Transcript Patient Empowerment in Chronic Obstructive Pulmonary Disease

Patient Empowerment in
Chronic Obstructive
Pulmonary Disease (COPD)
Noreen Baxter
Respiratory Nurse Specialist
May 2005
Definition of COPD
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Chronic obstructive pulmonary disease (COPD) is
characterised by airflow obstruction. The airflow
obstruction is usually progressive, not fully
reversible and does not change markedly over
several months. The disease is predominantly
caused by smoking (NICE 2004)
 COPD produces symptoms, disability and
impaired quality of life.
Epidemiology of COPD
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1% of the UK population is diagnosed with
COPD
• 50% of presenting patients are correctly
diagnosed
25% of the total number of COPD patients are
recognised
• The potential prevalence of COPD in the UK is
estimated to be approximately 3 million
Global Impact
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Only preventable cause of death
currently increasing
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COPD is currently the 4th leading cause of
death
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By 2020 expected to rank 5th as a world
wide burden of disease
Local Impact
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50 practices in North and West Belfast
 6 practices involved in the project
 Total number of patients-19,524 patients
 Patients on the COPD register-598 patients
 75% of patients not diagnosed
Aims
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To initiate change in practice using evidence based
guidelines and protocols
Implement a well researched and planned pilot
study
Provide a seamless carepathway between primary
and secondary care from diagnosis to palliation
Provide greater patient choice and individualised
expert care in the patients home
Increase patient satisfaction
Provide an efficient and effective patient focused
service
Gaps in Services in
Community and Primary Care
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Publics lack of awareness of COPD
Lack of early screening resulting in lack of health
promotion and prevention
Detection of early stages ignored
COPD clinics- fragmented care
Treatment and follow-up not standardised
Seamless care needed addressed
No support for staff
Slow access to specialist clinics
Gaps in Secondary Care
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Lack of support for patients / carer on discharge
No formal structured education in primary care,
community care and secondary care
Lack of understanding in the importance of self
management advice
Importance of referrals for holistic management
and home support were not recognised
Palliative care needs were not addressed
Patients choice and autonomy were ignored
Action in Primary Care
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Training needs were identified
Multiprofessional study days /educational sessions
held
Health screening for early diagnosis / prevention
(30% of patients with COPD)
Facilitation at COPD clinics, smoke cessation
clinics, health promotion awareness sessions
Evidence based standardised care / follow-up
Initiate optimal treatment / seamless care
Self management strategies
Action in Secondary Care
Intensive Home Support
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Follow up for those with severe disease /
NIV
Patients commenced on Long Term Oxygen
 Non attendees at clinics
 Regular attendees at A/E
 Follow up for those discharged from A/E
 Housebound patients referred by GP for
management and optimal treatment
Education Package
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Disease / Symptom and anxiety management
Exacerbation management
Self management plan
Smoking cessation /energy conservation/breathing
techniques / nutritional advice / exercise/relaxation
Goal setting /appropriate MDT referrals
Advice on LTOT/nebuliser /inhalers
Sexuality / travel/ benefits
Advanced directives. Palliative care issues
addressed
Contact number
Outcomes
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69 patients involved
 32% were not readmitted
 9% had fewer admissions
 41% reduction in readmissions (despite
being at the severe end of the disease)
 40% of patients had been treated at home
for exacerbations
Benefits for the patient
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Raise self esteem/self worth/ self control
Patients are listened to as experts of their own
disease initiating individualised care
Empowerment,quality, choice and autonomy
Provide a holistic approach to patient care
Patient / carer satisfaction
Palliative end stage care and support
Anxiety and depression are identified and
addressed
Improved compliance with treatment
Benefits for the service
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Raise awareness
Health screening, health promotion /prevention
Early diagnosis
Improved communication and documentation
between secondary and primary care
Seamless approach to care. Evidence based with
local protocols.
Patients expertise are used in education
Reduced admission rates
Improved access to specialist clinics
Moving On
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Early Supported Discharge Scheme
Community based Respiratory Nurse Specialists
Intensive home support to continue
Specialist Physiotherapist/Occupational
therapist/Dietician/Social worker/Psychologist
Medical staff grade working across the interface
Respiratory teams working in collaboration
Joint working between Trusts/Primary care and
community