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Chronic Obstructive Pulmonary Disease (COPD): Post-Acute and Long-Term Healthcare Setting

Presentation to Executive Leadership

Introduction: Major of Study

Master’s of Science in Nursing Generalist (MSN)

Analyze, Design, Implement, and Evaluate Nursing Care

Simplify the Complexity of Transitions in Care

Post-Acute /Long-Term Care Rehabilitation

Community Services/Dwelling

Clinic – Preventive and Palliative Care

Acute – Reducing Readmission Rates for Exacerbation of Chronic Illness

MSN competencies allow for a full analysis of design, implementation, and evaluation of nursing care to diverse populations and cohorts of patients, in clinical and community-based systems, (American Association of Colleges of Nursing [AACN], 2011).

As a Director of Nursing within the long-term care continuum, having a MSN degree will allow for the integration of findings from across the sciences and humanities, and will facilitate continuous improvement of nursing care at the unit, clinic, home, and program level (AACN, 2011).

The DON who acquires their MSN provides for a strong background in healthcare leadership, assessment, pharmacology, and pathophysiology in preparation to understand how the systems and organizational sciences can blend to meet the healthcare needs of a diverse population (AACN, 2011). This blending of core components will provide the knowledge necessary for transitioning patients with Chronic Obstructive Pulmonary Disease (COPD) safely through their continuum of healthcare needs, within the micro-, meso-, and macrosystems of healthcare.

Introduction: Chronic Disease

COPD

Characteristics

Dyspnea

Exercise Intolerance

Shortness of Breath

Chronic Cough

Expiratory Exertional Effort – Force or Time

Sputum Production

Wheezing

Exposure to Risk Factors for the Disease

COPD is characterized by exertional effort, force or time, needed during the expiratory phase of the respiratory cycle, with the central symptoms being dyspnea, exercise intolerance, shortness of breath, chronic cough or sputum production, and/or exposure to risk factors for the disease, with the central sign being wheezing (Global Initiative for Chronic Obstructive Lung Disease [GOLD], 2018; McCance, & Huether, 2014).

Introduction: COPD

Pathophysiology of COPD

Insult to Respiratory System

Airway Inflammation

WBC Enter Bronchial Wall

Pulmonary Edema

Enlarged Mucous Glands & Goblet Cells

Ciliary Impairment

Inability to Clear Airway

The pathophysiology of COPD involves the inspired agent resulting in airway inflammation, white blood cells enter the bronchial wall, leading to edema and enlarged mucous glands and goblet cells, which in turn impairs ciliary function, which results in the body being unable to clear the lungs of debris (McCance, & Huether, 2014).

Introduction: COPD

Risk Factors

Primary: Tobacco Use

Air Pollution

Genetic Factors

Abnormal Lung Development

Respiratory Infections

The primary risk factor for COPD is tobacco use, with other risk factors including indoor air pollution, such as biomass fuel used for indoor cooking and heating, air pollution, genetic factors, abnormal lung development, and respiratory infections (GOLD, 2018; McCance, & Huether, 2014).

Introduction: COPD

What happens with pulmonary insults?

COPD Exacerbations

Worsening Dyspnea

Productive Cough

Air Trapping

Reduced Tidal Volume

Hypoventilation

Hypercapnia

Insults to the respiratory system results in an increased risk for respiratory infection, leading to further respiratory injury, resulting in COPD exacerbations of worsening dyspnea, productive cough, and air trapping; leading to reduced tidal volume, hypoventilation, and hypercapnia (McCance, & Huether, 2014, p. 1266-1267).

As lung function worsens, all other organs in the body are impacted.

Introduction: COPD

Diagnosis

Symptoms

Physical Exam

Chest X-ray

Pulmonary Function Tests

Spirometry is most reproducible

Mild, Moderate, Severe, Very Severe

Blood Gas Analysis

(GOLD, 2018; McCance, & Huether, 2014)

Diagnosis is based on symptoms, physical examination, chest x-ray, pulmonary function tests, and blood gas analyses (GOLD, 2018; McCance, & Huether, 2014). GOLD (2018) notes that spirometry is the most reproducible and objective airflow measurement when diagnosing COPD. Airflow limitation severity is classified as mild, moderate, severe, and very severe (GOLD, 2018).

Introduction: COPD

Prevention is key

Pathologic Changes are Irreversible

Smoking Cessation

Halts Disease Progression

Immunizations Reduce Risk

Influenza

Pneumococcal

(GOLD, 2018; McCance, & Huether, 2014)

Prevention of chronic bronchitis is the best treatment because pathologic changes are not reversible. However, if a person quits smoking tobacco, disease progression can be halted (GOLD, 2018; McCance, & Huether, 2014). Immunizations, such as influenza and pneumococcal, can reduce the risk of serious infection (GOLD, 2018).

