Robin Rowell, MSN, RN, CNPVice President, Harrington Heart & Vascular InstituteAssociate Chief Nursing Officer for Licensed Independent PractitionersTodd Zeiger, MD

VP, UH Primary Care Institute

Marianne Vest, MA, RN, CTTSSenior Clinical NurseCardiovascular and Pulmonary RehabilitationHarrington Heart & Vascular Institute

Michelle Block, Esq. Assistant General Counsel

Christy A. Cox BSN, RNQuality Improvement NurseInstitute for Healthcare Quality & Innovation University Hospitals Case Medical Center

Vincent FazioClinical Application Analyst II

Rodney J Folz, MD, PhDChief, Division of Pulmonary, Critical Care and Sleep MedicineVisiting Professor, Medicine – CWRU School of Medicine

Rebecca LovejoyClinical Application Analyst II, EMR Ambulatory

Crystal Mosca, MDSharon Family PhysiciansAmbulatory EMR Physician Lead

COPD - Go for the Gold

Theresa Kearns, MBA, RN, NE-BCDirector, HHVI System Ambulatory Cardiovascular Services

Disclosures

• Speakers in this presentation have no disclosures.

Objectives• Introduce new UH COPD CareGuide and template note in AEMR.

• Review interpretation of spirometry results and flow volume curves• Understand specific criteria for diagnosis and classification of COPD using

spirometry• Determination of a quality test

• Tobacco use/cessation• Importance of assessing tobacco use history at every encounter• Discuss how to motivate patients to quit and methods of treating those motivated to

quit • Recognize available UH resources for smoking cessation

• Vaccination• Review new guidelines on Pneumococcal Vaccination and high risk indications for

use under 65 • Review Influenza Vaccination Protocols and discuss cost effectiveness of high

dose

COPD CareGuide

Crystal Mosca, MD

Sharon Family Physicians

Ambulatory EMR Physician Lead

High Reliability Medicine

• Reliability = consistent excellence over long periods of time

• Zero patient harm

• Guidelines built into template

How to Access

• Choose diagnosis–COPD–Chronic Bronchitis–Emphysema

–Click Recompile

CAT SCORE

• COPD Assessment Test• Patient completed quality of life

assessment• Numerical score of respiratory health • Form will be embedded in EMR – will

allow for data collection in the future

Depression

• 40% of COPD patients are affected by severe depressive symptoms

• Screening with PHQ-2 is embedded into the HPI with option to pull in PHQ-9

• Prompts physicians to think about depression as a comorbidity and further screen or treat as needed

Orderables

• Orders –Diagnostic testing–Labs

• Instructions/Patient Education• Rx• Follow-ups and Referrals

screenshot

Rx

• Prescriptions are listed in order of priority of treatment in COPD

• Under each category listed in order of preferred use by UH formulary and cost

Examples

• screenshot

Spirometry

Rodney J Folz, MD, PhD

Chief, Division of Pulmonary, Critical Care and Sleep Medicine

Visiting Professor, Medicine – CWRU School of Medicine

lobal Initiative for Chronicbstructiveungisease

G

OLD http://www.goldcopd.org

Definition of COPD

• COPD is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients.

• Its pulmonary component is characterized by airflow limitation that is not fully reversible.

• The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases … 85% of the time due to tobacco smoke.

MMWR 57:1221, 2008

Celebrities with COPD

Amy Winehouse

Dean Martin

Christy TurlingtonJohnny Carson

Leonard Bernstein

Loni Anderson

Leonard Nimoy

Risk Factors for COPD

Nutrition

Infections

Socio-economic status

Aging Populations

Genetics

Diagnosis of COPD

• Clinical diagnosis suspected in any patient with:

• Dyspnea• Chronic cough• Sputum production• History of exposure to risk

factors for COPD.

• Post bronchodilator FEV1/FVC < 0.70

COPD Diagnostic Criteria Caveats• Characteristic symptoms

are chronic and progressive.

– dyspnea, cough, and sputum.

• Cough and sputum may precede airflow limitations by many years.

• Airflow limitations may develop without cough and sputum.

