDC=54 meters (177 feet)

MCID= 54 meters

Average distance walked: 380 m

Distance<200 m is predictive of hospitalization

or mortality

6 MWD declines as healthy adults age increases

6 MINUTE WALK TEST AND COPD

17

Used for pts with moderate to severe COPD

(FEV1 42% pred)

Leung (2006) compared 2min walk test with 6 MWT, VO2 max

and VO2max/kg , and Watts (Wmax) .

Very high correlation with 6 MWT.

Moderate correlations with VO2m ax and VO2m ax/ k g.

Responsive to pulmonary rehab (17.2 m ± 13.8m)

Reliable and reproducible

Valid as a test for exercise capacity

pts with moderate to severe COPD

** 2 MINUTE WALK TEST**

Inter-rater Reliability: 0.90 in Community -

dwelling older adults (Rikli,1999)

Criterion Validity: Moderate correlation .73 with 1 mile walk in

Comm Dwelling older adults (Dugas, 1996)

.74 with time on TM to 85% max HRin commdwelling older adults (Johnston, 1998)

SEM, MDC, MCID –not researched yet

2 MINUTE STEP IN PLACE TEST

30 sec chair stand

Correlated with 6mwd

Can be used to evaluate

exercise tolerance in

pts with COPD

Kato, 2014

5x sit<>stand

Excellent reliability

Correlates with exercise

capacity(6 mwt) and

lower limb strength

Responsive to

pulmonary rehab

MCID 1.7 sec

Jones, 2013

FUNCTIONAL STRENGTH

18

BALANCE

Berg Balance Test

Timed-Up and Go

DEMMI**

PARTICIPATION RESTRICTION

Chronic Respiratory Questionnaire (CRQ)

St George Respiratory Questionnaire (SGRQ)

COPD Assessment Test (CAT)**

ACTIVITY LIMITATIONS AND

PARTICIPATION RESTRICTIONS

Jewell and Schworn, 2015

2016 Berg Balance test was found to be a valid, reliable and

valuable test to dif ferentiate fall status in patients with COPD.

Jacome 2016

Sensitivity 73% and Specificity 77%

Moderate to good relative intrarater reliability ( Icc=.52)

MDC95 was 5.9 (SEM=2.1, MDC% =11.1%)

BBS high ceiling effect

Alternative tests with lower ceiling effects was the Brief-BESTest,

following by the BESTest and Mini-BESTest.

Good convergent and concurrent validity

BERG BALANCE TEST AND COPD

Excellent RELIABILITY for inter -rater and intra-rater

SEM was .97 sec (exact) and .66 sec (mean)

MDC95 was 2.68 sec (exact) and .84 sec (mean) ( marquest,

2015)

Responsive to pulmonary rehabilitation

Did not change significantly over one year

Significant weak to strong correlations were found between TUG and

other health outcomes, but the strongest correlation was found with

a 6 MWD.

Valid for the assessment of functional performance in patients with

COPD. (mesquite, 2014)

TIMED UP AND GO AND COPD

19

Predictive utility for

falls

9 min to administer

No special equipment

Rasch analysis

MDC90 =9 pts

MCID10=10 pts

**DEMORTON MOBILITY INDEX**

www.demmi.org.au

20 items across 4 dimensions – dyspnea, fatigue, emotional

function and mastery

COPD MCID change of .5 per item;

QoL score

MDC .5 on 7 point scale clinically significant small change

MDC 1.0 reflects a moderate change

QoL MCID change of .5 per item

COPD

Excellent test re-test reliability for COPD, all four dimensions

Excellent internal consistency for all four dimensions

Adequate construct validity with SGR

Poor correlations between CRQ and lung function

Poor correlations between CRQ and exercise capacity

CHRONIC RESPIRATORY QUESTIONNAIRE

St. George Respiratory Questionnaire (disease specific

questionnaire)

HRQOL for patients with asthma and COPD

76 item questionnaire classified into 3 domains that measure:

symptoms,

activity limitations, and

psychological impact of specific disease of COPD.

each domain is scored with a preset formula that individually

weighs each option.

a total score sums the 3 domains with a score between 0-100..

