The Wake Health Model Sharon D Cornelison RCP RRTNPS COPD Pathway Team Inpatient Team Hospitalist Critical Care Physician andor APP Respiratory Therapist COPD Navigators Pulmonary Consult Service MD andor NP ID: 1043461
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1. Reducing COPD Readmissions:The Wake Health ModelSharon D. Cornelison RCP, RRT-NPS
2. COPD Pathway TeamInpatient TeamHospitalist, Critical Care Physician, and/or APPRespiratory Therapist COPD NavigatorsPulmonary Consult Service (MD and/or NP)Transitional Care PharmacySocial Work/Case ManagementOutpatient Transitional Care Clinic TeamPulmonary Physician/Nurse PractitionerPulmonary Transitional Care Specialist (RT)Social Work/Case Management 2
3. COPD Pathway TeamOur team is RT centric5 Inpatient RT COPD Navigators & 1 Outpatient RTChart BiopsyBedside assessment/education including: - Hx - mMRC - Spirometry - CAT - PIFR - Breathing techniques, tobacco cessation, inhaler techniques/priming, COPD, exacerbation mgmtRT Navs follow patients daily until d/c (DME needs met, schedule TCM clinic appt, 24 hr f/u call, monitor ongoing meds/COPD ed, patient hotline # 3
4. Clinical Criteria for COPD Pathway SelectionInclusionary CriteriaAge ≥ 40 years oldTobacco history: ≥ 20 pack yearsMust have at least 2 of 3 sxs: - Increased cough above baseline - Worsening dyspnea above baseline - Changes in sputum (color, consistency, volume)Pneumonia (many patients with “undiagnosed” COPD may present with initial AECOPD 2/2 PNA)CHF (common comorbidity in COPD)4
5. Clinical Criteria for COPD Pathway ExclusionExclusionary CriteriaAge < 40 years (hx of A1AD, premature birth, BPD)Restrictive Spirometry Pulmonary EmbolismPneumothoraxPulmonary Edema 5
6. Inpatient Pathway InterventionsDiagnostic:CXR/CTBNP (common overlap & often elevated in AECOPD)ECHO (order if not current w/in 2 years)Bedside SpirometryPrior SpirometryPIFR (Peak Inspiratory Flow Rate)** Comorbidities that Increase Readmission Risk**CHFPneumoniaCancerCKD and/or Renal Failure (HD)DMMental Illness, Substance Abuse & Homelessness6
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10. Inpatient Pathway InterventionsTherapeutic:Scheduled albuterol/ipratropium nebs transitioned to PRNLABA+LAMA+ICS (neb vs MDI/DPI based on PIFR)Prednisone 40mg x 5 days POBroad spectrum abx (Moxifloxacin) x 5 days POAeroBika Mucus Clearance Device (TID x 10-20min session)Pulmonary Consult (MD/Fellow or NP)Palliative Care Consult for FEV1 < 50% pred, have at least 1 comorbidity, and > 1 hospital admission in 1 year10
11. Inpatient Pathway InterventionsTherapeutic:Transitional Care Pharmacy run test scripts to ensure meds - D/C home on LABA+LAMA+ICS w/PRN albuterol - D/C home with 30 days Spiriva Hospital to Home program Evaluate for home NIV or RAD if FEV1 < 50%, have baseline hypercapnia, and have > 1 admission requiring NIV/MV for hypercapniaSocial Work (eval SNF placement, Home Health needs, DME in place, assist with transportation, mental health resources, housing help)Referral to Pulmonary Rehab (current AARC recommendations support entry within 3 weeks of hospital discharge after AECOPD)11
12. Transitional Care Pulmonary Clinic VisitVisit with Physician/NP within 7-14 days post hospital d/c - Exam, tobacco cessation education, address comorbiditiesPre/Post Spirometry to confirm COPD dx and establish new baseline to determine ongoing need for triple therapyWalk for Desat and O2 Titration testingA1AD Testing for all post FEV1/FVC ration < 0.70Up to date on all vaccines (flu, PNA, pertussis)Reassess PIFR & personalize meds based on affordability, cognitive function, technique, & manual dexterityInhaler technique assessment & meds education12
13. Transitional Care Pulmonary Clinic VisitEvaluation & referral for Pulmonary Rehab vs Home Health/PTPalliative Care & Hospice referral, as indicatedSocial Work (DME, meds access, substance abuse resources, transportation to appts)13
14. Patient Education ToolsCOPD Action PlanBreathing RetrainingMedicationsExacerbation MgmtEnergy ConservationOxygen script What is COPD?Tobacco CessationCOPD Pathway Clinic 14
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22. Formulary.com 22App & website helps clinicians know what meds are covered under each insurance planCovers MCR, MCD, Commercial plans
