St. Anthony Medical Clinic - PowerPoint Presentation

1. St. Anthony Medical ClinicSpirometry Implementation June 07, 2013

2. Financial Disclosure I have no financial disclosures or ties to any company. S Bledsoe MD

3. SAMC ASTHMA TEAMChampions & Coaches

4. i2i tracking and Asthma panelWe use a registry for tracking our care and outcomes. This is essential. If possible use your EMR.Created by 2 clinicians in our clinic and presented to the SFGH i2i committee. Done through the Living Clinical Record. Our first year of Kaiser funding was spent on this and developing an asthma panel. At the same time the SF Asthma Task Force provided our first Koko spirometer and training.Used also for calling patients in for the needed appointments in asthma care, screening, and for special educational events.

5. SAMCAsthma Patients as of April 2013 127Adult Asthma pts92 Pedi Asthma pts35

6. Spirometry in primary Care at SAMCWe use spirometry for :Diagnosis and severity assessment of asthma Follow up for asthma, especially with changing medication needs. Diagnosis and Severity assessment of COPD.Intermittent bronchitis and bronchiolitis in children. Is this asthma? Chronic smokers: to assess for damage and as motivator to show we are concerned with the health of their lungs. Great for clients entering recovery when they are changing many habits. History of shortness of breath or other respiratory complaints. Is this anxiety or a respiratory problem?

7. KO KO Legend machineFrom 06/2010 to 09/2011 We performed 91 Spirometry tests for Asthma evaluation using the Ko Ko Legend spirometer.SAMC started spirometry in 2009 using the small Ko Ko Legend with volunteer respiratory therapists. In 2010 we had more coaches training to use the Ko Ko for spirometry in primary care.

8. Spirometry Rpt from Ko Ko legend example#1

9. Features of the Koko in our clinic.Small, easily portable except for the calibration tube which was 4 feet long and hard to safely store.Fragile--this presenter broke the screen during the second training session! Flow gauge was fragile, cracked.Poor quality print-out paper, needed to photocopy, and manually scan into the chart. But it did give us some raw data and we were able to include all clinical providers into the training .

10. San Francisco Community Primary Care Spirometry ProgramIn March 17, 2011 we enrolled as a member of the San Francisco Community Primary Care Spirometry Program with Medical Director George Su MD, Eula Lewis Program Director, Stephanie Tsao, NP Healthy SF Asthma/COPD Program. Under the partnership agreement with SFPCSP, SAMC champions adults-Sonia Bledsoe MD, Pediatrics- Katy Broner MD, coaches Jackie Mojigo MA, Asthma care coordinator, and Zoe Arends-Derning completed the SPIROMETRY 360 course successfully between 03/2011-07/2011.Site Champions and coaches received the Certification from Spirometry 360 course, University of Washington, Seattle.

11. V Max Spirometry Machine ImageWe start using the V max in April 2011

12. V max features and useAll portions of testing equipment contained in 1 space which can be easily rolled as a unit.High quality recording of pulmonary function with flow volume loops and guarantee of accuracy if the spirometry technologist is trained and certified.The included laptop records results which then can be downloaded into our electronic medical record or sent via secure line or secure internet e-mail to chest physicians for interpretation.Secure storage--- area away from possible bumping or theft!

13. TrainingSpirometry 360 essential to learn the concepts about respiratory function. 3 months (3 hours/ week) for Webinars and then practice with equipment and coaching each other. Start with patients. Presumably V max training concurrently?Coaching education and practice is essential !!

14. SAMC Spirometry using V max

15. SAMC Asthma Care ProcessFO PCPPCPNew ptRegular ptInterpretation SFGH/LCR Final Rpt SAMC import Rpt to pt Chart Pharmacy Doctor visit: Asthma Ed. Med Counseling, AAplan Allergy Specialist Smoking Cessation SpirometryReferral To SFGH add to I2I

16. SAMC Cases of using Spirometry at Clinic site 1. Ms. Tan 59 years old asthmatic, a regular pt. in forf/u on asthma. Major mental health issues so objective criteria key to care. Referred by SB for spirometry. Ms Tan has seen Dr. Bledsoe since 2007, pt’s last spirometry was in 2012. 2. Mr. DJ new patient, 53 years old, smoker c/o SOB, cough for 2 weeks.On medication from an outside provider. Referred by SB for spirometry. No previous spirometry .

