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La dimissioneLa dimissione

Joan Escarrabill, MDMaster Plan For Respiratory Diseases (PDMAR)

Ministry of Health

Health Studies Institute

Barcelona

jescarrabill@gencat.cat

Punti chiave

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1La dimissione è importante dal punto di vista de la sicurezza dei pazienti e de l'efficacia del trattamento

2Il processo è complesso e richiede il lavoro di squadra.

3Ogni volta che si verifichino dei cambiamenti di trattamento è necessario prendere in considerazione l'adattamento del paziente.

Agenda

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4

Discharge planning

Discharge planning

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Long-term care facilitiesGeneral

wardICU

Emergency department

Outpatient clinic

Weaning center

Monaldi Arch Chest Dis 2007; 67: 3, 142-147.n = 792 patients

20%20%

45%45%

16%16%

36%36%

Monaldi Arch Chest Dis 2007; 67: 3, 142-147.n = 792 patients

18%

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Escarrabill J. Eur Respir Mon, 2008, 41, 367–376

9

10

Neale G. J R Soc Med 2001;94:322-330.

20%

10%

52%

18%

Preventable adverse events

Invasive procedures

Misdiagnoses

General ward care

Discharge

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CMAJ 2004;170:1235-40

1212

TeamworkTeamwork

CommunicationCommunication

Most problems (and accidents) relate with …

Barriers to effective nurse-physician communication

Feeling hurried by the physician (28%) Finding a quiet place to call (25%) Difficulty reaching the physician (21%)

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Effective team Ha una gamma di individui che contribuiscono in modi

diversi. Obiettivi chiari. Tutti capiscono i compiti che devono fare. Coordinatore Atmosfera informale. Discussione (I membri del gruppo ascoltare gli altri) Sentitevi liberi di criticare. Comodo con disaccordo. Apprendimento dall'esperienza.

www.kent.ac.uk/careers/sk/teamwork.htm

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Il team ottiene risultati migliori rispetto alla somma dei risultati ottenuti da ogni singolo membro.

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Wagner. BMJ 2000;320:569-72.

Casas and Romeu in tandem (1897)

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Aiken L. NEJM 2003;348:164-6

Increasing role of non-physcian health professionals.

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• Competenze relative alla ventilazione meccanica a casa (HMV), la tecnologia e l'assistenza domiciliare.

• Capacità di valutare l'adeguatezza dei caregivers.

• La conoscenza delle risorse della comunità.

• Capacità di integrare casa, ambulatoriale e ospedaliera.

• Progettazione di piani di cura a base di linea guida che integrano le esigenze cliniche e le preferenze del paziente.

• Behavioral consulenza e l'insegnamento di auto-gestione.

• Esperienza in consultazioni gruppo

BMJ 2009; 339:b3595

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The network of discharge

Health Service Health professionals

SupplierCaregiver

Home carers

Financial issues

Public/Private

Discharge teamCase manager

Risk management

Education

Experience

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Escarrabill J. Eur Respir Mon, 2008, 41, 367–376

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Piper A. Breathe 2010;6:323-33

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J Nurs Care Qual 2004;19:67-73

Case manager coordinates the discharge plan

Patient and caregiver Confidence & competence

Nurses & RRT Understanding of what is needed

PhysicianConfidence that the patient’s needs are being met

Agenda

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Thorax 1998;53:762–767

• to enhance quality of life

• to sustain and extend life without compromising quality.

• to improve or sustain physical and psychological function

• to provide cost effective care.

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Discharge planning...

...is defined as the development of an individualised discharge plan...

...prior to them leaving hospital.

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NIV: Feasibility

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103 pazienti

457 transitions

Aumento del rischio, i risultati clinici più incerto epiù costosi.

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Needs assessment

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Home carers Equipment & supplies Communication Daily living Risk management Funding

Home carers

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Tailored educational programmes for patients and caregivers

Home carers Equipment & supplies Communication Daily living Risk management Funding

O Noeregaard & J Escarrabill

Well-structured programme with theoretical knowledge and practical skills

Patient & Caregiver Training

Patients Caregivers

Is training crucial before discharge?

97% 84%

Is there a continued training after discharge?