23. EPIC EMR SmartPhrase for pMDIsSYMBICORT (budesonide/formoterol fumarate dihydrate) MDI at a dose of 80 or 160mcg/4.5mcg It is recommended to prime the MDI inhaler before using for the first time and in cases where the inhaler has not been used for more than 1 week. Prime the inhaler by making sure it is at room temperature, then shake well for 30 sec, and finally, by spraying four “test sprays” into the air and away from your face. Your inhaler is now ready for use.Instructions: 2 puffs inhaled SLOWLY every morning and evening with spacer** Your spacer SHOULD NOT whistle when you inhale your medications. If it does, you are breathing in too quickly. SLOW DOWN!RINSE SWISH GARGLE & SPIT with water only after use to prevent oral thrushDO NOT USE alcohol based rinses (Listerine, Scope, etc) as this increases risk of thrushALWAYS use a spacer with this inhaler as pictured aboveSee website below for instructional video:http://www.nationaljewish.org/healthinfo/medications/lung-diseases/devices/metered-dose/aerochamber/23
24. EPIC EMR SmartPhrase for Respimat® SMIsSPIRIVA (tiotropium bromide) RESPIMAT at a dose of 2.5 or 5mcgIt is recommended to prime the Respimat inhaler before using for the first time and in cases where the inhaler has not been used for more than 1 week. Assemble inhaler as directed. Prime the inhaler by making sure it is at room temperature, and finally, by using the TOP technique (twist - open - press) & spraying four “test sprays” into the air and away from your face. Your inhaler is now ready for use.Instructions: 2 sprays inhaled SLOWLY every morningRINSE SWISH GARGLE & SPIT after use to reduce dry mouth effects/cavitiesContact your physician with any changes in vision, urination or worsening constipation while on this medicationSee website below for instructional video:https://hcp.spiriva.com/UsingRespimatwww.TheMist.comSmart Phone users: Text MIST to 9080324
25. The Wake Forest Baptist Health ModelSpirometric testing at bedside/in clinic to confirm obstructive pattern and a COPD diagnosisAppropriate inhaled device selection during admission and/or clinicTCM pharmacist-supervised medication reconciliation protocol before hospital d/cReceipt and filling of all respiratory medications prior to hospital discharge when possible (send home remainder of in house inhalers)Provide BI Spiriva Hospital to Home x 1 month25
26. The Wake Forest Baptist Health ModelRefer patients to our Medication Access Center (MAC) if uninsured or can’t afford copayEarly outpatient follow-up within 7-14 days after discharge in our pulmonary clinic to assess for meds efficacy, recheck PIFR & adjust device, if neededAdding adjunct medications to help reduce exacerbations and readmissions (e.g. roflumilast, chronic macrolides)Frequent inhaler device review & training Pulmonary rehabilitation referral for disease/self management skills & ongoing inhaler training26
27. ReferencesGlobal Initiative for Chronic Obstructive Lung Disease. Pocket Guide to COPD Diagnosis, Management, and Prevention: A Guide for Healthcare Professionals. pp. 48-57. Atkins PJ. Dry Powder Inhalers: An Overview. Respiratory Care. 2005; 50 (10): 1304-1312.Clark AR, Hollingsworth AM. The relationship between dry powder inhaler resistance and peak inspiratory conditions in healthy volunteers – implications for in vitro testing. J of Aerosol Med. 1993; 6 (2): 99-110.Loh CH. Peters SP, Lovings TM, et al. Suboptimal inspiratory flow rates are associated with chronic obstructive pulmonary disease and all-cause readmissions. Ann Am Thorac Soc. 2017:14 (8): 1305-1311www.alliancetechmedical.comRestrepo RD, Alvarez MT, Wittnebel LD, et al. Medication adherence issues in patients treated for COPD. Int J Chron Obstruct Pulmon Dis. 2008;3(3):371-384.Tashkin DP. A review of nebulized drug delivery in COPD. Int J Chron Obstruct Pulmon Dis. 2016;11:2585-2596.Dolovich MB, Ahrens RC, Hess DR, et al. Device selection and outcomes of aerosol therapy: Evidence-based guidelines: American College of Chest Physicians/American College of Asthma, Allergy, and Immunology. Chest. 2005;127(1):335-371.27
28. ReferencesLavorini F, Magnan A, Dubus JC, et al. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respir Med. 2008;102(4):593-604. Al-Showair RA, Tarsin WY, Assi KH, Pearson SB, Chrystyn H. Can all patients with COPD use the correct inhalation flow with all inhalers and does training help? Respir Med. 2007;101(11):2395-2401. Virchow JC, Crompton GK, Dal Negro R, et al. Importance of inhaler devices in the management of airway disease. Respir Med. 2008;102(1):10-19. Tashkin DP. A review of nebulized drug delivery in COPD. Int J Chron Obstruct Pulmon Dis. 2016;11:2585-2596. 28
29. Thank You!Sharon D. Cornelison RCP, RRT-NPSscorneli@wakehealth.edu(office) 336-713-8858(cell) 336-688-2389(fax) 336-713-8856Wake Forest Baptist HealthWinston-Salem, NC USA“A Mission to Care. A Mission to Cure.”29