CARE OF THE ADULT COPD PATIENT Target Audience: The target audience for this clinical guideline is all MultiCare providers and staff including those associated with our Clinically Integrated Network. The secondary audience includes MultiCare clinical support staff in these areas: Pharmacy, Nursing, Imaging, Lab, Casre Management, Transitions of Care, and Respiratory Therapy. Scope/Patient Population: This guideline applies to all adult patients in MultiCare s adult hospitals to include Tacoma General, Allenmore, Good Samaritan, Auburn Medical Center, Covington Medical Center and all of MultiCare Health System s primary care, specialty care and urgent care clinics. The target patient population includes adults diagnosed with COPD and other patients who meet the following definition provided by the Global Initiative for Chronic Obstructive Lung Disease. Definition of COPD Chronic Obstructive Pulmonary Disease a common preventable and treatable disease is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients. Rationale: Chronic Obstructive Pulmonary disease (COPD) is the fourth leading cause of death in the world and represents an important health challenge that is both preventable and treatable. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) standard is the Universally accepted measure for the diagnosis and grading of COPD, the 201994 GOLD standards were referenced extensively to create a single smart set and order set to serve providers and adult patients in both the outpatient/ambulatory and inpatient arenas. If the patients are engaged and involved with their care by use of tools, the outcomes will be improved. Page 1 of 7
Objective Goal Statement Reduce the mortality rate associated with COPD Reduction symptoms and future risk of exacerbations. Reduce the rates of both admission and readmission to healthcare facilities for COPD exacerbations when avoidable. In turn, reduce the cost per hospital stay and maintain or decrease the length of stay for patients admitted with COPD exacerbations. Standardize and improve appropriate delivery of pharmacologic treatment and nonpharmacological treatment of COPD to include: Smoking cessation, nutrition, Vaccinations, Short and long acting Beta2-agonists and Anti- Cholinergics, roflumilast, macrolide, Methylxanthines, inhaled corticosteroids, systemic corticosteroids, Oxygen, BiPAP, COPD education including effective utilization of multi-dose inhalers, and pulmonary rehabilitation for patients at all MultiCare entities by use standard order sets for admission and discharge. Formatted: Font: 11 pt, Font color: Blue, Strikethrough Recommendations: Disclaimer: The below serves as a reference for health care professionals and patients within the MultiCare Connected Care affiliated network. The guideline provides an evidence-based* framework for evaluating, treating or preventing various health conditions. The guideline is not meant to replace clinical judgment of individual providers and is not meant for all circumstances. * The process of determining evidence based criteria involves the review of peerreviewed literature and nationally published guidelines in the open literature where there is evidence supporting these recommendations. When possible, along with the reference, the original literature or links are provided to provide accurate assignment of original authorship. DIAGNOSTIC ASSESSMENT Page 2 of 7 Clinical diagnosis of COPD should be considered in any patient over age of 40 who has dyspnea, chronic cough or sputum production, and a history of exposure to risk factors for the disease. Spirometry is required to make the diagnosis in this clinical context; the presence of a postbronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation and thus of COPD. Spirometry is unable to be tested during a hospital admission and needs to be ordered in the ambulatory setting. Administration of spirometry may vary from clinic to clinic; the person conducting the test should be signed off on the appropriate MultiCare competency.
Spirometry testing done in the ambulatory setting has the following recommendations: o Short acting bronchodilators or anticholinergic agent should not be used 4 hours prior to testing o Long acting bronchodilators should not be used 12 hours prior to testing o No smoking greater than or equal to 1 hour prior to testing o Post spirometry testing can be administered greater than or equal to 10 minutes and up to 15 min for short acting bronchodilator and 30 minutes later for short acting anticholinergic agents. The GOLD guidelines 20197 recommends the use of the revised ABCD assessment tool for COPD which includes spirometry to note the severity of airflow limitation, a subjective functional assessment of the patient s symptoms using mmrc (modified British Medical Research Council Questionnaire) or CAT (COPD Assessment Test) and assessment of recent exacerbations and/or hospitalizations. Comorbidities occur frequently in COPD patients, including cardiovascular disease, skeletal muscle dysfunction, metabolic syndrome, osteoporosis, depression, and lung cancer. Given that they can occur in patients with mild, moderate and severe airflow limitation and influence mortality and hospitalizations independently, comorbidities should be actively looked for, and treated appropriately if present. Assessment of Co-Morbidities and risk for exacerbations are documented by the health care provider while conducting the History & Physical on admission whenever possible. THERAPEUTIC OPTIONS In patients who smoke, smoking cessation is very important. Pharmacotherapy and nicotine replacement reliably increase long-term smoking abstinence rates. Appropriate pharmacologic therapy can reduce COPD symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance. To date, none of the existing medications for COPD has been shown conclusively to modify the long-term decline in lung function. The patient severity should be assessed periodically to determine if updates in treatment regime are needed. Each pharmacological treatment regimen needs to be patient-specific, guided by severity of symptoms, risk of exacerbations, drug availability, and the patient s response. Inhaler technique should be assessed frequently. Page 3 of 7
