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Guoman Tower Hotel, London
How to deliver quality and value in chronic care:sharing the learning from the respiratory programme
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follow up discussion one paragraph with intext citation and referenc.docxalfred4lewis58146
follow up discussion one paragraph with intext citation and reference respond tho the below discussion to add information or comment
First off, chronic obstructive pulmonary disease (COPD) refers to “a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis” (cdc.gov, 2018). In many cases, people suffer from COPD where they have not been diagnosed and may not receive treatment for their disease. Since COPD is not a curable disease, supportive treatment is recommended with follow-ups and adjustments to a plan of care as needed. An interdisciplinary team with multiple focuses would be best for a patient like this. For instance, controlling and maintaining a chronic disease is not easy for one person to handle. Therefore, the roles of nurses, physicians, and respiratory therapists would be included in a comprehensive plan of care, while also involving family and anyone else involved in home care. Since each patient would have different goals and desired outcomes of treatment, each case should be treated with individuality and specific to improving the quality of life for each.
For this discussion, my patient is a 73-year-old female who has smoked cigarettes for the past 50 years while developing chronic breathing problems with frequent emergency department admissions. Since the initial visit, this patient has exhibited a resistance to smoking cessation programs offered and continues to smoke cigarettes when she is not in the hospital. This trip to the ED, the client is using accessory muscles for breathing, is short of breath, and reports dyspnea with minimal exertion. She states, “I have not had a cigarette in 36 hours, I feel like I need to light up to make myself feel better.” This only furthers the need for education related to smoking cessation, since it seems this patient may not understand what smoking cigarettes is doing to her body. She is taking a blood pressure medication along with other supplemental vitamins. She has been told by previous providers that home oxygen therapy would help but has refused these offers due to financial reasons. However, the client mentioned she does not use her inhaler unless her breathing is causing severe pain. Her vitals are as follows: BP – 128/72, HR – 118, RR – 30, Temp – 99.0, Pain - 7/10, and SpO2 – 88% on room air. Specific interventions are aimed at providing structure for a smoking cessation program, reconciling discharge information to update her plan of care based on her exacerbations, while including direct and prompt communication between healthcare professionals and coordinated follow-up care (Drummer & Stokes, 2020). Improved health outcomes would incorporate reduced hospitalizations, improved measures of continuity of care, and improvement of quality of life and satisfaction of the patient. Along with education about smoking cessation, this client should receive a respiratory therapy consult, pulmonologist referral, and.
Chronic obstructive pulmonary disease or COPD is a group of inflammatory diseases affecting the lungs which cause airflow obstruction and difficulty in breathing. COPD symptoms can include chronic cough and wheezing, frequent respiratory infections, fatigue, overproduction of phlegm and sputum, unexplained weight loss and feelings of lightheadedness and dizziness throughout the day.
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follow up discussion one paragraph with intext citation and referenc.docxalfred4lewis58146
follow up discussion one paragraph with intext citation and reference respond tho the below discussion to add information or comment
First off, chronic obstructive pulmonary disease (COPD) refers to “a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis” (cdc.gov, 2018). In many cases, people suffer from COPD where they have not been diagnosed and may not receive treatment for their disease. Since COPD is not a curable disease, supportive treatment is recommended with follow-ups and adjustments to a plan of care as needed. An interdisciplinary team with multiple focuses would be best for a patient like this. For instance, controlling and maintaining a chronic disease is not easy for one person to handle. Therefore, the roles of nurses, physicians, and respiratory therapists would be included in a comprehensive plan of care, while also involving family and anyone else involved in home care. Since each patient would have different goals and desired outcomes of treatment, each case should be treated with individuality and specific to improving the quality of life for each.
For this discussion, my patient is a 73-year-old female who has smoked cigarettes for the past 50 years while developing chronic breathing problems with frequent emergency department admissions. Since the initial visit, this patient has exhibited a resistance to smoking cessation programs offered and continues to smoke cigarettes when she is not in the hospital. This trip to the ED, the client is using accessory muscles for breathing, is short of breath, and reports dyspnea with minimal exertion. She states, “I have not had a cigarette in 36 hours, I feel like I need to light up to make myself feel better.” This only furthers the need for education related to smoking cessation, since it seems this patient may not understand what smoking cigarettes is doing to her body. She is taking a blood pressure medication along with other supplemental vitamins. She has been told by previous providers that home oxygen therapy would help but has refused these offers due to financial reasons. However, the client mentioned she does not use her inhaler unless her breathing is causing severe pain. Her vitals are as follows: BP – 128/72, HR – 118, RR – 30, Temp – 99.0, Pain - 7/10, and SpO2 – 88% on room air. Specific interventions are aimed at providing structure for a smoking cessation program, reconciling discharge information to update her plan of care based on her exacerbations, while including direct and prompt communication between healthcare professionals and coordinated follow-up care (Drummer & Stokes, 2020). Improved health outcomes would incorporate reduced hospitalizations, improved measures of continuity of care, and improvement of quality of life and satisfaction of the patient. Along with education about smoking cessation, this client should receive a respiratory therapy consult, pulmonologist referral, and.
