Clinical Guideline Ver. 2.0 MULTICARE Health System Care of the Adult Chronic Obstructive Pulmonary Disease (COPD) Patient Target Audience: The target audience for this clinical guideline is all MHS providers and staff including those associated with our clinically integrated network. The secondary audience includes MHS clinical support staff in these areas: Pharmacy, Nursing, Imaging, Lab, Care 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 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 (COPD) 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 2014 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. CARE OF THE ADULT CHRONIC OBSTRUCTIVE PULMONARY DISEASE PATIENT (COPD) Page 1 of 9
If the patients are engaged and involved with their care by use of tools, the outcomes will be improved. Objective Goal Statement Reduce the mortality rate associated with COPD and rates of both admission and readmission to healthcare facilities when avoidable. This will decrease the cost per case, and maintain or improve the LOS required to treat COPD. Standardize and improve appropriate delivery of pharmacologic treatment of COPD to include: Short and long acting Beta 2 -agonists and Anti-Cholinergics, Methylxanthines, inhaled corticosteroids, and systemic corticosteroids for patients at all MultiCare entities by providing the correct dosage and proper adjustments through the use of a single, validated order set. Recommendations: The GOLD guidelines most recent update in 2014 recommends the use of a classification system using 4 dimensions to Grade COPD. The dimensions are: (1) a subjective functional assessment of perceived dyspnea, (2) spirometry assessment, (3) assessment of comorbidities, and (4) assessment of recent exacerbations and/or hospitalizations. Subjective Assessment The subjective assessment is from the Modified British Medical Research Council (mmrc) which is a forced choice Likert scale 0 4; no breathlessness to breathlessness with ADLs. Spirometry The ideal Spirometry test is performed when the patient has abstained from smoking and short or long-acting bronchodilator use for 4 hours prior to the test. A post-bronchdilator spriometry test may be performed to determine the patient s response to bronchodilators, and is ideally performed 20 minutes after a bronchodilator dose is given. Administration of spirometry may vary from clinic to clinic; the person conducting the test should be signed off on the appropriate MultiCare competency. Co-Morbidities & Exacerbations Assessment of Co-Morbidities and risk for exacerbations is completed by the health care provider while conducting the History & Physical. Exacerbations & Co-morbidities have been added to the Grading system due to extensive literature describing higher mortality rates connected with exacerbations that require hospitalization and the increased loss in FEV 1 that accompanies each exacerbation. CARE OF THE ADULT CHRONIC OBSTRUCTIVE PULMONARY DISEASE PATIENT (COPD) Page 2 of 9
Modified Medical Research Council Questionnaire for Assessing the Severity of Breathlessness *The patient s mmrc grade is based on the statement below that the patient states most applies the them. mmrc Grade 0. I only get breathless with strenuous exercise mmrc Grade 1. I get short of breath when hurrying on the level or walking up a slight hill. mmrc Grade 2. I walk slower than people of the same age on the level because of breathlessness, or I have to stop for breath when walking on my own pace on the level. mmrc Grade 3. I stop for breath after walking about 100 meters or after a few minutes on the level. mmrc Grade 4. I am too breathless to leave the house or I am breathless when dressing or undressing. Modified Medical Research Council (mmrc) Grade mmrc Grade 0 mmrc Grade 1 Patient Statement in Answer to Which Applies Most to You? I only get breathless with strenuous exercise I get short of breath when hurrying on the level or walking up a Action Go To Algorithim CARE OF THE ADULT CHRONIC OBSTRUCTIVE PULMONARY DISEASE PATIENT (COPD) Page 3 of 9
mmrc Grade 2 mmrc Grade 3 mmrc Grade 4 slight hill. I walk slower than people of the same age on the level because of breathlessness, or I have to stop for breath when walking on my own pace on the level. I stop for breath after walking about 100 meters or after a few minutes on the level. I am too breathless to leave the house or I am breathless when dressing or undressing. Evidence: Reference Document 1. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease, Updated 2014. 2. At-A-Glance Outpatient Management Reference for Chronic Obstructive Pulmonary Disease (COPD) Global Initiative for Chronic Obstructive Lung Disease (GOLD), Updated 2014. Algorithm: The algorithim for managing adult patients with COPD is contained in the attachments. Click here. Implementation Items and Patient Education: MultiView Applications CARE OF THE ADULT CHRONIC OBSTRUCTIVE PULMONARY DISEASE PATIENT (COPD) Page 4 of 9
Order Sets and Smart Sets 1. These are under construction with the EPIC build team, names & numbers will be assigned to both the Smart & Order sets when they are completed. Patient Education materials 1. This is under construction, will follow the standard RED/YELLOW/GREEN format, and will be available through the MHS print shop and able to be downloaded from the MultiCare Guideline Home page as a PDF. 2. Patient Education is available through the link on the MultiCare Guidelines Homepage under the name of this guideline. Link to Home Page. CARE OF THE ADULT CHRONIC OBSTRUCTIVE PULMONARY DISEASE PATIENT (COPD) Page 5 of 9
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MultiCare Connect Tip Sheet This Tip Sheet will be published following standard MHS change management protocols for MultiCare Connect updates. Metrics Plan: AIM Statements 1. TBD 2. TBD 3. COPD Readmissions & Mortality will decrease as a result of implementing and adhering to the order sets & smart set. MultiView COPD readmissions and Smart Set & Order Set adherence applications will be monitored by the Medicine Collaborative for the immediate post Go Live period. All suggestions for change or improvements will be captured using standard project management methodologies and the MHS MOCHA system. Suggestions will be compiled and brought to the Physician Leaders of the Medicine Collaborative for action. The Medicine Collaborative will continue to review all COPD readmissions on a quarterly basis for 3 quarters following the Go Live date. This data will be aggregated and brought back to the Physician Leaders for action. PDCA Plan: The Medicine collaborative implementation team will utilize standard project management methodologies and existing MHS processes to ensure a successful launch & adoption of order sets and smart set. 1. All EPIC functionality issues should be called in to the MHS help desk at 403-1160 then press #1 for non-urgent or #5 for urgent issues. 2. Order set and Smart set accessibility and operational issues should be reported through the Clinical Informaticist normally assigned to your CARE OF THE ADULT CHRONIC OBSTRUCTIVE PULMONARY DISEASE PATIENT (COPD) Page 7 of 9
area. 3. The Collaborative team and the Clinical Application Services team will work to ensure that all reported problems/issues are resolved. The Medicine Collaborative will be responsible for ongoing and active surveillance of the MultiView COPD application data, the MultiView Order Set usage data, and quarterly chart review of all patients readmitted with any COPD diagnosis code. The assigned MMA physician leader will be responsible to ensure that the content of the COPD order sets and smart sets remain current against recognized industry standards in research and literature. Point of Contact: Medicine Collaborative (Current Chair of Medicine Collaborative) Approval By: Date of Approval: 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 Auburn Medical Executive Committee TG/AH Medical Executive Committee Good Samaritan Medical Executive Committee August 2014 August 2014 July/August 2014 July/August 2014 September 2014 July 2014 September 2014 September 2014 September 2014 November 2014 November 2014 November 2014 Original Date: Revision Dates: Reviewed with no Changes Dates: Distribution: MHS Intranet August 2014 X/XX; X/XX X/XX; X/XX CARE OF THE ADULT CHRONIC OBSTRUCTIVE PULMONARY DISEASE PATIENT (COPD) Page 8 of 9
Attachment A. MHS COPD Adult Clinical Pathway (Algorithm) CARE OF THE ADULT CHRONIC OBSTRUCTIVE PULMONARY DISEASE PATIENT (COPD) Page 9 of 9