Higher scores indicated poorer health status.

mMRC correlates with activity domains

ST GEORGE RESPIRATORY

QUESTIONNAIRE

20

8 question item

2-3 min to fill out

MCID = -2

Responsive to effects of

pulmonary rehab

Responsive to recovery from

admission to hospital for

acute exacerbation of COPD.

(Kon, Canavan, Jones, e t al., 2014)

COPD ASSESSMENT TEST

PROGNOSIS

Tool that helps predict mortality in patients with COPD

Points are assigned to each category with a total of 10 possible points.

Higher the score the higher the risk of mortality

---also higher risk for hospital readmission (LEAP)

BODE INDEX components

Body Mass Index (B)

BMI (kg/m2)

Airflow Obstruction (O) based on FEV1

% predicted

Dyspnea (D) as measured by the mMRC dyspnea scale

0-4

Exercise capacity (E)

6 minute walk test distance in meters

BODE INDEX

Jewell and Schworn, 2015

21

BODE INDEX

0 points 1 point 2 points 3 points

Body Mass

Index (kg/m2)

>21 kg/m2 ≤ 21 kg/m2

FEV1%

Predicted

After

Bronchodilator

≥65% 50-64% 36-49% ≤35%

MMRC

Dyspnea scale

0-1 2 3 4

6 Minute Walk

Distance (m)

≥350 m 250-349 m 150-249 m <149 m

Jewell and Schworn, 2015

http://reference.medscape.com/calculator/bode-index-copd

BODE INDEX FOR

COPD SURVIVAL PREDICTION

Simple tool that can effectively stratify patients’ risk of 90-day readmission or death

Discriminative and accurate

Higher PEARL scores were associated with a shorter time to readmission.

P=previous

admissions

E=eMRCD score

A=Age

R=Right sided HF

L= Left sided HF

PEARL

22

EDUCATION

BLOCK 1 DISEASE MANAGEMENT

COPD pathology/risk factors

Oxygen Management

Pursed Lip Breathing

Airway Clearance

BLOCK 2 DAILY ROUTINE MANAGEMENT

Daily Checklist

Medication Management

Avoidance Behaviors

Exacerbation Prevention

BLOCK 3 PREVENTION MANAGEMENT

Risk factors for HOSPITAL READMISSION

Active Lifestyle

Rapid Action Plan

Self-Management and Self-Monitoring

REDUCING HOSPITAL READMISSION

THROUGH EDUCATION

Helping patients to understand the disease process is the

goal. Many do not understand how to manage their chronic

illness, much less how to PREVENT an exacerbation.

Help them to understand what the precipitating factors may

have been.

Find out what their signs and symptoms have been

COPD PATHOPHYSIOLOGY AND RISK

FACTORS

23

The LOTT study revealed that oxygen has a benefit in those who wear for longer than 15 hours per day.

Oxygen helps with vital signs, activity tolerance, and helps pts to remain alert.

COPD people generally have SpO2 between 88-92%

Oxygen has been shown to improve long-term survival AND it decreases the risk of not only being admitted to the hospital, but also decreases the length of time pts need to be in the hospital.

ROLE OF OXYGEN

(LOTT STUDY, 2016)

Controlled exhalation used to do the following:

Improve ventilation

Released trapped air in the lungs

Keeps airways open longer and decreased the work of breathing

Prolongs exhalation to slow down respirator y rate

Improves breathing patterns by moving old air out

Relieves shortness of breath

Causes general relaxation

PURSED LIP BREATHING

This is used to clear the airways of mucus, sputum or phlegm.

Recurrent chest infections have been shown to contribute to worsening lung function and ongoing inflammation. This is DIRECTLY related to the rate of

hospital admission.

Airway clearance techniques can keep the risk of chest infections down to a minimum thus leading to less hospital days.

Airway clearance is use with people with COPD who have a moist productive cough when they have an infection and in those who cough up sputum daily.

AIRWAY CLEARANCE TECHNIQUES

24

When patients are consistent in their daily activities, it is easy to spot a change for the worsein per formance of those daily activities. They will use those changes as an

EARLY indicator to seek medical attention.

Key components to preventing rehospitalization include: Being consistent from day to day

using a daily checklist.