Four ways to Assess COPD

1. Assessment of current symptoms2. Assessment of severity of airflow

limitation3. Assessment of exacerbation risk4. Assessment of presence of co-

morbidities

1. Assessment of Symptoms

• Best way to assess symptoms is to use validated questionnaires:

– Modified Medical Research Council dyspnea scale. MMRC

– COPD Assessment Test CAT

2. Assessment of Airflow Limitation Severity

Global Strategy for Diagnosis, Management and Prevention of COPD

Combined Assessment of COPD

© 2015 Global Initiative for Chronic Obstructive Lung Disease

Ris

k (G

OLD

Cla

ssifi

catio

n of

Airf

low

Lim

itatio

n)

Ris

k (E

xace

rba

tion

his

tory

)

≥ 2 or > 1 leading to hospital admission

1 (not leading to hospital admission)

0

Symptoms

(C) (D)

(A) (B)

CAT < 10

4

3

2

1

CAT > 10

BreathlessnessmMRC 0–1 mMRC > 2

Exac

erba

tions

per

yea

r

0

CAT < 10mMRC 0-1

GOLD 4

CAT > 10

mMRC > 2

GOLD 3

GOLD 2

GOLD 1

SAMA prnor

SABA prn

LABA or

LAMA

ICS + LABAor

LAMA

Global Strategy for Diagnosis, Management and Prevention of COPD

Manage Stable COPD: Pharmacologic TherapyRECOMMENDED FIRST CHOICE

A B

DCICS + LABAand/or LAMA

© 2015 Global Initiative for Chronic Obstructive Lung Disease

2 or more or > 1 leading to hospital admission

1 (not leading to hospital admission)

Spirometry in Primary Care

Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2010

Spirometry - Introduction

• Spirometry is the gold standard for COPD diagnosis

• Underuse leads to inaccurate COPD diagnosis

• Widespread uptake has been limited by:– Concerns over technical performance of operators– Difficulty with interpretation of results– Lack of approved local training courses– Lack of evidence showing clear benefit when

spirometry is incorporated into management

What is Spirometry?

Spirometry is a method of assessing lung function by measuring the total volume of air the patient can expel from the lungs after a maximal inhalation.

Why Perform Spirometry?• Measure airflow obstruction to help make a

definitive diagnosis of COPD

• Confirm presence of airway obstruction

• Assess severity of airflow obstruction in COPD

• Detect airflow obstruction in smokers who may have few or no symptoms

• Monitor disease progression in COPD

• Assess one aspect of response to therapy

• Assess prognosis (FEV1) in COPD

• Perform pre-operative assessment

Desktop Electronic Spirometers

Small Hand-held Spirometers

Standard Spirometric Indicies

• FEV1 - Forced expiratory volume in one second:

The volume of air expired in the first second the blow

• FVC - Forced vital capacity:

The total volume of air that can be forcibly exhaled breath

• FEV1/FVC ratio:

The fraction of air exhaled in the first second relative to the total volume exhaled

Predicted Normal Values

Age

Height

Sex

Ethnic Origin

Affected by:

Criteria for Normal Post-bronchodilator Spirometry

•FEV1: % predicted > 80%

•FVC: % predicted > 80%

•FEV1/FVC: > 0.7 - 0.8 (depending on age)

Normal Trace Showing FEV1 and FVC

1 2 3 4 5 6

1

2

3

4

Volu

me,

liters

Time, sec

FVC5

1

FEV1 = 4L

FVC = 5L

FEV1/FVC = 0.8

SPIROMETRY

OBSTRUCTIVE DISEASE

Spirometry: Obstructive Disease

Volu

me,

liters

Time, seconds

5

4

3

2

1

1 2 3 4 5 6

FEV1 = 1.8L

FVC = 3.2L

FEV1/FVC = 0.56

Normal

Obstructive

Spirometric Diagnosis of COPD

•COPD is confirmed by post–bronchodilator FEV1/FVC < 0.7

•Post-bronchodilator FEV1/FVC measured 15 minutes after 400µg salbutamol or equivalent

Bronchodilator Reversibility Testing

• Provides the best achievable FEV1 (and FVC)

• Helps to differentiate COPD from asthma

Must be interpreted with clinical history - neither asthma nor COPD are diagnosed on spirometry alone

