Evaluation of Pulmonary Rehabilitation Program - Essay Example

Running Head: PULMONARY REHABILITATION EVALUATION EVALUATION OF PULMONARY REHABILITATION PROGRAM (CLINICAL ELEMENTS Name Grade Course: Tutor’s Name: 10th, November, 2009 Introduction Rehabilitation programs aim at specific objectives one of which is to improve the patient’s function. They aim at specific outcomes. These outcomes are not only meant to improve the patient’s respiratory functions in relation to the disease/condition causing the disability/abnormal condition, but also to maintain function, provide satisfaction with services and provide adequate quality of life (Martinson et al, 2002). The outcomes focus on the patient’s sense of wellbeing which considers the emotional, social and physical well being. This is why the rehabilitation programs focus on methods of achieving their aim (Meek & Lareau, 2003). For a program to ensure that the patient’s emotional well being is taken care of for example, it has to incorporate education programs that will enlighten the patient and family members on how to handle the patient’s emotions in his or her condition. This does not mean that education as an element of a pulmonary rehabilitation is only meant for improving and maintaining patients’ emotional well being. It only gives the idea that every element is a function of what the rehabilitation program achieves. The aims determine what elements should be incorporated in a rehabilitation program. It is important to evaluate such programs in order to ensure the program works towards its aims. As noted previously, the program aims to improve the quality of life, maintain function and provide satisfaction with services (UMCP, 2009). Below is a short description of what to include in the evaluation of a pulmonary rehabilitation program with the elements to be evaluated and the reasons why it is important to evaluate them. The rehabilitation program described has been adopted from a University Medical Center’s rehabilitation program for purposes of evaluation. The program goals, assessment criteria and interventions have been described. Pulmonary Rehabilitation Program at Jhone The pulmonary rehabilitation program at Jhone was started 15 years ago and holds its therapy sessions twice in a week. It accommodates both out patient and inpatient rehabilitation. The program is meant for out patients but has special arrangements for patients who come from far. The patients take four days within the hospital facility while undergoing rehabilitation. This pulmonary rehabilitation program is totally funded and so charges no patient. There are only three rehabilitation programs sessions per week, that is, a 2 hour education class and 45 min gym session on Wednesdays and a 45 minute gym session every Monday. It can only accommodate two groups with 15-20 patients at a time. Assessment is done by the multidisciplinary team who conduct their assessment the first few hours of admission. The team then plans on how to conduct the therapy based on each patient’s requirements. The respiratory physician and the rehabilitation’s physiotherapists conduct a thorough assessment then refer the patients for ABG, routine blood test, respiratory function test and the six minute walk test. Hospital Anxiety and Depression Scale (HADS) respiratory questionnaire has also to be completed by every patient. For admission to the rehabilitation program, patients are referred by any health professional (GPs, respiratory physicians and nurses) either from private hospitals, from within the hospital or public hospitals to the rehabilitation program. The patients are given information about the effects of pulmonary rehabilitation and the disease in a very short period of time. This has raised complains from the practitioners but no changes have been made yet. Below is the selection criterion for the program: The program accepts COPPD patients and patients with other chronic lung diseases. The patients should have no cardiac problems, not be infected by other diseases, should be cognitively stable and should have good mobility. Jhone pulmonary rehabilitation team follows COPDX Guidelines. Its exercise program involves aerobic and strengthening exercises both for upper and lower limbs (that is, the free weights, arm cycle, treadmill, recumbent cycle and some gym machines. The least number of charted exercises a patient ca do is 4 and the maximum is 10. Patients’ SPo2 and HR are noted before the exercise session begins and after it ends. Program Evaluation: The program has follow up strategies for each patient which ensures that the patient’s and the rehabilitation’s missions are accomplished (UMCP, 2009). Its effectiveness is determined by the outcome measures and the response obtained from patients about the services. Information regarding the rehabilitations performance is discussed in quality assurance meetings and changes made when necessary (Flannery, 2005). Outcome assessment is done based on the following: Dyspnoea level Participation in ADLs 6 minute walk test length of stay mortality cost effectiveness What to Evaluate Based on the above program Evaluation is meant to determine if the program achieves its aims. The aims of a rehabilitation program include: To reduce the symptoms of the patient’s condition Reduce health care costs Increase participation Improve cognitive function (affected cases) Improve functional ability of the patient Improve the quality of life in relation to health status (Mayo Clinic, 2009; UMCP, 2009). In order to achieve such aims, the rehabilitation program has to have the necessary components or elements. Achieving