Pulmonary Rehabilitation Program at the Repatriation General Hospital - Case Study Example

Introduction Chronic Obstructive Pulmonary Disease (COPD) is a common cause of disability and hospitalization globally. Also, it is the second most common cause of avoidable hospitalization in Australia (Australia Institute of Health and Welfare, 2013). Some developed countries have prioritized attack of such a disease. They have started rehabilitation programs for people who suffer from COPD or other chronic respiratory illnesses. These programs show a magnificent transition in the life of the COPD population and improve their general quality of life (Gershon, Wang, Wilton, Raut, & To, 2010). Despite a tremendous improvement in patients with COPD through these rehabilitation programs, the disease is still underreported and under-diagnosed in some countries (World Health Organization, 2013). According to the Australian Lung Foundation’s report [ALF] (2007), there are approximately 200 pulmonary rehabilitation centers that serve the population around the country. One of these programs is the Pulmonary Rehabilitation (PR) program at the Repatriation General Hospital (RGH) in Adelaide, South Australia. This paper will focus on analyzing this PR program and describing its processes for maintaining a better quality of life for patients with COPD or other chronic lung diseases. Target Population COPD, which is categorized under chronic illnesses, typically effects elderly people more than other age groups. It is believed that COPD limits the daily activities of elderly patients over a period of time (Garcia-Rio et al., 2009). The RGH PR program aims to improve the Health Related Quality of Life (HRQoL) for these patients and reduce their activity limitations so that they can be more active in the community. The program serves patients older than 45 who live in the southern and rural areas of the city of Adelaide. The program is a comprehensive PR that consists of exercise training and educational sessions. While the program targets patients with COPD and/or chronic lung illnesses, it is largely focused on those who experience symptoms of dyspnea and fatigue. Referral System The PR program is funded by the state government, yet it also accepts Medicare and other private health providers. The referral system is based on the current Australian Lung Foundation’s guidelines (ALF, 2009). Patients are usually referred to the program after recovering from an acute exacerbation or having received primary care at a local hospital. The patients are usually referred from a general practitioner or specialist from all major hospitals within the city’s limits. The PR program is designed for outpatients with chronic lung illnesses. Therefore, the outpatient respiratory medicine clinic further assesses patients to see if they are eligibility for any of the criteria needed to be included in the program. The inclusion criteria are as follows: the existence of COPD in mild to severe stages according to GOLD guidelines (Global Initiative for Chronic Obstructive Lung Disease, 2013) or other chronic respiratory conditions. They must also be willing to participate even if they are current smokers. Patients are excluded from the program if they have severe cognitive impairment, severe psychotic disturbance, or a relevant infectious disease. Due to a limitation placed on the number of participants per group, patients may be required to go onto a waiting list. Once this is done, they will be assessed accordingly. Facilities The PR program at RGH uses variety of equipment to ensure that the aims of the program are correctly delivered to patients. At the pulmonary medicine department, where the initial assessments take place, a pulmonary function unit is used to measure each patient’s lung capacity. In addition, a stationary cardiopulmonary bike is used to assess each patient’s maximum work capacity. The six-minute walking test (6MWT) is conducted in a 20-meter corridor to measure the distance that each patient can walk in 6 minutes. Other facilities used are as follows: a physiotherapy gym where patients can exercise using different exercise training equipment and a class for group discussion, where patients can learn more about the disease and enhance their self-management skills at the same time. An optional facility that can be used is a hydrotherapy pool. In some cases, disabled patients who are wheel-chair dependent may use the occupational therapy department lab to learn how to access their home and kitchen. The PR program uses a multidisciplinary approach that is composed of different allied health professions. The team includes a pulmonary physician, respiratory nurse, pulmonary function testing technician, physiotherapist, occupational therapist, clinical psychologist, dietician, and social worker. Each member plays a role in the management of the disease for each patient. Most team members interact with the patients in the education department, where they can give lectures on specified topics that reflect their area of expertise. Opportunities and Constraints Influencing the Development of PR The RGH was built in 1942 with the purpose of caring for wounded veterans returning from World War II. Since that time, the hospital’s capacity has increased significantly. As a result, the hospital gradually began to accept community patients and became a teaching hospital affiliated with Flinders University. The hospital was transferred from the Commonwealth Government’s Repatriation Commission to the State of South Australia in 1995 (Repatriation General Hospital, 2012). It now serves the southern community and works closely with Flinders Medical Center and Noarlunga Health Services as part of the Southern Adelaide Local Health Network. The PR at RGH is an evidence-based and center-based program. Despite improvements in the patients’ quality of life, the protocol has undergone