Having access to their PCP when they need it most.

Participating in education sessions to help them better understand their chronic condition.

DAILY CHECKLIST

An important part of medication management is making sure the patient is taking the medicine as the doctor has prescribed it.

Many medications have side effects such as nausea, vomiting, confusion or dizziness.

Prescriptions can become confusing, especially when you don’t feel good.

MEDICATION MANAGEMENT

Research has shown that avoiding smoking and people who

smoke (second-hand smoke) is the BEST WAY TO DELAY THE

PROGRESSION of COPD at ALL STAGES

Per fumes and chemicals are toxic to people who have COPD.

They are a primary reason for EXACERBATIONS.

Avoiding people and places with perfumes and chemical will help

avoid a hospital admission

Bacterial and viral infections are major causes of

exacerbations.

These may contribute to the development of COPD

and/or the progression of COPD.

AVOIDANCE BEHAVIORS

25

See healthcare professional at regularly scheduled appointments – even if feeling fine.

Get a flu shot every year.

Check if due for pneumonia and pertussis shots.

Wash hands of ten for 20 seconds with warm water and mild soap.

Carry a small bottle of hand sanitizer for when times are desperate.

Avoid touching mouth, eyes, and nose in public to help prevent germs from entering the body.

Stay away from crowds, especially during cold and flu season.

Use own pen – especially at the doctor’s of fice!

Get plenty of sleep. When the body is tired, it is more likely to get sick.

Drink plenty of water. Thick mucus is more likely to get stuck in the lungs and cause problems.

EXACERBATION PREVENTION

Preventing fur ther progression of the disease and Avoiding future

hospitalizations.

Transitional Care Plans

PAVS – walking <50 feet at discharge

Review Risk Factors of REHOSPITALIZATION

Exacerbations (episodes where your breathing becomes worse) which are

not fully resolved at the time of hospital discharge.

COPD management from more than one doctor and poor communication

between doctors.

Incorrectly taking medication or Improper or insufficient use of oxygen

Return to smoking or Return to an inactive lifestyle

Missing follow-ups with the doctor or lack of a rapid action plan

Inadequate or heavy equipment (including oxygen tanks)

PREVENTION MANAGEMENT

Benefits of walking and physical ac tiv ity:

Research has shown that being able to walk a minimum of 50 feet

reduces the risk for re-hospitalization within the first 30 days after

discharge.

In addition, tolerating walking a minimum of 16 minutes daily, every

day, reduces the risk for re-hospitalization.

Daily activity promotes positive effects to your mood for anxiety and

depression sufferers.

Improved stamina for activities of daily living.

Improved strength of muscles and bones for other functional tasks.

Maintain healthy weight.

Improve balance and coordination.

ACTIVE LIFESTYLE

26

The American Lung Association has a hand out to take to the doctor that will help to guide your management plan. You will need to find out from the doctor what he/she wants you do when your symptoms don’t improve.

http://ww w. l ung. org / assets/ doc um e nts/copd/copd- ac tion- pl an. pdf

RAPID ACTION PLAN

SELF-MANAGEMENT and SELF-MONITORING

MEDICATION MANAGEMENT

COMMUNICATION and CARE COORDINATION

TIMELY FOLLOW-UP BY THE HEALTH CARE TEAM

ASK QUESTIONS!

SELF MANAGEMENT AND

SELF MONITORING

CASE STUDIES

27

74 y/o female admitted following COPD exacerbation with

PMH of COPD, debility and anxiety. O2 dependent on 3 lpm

24/7.

Lives with daughter in a motel room on the ground floor with

4 cats and 2 dogs. Her daughter is a smoker and wears

per fume.

Upon examination, she could not get her breath. Shor t, fast

breaths with paradoxical movements of the chest/abdomen.

Heavy use of accessory muscles, with poor chest wall

excursion. Demonstrating increased RR (28) and WOB.

Vitals: BP 160/70 HR 107 SpO2 96% on 3 lpm O2 via nc

Everything she does is fast!

A FISH (OUT OF WATER)

CALLED WANDA

Strength: MRC-SS 40/60;

5x sit<>stand: 0 – unable to perform

Kansas University Balance scale: 1/5 for

sitting/standing

Gait: unable to perform

Step Test: 0 - to lift knees to required height.