SPIROMETRY

RESTRICTIVE DISEASE

Criteria: Restrictive Disease

• FEV1: normal or mildly reduced

• FVC: < 80% predicted

• FEV1/FVC: > 0.7

Volu

me,

liters

Time, seconds

FEV1 = 1.9L

FVC = 2.0L

FEV1/FVC = 0.95

1 2 3 4 5 6

5

4

3

2

1

Spirometry: Restrictive Disease

Normal

Restrictive

SPIROMETRY

Flow Volume

Flow Volume Curve

• Standard on most desk-top spirometers• Adds more information than volume time

curve• Less understood but not too difficult to

interpret• Better at demonstrating mild airflow

obstruction

Flow Volume Curve

Expiratory flow rateL/sec

Volume (L)

FVC

Maximum expiratory flow (PEF)

Inspiratory flow rate

L/sec

RVTLC

Flow Volume Curve Patterns Obstructive and Restrictive

Obstructive Severe obstructive Restrictive

Volume (L)

E

xpira

tory

flo

w r

ate

Exp

irato

ry f

low

rat

e

Exp

irato

ry f

low

rat

e

Volume (L) Volume (L)

Steeple pattern, reduced peak flow,

rapid fall off

Normal shape, normal peak flow, reduced

volume

Reduced peak flow, scooped out mid-

curve

PRACTICAL SESSION

Performing Spirometry

Spirometry Training

• Training is essential for operators to learn correct performance and interpretation of results

• Training for competent performance of spirometry requires a minimum of 3 hours

• Acquiring good spirometry performance and interpretation skills requires practice, evaluation, and review

• Spirometry performance (who, when and where) should be adapted to local needs and resources

• Training for spirometry should be evaluated

Obtaining Predicted Values

• Independent of the type of spirometer

• Choose values that best represent the

tested population

• Check for appropriateness if built into

the spirometer

Optimally, subjects should rest 10 minutesbefore performing spirometry

Withholding Medications

Before performing spirometry, withhold: Short acting β2-agonists for 6 hours

Long acting β2-agonists for 12 hours

Ipratropium for 6 hours

Tiotropium for 24 hours

Optimally, subjects should avoid caffeine and cigarette smoking for 30 minutes before performing

spirometry

Three times FVC within 5% or 0.15 litre (150 ml)

Reproducibility - Quality of Results

Vol

um

e, li

ters

Time, seconds

Spirometry - Quality Control

• Most common cause of inconsistent readings is poor patient technique Sub-optimal inspiration Sub-maximal expiratory effort Delay in forced expiration Shortened expiratory time Air leak around the mouthpiece

• Subjects must be observed and encouraged throughout the procedure

Equipment Maintenance

• Most spirometers need regular calibration to check accuracy

• Calibration is normally performed with a 3 litre syringe

• Some electronic spirometers do not require daily/weekly calibration

• Good equipment cleanliness and anti-infection control are important; check instruction manual

• Spirometers should be regularly serviced; check manufacturer’s recommendations

Troubleshooting

Examples - Unacceptable Traces

Vol

um

e, li

ters

Time, seconds

Unacceptable Trace – Stop Early

Normal

Vol

um

e, li

ters

Time, seconds

Unacceptable Trace - Coughing

Normal

Some Spirometry Resources

• Global Initiative for Chronic Obstructive Lung Disease (GOLD) - www.goldcopd.org

• Spirometry in Practice - www.brit-thoracic.org.uk

• ATS-ERS Taskforce: Standardization of Spirometry. ERJ 2005;29:319-338

www.thoracic.org/sections/publications/statements

• National Asthma Council: Spirometry Handbook

www.nationalasthma.org.au

Immunization Update for the COPD patient

Todd Zeiger, MD

Vice President, University Hospitals Primary Care Institute

Purpose of review

• Acute exacerbations of chronic obstructive pulmonary disease (COPD) are a major cause of morbidity and mortality worldwide.

• Most acute exacerbations are triggered by community-acquired respiratory infections.

• Medications to treat COPD exacerbations are limited; therefore, identifying and executing effective ways to prevent exacerbations are needed.

• Influenza and pneumococcal vaccines are currently recommended for all persons with COPD. However, current immunization rates are low

Vaccination of the COPD patient

• Tdap vaccine to protect against whooping cough and tetanus

• Influenza vaccine each year to protect against seasonal flu

• Pneumococcal polysaccharide vaccine to protect against pneumonia and other pneumococcal disease

Influenza Vaccination: How well does it work?