a review by the pulmonary medicine department in order to improve the protocol of the program. Beginning in 2014, the program will run for 12-weeks instead of 8-weeks. This will help to optimize functional status and decrease health care costs through reducing hospital readmission. The PR program is the only outpatient program in the southern area, and it is a research-based program where randomized clinical trials take place. Constraints may include a lack of transportation to the clinic, especially for patients who live in rural areas. The RGH has minimized the lack of transportation opportunities by providing discounted taxi or bus services. Patients who have to travel over 100 kilometers one way may be eligible to receive financial reimbursement according to the Patient Assistance Transport Scheme (PATS) (SA Health, 2013). The lack of PR programs in the area may influence the increase in waiting time for patients who are eligible to receive the intervention. Luckily, SA health has approved the implementation of a PR program based on RGH program at Noarlunga. Such a program will reduce the number of referred patients to RGH, as patients who live near Noarlunga can continue their program at Noarlunga Hospital. However, the limited resources and availability of exercise equipment there has influenced the limited number of patients participating per group. The Rehabilitation Process Relevancy of Teamwork: The program adopts a patient-centered approach that consists of screening, assessment, goal setting, implementation, and modification processes. In order to deliver the best treatment to patients, the interventions should be tailored to meet each patient’s needs (Spruit et al., 2013). Therefore, a multidisciplinary approach has been established to assess patients on an individual basis, as some patients may not need specific interventions that are essential for other patients. The program is up-to-date with current guidelines that are provided by (ALF, YEAR) and American Thoracic Society/ European Respiratory Society’s (Spruit et al., 2013) guidelines for PR. Patients are assessed prior to entering the program by different allied health professionals to highlight each patient’s limitations. Therefore, regular staff meetings are held to evaluate patients based on the severity of their diseases and urgency to receive a PR intervention. It is suggested that patients should be prioritized depending on the severity of their disease (Spruit et al., 2013). After that, a case manager will contact eligible patients for further initial assessments prior to commencing the program. Individualized meetings with the patients and their families or carers are then used to identify their goals and needs. Once this is completed, a plan is drawn up that includes goals that should be achieved by the end of the program. Although the program currently runs for a total of 8 weeks, it is projected to be increased to 12 weeks by 2014. Each patient will undergo one 2-hour education session and two 60-minute exercise-training sessions per week. Involvement of Patient and Family Fatigue and dyspnea on exertion in patients with COPD may limit their functional activity and capacity (van Helvoort, Dekhuijzen, & Heijdra, 2010). Thus, the severity of the disease may require some adjustments to each patient’s lifestyle. Some patients require the involvement of their family or partner during their disease management. The importance of the education sessions is to teach patients how to cope better with the disease in their daily lives. According to ALF (YEAR), it is recommended to encourage families or partners to attend education sessions so that they can extend their knowledge on how to provide the appropriate support to the patient. The family can play a major role in restoring a patient’s self-confidence back up to its normal level (Caress, Luker, Chalmers, & Salmon, 2009). Patients who either live alone or are disabled will have individual sessions with multidisciplinary team members in order to improve their daily needs and to learn how to cope with such a disease. On the other hand, anxiety and depression is a factor that may result in deterioration of the patient’s condition. Older patients with chronic diseases can experience anxiety and depression easily (Coventry, & Hind, 2007; Kunik, 2005). Preventing this from occurring will enhance the patient’s ability to better manage their condition (Coventry & Hind, 2007). Patient Assessment After referring the patient to the program, the patient will be assessed before, during, and after the program. The initial assessment will include 6MWT, pulmonary function test, and measurement of the HRQoL through the use of questionnaires. The case manager then contacts the patient to schedule an assessment appointment. The 6MWT has been widely used to measure the functional capacity and outcome of COPD patients (Dourado et al., 2009; Spruit et al., 2013). A nurse practitioner helps to assess each patient’s functional capacity by instructing the patient to walk up and down a 20-meter corridor as far as he or she can in six minutes. Prior to the test, the nurse uses a Borg modified scale (Borg, 1982) to rate the patient’s dyspnea and fatigue on a scale of 0 to 10 (0 describes no exertion at all, while 10 indicates very severe dyspnea and/or fatigue). The Borg scale can also be used during and after the 6MWT. The heart rate and oxygen saturation are continuously measured during the performed test. The patient is instructed to rest or slow down whenever they feel like during the test. After the test, their distance is recorded and compared with the predicted normal values for the 6MWT (American Thoracic Society, 2002). Each patient will perform the 6MWT twice with a 30-minute rest in between. The longest distance is then recorded to calculate the maximum intensity that the patient can reach. The intensity is calculated by a