17. 3. Mrs.Dam, new patient, 40 years old, history of childhood asthma and pollen allergies. c/o wheezing, SOB, and allergies. Referred by Dr.Rayburn for spirometry. No previous spirometry .4. Mr.WP, 65 years old asthmatic, established patient. F/u asthma, referred by Dr.Rayburn for spirometry. Last Spirometry was in 2010.

18. Work Flow: Spirometry Internal Referral by PCP to Asthma DesktopEMR, orders sectionInternal referral: SpirometryAfter selecting: Instructions:Please indicate what test to perform: FVC pre-bronchodilator_________ or FVC Pre/ FVC Post______x______________.Standing orders cover the MA use of Albuterol

19. Appointment card and instructions SPIROMETRY /PULMONARY FUNCTION TESTING/ ORDERS Lab Location: St. Anthony Medical Clinic Appointment date. ……………Time…… Instructions:Don’t drink caffeine or use Inhalers / bronchodilators / for at least 12 hours before your test Don’t smoke for at least 2 hours before your test Don’t eat a heavy meal or do vigorous exercise for at least 2 hours before your testWear loose fitting clothes and remove back bracesOther: If you have an Inhaler / Albuterol/ bring it with you. Kids bring their Spacer.

20. Front Office work flowTake the card and while filling in times, remind the patient that they need to follow the instructions for the testing.Make sure there are language appropriate instructions explained and given. Send flag to translator if not in clinic.Just before the appointment call to confirm the appointment and the directions. If patients are sick or coughing we generally reschedule.

21. Front Office Scheduling ProcessWednesday AMFriday PM 8:30 am Mrs. Tan1:30 pm Mr. DJ9:20am Mrs. Dam2:20pm Mr. WP10:10 am3:10pm

22. Ms.Tan’s Spirometry Visit 8.30 AM Wednesday Pt. performed FVC pre/post bronchodilator. Spirometry Report sent to SFGH Chest Clinic to Dr. Su for evaluation.

23. MedicinesPt takes VENTOLIN HFA 108 (90 BASE) MCG/ACT AERS (ALBUTEROL SULFATE) 2 puffs every 4-6 hours as needed for shortness of breath NASONEX 50 MCG/ACT SUSP (MOMETASONE FUROATE) or nasacort AQ 2 inhalations every morning ALLEGRA ALLERGY 180 MG TABS (FEXOFENADINE HCL) 1 tablet a day for allergies, asthmaADVAIR DISKUS 250-50 MCG/DOSE AEPB (FLUTICASONE-SALMETEROL) Inhale 1 puff by mouth twice a day

24. PFT Interpretation /posted in LCR/DATE OF TEST: 02/15/13 The flow-volume curve is steep and vertically oriented. The forced expiratory volume in one second is normal. The forced vital capacity is normal. The ratio of FEV1 to FVC is normal. There is no significant reversal of airway obstruction after inhaling albuterol. This lack of response to a single inhalation of albuterol does not exclude reversible airway disease. Spirometry is normal. The steep and vertically oriented shape of the flow-volume loop and low normal forced vital capacity (80% predicted) are likely due to the patient's body habitus (BMI 30.63). If, however, there is concern for a concomitant restrictive lung process, you may consider full pulmonary function testing, including lung volumes and diffusion capacity measurements. Pre-Bronchodilator: Grade A (meets ATS rules). 3 acceptable efforts and variance </= 150 ml. Post-Bronchodilator: Grade B (meets ATS rules). 2 acceptable efforts and variance </= 150 ml. This spirometry study was performed at St. Anthony Medical Clinic through the SF Community Primary Care Spirometry Program. George Su M.D. 963835 reviewed and edited, as necessary, the above interpretation. Thank you for referring your patient to us for pulmonary function studies. Attending Physician

25. PCP Referral for Ms.Tan after SpirometryWe may consider reducing the steroid component in her Advair.Pharmacy Doctor visit: Asthma Ed. Med Counseling, Asthma Action Plan update.

26. Case#2 Mr. DJ’s Spirometry Visit Friday 1.30 PMPt. performed FVC pre/post bronchodilator. Spirometry Report sent to SFGH Chest Clinic to Dr.Su for evaluation.

