What We Tried

Implementation of our comprehensive pulmonary program began by working with a multidisciplinary team composed of hospital staff, home health staff, and pulmonology physicians. We created a pulmonary unit in our hospital designed to manage complex chronic lung disease and assist with transitioning patients with respiratory diagnoses out of the ICU sooner. This is a 23 bed unit where nurses are trained to manage complex respiratory patients. The pulmonary unit is able to manage high and low oxygen needs, BIPAPs (Biphasic Intermittent Positive Airway Pressure), and non-invasive ventilator patients as well as manage pneumonia, asthma and respiratory failure patients. Then, we designed consistent education for patients to receive as soon as the patient is diagnosed with a chronic lung disease. The same education is delivered to the patient by the nursing staff, the respiratory therapists, the physicians and their office staff, pulmonary rehabilitation and from community pulmonary staff. By providing the same education from all staff, our team is able to ensure the patient is receiving consistent, accurate messaging. Our education has included the use of the Krames “Living Well with Chronic Lung Disease” pulmonary education book as well as zone tools. The occupational therapists teach energy conservation techniques in the home setting as well. Other components of the patient and family education of disease process include warning signs and exacerbation management, as well as medication reconciliation and adherence.

In collaboration with our system home health agency, we have a nurse assigned to the program. Patients can be referred to the program from the acute care hospital or from a physician’s office; however, a physician’s order is needed to enroll. To quality for program enrollment, the patient must have a chronic respiratory diagnosis. The nurse does follow-up with the patients in their home after discharge, a free service paid for by the hospital. The nurse assesses the patient for signs of distress and serves as a resource if the patient feels ill or has questions and concerns. If the patient has an exacerbation of their symptoms, the nurse calls the physician and has the medications arranged, labs drawn or organizes physician appointments to prevent emergency room admission.