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Presentació a Volterra (18 de febrer de 2011)
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11
La dimissioneLa dimissione
Joan Escarrabill, MDMaster Plan For Respiratory Diseases (PDMAR)
Ministry of Health
Health Studies Institute
Barcelona
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
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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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