Introduction: COPD

Pharmacological Therapy

Symptom Relief

Improve Exercise Intolerance

Exacerbation Reduction

Individualized

Comorbidities

Side-Effects

Risk for Exacerbation

Symptom Severity

Preference

Ability

(GOLD, 2018)

Pharmacological therapy can improve COPD symptoms and exercise intolerance, and reduce exacerbations; however, treatment will be dependent on the individual’s symptom severity, risk for exacerbation, medication side-effects, comorbidities, pharmacological availability and cost, patient response to the agent, their preference, and ability to use the device (GOLD, 2018).

Introduction: COPD

Pharmacological Therapy

Bronchodilators

Beta2-Agonists

Short Acting

Long Acting

Antimuscarinic Agents

Short Acting

Long Acting

Methylxanthines

Combination Agents

Inhaled & Oral Corticosteroids

Oxygen

(GOLD, 2018)

Pharmacological agents include bronchodilators, Beta2-agonists – short and long acting, antimuscarinic agents – short and long acting, Methylxanthines, combination bronchodilator agents – short and long acting, anti-inflammatory agents, inhaled and oral corticosteroids, and oxygen (GOLD, 2018).

Introduction: COPD

Nonpharmacological Interventions

Smoking Cessation

May incorporate pharmacological agents in some situations.

Pulmonary Rehabilitation

Surgical Procedures

Palliative Care

End of Life Care

Hospice Care

Ventilatory Support

(GOLD, 2018)

Individualized to the patient and their family.

COPD: Typical Visit

Post-Acute/Long-Term Care

Less than 20 Days

Discharge Goals are Individualized

Admission Intake

Social Services

Admission Nurse

The typical visit for someone entering the post-acute care setting is less than twenty days in length. The discharge goal and treatment options will be individualized to the patient. They will complete the admission process with Social Services, and the admission nurse, developing a baseline care plan.

COPD: Typical Visit

Baseline Care Plan

Language & Manner Understood by Patient & Family

Medication/Treatment Reconciliation

Advance Directives

Dietary Needs

Religious/Spiritual Needs

Cultural Needs

ADLs

The admission nurse will interview the patient and their representative, if not completed ahead of time, to determine their goals and preferences for care, such as code status, advance directives, living will, bathing and dining rituals, sleep patterns, spiritual needs, activities and hobbies, education level, occupation(s), level of assistance desired for activities of daily living, special equipment or treatments, desired discharge location and the ADL ability level needed for successful discharge. The patient and their representative will sign and date the baseline care plan, to include medication reconciliation, which will be produced in a language and manner they are able to understand.

COPD: Typical Visit

Meet & Greet

Dietary Manager

Activity Department

Introduction to Primary Staff

Nursing Assistant(s)

Nurse

Physician Visits Every 30 Days, for first 90 days, every 60 days thereafter, and as needed

ARNP may complete every-other Physician required visit in SNF.

Housekeeper

Unit Aide

Activity Aide

Nursing Supervisor(s)

Therapist(s)

They will receive a visit from dietary services and the activity department, to learn likes, dislikes, and interests.

They will be introduced to their primary staff, to include: nursing assistant, housekeeper, unit aide, activity aide, nurse, and nursing supervisor. If therapy is ordered, evaluation and treatment will likely begin on day of admission. Their attending Physician or ARNP will make rounds every 30 days for the first 90 days, and every 60 days thereafter.

COPD: Typical Visit

Discharge Planning

Begins on Day One

Comprehensive Care Plan

Updated Summary from Baseline

Rehabilitation to Meet Goals

Medication/Treatment

Assessment

Teaching

Adherence

Internal & External Service Coordination

Transitions Between Levels of Care

Discharge planning also begins on day one. The comprehensive care plan will be completed within the first few weeks, within the time allowed as per state and federal regulations, and an updated summary will be provided to the patient and their representative if there are changes, also in a language and manner they are able to understand. The patient will receive restorative and/or rehabilitative services to meet their discharge goals, as well as medication and treatment assessment and teaching for adherence. Providers, social services, pharmacy, resident accounts, billers, therapists, dietary, activities, environmental service, special vendors (i.e., oxygen delivery, private or managed insurance companies, home health services) and nursing will coordinate internal and external services to ensure smooth transitions between healthcare providers, as the patient moves through the long-term care continuum and back to their prior or new setting.