• Flu vaccination also has been shown to be associated with reduced hospitalizations among people with diabetes (79%) and chronic lung disease (52%).

• A study that looked at flu vaccine effectiveness over the course of three flu seasons estimated that flu vaccination lowered the risk of hospitalizations by 61% in people 50 years of age and older.

2015-2016 Influenza Vaccine Preparations

• Intramuscular (IM) vaccines will be available in both trivalent and quadrivalent formulations.

• High dose vaccines(IM) will all be trivalent this season

• For people who are 18 through 64 years old, a jet injector can be used for delivery of one particular trivalent flu vaccine (AFLURIA® by bioCSL Inc.).

• Nasal spray vaccines will all be quadrivalent this season.

• Intradermal vaccine will all be quadrivalent

2015-2016 Influenza Vaccine

• Contains the following 4 viral strains for 2015/2016 northern hemisphere season

–A/California/7/2009 (H1N1) pdm09-like virus (same strain as was used for 2009 H1N1 monovalent vaccines)

–A/Switzerland/9715293/2013 (H3N2)-like virus (new strain for 2015/2016)

–B/Phuket/3073/2013-like virus (B/Yamagata lineage) (new strain for 2015/2016)

–B/Brisbane/60/2008-like virus (B/Victoria lineage vaccine virus)

Who Should Receive Influenza Vaccine?

EVERYONE

Who Should Not Receive Influenza Vaccine?

• Severe hypersensitivity (eg, anaphylaxis) to any component of the vaccine, including egg protein, or following a previous administration of any influenza vaccine

• Persons with hives-only allergy to eggs, can receive the inactivated influenza vaccine

• History of Guillain-Barre within 6 weeks of influenza vaccination

High-Dose vs Standard-Dose

•Increased Immunological response• ? Improved clinical efficacy•Recent data- high dose Fluvax may show increased clinical utility in Nursing home patients – to be presented Oct•A study published in the New England Journal of Medicine (08/2014) indicated that the high-dose vaccine was 24.2% more effective in preventing flu in adults 65 years of age and older relative to a standard-dose vaccine. The confidence interval for this result was 9.7% to 36.5%).

Pneumococcal Vaccination:PPSV23 Vaccine

• Vaccine strains account for 88% of

bacteremic pneumococcal disease• 75% efficacy against invasive disease• 30% efficacy against pneumonia • Duration of immunity at least 6 years

File TM, et al. Infect Dis Clin Pract. 2012; 20:3-9

Adult PPSV23 Vaccine Recommendations

• All Adults 65 years of age and older• Adults 19-64 (immunocompetent)

• Chronic illness (heart, lung, liver, diabetes, alcoholism, CSF leaks, cochlear implants)

• Asthma • Cigarette smoking

Pneumococcal Vaccination:PCV13

• CAPiTA trial • demonstrated 45.6% efficacy of PCV13

against vaccine-type pneumococcal pneumonia

• 45.0% efficacy against vaccine-type nonbacteremic pneumococcal pneumonia

• 75.0% efficacy against vaccine-type IPD among adults aged ≥65 years

PCV13 Vaccine in Adults

• Pneumococcal (PPSV23) vaccine naïve subjects:

• An evaluation of immune response after a second pneumococcal vaccination administered 1 year after the initial study doses showed that subjects who received PPSV23 as the initial study dose had lower antibody responses after subsequent administration of PCV13 than those who had received PCV13 as the initial dose followed by a dose of PPSV23, regardless of the level of the initial response to PPSV23

COPD:PCV13 and PPSV23 before age 65

Summary

• Pneumococcal disease results in significant clinical and economic burden

• Current vaccines are effective in preventing invasive pneumococcal disease (IPD)

• Despite proven efficacy and safety of vaccines, <20% of at-risk adults < 65 years of age are vaccinated

Summary

• Advances of vaccines often caused by refusals due to irrational beliefs

• Responsible healthcare professionals must increase education of public and encourage usage

• Practice what we preach

• Be vaccine champions

• “You are going to get your x shot today”

Tobacco Cessation

Marianne Vest, MA, RN, CTTS

Senior Clinical Nurse

Cardiovascular and Pulmonary Rehabilitation

Harrington Heart & Vascular Institute

Tobacco Dependence

• Tobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit.

