La dimissione vs 4

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Presentació a Volterra (18 de febrer de 2011)

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La dimissione vs 4

  1. 1. La dimissione Joan Escarrabill, MD Master Plan For Respiratory Diseases (PDMAR) Ministry of Health Health Studies Institute Barcelona [email_address]
  2. 2. Punti chiave 1 La dimissione è importante dal punto di vista de la sicurezza dei pazienti e de l'efficacia del trattamento 2 Il processo è complesso e richiede il lavoro di squadra. 3 Ogni volta che si verifichino dei cambiamenti di trattamento è necessario prendere in considerazione l'adattamento del paziente.
  3. 3. Agenda
  4. 4. Discharge planning
  5. 5. Discharge planning Long-term care facilities General ward ICU Emergency department Outpatient clinic Weaning center
  6. 6. Monaldi Arch Chest Dis 2007; 67: 3, 142-147. n = 792 patients 20% 45% 16% 36%
  7. 7. Monaldi Arch Chest Dis 2007; 67: 3, 142-147. n = 792 patients 18%
  8. 8. Escarrabill J. Eur Respir Mon, 2008, 41, 367–376
  9. 9.
  10. 10. Neale G. J R Soc Med 2001;94:322-330.
  11. 11. CMAJ 2004;170:1235-40
  12. 12. Teamwork Communication Most problems (and accidents) relate with …
  13. 13. <ul><li>Feeling hurried by the physician (28%) </li></ul><ul><li>Finding a quiet place to call (25%) </li></ul><ul><li>Difficulty reaching the physician (21%) </li></ul>Barriers to effective nurse-physician communication
  14. 14. Effective team <ul><li>Ha una gamma di individui che contribuiscono in modi diversi. </li></ul><ul><li>Obiettivi chiari . </li></ul><ul><li>Tutti capiscono i compiti che devono fare . </li></ul><ul><li>Co ordinatore </li></ul><ul><li>Atmosfera informale . </li></ul><ul><li>D iscussione ( I membri del gruppo ascoltare gli altri ) </li></ul><ul><li>Sentitevi liberi di criticare. </li></ul><ul><li>Comodo con disaccordo. </li></ul><ul><li>Apprendimento dall'esperienza. </li></ul>www.kent.ac.uk/careers/sk/teamwork.htm
  15. 15. Il team ottiene risultati migliori rispetto alla somma dei risultati ottenuti da ogni singolo membro.
  16. 16. Wagner. BMJ 2000;320:569-72. Casas and Romeu in tandem (1897)
  17. 17. Aiken L. NEJM 2003;348:164-6 Increasing role of non-physcian health professionals .
  18. 18. <ul><li>Competenze relative alla ventilazione meccanica a casa (HMV), la tecnologia e l'assistenza domiciliare. </li></ul><ul><li>Capacità di valutare l'adeguatezza dei caregivers. </li></ul><ul><li>La conoscenza delle risorse della comunità. </li></ul><ul><li>Capacità di integrare casa, ambulatoriale e ospedaliera. </li></ul><ul><li>Progettazione di piani di cura a base di linea guida che integrano le esigenze cliniche e le preferenze del paziente. </li></ul><ul><li>Behavioral consulenza e l'insegnamento di auto-gestione. </li></ul><ul><li>Esperienza in consultazioni gruppo </li></ul>
  19. 19. BMJ 2009; 339:b3595
  20. 20. The network of discharge Financial issues Public/Private Discharge team Case manager Risk management Education Experience Health Service Health professionals Supplier Caregiver Home carers
  21. 21. Escarrabill J. Eur Respir Mon, 2008, 41, 367–376
  22. 22. Piper A. Breathe 2010;6:323-33
  23. 23. J Nurs Care Qual 2004;19:67-73 Case manager coordinates the discharge plan Confidence & competence Understanding of what is needed Confidence that the patient’s needs are being met Patient and caregiver Nurses & RRT Physician
  24. 24. Agenda
  25. 25. Thorax 1998;53:762–767 <ul><li>to enhance quality of life </li></ul><ul><li>to sustain and extend life without compromising quality. </li></ul><ul><li>to improve or sustain physical and psychological function </li></ul><ul><li>to provide cost effective care. </li></ul>
  26. 26. Discharge planning... ...is defined as the development of an individualised discharge plan... ...prior to them leaving hospital.
  27. 27. NIV: Feasibility
  28. 28. Aumento del rischio, i risultati clinici più incerto e più costosi. 103 pazienti 457 transitions
  29. 29.
  30. 30. Needs assessment Home carers Equipment & supplies Communication Daily living Risk management Funding
  31. 31. Home carers Home carers Equipment & supplies Communication Daily living Risk management Funding O Noeregaard & J Escarrabill Tailored educational programmes for patients and caregivers Well-structured programme with theoretical knowledge and practical skills
  32. 32. Patient & Caregiver Training Source: Eurovent Survey Home carers Equipment & supplies Communication Daily living Risk management Funding Patients Caregivers Is training crucial before discharge? 97% 84% Is there a continued training after discharge? 36% 34%
