137. Nurses’ involvement in the follow-up of Sunday, September 16th 2007

Oral Presentation
Room C8 - 14:45-16:45
Sunday, September 16th 2007
137. Nurses’ involvement in the follow-up of
patients with COPD and lung cancer
1284
Descriptive study of overweight and obese patients with COPD
B.J. Garvin1 , G.L. Narsavage1 . 1 School of Nursing, Medical College of Georgia,
Augusta, GA, United States
Background: Obesity is escalating in the southeastern (SE) USA and is associated
with multiple disease risks. Obese COPD patients may differ from traditional nonobese or cachectic patients with COPD.
Aims: (1) To identify differences in patient characteristics related to body mass
index (BMI), a measure of obesity. (2) To determine if there were significant
differences in rehospitalization and annual cost of care between COPD patients
who were and were not overweight/obese.
Methods: Descriptive, comparative, retrospective record analysis. All patients
discharged in 2004 with physician diagnosed COPD from an academic health
science center in the SE US were included. BMI25kg/m2 = overweight;
BMI30kg/m2 =obese.
Results: 34/83 (41%) had information to calculate BMI. Females 53% (n = 18);
mean age 66; 35% (n = 12) African American(AA); 29%(n = 10) married. Over
76% were overweight/obese. Obese patients had a higher percentage of diagnosed
diabetes, heart failure, hypertension, and psychiatric illness. Mean BMI for AAs
(37.8kg/m2 ) vs. non-AAs(28.5kg/ m2 ) was significant(p = 0.047). Readmitted patients had a mean BMI of 34.9kg/m2 vs. non-readmitted patients with 27. 9kg/m2
(p = 0.072). Annual cost: non-overweight/obese $10,191/patient; overweight/obese
$40,027/patient.
Conclusions: Respiratory professionals need to document height and weight
(BMI). Patient characteristic of race for AAs significantly related to BMI.
While readmitted patients had a higher mean BMI than non-readmitted patients,
significance could not be determined due to the small sample size; there was a
definite trend toward significance. Elevated BMI interacting with race (AA) should
be further studied as potential predictors of readmission.
1285
Calorie-intake in patients hospitalized for an acute COPD exacerbation
G. Celis, N. Cuvillier, S. Vanhaesebrouck, M. Decramer. Pneumology Division,
University Hospital Gasthuisberg, Katholieke Universiteit, Leuven, Belgium
Background: malnutrition in COPD patients causes severe complications like
decrease in muscle mass, increase in morbidity and increase in medical costs. A
Critical Pathway is used as tool in the treatment of COPD exacerbations. The
doctor in attendance gets in touch with the dietician on an irregular base.
Objective: to explore the malnutrition status in patients hospitalized due a COPD
exacerbation on a regular pneumology ward.
Methods: 28 patients hospitalized due a COPD exacerbation were examined. We
measured the calorie-need and the calorie-intake at home and also the calorieintake during hospitalisation-day 2 until day 4. The Body Mass Index (BMI) and
Fat Free Mass-index (FFMi) were also measured.
Results: the mean calorie-intake during hospitalization was 29.51% lower than
the calorie-need and 22.66% lower than the intake at home. Thirty-two% of the
patients had a BMI lower than 21% and there was a depletion of 50% on FFMi.
We found a correlation between BMI and FFMi.
Conclusion: more attention should be paid to the calorie-intake for patients
hospitalized for an acute COPD exacerbation. The BMI should be implemented
in the Critical Pathway used as a screening tool to alert the dietician.
1286
Long-term follow-up of the ISOLDE participants: causes of death after 13
years of the trial completion
G. Bale1 , S. Burge1 , C. Burge1 , P. Martinez-Camblor2 , J.B. Soriano2 . 1 Respiratory
Medicine, Birmingham Heartlands Hospital, Birmingham, United Kingdom;
2
Program of Epidemiology and Clinical Research, Fundacio Caubet-Cimera,
Bunyola, Illes Balears, Spain
The Inhaled Steroids In Obstructive Lung Disease (ISOLDE) study was a trial that
randomized 752 patients with moderate to severe COPD to fluticasone propionate
1000mg/day or placebo for three years. Trial results are reported elsewhere (Burge
PS, BMJ 2000).
The aim of this study is to examine the causes of death of the ISOLDE participants
beyond the three years and up to 13 years post-randomisation.
Data from seven of the 18 original participating sites in the UK gained ethics
approval, and either from the NHS Strategic Tracing Service or from the Office
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of National statistics, death certificates were obtained, and classified according to
the trial protocol.
Baseline characteristics of the 376 participants in the seven centers which completed extended follow-up were similar to the ones in the 366 participants of the
11 centers not surveyed.