MMRC – (dyspnea) Grade 4

DEMMI 8/100

WANDA EXAMINATION

First Month

Seated ther ex to work on LE strength, activity tolerance, transfer training, and gait training.

After 10 days, she stopped gait training at her request for 12 days. Restar ted in the parallel bars

2 weeks: 2 min step test completed: 14

steps in 1 min 4 sec.

DEMMI 27/100

6mwt not tested

RPE 6 at rest/11 with activity

Second Month

Star ted COPD education

series

eager to learn more,

doing homework/practice

Wheelchair protocol for

aerobic conditioning

Week 6 still in parallel bars.

Educated on risk of

rehospitalization if walking <50 ft

daily

Started walking with walker

50/62/80 ft distances

DEMMI 48/100

RPE 9 with activity

WANDA TREATMENT

28

Took 8 weeks to get her ready to complete 6mwt=49.68 m

MRC-SS 46/60

DEMMI 48/100

Gait distance 150+ feet x3 reps each one session with sitting

rest breaks between sessions.

Education:

Understanding her disease process, triggers, and role of oxygen.

Able to perform PLB and has multiple ways to assist with airway

clearance.

She developed a daily checklist and an plan with her doctor to avoid

exacerbations

She understands the role of her meds and the role of activity in

avoiding exacerbations.

WANDA DISCHARGE

76 y/o female admitted following COPD exacerbation after her

concentrator burned up.

PMH of COPD, severe pulmonary HTN, CAD, mild pulmonary

edema, and protein calorie malnutrition. O2 dependent on 8

lpm 24/7 via facemask.

Lives with daughter in a trailer with 3 steps to enter. Multiple

adult smokers in the home. Resident wants to live on her own.

Upon examination, she was calm and in no apparent distress.

Vitals: BP 120/70 HR 85 SpO2 87% on 8 lpm O2 via

facemask

Takes 5-6 min to recover SpO2 to 90% after walking to the

bathroom.

Visibly cyanotic in hands with complaints of pain across the collar

bones secondar y to hypoxia.

BETTY BLUE

Strength: MRC-SS 55/60;

5x sit<>stand: 0 – unable to perform

Kansas University Balance scale: 2/5 for sitting/1+

for standing

Gait: FIM 1 with SPO2 dropping to 87% after 10 steps.

6 min walk test: refused during examination

2 min walk test: 4 days later 22.5 meters 88%

DEMMI 30/100

MMRC Grade 4

BETTY BLUE EXAMINATION

29

Resident was noncompliant with treatment protocols

Emotional, unrealistic about discharge planning

COPD Education Series – completed 8/12 sessions

Felt she learned some new things despite being on O2 for >6 years.

Education on using RPE as a means to determine workload instead of

cyanosis.

2 min walk test as a form of exercise

Walking scores kept declining so aerobic conditioning was performed

using wheelchair mobility for 2 min bouts with improved

hemodynamics.

Seated ther ex deferred for functional activities.

BETTY BLUE TREATMENT

Left building early in order to avoid paying co -pay

risk factor for readmission

DEMMI 48/100

TINETTI 26/28

6mwt – unable to per form

2mwt – 24.4 m (130 m was average performed in study)

COPD Education Series – completed 8/12 topics

Missed BLOCK 3 – Prevention Management including:

risk factors for hospital admission,

active lifestyle,

rapid action plan and

self-management and self-monitoring.

BETTY BLUE DISCHARGE

QUESTIONS

Lisa Alexander - alexanderpt@gmail.com

Rhonda Schnable - schnablept@gmail.com

30

B ak e r , C . , & Z o u , K . ( 2 0 1 3 ) . R i s k as s e s s me nt o f r e ad mi s s i o n s f o l l o w i ng an i n i t i a l C O P D - r e l a t e d ho s p i t a l i z a t i o n . I n t e r n a t i o n a l J o u r n a l o f C h r o n i c O b s t r u c t i v e P u l m o n a r y D i s e a s e , 5 5 1 . d o i : 1 0 . 2 1 4 7 / c o p d . s 5 1 5 0 7

