Princess Margaret Hospital
Chronic Respiratory Disease
Out-patient
Pulmonary rehabilitation Programme
(2011-2012)
Final draft
Prepared by PR Team,PMH
Date: 22nd November 2011
Endorsed by: Endorsed by:
Dr. W C Yu
Consultant, M&G
Signature:_______________ Signature:_______________
Date:___________________ Date:___________________
Endorsed by:
Endorsed by:
Signature:_______________ Signature:_______________
Date:___________________ Date:___________________
Chronic Respiratory Disease Out-patient Pulmonary Rehabilitation Program ( CRD OP PRP)
Background:
The high disease burden and resource implication of chronic respiratory diseases attract global attention. Chronic Obstructive Pulmonary Disease (COPD), one of the chronic respiratory disease, is the fifth leading cause of death in 2002 and will become the third leading cause of death in 2030 [1]. Pulmonary rehabilitation is defined as a multidisciplinary program of care for patients with chronic respiratory impairment that is individually tailored and designed to optimize physical and social performance and autonomy [2].
Tremendous evidence supported the effectiveness of pulmonary rehabilitation in decreasing the dyspnoea and improving the exercise tolerance as well as quality of life [2]. The GOLD guideline had recommended that the pulmonary rehabilitation program (PRP) should be offered to COPD patients with moderate to severe stage (ie stage II to stage III equivalence to FEV1 30-80%) [3]. This probably constitute over 90% of all COPD patients currently followed up at PMH SOPCs (~1300 patients) and Kwai-Tsing GOPCs (~800 patients). Currently we are only able to offer in-patient PRP to 30-40 patients per year. As the in-patient resources are relatively expensive, it will be better to develop the out-patient phase PRP.
Objectives of OP PRP:
1. To improve the respiratory symptoms
2. To restore functional capabilities and reduce handicap
3. To enhance and maintain the quality of life of patients
4. To reduce development of complications and early identification of self-care problems
5. To enhance patient’s and carer’s knowledge and confidence on self-care
6. To facilitate the patient / carer to utilize community resources
7. Reduce the unplanned admission or re-admission rate
8. To reduce A&E attendance
9. To reduce hospital bed–days occupancy
Design of OP PRP
Multi-disciplinary approach that consists of 2 phases
1. Active phase (1 session of assessments, 8 sessions of interventions, 1 session of re-assessment & phone FU for default patients (Follow-up by PT, OT and Resp. Nurse)
2. Maintenance phase (FU once in each month for six months)
Active Phase
Target Group:
A. Inclusion Criteria
1. Symptomatic impairment attributable to pulmonary disability
2. Failure of standard medical regimen to achieve adequate symptomatic relief
3. Motivated, adherent patient
4. Can assess the OPD setting independently
5. Quit smoking for over 3 months
6. FEV1 30-80%
B. Exclusion Criteria
1. Poor motivation
2. Patients with significant physical co-morbidity, e.g. heart failure, renal failure, severe parkinsonism, underlying malignancy, severe osteoporosis & etc
3. Patient with significant mental co-morbidity, e.g. dementia, psychosis
4. Active smokers
5. Requiring NEATS service for follow-up
6. LTOT 2L/min
Referral Source
A. In-patient referral (Patients who are just discharged from hospital)
B. Out-patient referral (Patients who are followed up at OPD by COPD clinic, Respiratory clinic, Medical Team A & Geri OPD (phase 1) ; GOPD (phase 2))
Target size:
4-6 clients for each session
Programme contents: (Refer to Appendix 1-3)
Multidisciplinary team approach
Promote self-management in the following aspect
Understanding your respiratory system and the disease
Puff techniques and medication
Reduction of risk factors (including smoking cessation)
Breathing retraining
Bronchial hygiene promotion
Dyspnoea management
Exercises training
Stress management and relaxation
Energy conservation techniques
Suitable nutrition by referring to dietitian
Change your life style
Home recommendation
Know more about the community resources
Exercise intervention
Clinical guidelines and protocols development
Regular operational and clinical meetings
Continuous evaluation & outcome monitoring bi- monthly
Cost effective evaluation by end of the year
Registration Procedure:
1. Referral (Appendix 4) made by physicians.
2. Fax to M&G (Respiratory Nurse) who will perform the patient’s initial screening and enrollment.
3. M&G (Respiratory Nurse) will open the file and arrange the initial team assessment accordingly
Method
1. Assess and implement the CRD OP PRP protocol (see Appendix 5) – with cases conference
2. Refer to community resource if necessary, e.g. CNS, NGO, CRN, Integrated Family Service Centre
3. The multi-disciplinary case conference (every Thursday: 4:30 – 5:00 p.m. in Acc) will decide the recruitment of participants in acute phase and maintenance after initial assessment and follow-up respectively. Respiratory nurse will arrange the treatment sessions with appointment card given accordingly.