Key Leadership Positions

Formal

County Commissioners – Operational Rules

Delegation Members – Financial Resources

Administrator – Vision & Mission

Department Heads – Supports Vision & Mission

Resident Council President – Guides Delivery of Services

Informal

Front-line Managers – Organize workflow

Natural Leaders – Optimize workflow, Feedback

Lead Nursing Assistants

Lead Housekeepers

(Linkosky, 2014)

Leadership positions within the long-term care continuum include those in formal and informal positions of authority. Formal leadership positions include the county commissioners and delegation members, the administrator, and the organization’s department heads, and resident council president. Informal positions of authority include front-line managers, and the natural leaders within a peer work group may include a nursing assistant who is passionate about a new or emerging topic, or a housekeeper who had a personal goal for keeping high-touch areas within the patient environment cleaned and disinfected hourly and is recruiting people to help her.

The macrosystem of the long-term care facility includes the county commissioners, the county delegation, and the nursing home administrator; the mesosystem includes the department heads and their interdepartmental staff (Linkosky, 2014). How these systems relate are knowing their functions, so as to leverage them to meet stakeholder expectations for improving quality, safety, and cost of care. The county commissioners determine the county rules for operational direction and setting of budgetary goals, the delegation oversee funding, and the administrator enforces policy and leads the safety and quality initiatives facility wide. The mesosystem supports the vision and mission of the macrosystem in the delivery of care.

For example, the county commissioners may instruct the administrator to seek additional revenue. The administrator seeks a Nurse Practitioner (NP) to hire, and will be billing Medicare for services rendered to patients within the long-term care facility. The DON and front-line managers formulate a plan to best organize the workflow to maximize the NP’s time, and to best meet the needs of the patients, optimizing the care delivery system.

Leadership Style Effectiveness

Resonant Leadership

Visionary

Anticipate Barriers to Goal Attainment

Coaching

Facilitate Independence

Affiliative

Coping & Positive Reinforcement

Democratic

Time Consuming

Gives All Team Members Voice in Workflow

Improved Communication

(Cummings, Midodzi, Wong, & Estabrooks, 2010)

Leadership styles considered effective in reducing 30-day patient mortality in healthcare settings, in relationship to the management of COPD, include resonant leadership styles, such as visionary, coaching, affiliative, and democratic (Cummings, Midodzi, Wong, & Estabrooks, 2010). Using visionary leadership will help the patient to anticipate barriers in their treatment course and help them to plan for what they will need when returning to the community. With a coaching leadership style, the natural leaders at the bedside can facilitate independence in the patient, making their rehabilitation timelier. Understanding how to approach a difficult situation and avoiding negative coping through positive reinforcement will improve relationships and foster teamwork. Use of a democratic leadership style in the care environment can be time consuming, however, it allows for all team members to have a voice in the workflow, improving communication so that each team member can vocalize concerns and ideas for meeting the patients’ goals.

Common Barriers

Transportation

Technological Resources

Oxygen Reserves for ADLs

Primary Care Access

(GOLD, 2018)

In the post-acute/long-term care setting, barriers encountered by patients when managing their chronic disease include lack of transportation, lack of technological resources, lack of oxygen reserves for meeting selfcare needs/goals, and lack of a primary care provider in the community.

Patients with COPD will require the special skill sets of an MSN to improve the quality of care received, and to reduce the healthcare cost-burden of COPD management. Through implementation of advanced clinical reasoning for challenging clinical presentations, the MSN is able to incorporate the concerns of the patient, their family, significant others, and community into the strategy and dissemination of patient care (AACN, 2011).

Creating interprofessional partnerships and working with community resources, allows the MSN to transition the patient safely back to their primary or desired environment.

Common Barriers

Comorbidities

Lung Cancer

Osteoporosis

Depression

Anxiety

Obstructive Sleep Apnea

Gastroesophageal Reflux Disease (GERD)

Comorbidities place a patient at higher risk of morbidity and mortality (GOLD, 2018). Additionally, comorbidities reduce the patient’s ability for self-management of their personal health. Complications or symptoms may duplicate between diseases. For example, a person having COPD and Heart Failure may be short of breath, and less likely to realize they are in fluid overload and not in a COPD exacerbation. Assimilating an interdisciplinary team, within the setting of the patient having COPD, will allow for collaboration, timely, and correct care (GOLD, 2018).

Barrier Solutions

Telemedicine may address:

Transportation

Access to Primary Care

Note research is promising, however, level of evidence is poor

Further Research Needed

Telemedicine has the potential to impact both transportation and access to care (limited providers) barriers (Barken, Thygeses, & Soderhamn, 2017). However, this would depend on the state (licensing and authority) and organizational boundaries regarding the advanced nurses’ availability, as well as the infrastructure in the patients’ location to support electronic communication, as the ability to video conference was demonstrated to facilitate improved care more efficiently and confidently, when compared to teleconferencing (Barken et al., 2017). However, the level of evidence to support telemedicine’s effectiveness is poor, with further research needed in this area (Roche, 2017).

