Discharge 03 04 09


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Discharge 03 04 09

  1. 1. P rotocols for discharge planning . Neuromuscular disorders – H ome mechanical ventilation for patients with neuromuscular disorders Joan Escarrabill MD Master Plan of Respiratory Diseases (PDMAR) Institut d’Estudis de la Salut Barcelona [email_address] Stressa, April 3th 2009
  2. 2. 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.
  3. 3. Bertoye. Lyon Médical 1965;38:389-410. <ul><li>HMV is not a simple acute discharge. </li></ul><ul><li>A greement between doctors, patients and caregivers </li></ul><ul><li>Caregiver involvement is essential </li></ul><ul><li>Patient confidence is crucial </li></ul><ul><li>M eet the technical needs </li></ul><ul><li>Minimization risk strategies </li></ul>
  4. 4. Agenda Agenda Team training Discharge planning Safety 1 2 3
  5. 5. Agenda Agenda Team training Discharge planning Safety 1 2 3
  6. 6. <ul><li>Skills related to home mechanical ventilation (HMV) technology and home care </li></ul><ul><li>Ability to assess the adequacy of caregivers </li></ul><ul><li>Knowledge of community resources </li></ul><ul><li>Capacity to integrate home, outpatient, and hospital care </li></ul><ul><li>Designing of guideline-based care plans that integrate the clinical needs and preferences of the patient </li></ul><ul><li>Behavioral counseling and teaching of self-management </li></ul><ul><li>Expertise in group consultations </li></ul>
  7. 7. Actors of discharge : Health professionals Health professionals Discharge team Case manager Risk management Experience <ul><li>Chest physicians </li></ul><ul><li>Nurses </li></ul><ul><li>Respiratory therapists </li></ul><ul><li>Speech therapists </li></ul><ul><li>Nutricionists </li></ul><ul><li>Social workers </li></ul><ul><li>.... </li></ul>Hospital Primary care Resources in the community Non-profit Private Volunteers
  8. 8. 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
  9. 9. Key elements in discharge Multidisciplinary effort Comprehensive                            Integrated Starts earlier Over time Process
  10. 10. Key elements in discharge Process Multidisciplinary effort Comprehensive Integrated Harmonic
  11. 11. Agenda Agenda Team training Discharge planning Safety 1 2 3
  12. 12. 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).
  13. 13. 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.
  14. 14. Monaldi Arch Chest Dis 2003; 59: 2, 119-122. <ul><li>Diurnal adaptation </li></ul><ul><li>Efficacy of nocturnal ventilation </li></ul><ul><li>Hospital training: caregiver & patient </li></ul><ul><li>Follow-up plan </li></ul>
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. Actors of discharge Health Service Hospital Supplier Caregiver Home Patient Financial issues Public/Private Discharge team Case manager Risk management Education Experience
  19. 19. 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
  20. 20. <ul><li>Ventilation and oxygen needs stable or palliative care plan. </li></ul><ul><li>Cardiovascular stability or palliative care plan . </li></ul><ul><li>Patient and family motivated to achieve discharge . </li></ul><ul><li>Feeding established. </li></ul><ul><li>Manageable secretions. </li></ul><ul><li>Technical resources can be managed at home . </li></ul><ul><li>Organization of care in the community can be achieved . </li></ul><ul><li>Funding can be gained for home care package . </li></ul><ul><li>No change expected in the management of the disease </li></ul>Criteria for discharge Addapted from Pratt P & Escarrabill J (2008) Kinnear (1994)
  21. 21. 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                                               
  22. 22. Practical tools Health professionals Checklist Patients & caregivers Written information Phone numbers Ventilator settings Especific recommendations
  23. 23. Equipment needs for NIV Schönhofer B, Sortor-Leger S. Eur Respir J 2002;20:1029-38 Respiratory accessories <ul><ul><li>Humidification </li></ul></ul><ul><ul><li>Oxygen supplementation </li></ul></ul><ul><ul><li>Drugs nebulisation </li></ul></ul><ul><ul><li>Power supply: battery power source, backup ventilator </li></ul></ul>Secretions management Daily living activities Communication Nutrition
  24. 24. 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
  25. 25. 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
