- Case Study -

Maximizing Non-Invasive Ventilator Support in Smaller Hospitals.

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Background

Chronic Obstructive Pulmonary Disease (COPD) exacerbations are one of the most common reasons for the hospital admission.1 This adversely affects smaller communities with limited resources. The COPD prevalence rate, for example, has been estimated to be about 12% for individuals living in rural communities compared to 7% across the United States.2 As the rate of COPD increases, particularly in women, smaller healthcare systems must be flexible and innovative in order to improve the resource burden of acute COPD exacerbations.3

Responding quickly and efficiently to COPD exacerbations can change the trajectory of care. These patients often warrant the full team’s attention or they may rapidly decline or even progress to cardiopulmonary arrest. COPD treated with NIV (non-invasive ventilation) at the time of hospitalization leads to lower inpatient mortality, shorter length of stay, and lower costs compared with those treated with invasive mechanical ventilation.4 Having trained personnel readily available to apply NIV, recognize when NIV is no longer warranted or effective, and troubleshoot its continued use are key.

Team-based care is necessary to provide the treatments required for severe COPD exacerbations. Allied health staff include nursing, respiratory therapy, hospital medicine, and pulmonology. This spectrum of providers may not be immediately or continuously accessible in smaller institutions. This limitation can create challenges to care provision particularly in individuals with advanced disease that elect to forego invasive mechanical ventilation and want to remain within their communities.

Leveraging Telemedicine

Telemedicine care can create opportunities to honor goals of care, increase use of team-based models, and help ensure patients can stay close to home. For example, a woman with severe COPD presented to one of our client institutions in significant distress. After initiation of NIV she failed to show improvement, and the nighttime telehospitalist engaged the patient and family in a frank discussion regarding her goals of care..

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The patient had been adamant that she did not want to be intubated, and confirmed DNR/DNI status and a desire to remain close to family. The conversation led to a plan to maximize NIV therapies with teamwork between the telehospitalist and respiratory therapy.  After three days of NIV therapy the patient failed to demonstrate meaningful improvement and was unable to be weaned. The care-team then expanded to include telemedicine pulmonology consultation. Respiratory therapy, hospitalist and pulmonology worked together to formulate plans for short intervals of heated high flow oxygen therapy to facilitate weaning. After two weeks in the ICU, multiple evaluations by telemedicine pulmonology and continued team based care the patient was able to lengthen the time off of NIV and then lengthen the time off of heated high flow oxygen. The patient no longer required any supplemental oxygen or NIV support at time of discharge home.

Through the collaboration of onsite Hospitalists, Nurses, Respiratory Therapists, and both telemedicine Hospitalists as well as Pulmonologists, the local healthcare system was able to expand the care-team, rally around a critically ill community member, and support her goals of care. Most smaller institutions would not have had the bandwidth to undergo such an expansion. Many small hospitals do not staff or have limited staffing for two of the key team members in this situation: Respiratory Therapists and Pulmonologists. Less than 4% of CAHs (Critical Access Hospitals) provide respiratory care services.5 Access to a Pulmonologist is difficult for rural patients with COPD because of limited geographic accessibility to this specialty.6 This resource limitation could create barriers to maximizing clinical support and care options in situations similar to the one described above.

Telemedicine Solutions From Beam Healthcare

Beam Healthcare provides clinical telemedicine services, offering access to multiple subspecialties and team based care. Beam’s telemedicine Pulmonary and Respiratory specialists are committed to creating enduring partnerships with clients and community members as they help evaluate, optimize, and manage patients with complex pulmonary disease. These telemedicine services are vital components of team based care models and both increase the ability to provide high quality, specialized care locally. The end result is more effective local care, decreased barriers to care, and increased care retention for smaller and rural health centers.

 

1. Jinjuvadia, C., Jinjuvadia, R., Mandapakala, C., Durairajan, N., Liangpunsakul, S., & Soubani, A. O. (2017). Trends in outcomes, financial burden, and mortality for acute exacerbation of chronic obstructive pulmonary disease (COPD) in the United States from 2002 to 2010. COPD: Journal of Chronic Obstructive Pulmonary Disease, 14(1), 72-79.

2. Adeloye, D., Chua, S., Lee, C., Basquill, C., Papana, A., Theodoratou, E., ... & Chan, K. Y. (2015). Global and regional estimates of COPD prevalence: Systematic review and meta–analysis. Journal of Global Health, 5(2).

3.Kendzerska, T., Sadatsafavi, M., Aaron, S. D., To, T. M., Lougheed, M. D., FitzGerald, J. M., ... & Canadian Respiratory Research Network. (2017). Concurrent physician- diagnosed asthma and chronic obstructive pulmonary disease: a population study of prevalence, incidence and mortality. PLoS One, 12(3), e0173830.

4. Lindenauer, P. K., Stefan, M. S., Shieh, M. S., Pekow, P. S., Rothberg, M. B., & Hill, N. S. (2014). Outcomes associated with invasive and noninvasive ventilation among patients hospitalized with exacerbations of chronic obstructive pulmonary disease. JAMA Internal Medicine, 174(12), 1982-1993.

5. Casey, M., Evenson, A., Moscovice, I., & Wu, Z. (2018). Availability of respiratory care services in critical access and rural hospitals. Policy Brief.(June 2018). University of Minnesota Rural Health Research Center. Retrieved from: http://rhrc.umn.edu/wpcontent/files_mf/1530149057UMNpolicybrie AvailabilityofRespiratoryCareServices.pdf.

6. Croft, J. B., Lu, H., Zhang, X., & Holt, J. B. (2016). Geographic accessibility of pulmonologists for adults with COPD: United States, 2013. Chest, 150(3), 544-553.

 

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