Barrier Solutions

Telemedicine in Conjunction with Home Health Services

Smoking Cessation Monitoring & Support

Vaccination in the community/primary care

If too ill during SNF visit

Pulmonary Rehabilitation Monitoring & Treatment

Telemedicine would depend on the state (licensing and authority) and organizational boundaries regarding the advanced nurses’ availability, as well as the infrastructure in the patients’ location to support electronic communication, as the ability to video conference was demonstrated to facilitate improved care more efficiently and confidently, when compared to teleconferencing (Barken et al., 2017).

In conjunction with Home Health Services, there will be a safety net should the telehealth system fail. What are areas of promise or concern that you have identified in the use of telemedicine?

Barrier Solutions

Pulmonary Rehabilitation

Interdisciplinary Team

Exercise Training

Nutritional Counseling

Muscle Strength

Quality of Life

Fatigue Symptoms

Disease Management

Energy Conserving Techniques

Breathing Strategies

Psychological Counseling

(National Heart, Lung, and Blood Institute [NHI], n.d.)

When considering which solution would be the most effective for the COPD patient in the long-term care setting, the focused need would be to improve services surrounding pulmonary rehabilitation, due to the complexity of the patient’s disease process, likelihood of comorbidities, and it having the highest level of evidence of all available therapeutic options to manage COPD symptoms. The long-term care organization has a smoke-free policy, and the patient is automatically provided smoking cessation interventions, based on their individual needs, excluding e-cigarettes. Vaccinations are also part of a routine protocol, which is followed closely by the Infection Preventionist. The health-promotion activity I propose we focus on, within the pulmonary rehabilitation complex, is nutritional counseling. Nutritional counseling will promote muscle strength and overall quality of life in the malnourished patient, and will improve fatigue symptoms (Roche, 2017).

Relationships, Roles, Leadership Theory

New Relationships

Commissioners & Delegation Members with Health Information Technology Companies

The patient with the interdisciplinary team specializing in COPD

Pulmonary Rehabilitation Focus

Nutrition Component Initial Focus

Director of Nursing, MSN, Therapy, and Dietitian with the front-line staff and patient with COPD

Weekly team huddles

Exchange of information

Education

Resource allocation

Revision of patients’ goals

With the executive leadership team facilitating the improvements needed in community electronic infrastructure and resource allocation, implementation of the evidence-based research on Pulmonary Rehabilitation presented here, will demonstrate the greatest benefit to our stakeholders.

Additionally, it is something that all team members can participate in to support the patient in meeting their goals. Taking a team approach to supporting the resident in their nutritional goals will require weekly team huddles, with the patient at the center and directing the team, to allow for exchange of information and provision of education, resource allocation, or revision of goals.

This change will require the Director of Nursing to use a transformational leadership style to motivate team cohesion.

Solutions: Affect

Reduce Hospital Readmissions

Improve Quality of Life in the COPD patient

Promote Staff Satisfaction

Facilitate Improved Transitions of Care

Improve Access to Healthcare

Health Promotion

Clients will be elder adults who may not easily be persuaded to the benefits of a nutritional diet, and the idea of pulmonary rehabilitation will be a new concept for this team (Porter-O’Grady, & Malloch, 2018). Further consideration will be needed when considering the best way to present this concept to the front-line staff and patient. Thoughts and ideas from the audience are encouraged. Invite audience to share their stories around this topic.

Educational Opportunities

Pulmonary Rehabilitation Program

Smoking Cessation

Nutritional Education

Breathing Strategies

Energy Conservation Techniques

Differential Diagnoses for COPD with Comorbidities

Disease Management – Clinician

Symptom Education & Reporting Guidelines – Patient

Knowledge and strategies to approach all areas of patient care and support in those living with COPD is important. The greater awareness of the presenting baseline symptoms will allow for sooner intervention in the face of an exacerbation (GOLD, 2018). Understanding the duplicative symptoms in a patient with COPD and comorbidities will facilitate greater depth in nursing assessment, more timely treatment/intervention, and improved patient quality of life.

