1 Mario Heirewegh az Sint-Blasius Belgium Heading Towards a COPD Care Pathway June 20, 2013 Dr Luc Van Zandweghe Mario Heirewegh Pulmonologist Head Nurse AZ Sint-Blasius Dendermonde Belgium
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Mario Heirewegh
az Sint-Blasius Belgium
Heading Towards a COPD Care Pathway
June 20, 2013
Dr Luc Van Zandweghe Mario Heirewegh
Pulmonologist Head Nurse
AZ Sint-Blasius Dendermonde Belgium
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Mario Heirewegh
az Sint-Blasius Belgium
AZ Sint-Blasius
Where We Are Located
Dendermonde Zele
AZ Sint-Blasius is a merger of five local hospitals established between
1976 and 1999 in East Flanders, Belgium, consisting of two campuses.
.
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Mario Heirewegh
az Sint-Blasius Belgium
AZ Sint-Blasius
Basic Figures
Beds: 440
Staff: 1,268 (in 2012)
Turnover: 125,000,000 Euros in
2012
Hospitalization: 17,380 in 2012
Consultations: 18,096 in 2012
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Mario Heirewegh
az Sint-Blasius Belgium
AZ Sint-Blasius
Organization M
atr
ix s
tructu
re
Care Units (eg. abdominal, thoracic,..)
Care Supporting Services (eg. labo, medical imaging,..)
Organisation Supporting Services (eg. HR, ICT,..)
Focus on process management (eg. clinical pathways, SLA’s)
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Mario Heirewegh
az Sint-Blasius Belgium
Carepathways in AZ Sint-Blasius
History Since 2003 member of Belgian Dutch Clinical Pathway Network
Hospital wide implementation ( each ward >= 1 careplan)
2003-2009 : focus on development and implementation
2010-2012: focus on follow-up,analyzing,keeping alive….
Evolution from central ( staff member) to decentral
follow- up- evaluation
Participation Network workgroups ( COPD, PFF)
Evolution
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Mario Heirewegh
az Sint-Blasius Belgium
Composition
Multidisciplinary Treatment Team COPD
3 pulmonologists
2 fysiotherapists
1 occupational therapist
1 psychologist/ tobaccologist
1 dietitian
1 social worker
headnurse and nursing staff
weekly multidisciplinary consultation on thursday
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Mario Heirewegh
az Sint-Blasius Belgium
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Mario Heirewegh
az Sint-Blasius Belgium
Thoracic Care Unit
hospitalization ward : 34 beds
16 FTE nurses, 3 nurses
specially trained in pulmonology;
main responsibles for patient
education
mostly lung patients
combination of both internal and
surgical pathology
21 rooms from which 4 negative
pressure isolation rooms
1,863 admissions in 2012
average LOS: 5 days
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Mario Heirewegh
az Sint-Blasius Belgium
What ‘s in a word ?
Chronic
Obstructive
Pulmonary
Disease
© Global Initiative for Chronic Obstructive Lung Disease
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Mario Heirewegh
az Sint-Blasius Belgium
What is COPD?
Risk Factors
Food Habits
Infections
Socio-Economical
Status
Aging
Global Initiative for Chronic Obstructive Lung Disease
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Mario Heirewegh
az Sint-Blasius Belgium
What is COPD?
Epidemiology
COPD is considered one of the leading causes
of death world wide and in the coming years
will become increasingly more important.
The current anti-smoking campaigns will pass
within decades which governed.
In Belgium, the number of COPD patients is
estimated at 680,000. Less than half of those
have been diagnosed.
2009: 190 admissions in AZSB
2010: 141 admissions in AZSB
© Global Initiative for Chronic Obstructive Lung Disease
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Mario Heirewegh
az Sint-Blasius Belgium
What is COPD?
Epidemiology
COPD is one of the
six leading causes of
death in the U.S.
with an increasing
trend since 1970!
Source: US Centers for Disease Control and Prevention, 2011
COPD
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Mario Heirewegh
az Sint-Blasius Belgium
What ‘s the effect
of COPD?
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Mario Heirewegh
az Sint-Blasius Belgium
What is COPD ?