  26. 26. Daily living activities <ul><li>Mobility </li></ul><ul><ul><li>Strollers. </li></ul></ul><ul><ul><li>Standard Wheelchairs. </li></ul></ul><ul><ul><li>Rigid Frame Weelchairs. </li></ul></ul><ul><ul><li>Nonrigid Frame Weelchairs. </li></ul></ul><ul><ul><li>Seating Systems. </li></ul></ul><ul><ul><li>Motorized Weelchairs </li></ul></ul><ul><li>Transfer and lifting systems </li></ul><ul><li>Transportation </li></ul>
  27. 27. Daily living activities www.mobilityexpress.com/
  28. 28. Room setting <ul><li>Accessibility </li></ul><ul><ul><li>Doors </li></ul></ul><ul><ul><li>Elevators </li></ul></ul><ul><ul><li>Alternative systems (volunteers) </li></ul></ul><ul><li>Bed and mattressses </li></ul><ul><li>Bathing and toileting </li></ul>
  29. 29. Room setting www.medame.com
  30. 30. Technological support <ul><li>Architectural Elements </li></ul><ul><li>Communication </li></ul><ul><li>Computers </li></ul><ul><li>Home Management </li></ul><ul><li>Personal Care: eating, personal higyene </li></ul><ul><li>Orthotics & Prosthetics </li></ul><ul><li>Recreation </li></ul><ul><li>Seating </li></ul><ul><li>Sensory Disabilities </li></ul><ul><li>Therapeutic Aids </li></ul><ul><li>Transportation </li></ul><ul><li>Vocational Management </li></ul><ul><li>Walking </li></ul><ul><li>Wheeled Mobility </li></ul>Patients will need a wide range of assistive devices, in some cases for a short period of time Support groups may help provide short term use devices
  31. 31. Nutritional status <ul><li>Difficulties in chewing and swallowing </li></ul><ul><li>Factors triggering or aggravating eating problems: </li></ul><ul><ul><li>Food textures </li></ul></ul><ul><ul><li>States / consistences </li></ul></ul><ul><ul><li>Bolus size </li></ul></ul><ul><li>Associated difficulties wuth salivation </li></ul><ul><li>Breathing d isorders while eating </li></ul>Proactive approach to anticipate dysphagia symptoms The BMI should be used with caution for the evaluation of the nutritional status of patients with ALS and Duchenne muscular dystrophy Pessolano FA et al . Am J Phys Med Rehabil 2003;82:182-185.
  32. 34. Effective communication The maintenance of effective communication favors patients remaining in the communitiy <ul><ul><li>Bach JR. Am J Phys Med Rehabil 1993;72:343-9 . </li></ul></ul>Simple icons
  33. 35. A ugmentative and alternative communication (AAC) devices N ot waiting until speech is affected to start asking around for a AAC <ul><li>symbol-based , </li></ul><ul><li>text-based , </li></ul><ul><li>text-to-speech machines , in which you can type a sentence and the computer “speaks it.” </li></ul>www.als-mda.org/publications/everydaylifeals/ch6/#aac_devices Eye Tracking Head Mouse Trackballs Joysticks Touch Screens Mouse Alternatives
  34. 36. 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
  35. 37. Agenda Agenda Team training Discharge planning Safety 1 2 3
  36. 38. 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
  37. 39. <ul><li>Power failure </li></ul><ul><li>Ventilator malfunction </li></ul><ul><li>Accidental disconnection </li></ul><ul><li>Circuit obstruction </li></ul><ul><li>Mask fit </li></ul><ul><li>Tracheostomy: </li></ul><ul><ul><li>Blocked </li></ul></ul><ul><ul><li>Falls out </li></ul></ul><ul><ul><li>Cannot be replaced after changing </li></ul></ul><ul><li>Medical problems </li></ul>Thorax 2006;61:369-71 Risk exist We can prevent risk Tecnical service Training (patient and caregiver) Patient shared records
  38. 40. www.ventusers.org/vume/TreatingNeuroPatients.pdf <ul><li>The patient and designated caregiver are experts . </li></ul><ul><ul><li>accept the patient's suggestions even if they run contrary to standard hospital protocols . </li></ul></ul><ul><li>Communication is critical . </li></ul><ul><li>Return to the patient’s routine as soon as possible. </li></ul><ul><li>No oxygen alone. </li></ul><ul><li>Be careful with anesthesia and sedation </li></ul><ul><li>Use the patient’s own ventilator </li></ul><ul><li>Ask the patient or caregiver about acceptable positions. </li></ul><ul><li>Life continuation/cessation is the patient’s decision </li></ul>
  39. 41. 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
  40. 42. 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
  41. 43. Follow-up assessment Pulsioximetry <ul><li>Home visits </li></ul><ul><li>Outpatient clinic </li></ul><ul><li>Hospital admission </li></ul><ul><li>Phone call </li></ul><ul><li>General practitioner </li></ul><ul><li>Community resources </li></ul><ul><li>e-mail </li></ul>
  42. 44. Vitacca M. Breathe 2006;3:149-158 Vitacca M. Telemed & e-Health 2007;13:1-5 Telemedicine is an innovative medical approach
  43. 45. 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
  44. 46. www.slideshare.net/ jescarra