C haw l a , H . , B u l a t hs i ng ha l a , C . , Te j ad a , J . P . , W ak e f i e l d , D . , & Z u w a l l ac k , R . ( 2 0 1 4 ) . P hy s i c a l A c t i v i t y as a P r e d i c t o r o f Th i r t y -D ay H o s p i t a l R e ad mi s s i o n a f t e r a D i s c har g e f o r a C l i n i c a l E x ac e r b a t i o n o f C hr o n i c O b s t r u c t i v e P u l mo nar y D i s e as e . A n n a l s o f t h e A m e r i c a n T h o r a c i c S o c i e t y , 1 1 ( 8 ) , 1 2 0 3 - 1 2 0 9 . d o i : 1 0 . 1 5 1 3 / anna l s a t s . 2 0 1 4 0 5 - 1 9 8 o c

G e r i a t r i c To o l K i t . A c c e s s e d 7 / 1 / 1 7 f r o m: h t t p : / / g e r i a t r i c t o o l k i t . mi s s o u r i . e d u / c v /

G l o b a l I n i t i a t i v e f o r C hr o n i c O b s t r u c t i v e L u ng D i s e as e . ( n . d . ) . R e t r i e v e d J u l y 3 1 , 2 0 1 7 , f r o m h t t p : / / g o l d c o p d . o r g /

G o o d man , C . C . , F u l l e r , K . S . , & O S he a , R . K . ( 2 0 1 2 ) . P a t h o l o g y f o r t h e p h y s i c a l t h e r a p i s t a s s i s t a n t . S t . L o u i s , M O : E l s e v i e r S au nd e r s .

E c he v ar r i a , C . , S t e e r , J . , H e s l o p - M ar s ha l l , K . , S t e n t o n , S . C . , H i c k e y , P . M . , & H u g he s , R . ( 2 0 1 7 ) . The P E A R L s c o r e p r e d i c t s 9 0 -d ay r e ad mi s s i o n o r d e a t h a f t e r ho s p i t a l i s a t i o n f o r ac u t e e x ac e r b a t i o n o f C O P D . T h o r a x , 7 2 ( 8 ) , 6 8 6 - 6 9 3 . d o i : 1 0 . 1 1 3 6 / t ho r ax j n l -2 0 1 6 - 2 0 9 2 9 8

H s u , K . , L i n , J . , L i n , M . , C he n , W . , C he n , Y . , & Y an , Y . ( 2 0 1 3 ) . The mo d i f i e d M e d i c a l R e s e ar c h C o u nc i l d y s p no e a s c a l e i s a g o o d i nd i c a t o r o f he a l t h - r e l a t e d qu a l i t y o f l i f e i n p a t i e n t s w i t h c h r o n i c o b s t r u c t i v e p u l mo nar y d i s e as e . S i n g a p o r e Me d i c a l J o u r n a l , 5 4 ( 6 ) , 3 2 1 - 3 2 7 . d o i : 1 0 . 1 1 6 2 2 / s me d j . 2 0 1 3 1 2 5

J e nc k s , S . , W i l l i ams , M . , & C o l e man , E . ( 2 0 0 9 ) . R e ho s p i t a l i z a t i o n s amo ng P at i e n t s i n t he M e d i c a r e F e e - f o r - S e r v i c e P r o g r am. J o u r n a l o f V a s c u l a r S u r g e r y , 5 0 ( 1 ) : 2 3 4 . d o i : 1 0 . 1 0 1 6 / j . j v s . 2 0 0 9 . 0 5 . 0 4 5

J e w e l l , D . , & S c hw o r m, K . A . C h r o n i c O b s t r u c t i v e P u l mo nar y D i s e as e ( C O P D ) : A P TA C l i n i c a l S u mmar y . A c c e s s e d 2 / 2 / 1 7 f r o m: h t t p : / / w w w . p t no w . o r g / c l i n i c a l - s u m m ar i e s - d e t a i l / c h r o n i c - o b s t r u c t i v e - p u l m o n ar y - d i s e a s e - c o p d