Pathogenesis
INFLAMMATION
Small airway disease
Airwayinflammation
Airway-remodeling
Lung tissue damage
Loss of alveoli
Decreased elasticity
AIRWAY
LIMITATION
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Mario Heirewegh
az Sint-Blasius Belgium
What is COPD?
Symptoms
cough
over production of mucus
dyspnea:
exercise-induced
exacerbation during surge
wheezing
typically, slowly progressive symptoms
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Mario Heirewegh
az Sint-Blasius Belgium
What is COPD ?
Treatment Aimed At :
prevention of disease progression
relief of symptoms
improve exercise tolerance
improving the general health status
prevention and treatment of exacerbation
prevention and treatment of complications
prevention of mortality
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Mario Heirewegh
az Sint-Blasius Belgium
Occupational therapy and COPD
COPD influence on daily life tasks and Q.o.L.
Occupational therapist part of the multidisciplinary team
Education (patient and family)
Identify the limitations in ADL tasks
(interview, home evaluation scale, AMPS,...)
Skills training
(attention for breath control and energy efficiency)
If needed the OT gives information to adapt the environment
or advises device assistance
to increase participation in everyday life
to increase performance of daily activities
•
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Mario Heirewegh
az Sint-Blasius Belgium
Progress Of The Path:
May 2009: participation EQCP study baseline
inclusion of 20 COPD patiënts
survey on team-collaboration and group-dynamics
Spring 2010: developement and testing pathway
September 2010: official pathway kick off meeting with all
stakeholders
October 2010: start hospital COPD pathway follow-up
database at the ward
November 2010: EQCP post-test
Summer 2011: start tobaccologist activity
May 2012: COPD symposium presenting achieved goals
Spring 2013: start free information sessions for ambulatory
COPD patients and carers and start focus group
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Mario Heirewegh
az Sint-Blasius Belgium
The COPD Pathway
Concept
Checklist:
control and communication tool for the team
base for systematic quality analysis
Education plan:
methodology used
evaluation of results: often repetition needed
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Mario Heirewegh
az Sint-Blasius Belgium
The COPD Pathway
Concept
Patiënt Folder:
a “patient version” of the pathway:
patient is informed of the who, when and what
planned examinations/interventions
information leaflets
cover letter: what we aim our approach?
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Mario Heirewegh
az Sint-Blasius Belgium
The COPD Pathway
Scientific Key Interventions
Designed as a checklist, which includes five sections,
with all key interventions during hospitalization that
certainly need to be addressed.
Medical
eg. the pulmonologist systematically examines whether
there is an indication for start of chronic oxygen therapy
at home
Education
eg. the physical therapist teaches the patient a correct
inhalation technique and sees to it daily
eg. professional smoking cessation counseling by an
approved tobaccologist
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Mario Heirewegh
az Sint-Blasius Belgium
The COPD Pathway
Examinations
eg. ABG and lung function test at fixed intervals
Care planning
eg. systematic B.M.I. measurement , monitoring weight
and oxygen saturation → daily patient assesment
Medication
eg. → antibiotics only if strictly necessary based on
procalcitonin (= infection marker blood test)
eg. AB treatment as short as possible
eg. rapid transition to oral therapy
eg. reduction schedules for corticoids
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Mario Heirewegh
az Sint-Blasius Belgium
The COPD Pathway
The education plan, where all team members
contribute, comprises the following items;
disease understanding
(terminology, diagnosis, prognosis…)
smoking cessation
(motivational techniques, tools…)
inhalation- and oxygen therapy (inhaler use…)
physical exercise/ breathing
exercises/rehabilitation (prevent muscle atrophy…)
nutritional advice (risk of malnutrition…)
prevention (influenza vaccination…)
discharge instructions (medication schedule…)
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Mario Heirewegh
az Sint-Blasius Belgium
Together, with respect, for your
wellbeing!
Why this care vision?
Within the mission statement of the AZ Sint-Blasius, the team
developed a shared vision of care.
All members of the multidisciplinary treatment team COPD
endorse such a vision of care.
With this vision, we consider the patient and his relatives as
our first partner in the care process. These active partnership
that involves mutual commitments finally results in patient
empowerment also.
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Mario Heirewegh
az Sint-Blasius Belgium
Together, with respect, for your
wellbeing!
