Spring-Summer 2017 Continuing Care/Rehabilitation Section Bulletin

Take-Aways from the 2017 GOLD Update

Krystal Craddock, BSRC, RRT-NPS, CCM

As RTs, we know updates to the Global Obstructive Lung Disease (GOLD) guidelines are necessary to allow us, as clinicians, to better treat our COPD patients. Additional evidence from large clinical trials that have been conducted since the last update help to grow and shape these guidelines, and the most recent update proves just that.

The 2017 GOLD Report was released late last year. Here are some key points we, as RTs, should take away from this update:

1. Pharmacological treatment recommendations were arguably the biggest change. We have come a long way from the 2011 GOLD recommendations, where treatments were based solely on spirometry results and we had fewer options when it came to medications and delivery devices. In the 2017 update, GOLD has reported that the use of an LABA/LAMA has been shown to increase FEV1, reduce symptoms, and reduce exacerbations compared to monotherapy and LABA/ICS. The preference for LABA/LAMA therapy is also crucial for our patients who are at higher risk for pneumonia when using an LABA/ICS combination. As usual, we want to educate on the medication and inhaler use, as well as examine our patients’ technique with the delivery device. LABA/LAMA therapy use is, of course, explained in detail, including initiation and titration of treatment, in the GOLD guideline document.

2. Continuous assessment and evaluation of our patients with COPD is necessary. Yes, I know what you’re thinking: “of course!” Continuous assessment and evaluation of the COPD patient allows for escalation or de-escalation of his therapies, and GOLD is rightly stressing this issue a bit more with this update. But let us think about the patient alone with his physician in his primary care office. Are our patients always reporting their symptoms? Do they know what their symptoms and triggers are? Are the primary care physicians asking the right questions? Are they evaluating inhaler technique? Are they empathetic? Communication between patients and providers is not always as effective as one would like it to be. As RTs, educating our patients on their disease and symptoms, along with keeping providers up-to-date on our patients’ health status, is critical in managing their chronic lung disease — and it also leads to the next point that was highlighted in the GOLD update.

3. GOLD is advising more individualized care of the patient. Millions of people have COPD, but one person is not exactly like another, and neither are their diseases. Individualized care of the COPD patient cannot be stressed enough. People living with COPD have different symptoms, lifestyles, and insurance coverage. Different comorbid conditions also play a role. Treatments must be made based on all these differences, with the GOLD guidelines navigating our recommendations. COPD is not a “one size fits all” disease with “one size fits all” treatments either.

4. COPD exacerbation hospital discharges should include an integrated team care approach. GOLD is reporting that hospital pathways, including optimization of medication, education, assessment of inhaler technique, and assuring follow-up post discharge, are good practice. Interdisciplinary team approaches to COPD care and the evolution of RT navigators and RT case managers have become more common in recent years, especially with the introduction of the Hospital Readmission Reduction Program (a.k.a., CMS penalties). GOLD is recognizing such efforts as necessary in the management of hospitalizations for COPD exacerbations but appreciates the need for more studies showing improved outcomes.

Clearly, the GOLD update stresses assessment and individualization of treatment for patients, as well as changes in pharmacological therapy recommendations. But much still remains in treating a person living with COPD. Pulmonary rehabilitation and education of our patients after diagnosis is still a key treatment. Spirometry and symptom review continue to be the way to diagnosis and stage COPD. Lastly, prevention by way of smoking cessation and increasing public awareness of the disease remains the avenue to lessen the burden on society and individual patients and their families.

COPD Case Management: A Program That Fits a Small Community Hospital

Julie Howard, RRT-NPS, Feather River Hospital, Paradise, CA

With CMS penalties now being enforced, hospitals and RT departments are implementing programs to improve outcomes and reduce unnecessary hospital readmissions for COPD. At Feather River Hospital in Paradise, CA, Cardiopulmonary Director Ben Mullin identified in late 2015 that our hospital had a 30 day readmission rate for COPD patients of more than 24%.

To address this problem, he asked one of the cardiopulmonary rehabilitation therapists to spend part of her day checking into and providing education for this patient population. Four hours per day were allotted, enabling her to see approximately 60% of the COPD patients who were admitted. This respiratory care practitioner was identified as an RT COPD case manager.

Modeled after program at UC Davis

Feather River Hospital is a 100-bed hospital in Northern California with a high population of seniors and COPD patients. When we began our pilot program on January 4, 2016, we modeled it after the ROAD program at UC Davis Medical Center, which has shown significant reduction in COPD readmissions within 30 days of discharge.

Our goal was the same as the one at UC Davis: to start visiting COPD inpatients and identifying their needs to help them self-manage their COPD at home. In order to grow our efforts, our hospital applied for and received a three year grant through the Health Resources & Services Administration that allowed the RT COPD case manager to become full time as of August 1, 2016.

Patients who are identified with an acute exacerbation of COPD are seen two to three days in a row and provided one-on-one education aimed at preventing acute exacerbations that often lead to ER visits and hospitalizations. All of the patient’s respiratory medications are reviewed and patients are given instruction on how to take each of their inhalers, with demonstration at the bedside.

Education also includes understanding their disease, panic control, relaxation techniques, energy conservation tips, breathing strategies (demonstrated with the teach back method), infection prevention, recognizing exacerbation signs early, when to call your MD, oxygen use, and smoking cessation counseling. Each education session takes approximately 45-60 minutes and is conducted at the patient’s bedside. A COPD Assessment Test (CAT) is performed at the bedside and again two months post discharge. The CAT test is used as a measure of the patient’s quality of life as it relates to COPD.