The need for supplemental oxygen if not already prescribed should be assessed and effectiveness reassessed ongoing In patients with chronic hypercapnia and history of hospitalization with acute respiratory failure, long term noninvasive ventilation options could be considered Influenza and pneumococcal vaccination should be offered to every COPD patient; they appear to be more effective in older patients and those with more severe disease or cardiac comorbidity. All patients who get short of breath when walking on their own pace on level ground should be offered rehabilitation; it can improve symptoms, quality of life, and physical and emotional participation in everyday activities. Often rehab is prescribed to the most severe patients instead of moderately severe where the most impact can be obtained. COPD patients require nutritional support due to increased calorie expenditure and poor tolerance to the energy required to take in sufficient nutrients. Nutritional support promotes strength to respiratory muscle strength and increased activity tolerance. Non-surgical bronchoscopic lung volume reduction techniques should not be used outside clinical trials until more data are available. Palliative Care is underutilized in the COPD patient. Palliative care encompasses approaches to symptom management control as well as management of terminal illness when close to death. Even with optimal medical treatment chronic breathlessness, fatigue, activity intolerance, panic, anxiety and depression can be very distressing. MANAGEMENT OF EXACERBATIONS An exacerbation of COPD is defined as an acute worsening of respiratory symptoms that results in additional therapy. The goal for treatment of COPD exacerbation is to minimize the negative impact of the current exacerbation and to prevent subsequent events. Short-acting inhaled beta2-agonists with or without short-acting anticholinergics are usually the preferred bronchodilators for treatment of an exacerbation. Maintenance therapy with long-acting bronchodilators should be initiated as soon as possible before hospital discharge. Systemic corticosteroids and antibiotics can shorten recovery time, improve lung function (FEV1) and arterial hypoxemia (PaO2), and reduce the risk of early relapse, treatment failure, and length of hospital stay. Duration of therapy should not be more than 5-7 days. Antibiotics, when indicated, can shorten recovery time, reduce the risk of early relapse, treatment failure, and hospitalization duration. Duration of therapy should be 5-07 days. Methylxanthines are considered second line therapy for exacerbations of COPD and are generally not recommended due to lack of efficacy, with Page 4 of 7
increased side effects. not recommended due to increased side-effect profiles. The need for supplemental oxygen if not already prescribed should be assessed and effectiveness reassessed ongoing. ABGs should be considered. Noninvasive ventilation should be the first mode of ventilation used in COPD patients with acute respiratory failure with no contraindications COPD exacerbations can often be prevented. Smoking cessation, influenza and pneumococcal vaccination, knowledge of current therapy including inhaler technique, and treatment with long-acting inhaled bronchodilators, with or without inhaled corticosteroids, and treatment with a phosphodiesterase-4 inhibitor are all interventions that reduce the number of exacerbations and hospitalizations <ADD PICTURES/ALGORITHMS> Evidence: Reference Document Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease, 2019 ReportUpdated 2017 List of Implementation Items and Patient Education: MultiView Applications Order Sets and Smart Sets 1. Order set number for ED = 11293 2. Order set number for hospitalists = 11294 3. Order set number for inpatient discharge = 11268 4. EPIC Smart Text for After Visit Summary (AVS) Attachment B Patient Education materials 1. Standard RED/YELLOW/GREEN format will be available through the MHS print shop. Form #88-1667-9 Page 5 of 7
MultiCare Connect Tip Sheet This Tip Sheet has been published following standard MHS change management protocols for MultiCare Connect updates. <UPDATE WITH NEW COPD KEY ACTION PLAN ELEMENTS> MultiCare Connect Tip Sheet This Tip Sheet has been published following standard MHS change management protocols for MultiCare Connect updates. Metrics Plan: AIM Statements (for 2019?) 1. Increase the composite index score of the COPD NOREADMITS bundle to 70% by end of year 2017. Formatted: Font color: Blue Formatted: Font color: Blue Page 6 of 7
2. Reduce COPD Readmissions to less than or equal to 16.61% by end of year 2017. This team will launch at least one pilot to improve access to spirometry in 2017. PDCA Plan: The Medicine CollaborativeCARE Group/Collaboratives Program will review this Guideline and all supporting deliverables on an bi-annual basis. Point of Contact: Medicine Collaborative (Current chair until delegated to other point of contact)multicare Inpatient Specialists and Sound Inpatient Providers Medical Directors Approval By: MMA Clinical Quality & Compliance Committee Urgent Care Collaborative Emergency Department Provider Meeting MultiCare Inpatient Specialist Meeting Sound Inpatient Providers Medical Imaging Northwest Pharmacy and Therapeutic Committee MHS Nurse Executive Committee ESOC Medicine Collaborative Auburn Medical Executive Committee TG/AH Medical Executive Committee Good Samaritan Medical Executive Committee Quality Steering Council Original Date: Revision Dates: Reviewed with no Changes Dates: Distribution: MultiCare Connected Care + MultiCare Health System Date of Approval: 09/2014 07/2014 03/2014 09/2014 09/2014 05/2015 06/2015 07/2015 06/2015 06/2015 07/2015 08/2015 01/2015, 05/2015, 06/2015, 01/2017 Xx/xx Formatted: Font color: Blue, Strikethrough Page 7 of 7