"We are committed to work to improve, restore or longer
maintain health and well-being. Efficient in respectful
partnership with each care recipient and his or her family,
We want to achieve this goal together to form a high-
performance, multi-disciplinary team of which there is
appreciation for the input of all team members. We invest
all of our available resources, and our professional
expertise in team work. In this way we aim to
continuously optimize the quality of our total care. "
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Mario Heirewegh
az Sint-Blasius Belgium
What makes this project innovative ? Fully evidence based
Keyinterventions from the European Quality of Care
Pathways study conducted by the Centre for Health
Services and Nursing Research of the University
Leuven commissioned by the European Pathway
Association. (Examines the effectiveness of a COPD
care pathway in acute hospitals.)
Multidisciplinary collaboration from a clearly defined
team vision
"Together, with respect, for your well-being.“
Investment in human resources.
Team + care recipient = extra value
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Mario Heirewegh
az Sint-Blasius Belgium
What makes this project innovative ?
Patient empowerment due to an active
partnership with the patient and his relatives.
mutual commitment
Attention to a large but socially weaker and
often unsung, target with a current problem.
current prevention (smoking cessation) will affect the
incidence only in the longer term
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Mario Heirewegh
az Sint-Blasius Belgium
What makes this project innovative ?
Emphasis On Targeted Education
encouraging selfmanagement
active role for care recipient / relatives
Systematic monitoring and improvement
of the careproces →higher level of care quality.
database and clinical performance indicators
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Mario Heirewegh
az Sint-Blasius Belgium
What makes this project innovative ?
Positive effects on patient safety:
better coordinated care
shorter L.O.S.
better informed patients and relatives will report
(potential) incidents earlier than before
rational drug use:
oral instead of IV : risks of thrombophlebitis,
catheter sepsis ↓
AB en corticoïds: risks of AB resitence and side
effects ↓
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Mario Heirewegh
az Sint-Blasius Belgium
What makes this project innovative ?
Ambulatory Component
freely accessible, periodic, information sessions for
ambulatory patients and carer givers in collaboration
with the primary care (GP’s, homecare …)
involvement of patients in the organization of the care
process through focus groups
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Mario Heirewegh
az Sint-Blasius Belgium
*Antibiotics: Augmentin, Avelox, Biclar, Ciproxine, Maxipime, Tazocin (cfr. former studies clinical pathway COPD).
Facts and figures
Baseline
october 2009 - march 2010 october 2010 - march 2011 october 2011 - march 2012 october 2012 - march 2013
# Admiss ions 93 81 89 62
# Readmiss ions <= 30 days 6 1 5 3
# Patient days 1069 724 806 507
Average length s tay hospita l (days) 11,49 8,94 9,06 8,2
Average readmiss ions length s tay hospita l (days) 21,7 6 10,6 9,3
# Patients with antibiotics 68 49 66 38
% 73,12 60,49 74,16 61,29
# units antibiotics* 1721 1027 1537 851
Antibiotics , DDD* 1185 584 1043 535
# Patients with corticosteroids 88 76 83 59
% 94,62 93,83 93,26 95,16
# mg cortisosteroids/patientday 56,13 23,09 34,84 40,77
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Mario Heirewegh
az Sint-Blasius Belgium
Facts and figures
Downward trend
readmissions within
30 days after
discharge.
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Mario Heirewegh
az Sint-Blasius Belgium
Facts and figures
The average LOS
currently decreased
with 3,29 days since
the start of the PW.
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Mario Heirewegh
az Sint-Blasius Belgium
Facts and figures
Reduction in the
percentage of patients
receiving antibiotics
through stricter criteria.
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Mario Heirewegh
az Sint-Blasius Belgium
Facts and figures
Currently the
corticosteroid use still
almost 28% less than in
the baseline, in spite of
the re-rising trend.
Reduction of the total #
mg corticosteroids per
patientday → steroid-
related side effects ↓
Shift from intravenous to
oral adminstration → safer
and more cost efficient.
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Mario Heirewegh
az Sint-Blasius Belgium
Sincere thanks to the entire team for their
daily commitment.
Together, with respect, for your
wellbeing!
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Mario Heirewegh
az Sint-Blasius Belgium
It’s a matter of breath or death !
Questions ?