36% 34%

Source: Eurovent Survey

Home carers Equipment & supplies Communication Daily living Risk management Funding

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Equipment needs for NIV

Schönhofer B, Sortor-Leger S. Eur Respir J 2002;20:1029-38

Home carers Equipment & supplies Communication Daily living Risk management Funding

Specialized Telephone Equipment

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Augmentative and alternative communication (AAC)

Home carers Equipment & supplies Communication Daily living Risk management Funding

Speak slowlyIf able, use gesturesIdentify the topic first before

Writing Boards

Software: word prediction....

www.muscle.ca/

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Daily living activities

Home carers Equipment & supplies Communication Daily living Risk management Funding

• Strollers.• Standard Wheelchairs.• Rigid Frame Weelchairs.• Nonrigid Frame Weelchairs.• Seating Systems.• Motorized Weelchairs

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Daily living activities

Home carers Equipment & supplies Communication Daily living Risk management Funding

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Room setting

Home carers Equipment & supplies Communication Daily living Risk management Funding

• Doors• Elevators• Alternative systems• (volonteers)

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Room setting

www.medame.com

Home carers Equipment & supplies Communication Daily living Risk management Funding

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Sostegno tecnologico Architectural Elements Communication Computers Home Management Personal Care: eating, personal

higyene Orthotics & Prosthetics Recreation Seating Sensory Disabilities Therapeutic Aids Transportation Vocational Management Walking Wheeled Mobility

Pazienti avrà bisogno di una vasta gamma di dispositivi di assistenza, in alcuni casi, per

un breve periodo di tempo

Pazienti avrà bisogno di una vasta gamma di dispositivi di assistenza, in alcuni casi, per

un breve periodo di tempo

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Home carers Equipment & supplies Communication Daily living Risk management Funding

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Home carers Equipment & supplies Communication Daily living Risk management Funding

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Home carers Equipment & supplies Communication Daily living Risk management Funding

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http://freespace.virgin.net/michael.bowell/equip.html

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August 14 2000

Power cut kills man on home ventilator BY SAM TOWLSON

AN INVESTIGATION has been launched into the death of a disabled man whose life-saving equipment failed during a power cut.

Feb 15, 2001A Fatal Complication of Noninvasive VentilationLechtzin N., Weiner C. M., Clawson L.

N Engl J Med 2001;344:533

Safety

Home carers Equipment & supplies Communication Daily living Risk management Funding

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Risk minimisation (i)

Adapted from AK Simonds, 2001

Technical aspects

Home carers Equipment & supplies Communication Daily living Risk management Funding

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Adapted from AK Simonds, 2001

Medical and social aspects

Risk minimisation (ii)

Home carers Equipment & supplies Communication Daily living Risk management Funding

Check-list

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Piper A. Breathe 2010;6:323-33

HMV: Funding

Tax-funded

Social-insurance-funded

Home carers Equipment & supplies Communication Daily living Risk management Funding

Agenda

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Dimissione ospedaliera, in pratica

Timing il processo di dimissione ospedaliera inizia il più presto possibile

Fattibilità

Identificare il caregiver competenti

Istruzione

Analizzare i problemi pratici

Prenditi il tuo tempo

Caratteristiche della casa

Dimissione Evitare il week-end

Case manager

Characteristics of care

Source: Eurovent Survey 49% without home care49% without home care

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Systematic follow-up

Escarrabill J. Breathe 2009;6:37-42.

Population: 291.500.000

HMV in Europe Variability

HistoryHistory Number of centersNumber of centers Characteristics of the patientsCharacteristics of the patients Initiation of HMV: outpatient vs hospitalInitiation of HMV: outpatient vs hospital Educational issues and dischargeEducational issues and discharge Follow-upFollow-up

Chron Respir Dis. 2010 Jan 13.

Wise enthusiasm High competence Spreading competence Multidisciplinary collaboration

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Eur Respir J 2009; 33: 411–418

Nurse-centred tele-assistance

Tele-assistance

Control

Aveva meno ricoveri, meno ammissioni nel pronto soccorso, meno chiamate urgenti al GP

di riduzione dei costi 33%33%

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Follow-up

Home visits Outpatient clinic Hospital admission Phone call General practitioner Community resources e-mail

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Am J Phys Med Rehabil. 2010 May;89:401-6.

29 ALS patientsOximetry feedback program

Thirty hospitalizations

were avoided.

On-demand consult and MI-E access

program

Respite care

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Provision of short-term, temporary relief to those who are caring for family members

http://southlakemac.com

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Respir Med 2007;101:62-68

Post-operative intubation time

3,8 + 3,2 h.

Only 1 patient > 12 h.

Stay un postsurgical reanimation unit

19 + 9 h.

19 + 6 h. in the general population

n=16

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End-of-life57% of patients

died at home57% of patients

died at home

The percentage of patients who die in hospital ranges from 18.7 to 62.5% (p=0.045).

ERS 2010 (Barcelona)

n = 77

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Eur Respir J 2010; 35: 1064–1071

Family burden

26 %

17 %

private assistance

high financial burden

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Conclusione

Grazie per la vostra attenzione

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