All COPD patients should get information that will help them manage the disease effectively.
Many will benefit from COPD self-management plans. Some of those at highest risk should have full exacerbation plans with emergency packs containing antibiotics and steroids for the patient to use early in an exacerbation. This can help reduce the risk of a severe flare-up and unplanned admission.1 But it is vital that these patients are able to spot the signs of an exacerbation.
At-risk patients include those with severe and very severe COPD and patients who exacerbate frequently. But again, patients who don’t understand how to use the packs or may misuse them are unsuitable. The key to a successful action plan is to keep it simple, with instructions for different stages of exacerbation. A comprehensive approach is needed for an admission to be prevented – with regular review, self-care and exacerbation plans plus proper healthcare support.
A good exacerbation plan should have the following components:
• an explanation of an exacerbation
• clear explanation of symptoms, severity and red flags
• clear instructions on what to do according to the severity of exacerbation
• instructions for when and how to use the emergency antibiotic and steroid if appropriate
• contact details of the practice or of the healthcare professional looking after their COPD. Patients should have open access to facilitate prompt review
• advice on prompt follow-up for review – again, especially severe patients.
It is useful to ask the patient to contact the surgery within 24 hours of using the pack, especially if they have severe COPD or multiple comorbidities, to make sure they are responding to treatment. Sometimes patients underplay symptoms or have poor respiratory reserve. This also enables a follow-up appointment to be arranged to review disease and treatment.
Dr Tarek Bakht is a respiratory GPSI in Bolton
Patient education is the key to successful control. Teaching them how to manage their asthma by stepping treatment up and down may prevent unplanned admission and A&E attendance. Spending extra time with asthma patients and giving them the correct written resource will be invaluable for their long-term care.
The joint British Thoracic Society/SIGN guidance on asthma recognises that successful self-management programmes vary considerably, but usually include:2
• structured education – reinforced with written personal action plans – though the duration, intensity and format for delivery can vary
• specific advice about recognising loss of asthma control – either by assessing symptoms, peak flow readings or both
• actions, summarised as two or three action points, to take if asthma deteriorates, including
– seeking emergency help
– starting oral steroids – which may include an emergency course of tablets
– recommencing or temporarily increasing inhaled steroids, as appropriate to clinical severity.
Some of the evidence for asthma self-management plans is based on long, intensive programmes but there is evidence to back shorter programmes and to show usual care can be raised to a standard that incorporates many of the core elements of the successful extensive programmes (as listed above).2
The evidence is also stronger in secondary care studies but this could be because clinical benefit is harder to demonstrate in people with mild asthma.
Dr Tarek Bakht is a respiratory GPSI in Bolton
Diabetes and intercurrent illness
Around 95% of diabetes care is self-management. A patient may spend only one or two hours a year with a health professional.
With good self-management, people with diabetes can improve overall glucose control, reducing the risk of complications and improving quality of life. The cornerstone of this is a robust system of patient education with a regular programme of updates.
Part of this will be advice about ‘sick-day rules’ – simple guidelines that can then be individualised – telling patients what to do about medication, food and hydration, how often to test and when to call for help – with clear advice on who to contact in and out of hours. This will also reduce the likelihood of admission.
A frustration for patients has been that they are expected to self-manage at home but that this freedom is withdrawn on admission to hospital.
Recent initiatives have focused on self-management of diabetes in hospital and many hospitals now have guidance on the role a patient can play in diabetes control. This would include, if appropriate, an ability to continue insulin and self-monitor blood glucose. For elective admissions, planning diabetes control may need to begin some months before.
Evidence suggests that good glucose control reduces the risk of operative complications.
Dr Daniel Flanagan is a consultant diabetologist and endocrinologist at Plymouth Hospitals NHS Trust. He was lead author of the Joint British Diabetes Societies self-management guidelines
There are two important aspects to reducing unplanned – often unwanted – palliative care admissions: anticipatory care planning (ACP) and self-management of analgesics.
Anticipatory care planning
ACP attempts to anticipate significant changes in a patient’s condition or care needs and to specify preferred action to manage the problem.
Primary care research has shown ACP can reduce unplanned hospitalisations when applied to all patients in a practice who have been identified as at risk of an admission.3
But ACP is particularly vital in palliative care and can prevent potentially distressing admissions and interventions.
The possible components of an ACP can be split into:
– capacity (for example power of attorney or guardianship)
– advance decision to refuse treatment
– consideration of potential clinical problems, including what is likely to happen to the patient
– ‘just-in-case’ prescribing, for example a step up in analgesia (see below)
– Liverpool Care Pathway for the Dying.
It is important to remember these plans are not static and need to be reviewed – like any self-management plan – at least every six months.
In the palliative setting this is often assumed to mean a device such as a syringe driver – but it’s important to look at self-management of analgesia in a much broader sense.
• Assessment should always be done by the patient – at least daily – with visual analogue, numerical or verbal rating scales, allowing analgesia treatment to be modified quickly if necessary. This includes patients with cognitive impairment whenever possible.
• Agree treatment goals and encourage the patient to take an active role in pain management.
• Base the choice of drug on the severity of pain, not the stage of disease, and use the WHO ladder.
• Explain that it is easier to prevent pain than to relieve it so drugs should be prescribed on a prophylactic basis.
• Prescribe for breakthrough pain or pain that occurs with activities such as getting out of bed, walking or even just being moved.
• Anticipatory prescribing can prevent a delay in responding to symptoms that develop as the disease progresses. Ensure there is adequate prn analgesia, that anxiolytics and antiemetics are provided as appropriate and that your prescription is clearly worded, for example: ‘Supply 10 (ten) 2ml ampoules of midazolam injection (10mg in 2ml ampoules) 2mg – 5mg sc, hourly as needed for anxiety, distress or myoclonus’.
• Try to anticipate changes by involving patients, district nursing teams, community pharmacists and so on.
• Consider a ‘just-in-case box’ containing drugs that might be needed, especially over a weekend.
Dr Charles Lloyd is a GPSI in palliative care in Newport, Gwent
1 National Clinical Guideline Centre. Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care. NCCG 2010.
2 BTS/SIGN. British guideline on the management of asthma. May 2008, revised May 2011 brit-thoracic.org.uk
3 Baker A, Leak P, Ritchie LD et al. Anticipatory care planning and integration. Br J Gen Pract 2012; e113-e120.