Overall, after 13 years of follow-up of the 376 participants in the seven centers
which completed extended follow-up, 210 deaths were observed, death certificates
from all but 2 were obtained. Male gender, older age, and more severe COPD
were associated with observed higher mortality (p < 0.05). Causes of death were
distributed as: 89 (50%) respiratory, 35 (20%) cardiac, 25 (14%) lung cancer,
15 (8%) other cancer, and 15 (8%) other causes. The percentage of respiratoryrelated deaths increased with longer follow-up from 36% within the 3-year trial,
44% after 3−6 years, 58% after 6−9 years, to 60% after 9−13 years of follow-up
(p for trend < 0.05).
We conclude that participants survival is poor (44%) 13 years after the ISOLDE
trial, and that respiratory-related were the most frequent causes of death in these
moderate to severe COPD patients.
1287
Dissemination of clinical skills for better management of patients: nurse led
ABG monitoring in respiratory patients and its impact on management
A. Kavidasan, O. Phipps. Department of Respiratory Medicine, North Bristol
Lung Unit, Bristol, United Kingdom; Department of Respiratory Medicine, North
Bristol Lung Unit, Bristol, United Kingdom
Rationale: Arterial blood gas (ABG) analysis is an important clinical parameter
in the management of patients with respiratory problems. Traditionally this has
always been performed by doctors. We introduced a nurse led ABG analysis and
assessed its implications in terms of rapid availability and also its impact on patient
management, especially following the introduction of the European Working Time
Directive (EWTD), on junior doctors hours.
Methods: 17 nurses working in the respiratory ward have undertaken ABG
training. The assessment consisted of ten successful arterial punctures, three of
which was supervised by either an SpR or consultant in respiratory medicine.
Each nurse needed to perform at least three ABG per month in order to maintain
competence. Most nurses, on an average performed ten arterial punctures per
month.
Results: Over a ten month period, each nurse has performed approximately 80
ABG per month, resulting in an overall figure of 800 successful ABG. There has
been no documented complications in any of these cases.
Conclusion: ABG sampling and analysis is a vital tool in the assessment and
management of respiratory patients. The above experience shows that arterial
puncture is a safe procedure, with minimal or negligible complications in nursing
professionals, who are properly trained. This has helped immensely in the timely
management of inpatients on Non Invasive Ventilation (NIV) and also in the
assessment of outpatients for long term oxygen therapy (LTOT). This had a huge
positive impact on patient care, especially with the introduction of the European
Working Time Directives on junior doctors working hours in UK.
1288
Delivery of asthma and chronic obstructive pulmonary disease (COPD)
services in UK primary care: nurses’ roles and responsibilities
M. Fletcher1 , J. Upton1 , H. Madoc-Sutton1 , A. Sheikh2 , S. Walker1 . 1 Research
Department, Education for Health, Warwick, United Kingdom; 2 Division of
Community Health Sciences: GP Section, University of Edinburgh, Edinburgh,
United Kingdom
Introduction: Trained asthma nurses are central to the delivery of high quality
asthma services in UK primary care, although their role in the care of COPD is
unclear. Here we describe the organisation of primary care respiratory services,
emphasising nursing roles and training.
Methods: Lead asthma and COPD nurse(s) at 500 randomly selected practices in
the UK were sent questionnaires on the organisation of respiratory services, and
the role and qualifications of the nurse in delivering respiratory care. Roles were
ranked as minimum (no independent role), medium (diagnosed or followed up
patients) or maximum (diagnosed and followed up patients). Qualifications were
defined as none, workshop, short course or diploma/degree level.
Results: Response rates were 78% for the asthma (N = 389) and 74% (N = 368)
for the COPD sections of the questionnaire. 55% (210/381) of practices ran either
asthma, COPD and/or mixed respiratory clinics. In practices that ran clinics 74%
of asthma and 72% of COPD nurses had a maximum role, compared with 56% of
asthma and 43% of COPD nurses based in practices that did not run clinics. For
all practices, irrespective of whether they held clinics, 66% (255/389) of asthma
and 58% (215/368) of COPD nurses had a maximum role, and of these, 80% of
asthma and 48% of COPD nurses were educated to diploma/degree level.
Conclusion: In this highly representative sample, nurses delivering asthma care
held more responsible roles and had higher levels of disease specific training than
nurses delivering care for patients with COPD. Improving the quality of services
for COPD patients will rely on significant investment in education and training.
1289
Transitions at the end of life in severe COPD or advanced cancer: a
qualitative study of patients, family members, physicians and nurses
L. Reinke1 , R. Engelberg2 , S. Shannon1 , M. Wenrich3 , J.R. Curtis2 .
1
Biobehavioral Nursing & Health Systems, University of Washington, Seattle, WA,
United States; 2 Pulmonary & Critical Care, Medicine, University of Washington,
Seattle, WA, United States; 3 School of Medicine, University of Washington,
Seattle, WA, United States
Background: Trajectories of illness at the end of life (EOL) differ for patients
with cancer versus COPD. Clinicians often mark transitions based on clinical
deterioration with delivery of information about treatment or prognosis. Patients
may experience transitions differently, but prior studies have not examined this
issue. AIMS: To explore transitions from the perspectives of patients with
advanced COPD or cancer, their family, and clinicians to provide insight for
communication about EOL care.