• Effective treatments exist that can significantly increase rates of long-term abstinence.

• However, first the question must be asked!

Are you using any form of tobacco?

Importance of Regularly Assessing Tobacco Use

• Clinicians can make a difference with minimal intervention (<3 minutes)

• Research has shown a relation between intensity of intervention and cessation outcome

• Even if a patient is not ready to quit at that time, a brief intervention may enhance motivation & increase the likelihood of future quit attempts

• The average number of quit attempts prior to being successful = SIX!

Tobacco Cessation Counseling by physicians, nurses, and other clinicians

all are of proven benefit.

0

10

20

30

No clinician Self-helpmaterial

Nonphysicianclinician

Physicianclinician

Type of Clinician

Est

imate

d a

bst

inence

at

5+

m

onth

s

1.0 1.1

1.7

2.2

n = 29 studies

Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.

Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.

With help from a clinician, the odds of quitting approximately doubles.

Compared to patients who receive no assistance from a clinician, patients who receive assistance

are 1.7–2.2 * times as likely to quit successfully for 5 or more months.

* Odds ratios

Esti

mate

d a

bsti

nen

ce r

ate

at

5+

mon

ths

0

10

20

30

None One Two Three or more

Number of Clinician Types

1.0

1.8

2.5 2.4

n = 37 studies

Team work is effective: Counseling by more than one clinician (e.g. physician and nurse)

is better than either one alone!

Compared to smokers who receive assistance from no clinicians, smokers who receive

assistance from two or more types of clinicians are 2.4–2.5* times as likely to quit

successfully for 5 or more months.

Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.

Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.

* Odds ratiosNumber of Clinician Types

TOBACCO DEPENDENCE:A 2-PART PROBLEM

Tobacco Dependence

Treatment should address the physiological and the behavioral

aspects of dependence.

Physiological Behavioral

Treatment Treatment

The addiction to nicotine

Medications for cessation

The habit of using tobacco

Behavior change program

Behavioral Change: The Spirit of Motivational Interviewing

• Partnership – Not confrontation• Acceptance – Not judgement• Compassion – Not indifference• Evocation – Not advice

A meta-analysis of 14 randomized trials showed that compared to brief advice or usual care, MI increased 6-month cessation rates by about 30%

Lai et al, Cochrane Database Syst Rev 2010

Motivational Interviewing

• Express empathy- use open ended questions to explore- use reflective listening to seek shared understanding

• Develop discrepancy- between present behavior & expressed goals

• Roll with resistance• Support self-efficacy

-offer options for achievable small steps toward change

Elicit-Provide- Elicit

• Elicit: ask what the patient knows or would like to know (pharmacotherapy, relapse, etc)

• Ask permission: ‘Do you mind if I share with you some of what we know?’

• Provide: information in a neutral, nonjudgemental fashion (‘research suggests that….)

• Elicit: patient’s interpretation (‘what does this mean to you?’ ‘how can I help?’ ‘do you have any questions?’)

Suggestions for Behavioral (habit) Change

• Only smoke in one room of the home• Put cigs in trunk of car when driving• Change the routine: coffee in the AM• Put cigs in basement/not normal room • Change cigarette brands• Use a straw or toothpick in mouth

instead of cig

Behavioral Change

KEY POINTS• Position yourself as the beginning of the process,

not the provider of the entire cessation program

• You want the patient to talk themselves into changing rather than you telling them they have to change!

• Offer treatment “Quitting smoking can be hard, but there is good

treatment available and I can help. Would you like to try?”

Pharmacologic Methods:First-line therapies

Three general classes of FDA-approved drugs for tobacco cessation:

• Nicotine replacement therapy (NRT) Nicotine patch, gum, lozenge, nasal spray, inhaler

• Psychotropics Sustained-release bupropion administered twice daily

• Partial nicotinic receptor agonist Varenicline

**E-cigarettes and related products are NOT currently FDA approved for tobacco cessation.

Long-term (6 month) Quit Rates for Available Cessation Medications

0

5

10

15

20

25

30

Nicotine gum Nicotinepatch

Nicotinelozenge

Nicotinenasal spray

Nicotineinhaler

Bupropion Varenicline

Active drugPlacebo

Data adapted from Cahill et al. (2008). Cochrane Database Syst Rev; Stead et al. (2008).