J o ne s , S . E . , K o n , S . S . , C anav an , J . L . , P a t e l , M . S . , C l a r k , A . L . , N o l an , C . M . , . . . M an , W . D . ( 2 0 1 3 ) . The f i v e - r e p e t i t i o n s i t - t o -s t and t e s t as a f u nc t i o na l o u t c o me me as u r e i n C O P D . T h o r a x , 6 8 ( 1 1 ) , 1 0 1 5 - 1 0 2 0 . d o i : 1 0 . 1 1 3 6 / t ho r ax j n l - 2 0 1 3 - 2 0 3 5 7 6

K at o , D . , F u e k i , M . , E nd o , Y . , U g a , D . , D o b as h i , K . , N ak az aw a , R . & S ak amo t o . ( 2 0 1 4 ) . 3 0 - s e c o nd c ha i r - s t and t e s t i s a v a l u ab l e e v a l u a t i o n i n c h r o n i c r e s p i r a t o r y d i s t r e s s . E u r o p e a n Re s p i r a t o r y J o u r n a l , 4 4 : P 4 2 8 6 ab s t r ac t .

K o n , S . C . S . , C anav an , J . L . , J o ne s , S . E . , N o l an , C . M . , C l a r k , A . L . , D i c k s o n , M . J . , e t a l . ( 2 0 1 4 ) M i n i mu m c l i n i c a l l y i mp o r t an t d i f f e r e nc e f o r t he C O P D A s s e s s me nt Te s t : A p r o s p e c t i v e ana l y s i s . L a n c e t Re s p i r Me d , 2 : 1 9 5 - 2 0 3 .

L e u ng , A . S . , C han , K . K . , S y k e s , K . , & C han , K . ( 2 0 0 6 ) . R e l i ab i l i t y , Va l i d i t y , and R e s p o ns i v e ne s s o f a 2 - M i n W a l k Te s t To A s s e s s E x e r c i s e C ap ac i t y o f C O P D P at i e n t s . C h e s t , 1 3 0 ( 1 ) , 1 1 9 - 1 2 5 . d o i : 1 0 . 1 3 7 8 / c he s t . 1 3 0 . 1 . 1 1 9

M ar qu e s , I . , C r u z , J . , R e g e nc i o , M . , Q u i na , S . , O l i v e i r a , A . , & J ac o me , C . ( 2 0 1 5 ) . R e l i ab i l i t y and mi n i ma l d e t e c t ab l e c hang e o f t he Ti me d U p and G o t e s t i n C O P D . E u r o p e a n Re s p i r a t o r y J o u r n a l , 4 4 : P A 2 0 7 9 A b s t r ac t . d o i : 1 0 . 1 1 8 3 / 1 3 9 9 3 0 3 3 . c o ng r e s s -2 0 1 5 . P A 2 0 7 9 .

WORKS CITED

Me s q u i t a , R . , Wi l k e , S . , Sm i d , D . , J a n s s e n , D . J . A . , F r a n s s e n , F . M . E . , P r o b s t , V . S . , e t a l . ( 2 1 0 4 ) . T i m e d U P a n d G o t e s t i n C OP D : C h a n g e s o v e r t i m e , v a l i d i t y a n d r e s p o n s i v e n e s s t o p u l m o n a r y r e h a b i l i t a t i o n . E u r o p e a n R e s p i r a t o r y J o u r n a l , 4 4 : P 3 0 3 7 A b s t r a c t .

Na t i o n a l Qu a l i t y Me a s u r e s C l e a r i n g h o u s e ( NQMC ) . Me a s u r e s u m m a r y: C h r o n i c o b s t r u c t i v e p u l m o n a r y d i s e a s e ( C OP D ) : h o s p i t a l 3 0 - d a y, a l l - c a u s e , r i s k - s t a n d a r d i z e d r e a d m i s s i o n r a t e f o l l o w i n g a c u t e e xa c e r b a t i o n o f C OP D h o s p i t a l i za t i o n . In : Na t i o n a l Qu a l i t y Me a s u r e s C l e a r i n g h o u s e ( NQMC ) [ We b s i t e ] . Ro c k v i l l e ( MD ) : A g e n c y f o r H e a l t h c a r e Re s e a r c h a n d Qu a l i t y ( A H RQ) ; 2 0 1 5 Oc t 0 1 . [ d o w n l o a d e d 2 0 1 7 Ma r 1 8 ] . A v a i l a b l e : h t t p s : / / w w w . q u a l i t y m e a s u r e s . a h r q . g o v