Methods: We conducted a qualitative study examining participants’ perspectives
between the support for hope and the delivery of prognosis in the context of
advanced COPD or cancer. We interviewed 55 patients, 36 family members,
25 nurses, and 31 physicians representing 220 hours. This analysis explored
transitions as described by participants. We used principles of grounded theory
and content analysis.
Results: Six themes were identified as participants’ experiences with transitions.
Themes among both patients with COPD and those with cancer included: no more
treatment and new treatments. Themes unique to patients with COPD: activity
decline and initiation of oxygen therapy. A theme unique to clinicians was acute
exacerbation. Emotional responses including fear, accompanied transitions from
the perspective of patients but were not discussed by clinicians.
Conclusions: This study identified differences between the meaning of transitions
for patients and clinicians and between the two diseases. These findings offer
clinicians an opportunity to address transitions important to the patient and support
a patient-centered approach to improving EOL care.
1290
Discharge support and readmission of older patients with lung cancer
W. Gomez1 , G. Narsavage1 , B.J. Garvin1 . 1 School of Nursing, Medical College
of Georgia, Augusta, GA, United States
Background and Purpose: Lack of support following hospital discharge for
patients with lung cancer may contribute to high morbidity and mortality of this
population. The study purpose was examine discharge disposition and readmission
among lung cancer patients.
Methods: Descriptive/comparative analysis of medical records from patients
hospitalized in 2004 with lung cancer.
Results: Total sample: n = 93 patients; mean age 66 years; 51% female; 40%
African American; 55% Caucasian; 8 patients died during hospitalization, 26 died
outside the hospital for a total of 34 deaths during the study year. Of those
who did not die on initial hospitalization (n = 87), 21%(n = 18) were readmitted.
18 patients were responsible for all 41readmissions. 87% (76) of patients were
discharged without HHS on initial visits. 17 of 76 (22%) of patients with no HHS
were readmitted. HHS on initial hospitalization (n = 11); mean age 66years; 45%
female; 45% African American; 55% Caucasian. 1 of 11 patients discharged with
HHS on initial visit was readmitted (9%). HHS on index visit was not significantly
related to hospital readmission (fisher’s exact, p = 0.69). 2 patients received HHS
on a readmission and neither was subsequently readmitted. Overall, 13 of 140
visits concluded with HHS; of these 13, one resulted in readmission (8%).
Implications: Characteristics of those with HHS on initial visits were similar
to total sample. Patients with HHS had lower percentage of readmissions than
those without HHS. Small sample and large number of deaths precluded ability
to test for significance between readmission and HHS. Further research is needed
to evaluate characteristics and relationships between HHS and outcomes.
1291
An educational intervention for lung cancer patients treated with
chemotherapy: a first evaluation
M. Peys1 , M. Vandenberghen1 , A. Coolbrandt1 , E. Vanhove1 , J. Vansteenkiste1 ,
K. Nackaerts1 , P. Verrando2 . 1 Leuven Lung Cancer Group, University Hospital
Gasthuisberg, Leuven, Belgium; 2 Nursing Department, KHL, Leuven, Belgium
Background: Lung cancer patients who are treated with chemotherapy have to
deal with considerable physical and emotional demands resulting from their therapy. An educational intervention providing specific information about chemotherapy may help patients and their carers to cope better with the treatment.
Objectives: The aim of the evaluation was to gather pilot data on the implementation of an educational intervention for lung cancer patients receiving
chemotherapy.
Methods: The intervention consists of an educational booklet and oral education.
The intervention was implemented at the Respiratory Oncology ward of the
University Hospital Leuven. The booklet was developed as a resource for patients
to read the information given by their doctor and nurse, to share this information
with others, and to note items in a diary. The nurse gave oral information, guided
by the booklet and meeting the specific information need of the patient.
Data for this survey were obtained through interviews in the initial 20 lung cancer
patients.
Results: Between November 2006 and January 2007, 20 patients between 45 and
79 years old, were questioned. Eighty percent of the patients and community carers
actually read the information. The information was described as good, complete,
recognizable or too overwhelming. 55% of the patients had used a diary.
208s
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Conclusion: These pilot data demonstrate the usefulness of an educational
intervention combining a booklet and oral education in addressing the information
need of lung cancer patients being treated with chemotherapy. Further research is
needed in larger groups, to evaluate the additional role of oral education and to
measure the impact of this type of education.
209s
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