such aims would mean determination of the patients’ status, conditions and rehabilitation requirements and making use of the necessary interventions. Pulmonary rehabilitation is done through four interventions which are believed to help the program specialists in assisting the patient’s achieve their aims. The patients suffer certain symptoms and these have to be reduced. The patients suffer emotionally and this too has to be handled. There are factors that affect their improvement (barriers) and these too have to be dealt with. Research has revealed that education, exercise, psychosocial and nutritional interventions lead to the achievement of rehabilitation goals (Fishman, 1996). This is why it is important to evaluate the rehabilitation program based on the elements it uses to achieve its aims. Evaluation will consider their availability, provision of their services to the patients and their effectiveness in achieving the individual aims. Achievement of pulmonary rehabilitation program goals or its effectiveness can also be evaluated by measuring the patient outcomes. In order to determine if the aims have been achieved, the patient outcome measurement tools are used to determine the level of improvement or change (AAACPR, 2004; Meek & Lareau, 2003). Patient Outcomes after the rehabilitation (measures) considers the overall general health, vocational status, the incidence and types of complications, functional ability of the patient, ability to participate in community leisure activities, independence and echelon of self care (Martinson et al, 2002). All these reflect the health related quality of life provided by the program after completion. a) Measuring Reduction of Symptoms (Dyspnoea) Reduction of symptoms can be measured by use of the 10 point Borg dyspnoea scale which assesses the symptoms during exercise. This scale can be used at the end of the rehabilitation program to establish is the symptoms have reduced or not. Reduction of symptoms can also be measured using the CRDQ which assesses the domains of dyspnoea and fatigue considering the quality of life that the program aims to give the patient (Ries et al., 2006). According to Garrod, Dyspnoea is a perception of extreme and unpleasant breathlessness (Garrod, 2003 p. 14). It is the major symptom in pulmonary rehabilitation patients during exercise. Dyspnoea leads to anxiety, fear and further disability (Garrod, 2003). This perception has to be eliminated if the patient’s goals of improving his/ her health status are to be achieved. Improving the quality of life would also mean eliminating dyspnoea. This is why it is important to assess dyspnoea at the initial stages of rehabilitation, during the process and at the end. Reduction of dyspnoea reduces dyspnoea related anxiety, fear and disability hence improving the health status of the patient and achieving the aims of the rehabilitation program (Garrod, 2003). b) Measurement of Exercise Performance/ exercise tolerance Measurement tools vary in this case and can range from the six minute walk test to multipart cardio pulmonary exercise tests. This depends on the resources available, the staff members available and the program itself. The two common and recommended are the field test of exercise performance which are; the six minute walk test and the shuttle walk test (AAACPR, 2004). There are laboratory tests for exercise assessment as that can also be used. These are; the incremental up to maximum (cardiopulmonary exercise testing) and the sub maximal steady state exercise all which provide physiologic data for measurement of physiologic changes from exercise trainings (AAACPR, 2004). The rehabilitation program below uses the six minute walk test to assess patients for admission. This same tool should be used to evaluate progress. It is important to measure a patient’s exercise capacity since this determines the patient’s progress in the rehabilitation. In pulmonary rehabilitation, there is educational intervention, counseling and even exercise intervention approach. Exercise improves muscle endurance and increases peripheral muscle strength which helps in regaining or improving functional ability of the patient. Improving the functional ability of the patient is one of the aims of the pulmonary rehabilitation (Garrod, 2003) c) Measuring the Health Related Quality of Life Measurement of health related quality of life can be done by use of questionnaires. Its measurement quantifies the impact of the pulmonary disease, its treatment side effects and its co morbidity on the patient’s well being and daily life activities (AAACPR, 2004; Kaplan & Reis, 2005). The questionnaires have different functional domains depending on the pulmonary disease condition being treated in the program. They assess the functional status of the patient, the impact on the patient, the feeling of having control over the disease, the disease symptoms (fatigue and dyspnea) and the general dissatisfaction or satisfaction with life (AAACPR, 2004; Kaplan & Reis, 2005). Health related quality of life questionnaires are of two types, that is, the generic one that considers the overall health of the patient and the respiratory specific that considers the respiratory condition alone. In the rehabilitation program provided in the appendix, the questionnaires for quality of life assessment should be specific to COPD patients and those of other specific respiratory diseases being attended to in the hospital’s program, that is, the Chronic Respiratory Disease Questionnaire (CRDQ) and the already validated questionnaires; the Ferrans and Powers (QOL) pulmonary version and St George’s Respiratory