  33. 33. Equipment needs for NIV Schönhofer B, Sortor-Leger S. Eur Respir J 2002;20:1029-38 Home carers Equipment & supplies Communication Daily living Risk management Funding
  34. 34. Augmentative and alternative communication (AAC) Home carers Equipment & supplies Communication Daily living Risk management Funding Speak slowly If able, use gestures Identify the topic first before Writing Boards Software: word prediction.... www.muscle.ca/ Specialized Telephone Equipment
  35. 35. Daily living activities Home carers Equipment & supplies Communication Daily living Risk management Funding <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>
  36. 36. Daily living activities Home carers Equipment & supplies Communication Daily living Risk management Funding
  37. 37. Room setting Home carers Equipment & supplies Communication Daily living Risk management Funding <ul><li>Doors </li></ul><ul><li>Elevators </li></ul><ul><li>Alternative systems </li></ul><ul><li>(volonteers) </li></ul>
  38. 38. Room setting www.medame.com Home carers Equipment & supplies Communication Daily living Risk management Funding
  39. 39. Sostegno tecnologico <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>Pazienti avrà bisogno di una vasta gamma di dispositivi di assistenza, in alcuni casi, per un breve periodo di tempo
  40. 40. Home carers Equipment & supplies Communication Daily living Risk management Funding
  41. 41. Home carers Equipment & supplies Communication Daily living Risk management Funding
  42. 42. Home carers Equipment & supplies Communication Daily living Risk management Funding
  43. 43. http://freespace.virgin.net/michael.bowell/equip.html
  44. 44. 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 Home carers Equipment & supplies Communication Daily living Risk management Funding Feb 15, 2001 A Fatal Complication of Noninvasive Ventilation Lechtzin N., Weiner C. M., Clawson L. N Engl J Med 2001;344:533
  45. 45. Risk minimisation (i) Adapted from AK Simonds, 2001 Technical aspects Home carers Equipment & supplies Communication Daily living Risk management Funding
  46. 46. Risk minimisation (ii) Adapted from AK Simonds, 2001 Medical and social aspects Home carers Equipment & supplies Communication Daily living Risk management Funding
  47. 47. Check-list Piper A. Breathe 2010;6:323-33
  48. 48. HMV: Funding Home carers Equipment & supplies Communication Daily living Risk management Funding Tax-funded Social-insurance-funded
  49. 49. Agenda
  50. 50. Dimissione ospedaliera, in pratica Timing il processo di dimissione ospedaliera inizia il più presto possibile Fattibilità Identificare il caregiver competenti Istruzione Analizzare i problemi pratici Prenditi il tuo tempo Caratteristiche della casa Dimissione Evitare il week-end Case manager
  51. 51. Characteristics of care Source: Eurovent Survey 49% without home care
  52. 52. Systematic follow-up Escarrabill J. Breathe 2009;6:37-42. Population: 291.500.000
  53. 53. HMV in Europe Variability Chron Respir Dis. 2010 Jan 13. <ul><li>History </li></ul><ul><li>Number of centers </li></ul><ul><li>Characteristics of the patients </li></ul><ul><li>Initiation of HMV: outpatient vs hospital </li></ul><ul><li>Educational issues and discharge </li></ul><ul><li>Follow-up </li></ul><ul><li>Wise enthusiasm </li></ul><ul><li>High competence </li></ul><ul><li>Spreading competence </li></ul><ul><li>Multidisciplinary collaboration </li></ul>
  54. 54. Eur Respir J 2009; 33: 411–418 Nurse-centred tele-assistance Tele-assistance Control Aveva meno ricoveri, meno ammissioni nel pronto soccorso, meno chiamate urgenti al GP di riduzione dei costi 33%
  55. 55. Follow-up <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>
  56. 56. Am J Phys Med Rehabil. 2010 May;89:401-6. Thirty hospitalizations were avoided. On-demand consult and MI-E access program 29 ALS patients Oximetry feedback program
  57. 57. Respite care http://southlakemac.com Provision of short-term, temporary relief to those who are caring for family members
  58. 58. 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
  59. 59. End-of-life 57% of patients died at home The percentage of patients who die in hospital ranges from 18.7 to 62.5% (p=0.045). ERS 2010 (Barcelona) n = 77
  60. 60. Eur Respir J 2010; 35: 1064–1071 Family burden private assistance high financial burden 26 % 17 %
  61. 61. Conclusione
  62. 62. Grazie per la vostra attenzione Download la presentazione… www.slideshare.net/jescarra

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