New 'recipe' helps patients stay out of emergency

Even experienced nurses like Cheryl King run into surprises sometimes, like the patient with chronic obstructive pulmonary disorder (COPD) who hadn’t been properly trained to use his puffer. Cheryl was working a weekend shift in the emergency department at St. Mary’s Hospital in Camrose, checking a COPD patient who had just been admitted—again.

“He said to me, ‘I’ve been doing this for years, I think I know how to do it,’” says Cheryl. But she watched as he took his inhaler incorrectly.

“So I said to him, ‘That’s why you’re coming back.’ It was amazing to me, because I thought before, of course they know how to use their inhaler because they’ve had COPD for 20 years. But he didn’t.”

Keeping medications straight is a difficult task for patients and nurses alike. Cheryl says there are dozens of puffers, each with unique instructions that must be followed exactly. That can make it easy to make mistakes, which is why inhaler error is one of the biggest reasons COPD patients return to hospital. In fact, patients with COPD, along with heart failure, have some of the highest readmission rates and longest hospital stays. According to a 2013 Canadian Institute for Health Information report, the most frequently readmitted Alberta COPD patients were hospitalized an average of four times in a year for a total of 73 days.

“They hardly get home and they’re right back in, so that’s what we’re working on,” says Cheryl, Senior Practice Consultant with the Cardiovascular Health and Stroke Strategic Clinical Network. “They’d rather be at home.”

That’s why Alberta’s Respiratory Health and Cardiovascular Health and Stroke Strategic Clinical Networks (SCNs) are rolling out a new approach to help those patients better manage their disease and stay out of the emergency department. The SCNs spent three years examining the latest research and best practice and putting together a new order set—a sort of checklist–for COPD and heart failure patients who come to emergency experiencing shortness of breath, chest tightness and anxiety.

St. Mary’s Hospital in Camrose was the second site in Alberta to implement the new order sets in October 2017, followed by Grey Nuns Community Hospital in Edmonton in August 2018.

The new checklist, called Heart Failure and COPD Clinical Pathway – "The Pathway to Optimizing Patient Care," combines doctor’s orders, discharge preparation and community transition. It is expected to reduce hospital readmissions and length of stays for patients with COPD and heart failure while also improving patient outcomes.

“That’s what the research had shown: if you use these pathways you’re going to decrease your readmission rate and you’re going to positively affect the quality of life for our patients,” says Lana Chivers, Senior Director of Operations for Emergency, Cardiac Services, Critical Care, Medicine and Respiratory at Grey Nuns Community Hospital.

St. Mary’s Hospital Site Administrator Cherylyn Antymniuk compares it to a recipe.

“Like a recipe to make a cake. And this way, it would be the recipe to get the patient back home as fast as possible in the best shape possible,” says Cherylyn.

“If you follow the recipe, the likelihood of success is going to be very good.”

An important ingredient is education, especially when it comes to medications, to reduce puffer errors that lead to readmissions.

“I hate to say it but it is true: people will come in and they’ll have a bag full of medications and they won’t know what any of them are for,” says Cherylyn. “So it goes back to spending that time actually educating them—this is why you need to do this, this is when you need to do that.”

COPD and heart failure have different disease processes, says Lana, but both sets of patients benefit from a similar approach upon discharge. That’s why the checklists include everything from inhaler education to ordering oxygen to setting up rehab appointments and check-ins with their family physician.

“It involves just about every discipline, looking at how they touch that patient through their whole journey,” says Cheryl.

For example, COPD patients have a high rate of frailty and malnutrition. They may seek help because of weakness or falls, something their family physician might not be aware of. But the new order set includes a short questionnaire to assess whether the patient is at risk. And if they are, there is a referral to a physiotherapist.

“In the past, it’s always been a physician who has to think of those things and come up with those things and order them, but we’ve actually made it part of the order sets. It’s the third page of the recipe,” says Cheryl.

Co-ordination is key, adds Cherylyn. St. Mary’s Hospital has a strong relationship with the local primary care network, which helped with the implementation.

“It’s a huge change, because before we made this change, the hospital was doing their own thing, the primary care network was doing their own thing. The treatment pathways may be completely different depending on what the physician practice was.”

The early results suggest the new approach is working: patients are readmitted less often and for shorter stays. Cheryl says both St. Mary’s and Grey Nuns are “knocking it out of the park.”

Reducing readmissions and shortening hospital stays eases the burden on the healthcare system. But ultimately, it’s about helping people.

“The quality of life is the payoff, for us and for the patients,” says Cherylyn.

Lana agrees. “We’re not taking the disease process away. We’re just helping our patients live with it better.”