The RT COPD case manager calls the patient within two days of discharge to ask if he has received all of his respiratory inhalers and has scheduled an appointment with his pulmonologist or primary care physician. Phone calls are also made at three weeks to check in and review the MD appointment, and then repeated at two month intervals. Patients are encouraged to call the RT COPD case manager at any time with any questions they have regarding COPD, respiratory medications, oxygen use, or support with smoking cessation. During hospitalization and follow up calls, we direct our patients to our monthly Better Breathers Club, where they can find further education and the opportunity to socialize with other COPD patients.

One size does not fit all

These efforts may sound familiar to many of us, and they have been shown to work at many health care systems across the country. However, just as there isn’t a “one size fits all” treatment for our patients with COPD, there is no “one size fits all” program for hospitals. We shouldn’t reinvent the wheel, but we must adapt these already successful programs to work at our facilities, whether they are 1,000-plus bed university hospitals or small community hospitals.

At Feather River Hospital we have adapted our program to meet our individual patients’ needs. In addition to the bedside education necessary for our patients to be successful, our RT COPD case manager is an essential part of our daily hospital case management meetings. Here, hospitalists come in and review every patient, what their status is, and what their discharge needs may be. During these daily meetings the RT COPD case manager makes necessary recommendations to the physician for maintenance inhalers, discharge equipment, and pulmonary function testing, if the patient has not had a pulmonary function test in the past three years.

In comparing our data for 30 day COPD readmissions, we found a 35% reduction for January 1-October 31, 2016 versus the same time frame in 2015, 19% to 12.4%. Our daily case management meetings, which were once only inclusive of nurses and physicians, now warrant and welcome the expert advice of an RT. We will continue to grow and evolve our program and are currently working with Adventist Corporate to potentially present and assist in implementation of this program at other Adventist Hospitals. We are also looking ahead at potentially starting congestive heart failure and pneumonia education programs to reduce readmissions for those two diagnoses as well.

Singing as Therapy

Alexandra Elliott, BSRC, RRT

For patients with chronic respiratory issues, singing can be very therapeutic. As we know, patients with obstructive lung disease have difficulty effectively emptying the lungs with exhalation. When singing, the deep inhalation followed by slow and controlled exhalation provides a breathing pattern that can benefit the singer by ensuring the lungs empty more completely prior to the next inhalation. Singing provides physiological benefits similar to “pursed-lip” breathing techniques taught to patients with chronic breathing problems. Singing also provides a fun, inclusive community activity.

Inspired by British video

I first learned of singing as therapy two years ago when deciding on a Capstone Project for my bachelor’s program in respiratory care. I saw a video of a pulmonary rehabilitation (PR) singing group in England, and was inspired to present this idea to the PR leadership team here at UC Davis Medical Center (UCDMC) in Sacramento, CA.

It was December of 2015, and the idea was met with excitement and enthusiasm by PR coordinators, Aimee Kizzair, MHAL, RRT-NPS, and Angela Coburn, RRT, as well as 12 or so members of the rehab maintenance group. Jim Kesey, a member of the rehab group and musician, agreed to play keyboard/piano for the group.

We began practicing two Wednesdays a month following the group’s regular exercise time. The group voted on a name for themselves and “The Rockin’ Rehabbers” were born! All members were given a kazoo and a harmonica, which add variety and some humor to the music and have the same respiratory benefits as singing. Anyone enrolled in pulmonary rehab is welcome to join the group — no auditions required.

Since it was December, and close to the group’s own holiday potluck, we decided our first “gig” would be performing holiday songs for all who attended this event. Family members attended as well as hospital staff and the group was a huge success! Everyone agreed to keep the group going throughout the year. New songs are chosen by the group and reflect a “seasonal” flair.

Four performances so far

So far, roughly 30% of the maintenance group is involved in this singing group. We have had four performances to date and more are planned. The Rockin’ Rehabbers were featured live on Good Morning Sacramento, performed holiday music in the main lobby at UCDMC, and took the holiday program to Shriner’s Children’s Hospital in Sacramento, where they were able to perform for the patients there. In the near future, the group is entertaining the idea of performing at the California Society for Pulmonary Rehabilitation annual conference and doing an early summer concert of patriotic songs to be performed at the grand piano in the main lobby at UCDMC.

Singing therapy can be a fairly simple, inexpensive, and fun addition to an established PR program. The kazoos were less than $2 each, with the harmonicas approximately $10 apiece. The Rockin’ Rehabbers were fortunate to have a musician in the group who has been willing to help with a piano accompaniment; however, this group can also do very well acapella. The keyboard we use was donated by our PR coordinator and the music was downloaded from a music website with a small membership fee of $15 per year.

We started off slowly, with familiar songs that the group had heard and/or sang before. Over the past year, the group has expanded its repertoire to 35-40 songs. New songs are always being added, and members are also practicing with the kazoos and harmonicas.

PR is the ideal setting

Chronic respiratory issues can lead to anxiety, depression, and isolation. This in turn can lead to decreased adherence and compliance to respiratory medications. The safe environment in pulmonary rehab, coupled with camaraderie and a common purpose, provides an ideal setting for this group activity. It is a genuine example of a win-win situation where therapy becomes fun and the fruition of the efforts is shared with all who hear the group perform.

The Rockin’ Rehabbers are giving back to the community with periodic performances, sharing fun music with all those who hear them, and generating a feeling of elation that comes from the choir and the audience as they engage in this shared positive experience.

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Next Bulletin deadline: August 1