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Regional COPD Pre-printed Orders & Discharge Plan. Standardizing Improved COPD Management Across the Lower Mainland. Learning Objectives. COPD prevalence, admission rates, and economic burden in Canada & BC What COPD management looked like in 2009 How to improve COPD care in hospital

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regional copd pre printed orders discharge plan

Regional COPD Pre-printed Orders & Discharge Plan

Standardizing Improved COPD Management Across the Lower Mainland

learning objectives
Learning Objectives

COPD prevalence, admission rates, and economic burden in Canada & BC

What COPD management looked like in 2009

How to improve COPD care in hospital

Factors affecting QOL, morbidity, and mortality of COPD patients

How to better link your patient to community support programs and services

How to use the Regional COPD Care Planning & Discharge Plan

copd facts
COPD facts:

4th leading cause of death in Canada (2004)

COPD prevalence is on the rise, especially in women

Estimated 1.5 million Canadians have been diagnosed, another 1.6 million report symptoms but have not been tested (spirometry)

COPD exacerbations (aka “Lung Attacks”) have the same consequences as a heart attack in terms of the patient’s quality of life, future hospital admissions, and mortality


Trends in age-standardized death rates

(Percent change between 1970 and 2002)



COPD [#4]


COPD: greatest increase in death rate amongst the 6 leading causes











Diabetes [#6]

- 63.1%


- 52.1%

- 41.0%



Cancer [#2]



All causes


Accidents [#5]


Heart disease [#1]


Stroke [#3]

Adapted from Jamal A, et al. JAMA 2005; 294:1255-1259

Adapted from Jamal A, et al. JAMA 2005; 294:1255-1259

the human economic burden of copd
The Human & Economic Burden of COPD

COPD now accounts for the highest rate of hospital admissions among major

chronic illnesses in Canada (CIHI – 2008) – CTS report Feb 2010

feb 2010 cts report con t
Feb 2010 CTS Report (con’t)

Hospital admissions for COPD average 10-day LOS at cost of $10,000 per stay

Total annual cost estimated at $1.5 billion per year

COPD is frequently not diagnosed, even when patients are hospitalized for an exacerbation – COPD can contribute to other issues (ex. CHF, pneumonia)

vancouver snapshot
Vancouver Snapshot:

Study comparing 3 hospitals in Vancouver (Apr 2001 – Dec 2002)

Variations in care

59% patients received oral or parenteral corticosteroids in first 24 hours

Variable re-admission rates

38% of patients had at least one subsequent hospital readmission (within 5 (+/-4.08) month period)

Can Respir J Vol 16 No 4 July/August

existing barriers identified 2009
Existing Barriers Identified (2009)

PPO existing at most sites but all differed from each other (no standard of care)

No COPD discharge plan

Low awareness – both physicians and staff

Clinical Pathway resulted in redundant charting

goals for copd in hospital management
Goals for COPD In-hospital Management

Reduce Length of Stay (LOS)

Reduce Readmission rates

Minimize impact of exacerbation on overall disease progression

Improve overall management of AECOPD according to best practice guidelines (CTS, GOLD)

Create links between acute and primary care

Create links with community programs and follow-up post discharge

Improve patient quality of life (QOL)

in hospital documents
In-Hospital Documents

Regional documents assure streamlined care according to evidence based best practice guidelines

1. COPD Exacerbation Admission Order set (PPO) for admitted patients

3. COPD Discharge Plan

Documents tie into one another and attempt to fill gaps in care

links to programs support
Links to Programs & Support

Smoking cessation: QuitNow program

Links to COPD Discharge Plan

Referral to Spirometry and COPD Management Services (through COPD Discharge Plan)

List of patient education materials on back of care planning pathway

Links to GP

co morbidities associated with copd
Co-morbidities Associated with COPD

Ischemic Heart Disease

Congestive Heart Failure


Pulmonary Hypertention

Lung Cancer

Osteoporosis and Fractures

Skeletal Muscle Dysfunction

Cachexia and Malnutrition

Glaucoma and Cataracts


Anxiety and Panic Disorders

Metabolic Disorders

Can Respr J 2008;15(Suppl A):1A-8A

predictors of survival bode
Predictors of Survival (BODE)


Degree of Obstruction

Dyspnea (MRC Scale)

Exercise capacity

Other risk factors for increase mortality:

Presence of co-morbidities

History of repeat ED or hospital admission


Low PaO2

improving predictors of survival
Improving Predictors of Survival

BMI: Diet

Obstruction: Phamacotherapy

Dyspnea: Pulmonary Rehab, Self Management Education

Exercise capacity: Mobility, Pulmonary Rehab

Smoking cessation support

Co-morbidities: reduce risk of developing, management of existing co-morbidities

Repeat admission: Adequate follow up and referral post discharge

Age: no cure!

Low PaO2: Home O2 for those who qualify

copd plan of care indicators for improving los
COPD Plan of Care:Indicators for improving LOS


State of inflammation/infection (measured by temperature, sputum production)

Dyspnea (compared to patient baseline)

Activities of Daily Living/Mobility (compared to patient baseline)


Check box if indicator is met, or an “X” if indicator does not apply to the patient. Initial and date only if you sign off on the indicator


It’s important to remember to compare patient symptoms and activity tolerance to what was normal for them (baseline) prior to exacerbation

A patient’s baseline shortness of breath, mobility, diet tolerance, and sputum production will be unique in each patient

pre discharge phase teaching
Pre-Discharge Phase: Teaching

Teaching from the acute and transition phases should be reviewed and re-enforced

Introduce exercise and strength building exercises

Inhaler technique should be reviewed and checked

Smoking cessation strategies and post-discharge plan should be reviewed

Review the COPD Discharge Plan with the patient (copy will go with the patient)

pre discharge phase discharge planning
Pre-Discharge Phase: Discharge Planning

Complete the COPD Discharge Plan & fax COPD to Spirometry clinic/lab and COPD community program if referred

Home O2 assessment if you suspect they may need it

Patient vaccinations should be up to date (Influenza and pneumoccocal)

Links to follow up support in the community are made at this time

Notify the GP of discharge (fax/send discharge summary and COPD Discharge Plan)

Fax QuitNow referral (if applicable)

copd discharge plan
COPD Discharge Plan

Guides patient with post-discharge directions

Improves gap between acute and primary care

Serves as a referral to spirometry, pulmonary rehab, and/or COPD Clinic

Physician to fill out and sign page 1

If referred for spirometry or rehab, tick the location referred to on page 2

Fax as per booking directions

Copy of all 3 pages will go home with the patient, original stays in patient chart

copd pre printed order ppo
COPD Pre-Printed Order (PPO)

A Regional COPD Exacerbation Admission PPO has been approved across 3 health Authorities (VCH, PHC, and FHA)

There are areas of the PPO that can be modified as per site policy or resources

PPO should be initiated in the ED when the patient is admitted.

The PPO ties into the Care Planning Pathway – part of admission instructions is to initiate clinical pathway. Which we are not trialing at this time.


Where will these documents be kept on your ward?

Who (if anyone) will take ownership of ensuring these documents are completed?

What tools are available to learn more about COPD and it’s management?

Who can be called if there are questions?