Chronic obstructive pulmonary disease or COPD is a group of inflammatory diseases affecting the lungs which cause airflow obstruction and difficulty in breathing. COPD symptoms can include chronic cough and wheezing, frequent respiratory infections, fatigue, overproduction of phlegm and sputum, unexplained weight loss and feelings of lightheadedness and dizziness throughout the day.
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As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
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Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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Breakout 4.3 How to manage… exacerbations of COPD, asthma and… in hospital - Delivering high value integrated care with KREDIT? Dr Louise Restrick
1. How to manage… exacerbations
of COPD, asthma &… in hospital
Delivering high value integrated care
with KREDIT?
Dr Louise Restrick, NHS London Respiratory Team Lead
Consultant Respiratory Physician, Whittington Health & NHS Islington
Improving Outcomes
Right Care
Doing the right things and doing things right
Right diagnosis including severity
Addressing respiratory failure and breathlessness
Structured admission & care planning conferences?
Value framework
KREDIT
1
2. Aligning and sharing
agendas…
Patients present with breathlessness…
Frightening … and disabling
Clinicians focus on respiratory failure
Frightening !!!
Breathlessness and hypoxaemia
Present to ED pathways of care
Respiratory failure
Care at home? treatment in
hospital
Breathless
and low oxygen saturation
Breathless Hypoxaemia
with normal =
oxygen Low oxygen saturation
saturation
Low oxygen
saturation
but not breathless
Breathlessness
2
3. Right Care for Respiratory Failure
Getting the diagnosis right
Exacerbation is not the same as pneumonia …
Assessing severity and prognosis …
Getting oxygen therapy right
High flow O2 increases mortality - from 7% to 11%*
Using Non-Invasive Ventilation
appropriately
11% given NIV had metabolic acidosis…*
* Roberts et al NCROP Thorax 2011:66;43-48
Right Care for Respiratory Failure
…NOT EASY
Need clinicians with
respiratory diagnostic
& treatment knowledge,
skills & expertise
Appropriate NIV halves mortality due to respiratory
failure in acute exacerbations of COPD
from 20% to 10%
Getting it right saves lives
3
4. Value Framework
Health Value Cost
=
Outcomes Health Outcomes
Patient defined Cost of delivering
bundle of care Outcomes
NB Outcomes as defined by patients & their families
So we have to ask & listen …
Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483
What patients & families tell us…
‘I don’t want to die’
‘breathlessness is frightening and
disabling’
4
5. Right Care for disabling
breathlessness…NOT EASY
To deliver evidence-based support for patients
to stop smoking as treatment for sick smokers
Need long term condition
clinicians with behaviour
change & motivational
interviewing skills
To enable patients to
benefit from pulmonary
rehabilitation
KREDIT*
Respiratory Teams’ Shared Values …
Kindness
Respect
Empathy
Dignity
Interest
TRUST
*Whittington Health, London Respiratory Team and …
5
6. COPD ‘Value’ Pyramid
What we know…. Cost/QALY
Support to stop smoking
Triple Therapy
is key TREATMENT for
£35,000-
£187,000/QALY sick smokers …
LABA
Where are the sick
£8,000/QALY
smokers?
Tiotropium
£7,000/QALY … in our hospital beds
Pulmonary Rehabilitation
£2,000-8,000/QALY
Stop Smoking Support with
pharmacotherapy £2,000/QALY
Flu vaccination £1,000/QALY in “at risk” population
Is current smoking an issue in COPD?
2010 ERS Audit
6
7. Effect of smoking on hospital
admissions for COPD and
asthma ….and???
For every 1% increase in prevalence of smoking in your COPD
population there is a 1% increase in COPD admission rates
For every 1% increase in prevalence of smoking in your asthma
population there is a 1% increase in asthma admission rates
Emergency respiratory admissions: influence of practice,
population and hospital factors Purdey S et al
J Health Services Research Policy 2011;16:133-40
Changing how we think about smoking
‘Smoking kills, stopping works’
Sir Richard Peto 2012
Tobacco dependence
Sick smokers are admitted to hospitals - acute and psychiatric
Evidence based quit smoking treatment is the most important
treatment for sick smokers:
Behaviour change support and quit smoking medication
Delivering value in tobacco dependence
Top 10 Questions …
7
8. Does your hospital have a BTS Quit
Smoking Champion lead?