4. All patients information will be registered at Master list (Appendix 8) on web at PMH home page/clinical/ M&G/ Resp .
5. MSW will assess cases with acute financial and social problems regularly during every first Friday of each month (4:15 – 4:45pm) at K3 (room 5) in Out-patient Physiotherapy Department.
6. Liaise Respiratory team and arrange early follow up in COPD clinic (Tue), Respiratory Clinic(Wed.) or MA SOPD(Fri.) or clinical admission under Respiratory Team.
7. Liaise A&E staff if client attended A&E for acute exacerbation
8. Inform M&G Respiratory team for take over the patient if applicable
Acute Phase Programme Schedule (in black colour) (Refer to Appendix 6)
One initial assessment (with Case conference for recruitment),
8 intervention sessions (2 times per week)
One re-assessment session (with case conference)
Graduation certificate will be given to patients if completed active phase.
Phone FU will be done for defaulted patient (Follow-up by PT, OT or Resp. Nurse)
Additional or Ad hoc phone consultation if indicated
Weekly case conference with the Respiratory team (1/2 hour / PM session )
Maintenance Phase
Target Group:
A. Inclusion Criteria
1. Already attended full active phase PR program or full in-patient PRP
2. Recent deconditioning
3. Motivated, adherent patient
4. Can assess the OPD setting independently
5. Quit smoking for over 3 months
B. Exclusion Criteria
1. same as active phase
Recruitment procedure
1. For patients who have completed the in-patient PRP, referral for maintenance program should be faxed to resp nurse for screening and enrollment. M&G (Respiratory Nurse) will open the file and arrange the appointment of Allied Health accordingly.
2. For patients who have completed the OP PRP, after the agreement made in the case conference, resp nurse can arrange the maintenance phase appointment with appointment card given accordingly.
Maintenance Phase Programme Schedule
Follow up once in each month for six months on either Tuesday or Friday.
Phone FU will be done for defaulted patient (Follow-up by PT, OT or Resp. Nurse)
Outcome Measures:
Primary Outcome measure
Total hospital bed-days
A&E attendance
Medical admissions
BODE Index
6 minutes walk test
Quality of life: CRQ
COPD assessment test
etc
Equipment: portable pulse oximetry and portable spirometry with consumable, E-trolley, AED, ex equipment
Commencement Date:
To commence on 18th Oct 2011
List of appendix
Appendix 1 Program content: Nursing education
Appendix 2 Program content: Occupational therapy education
Appendix 3 Program content: Physiotherapy therapy education
Appendix 4 Referral of OP PRP
Appendix 5 Work flow for COPD Active phase Out-patient Pulmonary rehabilitation
Appendix 6 Arrangement and charging of the program
Appendix 7 Program schedule
Appendix 8 Master list
Appendix 1
Princess Margaret Hospital
Program content of OP PRP
Nursing Education
Date Topic Content Signature
Educate the knowledge about the disease of COPD a. The nature of disease
b. Sign and symptoms of COPD and reporting
c. Problem with COPD
d. Progress of COPD
e. Provide education to career
Smoking cessation Quitted Referred smoking cessation service
Second hand smoking environment
Vaccination Influenza vaccination Date:
Pneumococcal vaccination Date:
Advice for prevention of chest infection a. Avoid exposure to respiratory irritants
b. Recommend receiving annual influenza vaccination
c. Avoid crowd and poorly ventilated area
d. Observe sputum volume, nature and colour
Educate medication therapy a. Explain the effect and the side effect of medications
b. Reinforce the importance of good drugs compliance
c. Remind patient the correct administration of drugs
d. Check & instruct inhaler technique: * refer to MDI Techniques evaluation chart
e. Educate career for puff inhalation
Appendix 2
Princess Margaret Hospital
Occupational Therapy Department
Program Content of PRP – Occ. Therapy
One complete cycle include Health Qigong & education on ECT, Stress & Dyspnea management
Date Tue Date Fri
1. Initial Ax: SOBQ, PAR-Q, etc
Energy Conservation Technique 2. Warm Up
Teaching of Health Qigong
Cool down
2. Practice of Health Qigong
Dyspnea Management 4. Warm Up
Teaching of Health Qigong
Cool down
3. Practice of Health Qigong
Stress Management & Relaxation 6. Warm Up
Teaching of Health Qigong
Cool down
4. Practice of Health Qigong
ADL & environmental advice, Home Oxygen Therapy if indicated 8. Warm Up
Teaching of Health Qigong
Cool down
Location: K4 Occupational Therapy Dept.