27. Mr.DJ-s MedicinesADVAIR DISKUS 250-50 MCG/DOSE AEPB (FLUTICASONE-SALMETEROL) 1 inhalation every 12 hours for Asthma and COPDATROVENT HFA 17 MCG/ACT AERS (IPRATROPIUM BROMIDE HFA) 2 inhalations every 8 hours for COPD

28. PFT Interpretation /posted in LCR/DATE OF TEST: 02/22/13 The flow-volume loop is curvilinear. The forced expiratory volume in one second is moderately decreased. The forced vital capacity is normal. The pre-bronchodilator ratio of FEV1 to FVC is moderately decreased. The post-bronchodilator ratio of FEV1 to FVC is mildly decreased. There is no significant reversal of airway obstruction after inhaling albuterol. This lack of response to a single inhalation of albuterol does not exclude reversible airway disease. There is a mild obstructive ventilatory defect. Pre-Bronchodilator: Grade A (meets ATS rules). 3 acceptable efforts and variance </= 150 ml. Post-Bronchodilator: Grade A (meets ATS rules). 3 acceptable efforts and variance </= 150 ml. This spirometry study was performed at St. Anthony Medical Clinic through the SF Community Primary Care Spirometry Program. George Su M.D. 963835 reviewed and edited, as necessary, the above interpretation. Thank you for referring your patient to us for pulmonary function studies. Attending Physician

29. PCP Referral for MR.DJ after SpirometryPharmacy Doctor visit: Asthma Ed. Med Counseling, Asthma Action Plan updateSmoking Cessation

30. Ms.Dam’s Spirometry Visit 09.20 AM WednesdayPt performed FVC pre/pos BD. Pt Spirometry Rpt sent to SFGH Chest Clinic to Dr.Su for evaluation.

31. Mrs.Dam’s medicinesFLONASE 50 MCG/ACT SUSP (FLUTICASONE PROPIONATE)2 sprays/nostril Every day As Needed allergy symptoms.PROVENTIL HFA 108 (90 BASE) MCG/ACT AERS (ALBUTEROL SULFATE)1-2 puffs Every 4 hours As Needed cough, shortness of breath or wheezing

32. PFT Interpretation of Mrs.Dam /posted in LCR/DATE OF TEST: 03/27/13 The flow-volume loop is curvilinear. The forced expiratory volume in one second is normal. The forced vital capacity is normal. The ratio of FEV1 to FVC is normal. The flow-volume curve is curvilinear and suggests a mild obstructive ventilatory defect. There is no significant reversal of airway obstruction after inhaling albuterol. This lack of response to a single inhalation of albuterol does not exclude reversible airway disease. Pre-Bronchodilator: Grade A (meets ATS rules). 3 acceptable efforts and variance </= 150 ml. Post-Bronchodilator: Grade A (meets ATS rules). 3 acceptable efforts and variance </= 150 ml. This spirometry study was performed at St. Anthony Medical Clinic through the SF Community Primary Care Spirometry Program. George Su M.D. 963835 reviewed and edited, as necessary, the above interpretation. Thank you for referring your patient to us for pulmonary function studies. Attending Physician

33. PCP Referral for Mrs.Dam after SpirometryPharmacy Doctor visit: Asthma Ed. Med Counseling, Asthma Action Plan update.Possibly refer to Allergist

34. Mr.WP’s Spirometry Visit 09.20 AM Wednesday Pt couldn't perform FVC pre/post bronchodilator. A Note from the chart: Patient RTC for spirometry per Dr.Rayburn's order. Pt tried to perform spirometry but he had shortness of breath during test procedure and dizziness. He is not able to perform spirometry. Pt needs referral for PFT at SFGH. Sent flag to Dr. Rayburn’s desktop.

35. Mr.WP’s Current MedicinesSPIRIVA HANDIHALER 18 MCG CAPS (TIOTROPIUM BROMIDE MONOHYDRATE) one inhalation Every day for asthma/COPDXOPENEX HFA AERO (LEVALBUTEROL TARTRATE AERO) 1-2 puffs Every 4 hours As Needed cough, shortness of breath or wheezing

36. PCP Referral for Mr. WP after Spirometry VisitSFGH PFT ReferralSee his primary now or very soon

37. CostsDepending on the number of visits (6 in a day ) 8 hours of MA time per week. Spirometry takes time! Capture, download and entry of formal reading into clinic system, and updating i2i takes time.Training required takes about 6 months in our clinic between 360 and V max before proficiency is reached. Depends on training availability. Continuing education and recertification time.Miscellaneous: Albuterol inhalers , spacers for the Pedi patients using Albuterol, gloves, hand sanitizer.

38. SavingsTo the Community : with good asthma control we keep patients out of the ED and prevent avoidable admissions.To the Clinic: in our clinic fewer patients requiring walk-in or urgent nebulized treatments.For the providers: reliable information in patients who are stable allows for less frequent visits.Most importantly for the patient: Using Spirometry we have objective evidence to act on to prevent progression of damage and limit unecessary medications.