physiotherapist on the first day of the exercise training session. The pulmonary function test is performed using a spirometry to measure the capacity and volume of each patient’s lungs. Prior to the test, the patient inhales a nebulized bronchodilator and has to wait for 10 minutes. A post-spirometry is then performed, and the values will be compared to the predicted normal values. The test is performed by a pulmonary function test practitioner according to ATS/ERS guidelines (Lamprecht et al., 2013). On the same day each patient will be given set of questionnaires that measure his or her HRQoL. The questionnaires include a Chronic Respiratory Questionnaire-Self-Administered Standardized (CRQ-SAS) (Schünemann et al., 2005), Short Form Health Survey (SF-36) (Ware & Sherbourne, 1992), Illness Behaviour Questionnaire (IBQ) (Pilowsky, 1993), Revised Health Hardiness Inventory (RHHI-24) (Gebhardt, Van der Doef, & Paul, 2001), and Hospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith, 1983). These questionnaires are explained by the case manager to the patient and his or her family so that there are no misunderstandings. During the program each patient will be assessed using the 6MWT and questionnaires. At the end of the program, each patient will be assessed using the same initial assessment measures in order to compare the results both before and after the program. The differences in the assessment results can be used to evaluate the efficacy of the exercise-training program or to trace the natural history of change in exercise capacity over time (ALF, 2009). Delivery of Rehabilitation Intervention As explained earlier, the PR is a comprehensive program that consists of two components. The first component is physical exercise training sessions. There is one physiotherapist and one assistant to closely monitor each patient and describe the proper exercise and intensity. The program is tailored to meet each patient’s needs in order to achieve the planned goals. The program runs for one hour two times a week, and the exercise protocol includes but is not limited to cycling, walking, weight lifting, arm ergometer exercises, and walking up and down stairs. Some patients may require exercise in the hydrotherapy pool depending on their specific needs. The second component is education sessions. Each education session is conducted in groups delivered by a range of allied health professionals. It is composed of core and optional topics. Based on a survey conducted in 2000 that included 200 patients who completed a PR program, ALF (2009) recommended the following core topics to be covered in a PR program: The role and correct use of medications Breathing techniques / managing breathlessness Physical exercise Nutrition / healthy eating Information on diseases (e.g. what the lungs do) Coping with chronic lung disease and management of depression, anxiety, and panic attacks Optional topics may include: Sputum clearance Energy conservation techniques Continence Sexuality issues Swallowing Community resources, legal issues, and palliative care Home oxygen The education component of the pulmonary rehabilitation program should be tailored to meet the needs of each individual patient. Not every topic may be applicable or needed for each patient, while participation for in-group sessions should not be involuntary (Australian Lung Foundation and Australian Physiotherapy Association, 2009). The comprehensive PR program results in a better outcome compared to a PR program that provides only one component of the program (Lacasse, Goldstein, Lasserson, & Martin, 2006). Continuity of Care Post-discharge from the PR program Patients with COPD are encouraged to become more active in their community and to coordinate with local COPD support groups. Due to the limited number of community-based exercise services in southern areas, it is recommended that patients should join at least one support group if possible after the PR program (AFL, 2012). This is because engaging in community activities improves the physical performance of these patients and at the same time reduces their anxiety (Hynninen et al., 2010; Woo et al., 2006). Patients are asked to engage in activities that they prefer to participate in, such as playing lawn bowls or taking their pets for a walk. The patients also inferred that the sharing of positive stories among COPD patients had a positive influence on their health and created optimism for patients with unmanaged COPD. Brochures for local COPD support groups are also distributed for the patients within the group. Home-based exercises are prescribed to patients to prolong the benefits of the PR program. A study conducted by (Ghanem, Elaal, Mehany, & Tolba, 2010) to evaluate the effect of a two-month home-based PR program with outpatients on exercise tolerance and HRQoL concluded that post–discharge this PR program is an effective non-pharmacological intervention in the management of stable patients with COPD. The PR program at RGH uses telehealth technology to follow up patients six months after the program has concluded. In some cases, patients may require a follow up visit to the clinic for further assessments to be carried out. It is believed that follow up assessments will decrease readmission to primary care and increase the HRQoL in patients with chronic lung disease (Puhan, Scharplatz, Troosters, & Steurer, 2005). Conclusion The PR program at RGH follows a centered-patient approach that involves the use of multidisciplinary team members to deliver the best treatment available for patients with COPD and other chronic lung illnesses according to the latest guidelines. The program has significantly improved by providing rehabilitation services for patients in the community and also rural areas. The PR program is currently improving the protocol by extending the duration of the program to 12 weeks by the beginning of 2014. Read More