Health-Promotion Activity

Nutritional Counseling

Promotes muscle strength

Quality of Life

Improves Symptom Fatigue

If malnourished, reduced energy during respiration, due to high calorie needs

Prevents Infection

Maintain a Healthy Weight

Note: Smoking Cessation Halts COPD Progression

(GOLD, 2018; Roche, 2017; USDA|DHHS, 2015)

Additional Resources:

https://www.choosemyplate.gov

https://health.gov/dietaryguidelines/2015/guidelines/

Resources Needed

Pulmonary Rehabilitation

Nutritional Component Focus

Additional Funding for Dietitian & staff for team huddles

Human Resource Allocation & Learning Materials

Patient Teaching – Nursing, Dietary, Therapy

Patient Monitoring – Nursing, Provider, Therapy, Dietitian, Staff

Dietary Manager

Alternative Meals

Oxygen during meals as needed

Funding for Staff Education

Funding may be absorbed in this year’s budget excess. However, additional education funding for staff training should be dedicated to COPD and other chronic disease management education/training.

Summary: COPD Management

Patient-Centered Interdisciplinary Approach

Executive Leadership

Human & Financial Resources

Educational Resources – Staff & Patient

Technical Infrastructure

Telehealth Opportunities

Transformative Leadership

Resonant Leadership Styles

Visionary, Coaching, Affiliative, Democratic

Smoking Cessation

Halts Progression of COPD

Pulmonary Rehabilitation Program Implementation

Beginning with Nutritional Focus

Effectiveness & Results Communication

Balanced Score Card

Weekly Team Huddles

Clinical status – Electronic Health Record Data

Comorbidities

Vital Signs

Symptoms Summary

Meal Percentage

Caloric Intake

Protein Intake

ADL Score

Patient/Staff Satisfaction Rating

PDSA

QAPI – Director of Nursing, MSN

Reports outcomes for Department

When considering how recommendations will be measured to ensure they are effective for this COPD patient in the long-term care setting, a balanced scorecard model, as described by Nelson, Batalden, Godfrey, & Lazar (2011), will be used. During the weekly team huddle, the patient’s clinical status will be reviewed, using a facility generated standardized data collection form, summarizing the patient’s clinical status (comorbidities, vital signs, COPD symptom summary, meal percentage/caloric intake/protein intake/fluid intake), functional health status (ADL score), patient satisfaction rating, and number of Medicare A, B, Medicaid, or private pay days used during the pulmonary rehabilitation program in comparison to how many are remaining or anticipated discharge date. The Director of Nursing will take lead when reporting out these measures monthly to the Quality Assurance Process Improvement (QAPI) committee for further collaboration and monitoring of the program’s sustainability over time, and then provide follow-up feedback to the frontline staff during team huddles, incorporating a Plan Do Study Act (PDSA) process for continuous quality improvement (Nelson et al., 2011).

References

American Association of Colleges of Nursing. (2011). The essentials of master’s education in

nursing. Retrieved from http://www.aacnnursing.org/Portals/42/Publications/Masters

Essentials11.pdf

Barken, T. L., Thygeses, E., & Soderhamn, U. (2017). Advancing beyond the system:

Telemedicine nurses’ clinical reasoning using a computerized decision support system

for patients with COPD – an ethnographic study. BMC Medical Informatics and Decision

Making, 17,(181), 1-11. doi: 10.1186/s12911-017-0573-7

Cummings, G.G., Midodzi, W.K., Wong, C. A., & Estabrooks, C.A. (2010). The contribution of

hospital nursing leadership styles to 30 -day patient mortality. Nursing Research, 59(5),

331-339. doi: http://dx.doi.org.ezproxy.snhu.edu/10.1097/NNR.06013e3181ed74d5

Global Initiative for Chronic Obstruct ive Lung Disease. (2018). Pocket guide to COPD diagnosis

management, and prevention: A guide for health care professionals. Retrieved from

http://goldcopd.org/wp-content/uploads/2018/02/WMS -GOLD-2018-Feb-Final-to-print-

v2.pdf

National Heart, Lung, and Blood Institute. (n.d.). Pulmonary rehabilitation . Retrieved June 9,

2018 from https://www.nhlbi.gov/health -topics/pulmonary-rehabilitation

Porter-O’Grady, T., & Malloch, K. (2018). Quantum leadership: Creating sustainable value in

health care (5th ed.). Burlington, MA: Jones & Bartlett Learning.

Roche, N. (2017). GOLD COPD 2017 resource center activity four: Overview of therapeutic

options [Video]. Retrieved from education.goldcopd.org/video.php?event_id=1897&

stage_id =5&vcs=1

United States Department of Agriculture | Department of Health & Human Services. (2015).

Dietary guidelines for Americans 2015-2020 (8th ed). Retrieved from https://health.gov/

dietaryguidelines/2015/resources/2015 -2020_Dietary_Guidelines.pdf