Cochrane Database Syst Rev; Hughes et al. (2007). Cochrane Database Syst Rev

Per

cen

t q

uit

18.0

15.8

11.3

9.9

16.1

8.1

23.9

11.8

17.1

9.1

19.0

10.311.2

20.2

Combination Pharmacotherapy

• Combination NRTLong-acting formulation (patch)

• Produces relatively constant levels of nicotine

PLUS

Short-acting formulation (gum, lozenge)• Allows for acute dose titration as needed for

nicotine withdrawal symptoms

• Bupropion SR + NRT

Relative Efficacy/Safety of Tobacco

Dependence Pharmacotherapy

• Varenicline is superior to NRT monotherapy or Bupropion

• NRT monotherapy & Bupropion are of about equal efficacy

• Combination NRT may be as efficacious as Varenicline

UH Resources• Harrington Heart & Vascular Institute

-experienced Certified Tobacco Treatment

Specialists-referral for patients who have failed at least 1 recent trial of pharmacotherapy by primary or specialty physician-accessible via outpatient AEMR orders

• Beat the Pack – employee program• Plan Q Mobile app – Pfizer• LMS Tobacco Cessation education online course

-will go live 10/1/2015

AEMR Order

COPD System Steering Committee

Theresa Kearns, MBA, RN, NE-BC

Director, HHVI System Ambulatory

Cardiovascular Services

COPD System Steering Committee

• Reduce readmission rate of the PNA and COPD patient population

• Institute best practices from literature review

• Collaborate with pharmaceutical company to enhance medication accessibility for COPD patients

• Develop innovative interventions and sustainable outcomes to decrease LOS and prevent readmissions

• Prevent CMS penalties

• Representation from all system hospitals

Readmission Reduction Program Definition

• 30-day unplanned readmission to any U.S. hospital

• Populations: AMI, CHF, PN, COPD, Elective Hip/Knee Replacement

• Includes Traditional Medicare only

• Includes ages 65 and older only

• Excludes transfers to another short-term general hospital

• Excludes critical access hospitals (Conneaut & Geneva)

• Risk-adjusted by secondary conditions, demographics, and procedures

• Your hospital’s results are compared to similar hospitals (severity)

Readmissions Reduction Program – COPDDischarges July-2011 to June-2014. Medicare FY 2016

Hospital EligibleDischarges

Number of30-Day

Readmits

ObservedAdjusted

Rate

ExpectedReadmission

Rate

ReadmissionRatio (>1.0 = higher

than expected)

NationalObserved

Rate

Ahuja 217 40 18.7% 18.8% 0.9923 20.2%

Case 239 56 22.2% 21.3% 1.0428 20.2%

Elyria 813 191 22.5% 20.0% 1.1224 20.2%

Geauga 262 56 22.0% 22.4% 0.9792 20.2%

Parma 748 171 22.6% 22.0% 1.0271 20.2%

Regional 260 61 21.8% 20.6% 1.0616 20.2%

Portage 259 50 18.8% 18.5% 1.0176 20.2%

St. John 486 108 21.9% 21.5% 1.0187 20.2%

FY 2015 was the 1st year for the program

UH System

COPD VolumesJul-2014 to Jun-2015

Patient Type Facility Total CasesUH Case Medical Center 233UH Regional Hospitals Bedford Campus 125UH Conneaut Medical Center 138UH Geauga Medical Center 74UH Geneva Medical Center 181UH Regional Hospitals Richmond Campus 129UH Ahuja Medical Center 192UH Parma Medical Center 166UH Elyria Medical Center 405

Total 1,643

Patient Type Facility Total CasesUH Case Medical Center 396UH Regional Hospitals Bedford Campus 118UH Conneaut Medical Center 22UH Geauga Medical Center 211UH Geneva Medical Center 63UH Regional Hospitals Richmond Campus 139UH Ahuja Medical Center 149UH Parma Medical Center 394UH Elyria Medical Center 622

Total 2,114

Patient Type Facility Total CasesUH Case Medical Center 92UH Regional Hospitals Bedford Campus 13UH Conneaut Medical Center 20UH Geauga Medical Center 16UH Geneva Medical Center 11UH Regional Hospitals Richmond Campus 65UH Ahuja Medical Center 38UH Parma Medical Center 47UH Elyria Medical Center 136