Do your consultants believe that Quit
Smoking treatment is high value for their
patients?
Does your hospital provide NRT
routinely on admission for smokers?
Are your hospital staff able, & confident
to, prescribe Quit Smoking medication?
8
9. Do you have a Quit Smoking service for
patients and staff in the hospital?
Services Offered:
• Outpatient Quit Smoking Clinics: for patients and
staff
• Inpatient Assessment for Quit Smoking Support
• Special Clinics – Pre-operative Assessment &
Maternity Support for smokers to quit
Do your hospital staff know your Quit
Smoking advisors and refer to them?
Do your hospital staff routinely offer
‘Very Brief Advice’ to every smoker?
Online training module
WWW.NCSCT.CO.UK/VBA
‘This training is relevant to anyone who comes into
contact with smokers… GPs, practice nurses, hospital
doctors, pharmacists & other healthcare professionals.
… certificate on successful completion to provide
evidence of continuing professional development
(CPD).’
Do your hospital staff have and use behaviour
change skills to support smokers to stop?
9
10. Do your hospital decision makers
believe that Quit Smoking treatment is
high value for patients and staff?
Do your commissioners believe that
Quit Smoking treatment is high value
for patients and staff?
Increasing the value of care in COPD
COPD Discharge Bundle Hopkinson et al ThoraxCLARHC
Developed by
2012:67:90-92
Pre Bundle % With Bundle %
18 100
14 68
55 98
59 91
41 39
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11. Developed by CLARHC
Hopkinson et al Thorax 2012:67:90-92
CQINS to incentivise high value care
2011
11
12. One story from a respiratory ward
50+ year old man
Schizophrenia since 20s
Tobacco addiction: 60 pack-years
Cannabis addiction:100 joint-years
Severe COPD
Lives alone, isolated, not working
13 admissions and 112 bed-days in 2 years
Further emergency admission: ‘Unable to breathe’ & severe
(acute on chronic type II) respiratory failure …
Due to exacerbation/worsening of severe COPD & smoking
tobacco and cannabis ie sick smoker
Treated on respiratory ward including non-invasive ventilation
& quit smoking interventions …
50+ year old man
What he told us mattered to him
Disabled by breathlessness
Scared to use lift to his xth floor flat
Too breathless to go up stairs indoors
Sleeping on piece of foam under stairs
Electricity had been turned off
12
13. Care Planning Conference
why and who
High risk of premature death
Current care model not working
Under-treated schizophrenia preventing respiratory treatment
Untreated tobacco and cannabis addiction
Unsafe home situation
Bed-days +++
Respiratory team: physician, ward sister, nurse specialist,
physiotherapist, occupational therapist, quit smoking advisor
Mental health team: care co-ordinator, dual diagnosis specialist,
psychiatrist invited but unable to attend
Housing officer
Patient
Londoners dying from smoking
‘1 in 5 deaths due to smoking’
13
14. Care Planning Conference:
what
Person-centred integrated care
Identified care and treatment gaps and needs
Named actions and responsibilities
No social worker...
Smoking as tobacco addiction NOT a life-style choice
Anti-psychotics safe – regular depot injection given
Community respiratory support at home
Common needs assessment by mental health team
Rehoused to supported ground level accommodation
Integrated care: care planning conference
Outcomes for 50+ year old man
• Alive
• Ground floor warden controlled flat
• Mental health good, goes out regularly
• Still smoking but much less
• Supported at home by GP, warden, mental health
team and community respiratory team as needed
• Mostly telephone follow-up
• No admissions in 2012 or since …
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15. Person-centred integrated care in hospital
Care planning in out-patients too
Respiratory
Nurse
Specialist Respiratory Physician
Mental
Health Quit
Key Smoking
Worker Advisor
Delivering high value care for exacerbations
of …LONG-TERM conditions in hospital
• Workforce with the right competencies and interests
– Respiratory knowledge, skills and expertise
– Long-term conditions interest and expertise
– Behaviour change and motivational interviewing skills
• Design pathways around exacerbations of LTCs not episodes
– Acute medical assessment unit model does not work for these patients!
• Structure to admission – green days not red days
– Safe respiratory failure care
– Quit smoking support & medication as treatment for all sick smokers
– COPD discharge bundle interventions
– Diagnose & optimise care of all underlying long-term conditions
• Levers – CQINS, measure value outcomes
– Mortality & days at home in year or bed-days/year
15
16. A respiratory provider manifesto
I am a long term conditions clinician
I care about value
I know how to assess and support patients
and drive improvements
I work in a team
I personally deliver high value care
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