Presentation Post-graduate Course ERS Vienna Seotember 12th 2009

1. Joan Escarrabill MD Director of Master Plan for Respiratory Diseases Institut d’Estudis de la Salut Barcelona [email_address] How to organize teaching and discharge management Vienna. September 12th 2009

3. Lassen. Lancet 1953;i:37-41. Bag ventilation

4. of cases of polio that needed ventilation during the acute phase required long term ventilatory support 10% Kinnear Br J Dis Chest 1985;79:313-51.

6. Eur Respir J 2002; 20: 1343–1350

7. Discharge at different levels ICU Home Outpatient clinic General ward RICU High-dependency unit Hospice

9. Team Expertise +

11. The team produces more than the individual contributions of members.

12. Patient care team Wagner. BMJ 2000;320:569-72. R. Casas & P Romeu (1897)

15. Learning curve The amount of clinical exposure and levels of self-reported competence, not years after graduation , were positively associated with quality of care Hayashino Y. BMC Medical Education 2006, 6:33 Hasan A. BMJ 2000;320:171-3 We can minimise the learning curve Formal training courses Simulation Assistance from expert

16. Qual Saf Health Care 2009;18:63–68.

18. Actors of discharge Health Service Health professionals Supplier Caregiver Home Patient Financial issues Public/Private Discharge team Case manager Risk management Education Experience

20. Key elements in discharge Harmonic Multidisciplinary effort Comprehensive Integrated Starts earlier Over time Process

21. J Nurs Care Qual 2004;19:67-73 Case manager coordinates the discharge plan Patient and caregiver Confidence & competence Nurses & RRT Understanding of what is needed Physician Confidence that the patient’s needs are being met

23. Discharge planning Discharge planning is defined as the development of an individualised discharge plan for the patient prior to them leaving hospital for home Definition The discharge planning includes the multidis ci plinary effort for the transition between the hospital and the home (or the facility where we transfer the patient).

24. Aims of discharge planning SAFETY & EFFICACY O’Donohue W. Chest 1986;90(suppl):1S-37S. To prepare patients and carers... ...physiologically and psychologically for transfer home, with the highest level of independence that is feasible. To provide continuity of care... Bertoye A. Lyon Médical 1965;38:389-410.

26. Initiation of NIV 28 patients DMD Spinal musc atrophy Old polio Scoliosis Thoracoplasty Stable nocturnal hypoventilation IN group may be more effectively ventilated (al least in the first 2-3 months)

27. Respir Med 2007; 101:1177-82 5.5 + 1.3 ses s ions 7 + 1.1 LOS (days) 16 patients 6.8 + 1 hours/day 6.6 + 1.3 hours/day Compliance

28. Outpatient vs inpatient initiation of NIV Small impact in the hospital resources consoumption (availability of beds) Outpatient initiation of NIV It’s feasible and safe Not better than inpatient In some cases inpatient initiation is mandatory Social factors encourage inpatient initiation (distance, caregiver...)

29. NIV: Feasibility Indication Feasibility Characteristics of the respiratory failure Home conditions Patients preferences Discharge NON YES Alternatives Hospice Low tech hospitals Practicability of a proposed project

30. NIV: Feasibility Indication Feasibility Characteristics of the respiratory failure Home conditions Patients preferences Discharge NON YES Alternatives Hospice Low tech hospitals Technical criteria Social criteria

31. High dependency or high risk Impaired self-care Free time out ventilator < 10 hrs Dependency Accessibility Living far from the hospital Comorbidity Non respiratory clinical condicionts Home and caregiver conditions Respir Care 2007; 52:1056-62 Invasive home ventilation

32. Respir Med 2007;101:1068-1073 A = Acute E = Elective n = 43 Age = 77 + 1.9 yrs Compliance : 8.3 + 3.1 hrs/day Dropout 11% Patients < 75 yrs: 2% 9% 4,8% Compliance < 4 h/day

33. HMV in patients > 75 yrs old Survival 6 yrs Farrero et al. Respir Med 2007;101:1068-1073

34. Chest 2004;126:1583-91 15% Octogenarians of ICU Admissions 35% Discharge to care facility Mortality

36. Discharge in practice Timing Discharge process starts as soon as possible Feasibility Identify the competent caregiver Education Analize practical issues Take your time Home visit Discharge Avoid the weekend Case manager

37. Practical tools Health professionals Checklist Patients & caregivers Written information Phone numbers Ventilator settings Especific recommendations

39. Secretions management Hanayama. Am J Phys Med Rehab 1997;76:338-9 Seong-Wong. Chest 2000;118:61-5 Eductional programme Clearance secretions Manually assisted coughing Hyperinsufflations Insufflation-exuflation cycles Mechanically assisted coughing