Questionnaire (AAACPR, 2004; Kaplan & Reis, 2005). There has also been a proposal to quality of life measurement tool that has not yet been approved. If approved, this could also be used to assess the health related quality of life. The tool referred to in this case is the “AACVPR outcomes resource guide” (AAACPR, 2004 p.62). One of the aims of a pulmonary rehabilitation is to improve health related quality of life. If this is not assessed, it will not be easy to determine if the program has achieved its aim. It is therefore very important to measure the quality of life achieved by the program at the end (Mayo Clinic, 2009). d) Length of Stay In any rehabilitation program, there are clinical guidelines that give instructions on the amount of time a patient should take in a rehabilitation program. The average time is given but each patient is different and so each patient’s length of stay is determined by his or her progress. The amount of time for complete therapy as provided by pulmonary rehabilitation clinical guidelines however should be followed (Mall & Medeiros, 1988). Time spent in the rehabilitation program also helps in the recovery of the patient. Any session in a rehabilitation program aims at making progress in the patient’s condition. It is therefore important to evaluate the length of stay in a pulmonary rehabilitation program (Fishman, 1996). e) Cost Effectiveness Cost effectiveness of a rehabilitation program is evaluated for the patients’ choice. If a patient is stable enough and can attend out patient rehabilitation program, the cost effectiveness of undergoing rehabilitation in as a inpatient verses as an out patient will be analyzed and the patient advised on the most cost effective. Similarly, patients that cannot stay at home during rehabilitation are admitted as inpatients, this can be considered the most cost effective way of rehabilitating such a patient (Martinson et al, 2002). f) Effectiveness of PR on Hospitalizations This is measured based on the patient outcomes at the end of the program. Its effectiveness is determined by the achievement of its aims, that is, clinical, behavioural, health and service aims (AAACPR, 2004). Effectiveness of the rehabilitation program can also be measured based on the clinical practices and interventions. There are standard pulmonary rehabilitation clinical guidelines that provide information about what an effective pulmonary rehabilitation should, what it should have and how it should b conducted. The guidelines have assessment procedures, the period of a pulmonary rehabilitation program for specific patient conditions, the equipments the rehabilitation program should have, intervention strategies and the health professionals required for its management. It is important to evaluate the effectiveness of a program to determine if it accomplishes the goals for its implementation. Pulmonary rehabilitation programs are meant to help COPD patients and others with pulmonary diseases. If this cannot be achieved, it would be wastage of resources (Martinson et al, 2002). Conclusion Evaluation of a pulmonary rehabilitation can be based on a lot of factors as discussed in this paper. In most cases, it is the effectiveness of the program that is targeted. This requires evaluation of the services provided, the elements that make up the pulmonary rehabilitation program and their standards, the patient outcomes and the satisfaction of patients’ and their family members. This paper has described how a pulmonary rehabilitation program would be evaluated based on Exercise tolerance, Length of stay, Cost effectiveness, Effectiveness of PR on hospitalizations, quality of life and reduction of symptoms as elements that need to be evaluated in a pulmonary rehabilitation program. Reference List American Association of Cardiovascular & Pulmonary Rehabilitation (AAACPR). (2004). Guidelines for Pulmonary Rehabilitation Programs. 3rd Ed. Toronto, Canada: Human Kinetics. Garrod, R. (2003). The Effectiveness of Pulmonary Rehabilitation: Evidence and Implications for Physiotherapists. The Chartered Society of Physiotherapy. Fishman, A. P. (1996). Pulmonary Rehabilitation. Boston, Massachusetts: Informa Health Care. Flannery, J. (2005). Rehabilitation Nursing Secrets. London, UK: Elsevier Health Sciences. Kaplan and Reis (2005). Quality of life as an outcome measure in pulmonary diseases. Journal of Cardiopulmonary Rehabilitation. 25, p321-331 Mall, R. W. and Medeiros, M. (1988). Objective Evaluation of Results of a Pulmonary Rehabilitation Program in a Community Hospital. CHEST Journal. American College of Physicians. Retrieved on 3rd Nov, 2009 from: http://chestjournal.chestpubs.org/content/94/6/1156.full.pdf+html Martinson, I. M., Widmer, A. and Portillo, C. J. (2002). Home Health Care Nursing. 2nd Ed. New York, US: Elsevier Health Sciences. Mayo Clinic. (2009). Pulmonary and Critical Care Medicine in Minnesota: Pulmonary Rehabilitation Program at Mayo Clinic in Rochester. Retrieved on 3rd Nov, 2009 from: http://www.mayoclinic.org/pulmonary-rst/pulmrehabprgm.html Meek, P. M. and Lareau, S. C. (2003). Critical outcomes in pulmonary rehabilitation: Assessment and evaluation of Dyspnea and Fatigue. Journal of Rehabilitation Research and Development. Vol. 40, (5). pp. 13–24. Ries, A.L. (2006). Impact of Chronic Obstructive Pulmonary Disease on Quality of Life: The Role of Dyspnea. The American Journal of Medicine, 119(10A), s12-s20. University Medical Center at Princeton (UMCP). (2009). Pulmonary Rehabilitation. Retrieved on 3rd Nov, 2009 from: http://www.aacvpr.org/Portals/0/certification/2009/cert09_bp_tab14_princeton.pdf Read More