Time: 3:15 – 4:15 pm on Tue
2:00 – 3:00 pm on Fri
Remarks: Health Qigong will be taught in 4-week cycle.
Session no 2, 4, 6 & 8 will be the compulsory sessions.
Appendix 3
Princess Margaret Hospital Physiotherapy Department
Program content of OP PRP
Date of initial Ax:_______________ Date of re-ax:__________________
Friday (Room 5)
Date Session Contents
A Education on:
Breathing retraining, relaxed position, dyspnea Mx,
bronchial hygiene, +/- PEP therapy and resp equipment
eg nebulizer etc
Tai Chi ex ( 起式 + 雲手 ) +/- theraband
Others:_________________________________
B Education on :
Importance of ex +/- O2, diff. types of home ex, relaxation training.
Tai Chi ex ( 單鞭 + 如風似閉 ) +/- theraband
Others:___________________________________
C Education on:
Breathing retraining, relaxed position, dyspnea Mx,
bronchial hygiene, +/- PEP therapy and resp equipment
eg nebulizer etc
Tai Chi ex ( 起式 + 雲手 ) +/- theraband
Others:_________________________________
D Education on :
Importance of ex +/- O2, diff. types of home ex, relaxation training.
Tai Chi ex ( 單鞭 + 如風似閉 ) +/- theraband
Others:___________________________________
Tuesday (Room 7)
Date Sessions Contents
E Home ex and use of ex record sheet
Gym ex
Revised Tai Chi
Others :_________________________________
F
G
H
Remarks: Session A & C as well as session B & D are identical and compulsory sessions.
Sessions E, F G and H are identical.
Location: K3 Physiotherapy Dept.
Time: 2:00 – 3:00 pm on Tue
3:15 – 4:15 pm on Fri
Hospital Authority
Princess Margaret Hospital
Department of Medicine & Geriatrics Gum Label with address and phone number
Referral to CRD Day Patient Pulmonary Rehabilitation Program
Please fill in this form by referring doctor and fax to Respiratory Nurse of PMH at 2990 1640 (tel no: 2990 1636)
Reason(s) for referral:
□ Significant deconditioning
□ Problems in dyspnoea management
□ Problems in drug management
□ Lack of exercise
□ Others:________________________________________________________________________________________
Premorbid Mobility level: □ Independent walking □ Assisted walking □ Bed/Chair bound
Medical FU: COPD/RESP / GERI / GENA / GENB / GENC / GOPC / other:_________________ (please circle)
Criteria for recruitment to Pulmonary Rehabilitation Program
INCLUSION criteria (tick those that apply) EXCLUSION criteria (tick those that apply)
□ Recent deterioration in condition
□ Motivated, good compliance
□ Do not require NEATS to OPD
□ Quit smoking for over 3 months
□ FEV1 30-80%
□ Severe comorbid illness
□ Poor motivation
□ Poor mental state
□ Poor social support
□ OAH resident
□ LTOT 2L/min
Referring Physician:
Name: Rank: Signature:
Date of referral:
For official use only Date received:
□ Recruit into PRP
□ Active phase Date of appointment for initial assessment:
□ Maintenance phase Date of appointment for initial assessment:
□ Reject
Reason:
Doctor informed date:
Nurse name and signature: Date:
Appendix 6
Arrangement and charging of the program
1 assessment and 1 re-assessment at Ambulatory Care Centre (ACC) of PMH
Date: on Thursday afternoon
Charging : $150 at main shroff
Venue: PT at BLG2
Other disciplines at ACC
They are mainly replacing PR day-patient quota (at most 4).