40. Manually assisted cough Air stacking Deliver volumes of air that the patient retained to the deepest volume possible with a closed glottis Ambu bag Volume ventilator

42. Daily living activities www.mobilityexpress.com/

44. Room setting www.medame.com

51. A ugmentative and alternative communication (AAC) devices Though handheld or palm computers may be attractive, their small size may soon make them unmanageable to a person with neuro-muscular disease

53. Follow-up Package therapy Clinical follow-up Caregiver role Risk management Respite and Ongoing Support

55. Respir Med 2007;101:62-68 Post-operative intubation time 3,8 + 3,2 h. Only 1 patient > 12 h. Stay un postsurgical reanimation unit 19 + 9 h. 19 + 6 h. in the general population n=16

56. www.ventusers.org/vume/HomeVentuserChecklist.pdf

58. Therapy “package” Servera E. Sancho S. Lancet Neurol 2006;5:140-7 It’s mandatory to evaluate therapy “package” C hanges over time

59. Caregiver depression Chest 2003;123:1073-81 Caregivers of patients receiving LTV have similar characteristics to other caregiving populations

61. Neale G. J R Soc Med 2001;94:322-330. < 20% Directly related to surgical operations or invasive procedures < 10% General ward care 53% 18% Misdiagnoses At the time of discharge

62. Ann Intern Med 2005;142:121-8 41% ...test results return after discharge 9.4% of theses results were potentially actionable

63. CMAJ 2004;170(3):345-9 … of patients had an adverse event (AE) after hospital discharge 1/4 50% of the AEs were preventable or ameliorable.

65. August 14 2000 Power cut kills man on home ventilator BY SAM TOWLSON AN INVESTIGATION has been launched into the death of a disabled man whose life-saving equipment failed during a power cut. Safety Feb 15, 2001 A Fatal Complication of Noninvasive Ventilation Lechtzin N., Weiner C. M., Clawson L. N Engl J Med 2001;344:533

66. Alarm malfunction 0,9% Power off n = 300 18,6% Disconnection 5,1% Obstruction

67. 13 % 4 %

69. Risk minimisation (i) Accidental disconnection from ventilator Adapted from AK Simonds, 2001 Power failure Back-up ventilator Regular maintenance Battery Ambu bag Blocked Humidification Suction Falls out Trained caregiver to change trach Smaller size trach tube available Technical aspects The device Ventilator breakdown Tracheostomy

70. Risk minimisation (ii) Adapted from AK Simonds, 2001 Medical and social aspects Resources in the community Communication Medical problems Exacerbation alarm signs Ressucitation Medical hot-line Emergency phone numbers Ambulances Supplier

71. Respite and Ongoing Support.... when the burden of home care can be great Hospice Palliative care support

72. Hospital Pre-discharge Patient evaluation Community preparation Clinical stability Nutrition Secretion management Caregiver Technical support Financial issues Home conditions Feasible? Yes Non Home Alternatives (Hospice?) Discharge Plan Discharge Equipment Training Ventilator Humidification Suction devices Wheel chair Patient Caregiver Emergencies Funding application

75. Patients on HMV Prevalence / 100.000 hab (*) without pediatric patients

76. Relationship with resources in the community Population: 291.500.000

77. Generalists or specialized teams: only? Generalists Specialized teams Support network

78. Community nurse Home care General practitioner Resources in the community RRT Social worker Occupational therapist Multidisciplinary team

79. Network Reference center General practitioner Support network I nformation technology and communication Escarrabill J. Arch Bronconeumol 2007;43:527-9 Patient-centered care : accessibility vs performance

82. Monaldi Arch Chest Dis 2007; 67: 3, 142-147. n = 792 patients 16% HMV >12 hours/day 20% Tracheo 45% Mobility / Handicap 36% Living > 30 km far from hospital Severity of the disease Accessibility

83. The “S. Maugeri” Telepneumology Programm Pulse oximetry / HR Pneumotacograph Central workstation on call Tutor nurse Vitacca M. Telemed & e-Health 2007;13:1-5 Technical elements Health professional access General support Nurse solving problems Access to pneumologist on duty 24 h/day Educational material Link with GP Telemetric monitoring

84. Vitacca M. Breathe 2006;3:149-158 Telemedicine is an innovative medical approach

85. Community nurse Home care General practitioner Resources in the community RRT Social worker Occupational therapist Multidisciplinary team Support team Hospice

87. Health care system Direct access to the team Waiting time Fragmentation

88. Working for patients on home mechanical ventilation Organized by: With the contribution of: Welcome Benvinguts Bienvenidos

89. Technological innovation Care & organization Real life

90. Quality of life Autonomy: to decide Mobility Social networks Caregiver support