Ng u ye n , H . Q . , Ro n d i n e l l i , J . , H a r r i n g t o n , A . , e t a l . ( 2 0 1 5 ) . F u n c t i o n a l s t a t u s a t d i s c h a r g e a n d 3 0 - d a y r e a d m i s s i o n r i s k i n C OP D . R e s p i r a t o r y Me d i c i n e , 1 0 9 : 2 3 8 - 2 4 6 .

P u t c h a , N . , H a n , M . K . , Ma r t i n e z , C . H . , F o r e m a n , M . G . , A n zu e t o , A . R . , C a s a b u r i , R . , e t a l . ( 2 0 1 4 ) . C o m o r b i d i t i e s o f C OP D h a v e a m a j o r i m p a c t o n c l i n i c a l o u t c o m e s , p a r t i c u l a r l y i n A f r i c a n A m e r i c a n s . J o u r n a l o f t h e COP D Fo u n d a t i o n , 1 ( 1 ) : 1 0 6 - 1 1 4 .

P u h a n , M . A . , S i e b e l i n g , L . , Z o l l e r , M . , Mu g g e n s t u r m , P . , & t e r R i e t , G . ( 2 0 1 3 ) . S i m p l e f u n c t i o n a l p e r f o r m a n c e t e s t s a n d m o r t a l i t y i n C OP D . E u r o p e a n R e s p i r a t o r y J o u r n a l , 4 2 : 9 5 6 - 9 6 3 . d o i : 1 0 : 1 1 8 3 / 0 9 0 3 1 9 3 6 . 0 0 1 3 1 6 1 2

T h e Re h a b i l i t a t i o n Me a s u r e s D a t a b a s e . ( n . d . ) . Re t r i e v e d J u l y 3 1 , 2 0 1 7 , f r o m h t t p : / / w w w . r e h a b m e a s u r e s . o r g /

Sh a h , T . , C h u r p e k , M . M . , P e r r a i l l o n , M . C . , & K o n e t zk a , R . T . ( 2 0 1 5 ) . U n d e r s t a n d i n g Wh y P a t i e n t s Wi t h C OP D G e t Re a d m i t t e d . Ch e s t , 1 4 7 ( 5 ) , 1 2 1 9 - 1 2 2 6 . d o i : 1 0 . 1 3 7 8 / c h e s t . 1 4 - 2 1 8 1

T h o r p e , O . , K u m a r , S . , a n d J o h n s t o n , K . ( 2 0 1 4 ) . B a r r i e r s t o a n d e n a b l e r s o f p h ys i c a l a c t i v i t y i n p a t i e n t s w i t h C OP D f o l l o w i n g a h o s p i t a l a d m i s s i o n : A q u a l i t a t i v e s t u d y. In t e r n a t i o n a l J o u r n a l o f COP D , 9 : 1 1 5 - 1 2 8 .

T i e p , B . , C a r l i n , B . , L i m b e r g , T . , & Mc C o y, R . ( 2 0 1 5 ) . C OP D p a t i e n t 3 0 - d a y h o s p i t a l r e a d m i s s i o n r e d u c t i o n p r o g r a m . C OP D Wh i t e P a p e r .

T o r r e s - Sa n c h e z , I . , C a b r e r a - Ma r t o s , I . , D i a z - P e l e g r i n a , A . , e t a l . ( 2 0 1 7 ) . P h ys i c a l a n d f u n c t i o n a l i m p a i r m e n t d u r i n g a n d a f t e r h o s p i t a l i za t i o n i n s u b j e c t s w i t h s e v e r e C OP D e xa c e r b a t i o n . R e s p i r a t o r y Ca r e , 6 2 ( 2 ) : 2 0 9 - 2 1 4 . d o i : 1 0 . 4 1 8 7 / r e s p c a r e . 0 4 5 9 7

WORKS CITED

THANK YOU FOR

ATTENDING !