Arrangement of the 8 intervention sessions:
4 will be on Tuesday, PT (2:00 - 3:00 p.m. at K3), OT (3:15 – 4:15 p.m. at K4), Resp. Nurse (4:15 – 4:45 p.m. at K4)
Charging : $55 at K3
4 will be on Friday, OT (2:00 - 3:00 p.m. at K4), PT (3:15 – 4:15 p.m. at K3)
MSW will assess cases with acute financial and social problems regularly during every first Friday of each month (4:15 – 4:45pm at K3) in Out-patient Physiotherapy Department.
Charging : $55 at K4
Sessions AB or CD on Friday will be compulsory sessions.
Appendix 7
Programme Schedule
1st cycle in red colour
2nd cycle in pink colour
3rd cycle in purple colour
Maintenance in green
Sun Mon Tue Wed Thur Fri Sat
Ax x 2 quotas Session A
Session E Ax x 2 quotas Session B
Session F Ax x 2 quotas Session C
Session G Ax x 2 quotas Session D
Session H Ax x 2 quotas
Re-ax x 2 quotas Session A
Session E Ax x 2 quotas
Re-ax x 2 quotas Session B
Session F Ax x 2 quotas
Re-ax x 2 quotas Session C
Maintenance 1 Ax x 2 quotas
Re-ax x 2 quotas Session D
Session G Ax x 2 quotas
Re-ax x 2 quotas Session A
Session H Ax x 2 quotas
Re-ax x 2 quotas Session B
Session E Ax x 2 quotas
Re-ax x 2 quotas Session C
Maintenance 2 Ax x 2 quotas
Re-ax x 2 quotas Maintenance 1
Session F Ax x 2 quotas
Re-ax x 2 quotas Session D
Appendix 8
Chronic Respiratory Disease Out-patient Pulmonary Rehabilitation Program ( CRD OP PRP) master list
Doctor contact person
PT contact persons: Candy Leung (PTI) Ext:1307
Thomson Wong (PTI) Ext :1307
Keison Tam (PTII) Ext:3935
OT contact persons: Aileen Chu (OTI) Ext:
Stanley Chau (OTI) Ext:
Resp Nurse K W To Ext: 1636
MSW contact persons: Y Wong Ext: 3905
Please enter date of the booked appointments in RED. If the patient has already attended that session, please marked in Black.
If he/she has attended MSW, please add a . If he has attended RN please marked with
When default, please mark (Def). For new appointment date, please mark in green.
case no. Patients name HN/Day No Sex Age O2 Referral date Active phase Maintenance Phase
Initial Ax Session A Session B Session C SessionD Session 5 Session 6 Session 7 Session8 1st Re-ax 1st month 2nd month 3rd month 4th month 5th month 6th month 2nd Re-ax
1 Example Chan RD 123456 M 65 N 30/11/2011 1/12/2011 2/12/2011 6/12/2011 9/12/2011 13/12/11 (Def) 6/1/12 16/12/2011 23/12/2011 30/12/2011 3/1/2012 5/1/2012
2 Ex Chung RD 111111 M 72 N 30/11/2011 1/12/2011 2/12/2011 6/12/2011 9/12/2011 13/12/2011 16/12/2011 23/12/2011 30/12/2011 3/1/2012 5/1/2012
3 Happy RD000000 F 73 Y (2 L) 5/12/2011 8/12/2011 9/12/2011 13/12/201123/12/2011 30/12/2011 3/1/2012 6/1/2012 10/1/2012 12/1/2012
4 Joy RD222222 M 58 N 7/12/2011 8/12/2011 9/12/2011 13/12/2011 30/12/2011 3/1/2012 6/1/2012 10/1/2012 12/1/2012
5
References:
1. World Health Organisation: Burden of Chronic obstructive pulmonary disease. http://www.who.int/respiratory/copd/burden/en/index.html (accessed 28 February 2011)
2. Nici L, Donner C, Wouters E, ZuWallack R, Ambrosino N, Bourbeau J, et al. American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med 2006. 173:1390–413.
3. Vestbo J, Agusti A, Anzueto A, et al. The Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: National Heart, Lung, and Blood Institute and World Health Organization Global Initiative for Chronic Obstructive Lung Disease (GOLD): 2009 update. http://goldcopd.com/GuidelinesResources.asp (accessed 28 February 2011)