Total 438

OBSERVATION

INPATIENT ADMITS THRU THE ED

EMERGENCY

Source: Premier. Principal Diagnosis of COPD

Current Work

• Tobacco Cessation

• Home Care Pilot

• e-vouchers

• Monthly chart review by Dr. Schilz

• RN Discharge Clinic

• PFT ordering focus

Best Practice: Tobacco Cessation Process

Goal: System standardization and education for tobacco cessation process

• Standardized resource pamphlet(s)

• Utilize unbranded education resources

• Coding/reimbursement education to capture lost revenue– LMS Educational video available 10/2015

• Pilot UHCMC inpatient initiation of tobacco cessation consult for COPD patients

– Train additional educators

COPD Admissions - % Active Tobacco UseJul-2014 to Jun-2015

Source: Premier. Principal Diagnosis of COPD

Patient Type FacilityActive

Tobacco Cases

Total Admissions

% Active Tobacco Users

UH Case Medical Center 190 486 39%UH Regional Hospitals Bedford Campus 51 156 33%UH Conneaut Medical Center 9 26 35%UH Geauga Medical Center 89 253 35%UH Geneva Medical Center 38 103 37%UH Regional Hospitals Richmond Campus 50 169 30%UH Ahuja Medical Center 58 204 28%UH Parma Medical Center 118 488 24%UH Elyria Medical Center 221 664 33%

Total 824 2,549 32%

INPATIENT

UHCMC Home Care Services PNA & COPD Pilot

Goals• Enhance the quality of care for patients diagnosed with PNA

and/or COPD• Reduce readmissions

Patient Eligibility• Patient w/o insurance for home care or ineligible for traditional

homecare • PNA admit/diagnosis during hospitalization with or w/o COPD• COPD exacerbation/diagnosis during admit with/without PNA • If patient declines home care visit, referral to RN DC clinic for a

one time visit with same program goals as pilot.

Funding• Home care visit funded by UHCMC, billed at $145/visit.

Medication Management

Spiriva eVoucher Program -- 5/2015

• Give eVoucher to COPD patients with order for Spiriva for a free 30 day supply of medication

• Involve key leads from across UH to roll out to other facilities

– Parma and Geneva

• Review/explore additional pharmaceutical opportunities

Chart Review Summary COPD Readmissions to UHCMC

April 2014 – May 2015

• 80% of our COPD Admissions Represent African American Patients

• Readmissions are evenly spread through the 30 days following

discharge (28% in first week)

• 42% of our COPD readmit events represent multiple (2-6) readmits

from only 16 patients, 14 of 16 only admitted for COPD

• Initial MICU admission does not seem to be an indicator of future

readmission either to MICU or to UHCMC

• COPD represents the major reason for 30 day readmission (57%)

• CHF is the second leading reason for 30 day readmission (17%)

Suggested Action Items• Continue data review – consider initial coding review

• Understand population demographic

• Focus initially on 16 patients

• Focus on CHF management in complex patients, may independently

look at this population

• Suggest pulmonary consult for:

– All readmits with primary readmit diagnosis of COPD

– All GOLD III and IV patients (this will include oxygen dependent

patients)

– All MICU patients with COPD as admitting diagnosis to MICU

(although there is some evidence that this is already done on both

code white and current patients)

Best Practices: Patient ‘touch’ moments

• Respiratory Therapist:ˉ Educate patients during treatments on tobacco cessationˉ Utilize Skylight video as reinforce healthy livingˉ Leverage order sets for EMR - PNA and COPD

ˉ Appropriate dx and treatment

• Pharmacyˉ Investigate opportunities to partner with retail pharmacy

(Giant Eagle)

• Home Careˉ Educate Care Coordinators regarding home care services

pilot enrollment criteria

UH System COPD Findings (Jul-2014 to Jun-2015)

• No statistically significant trends up or down in admissions

• 1,643 emergency encounters / treat & release

• 2,114 admissions through the emergency dept.

• 17% of admissions are direct admits

• 32% of admissions with active tobacco use (per coding)

• 36.2% of admissions had a PFT in previous 5 years

• 83% COPD admits are thru the ED