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Discharge 03 04 09
1. P rotocols for discharge planning . Neuromuscular disorders – H ome mechanical ventilation for patients with neuromuscular disorders Joan Escarrabill MD Master Plan of Respiratory Diseases (PDMAR) Institut d’Estudis de la Salut Barcelona [email_address] Stressa, April 3th 2009
2. of cases of polio that needed ventilation during the acute phase required long term ventilatory support 10% Kinnear Br J Dis Chest 1985;79:313-51.
8. 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 Physician Confidence that the patient’s needs are being met
9. Key elements in discharge Multidisciplinary effort Comprehensive Integrated Starts earlier Over time Process
10. Key elements in discharge Process Multidisciplinary effort Comprehensive Integrated Harmonic
12. Discharge planning Discharge planning is defined as the development of an individualised discharge plan for the patient prior to them leaving hospital for home Definition The discharge planning includes the multidis ci plinary effort for the transition between the hospital and the home (or the facility where we transfer the patient).
13. Aims of discharge planning SAFETY & EFFICACY O’Donohue W. Chest 1986;90(suppl):1S-37S. To prepare patients and carers... ...physiologically and psychologically for transfer home, with the highest level of independence that is feasible. To provide continuity of care... Bertoye A. Lyon Médical 1965;38:389-410.
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15. Respir Med 2007; 101:1177-82 5.5 + 1.3 ses s ions 7 + 1.1 LOS (days) 16 patients 6.8 + 1 hours/day 6.6 + 1.3 hours/day Compliance
16. NIV: Feasibility Indication Feasibility Characteristics of the respiratory failure Home conditions Patients preferences Discharge NON YES Alternatives Hospice Low tech hospitals Practicability of a proposed project
17. NIV: Feasibility Indication Feasibility Characteristics of the respiratory failure Home conditions Patients preferences Discharge NON YES Alternatives Hospice Low tech hospitals Technical criteria Social criteria
18. Actors of discharge Health Service Hospital Supplier Caregiver Home Patient Financial issues Public/Private Discharge team Case manager Risk management Education Experience
19. High dependency or high risk Impaired self-care Free time out ventilator < 10 hrs Dependency Accessibility Living far from the hospital Comorbidity Non respiratory clinical condicionts Home and caregiver conditions Respir Care 2007; 52:1056-62 Invasive home ventilation
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21. Discharge in practice Timing Discharge process starts as soon as possible Feasibility Identify the competent caregiver Education Analize practical issues Take your time Home visit Discharge Avoid the weekend Case manager
22. Practical tools Health professionals Checklist Patients & caregivers Written information Phone numbers Ventilator settings Especific recommendations
25. Manually assisted cough Air stacking Deliver volumes of air that the patient retained to the deepest volume possible with a closed glottis Ambu bag Volume ventilator
36. A ugmentative and alternative communication (AAC) devices Though handheld or palm computers may be attractive, their small size may soon make them unmanageable to a person with neuro-muscular disease
38. Neale G. J R Soc Med 2001;94:322-330. < 20% Directly related to surgical operations or invasive procedures < 10% General ward care 53% 18% Misdiagnoses At the time of discharge
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41. Risk minimisation (i) Accidental disconnection from ventilator Adapted from AK Simonds, 2001 Power failure Back-up ventilator Regular maintenance Battery Ambu bag Blocked Humidification Suction Falls out Trained caregiver to change trach Smaller size trach tube available Technical aspects The device Ventilator breakdown Tracheostomy
42. Risk minimisation (ii) Adapted from AK Simonds, 2001 Medical and social aspects Resources in the community Communication Medical problems Exacerbation alarm signs Ressucitation Medical hot-line Emergency phone numbers Ambulances Supplier
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44. Vitacca M. Breathe 2006;3:149-158 Vitacca M. Telemed & e-Health 2007;13:1-5 Telemedicine is an innovative medical approach
45. Hospital Pre-discharge Patient evaluation Community preparation Clinical stability Nutrition Secretion management Caregiver Technical support Financial issues Home conditions Feasible? Yes Non Home Alternatives (Hospice?) Discharge Plan Discharge Equipment Training Ventilator Humidification Suction devices Wheel chair Patient Caregiver Emergencies Funding application
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