Collaboration to promote research between disciplines and among non-nursing medical professionals produces results!

As the movement to promote true evidence based practice continues (which should include all disciplines and medical professionals), it is important for nurses with research experience to mentor and assist others in their research pursuits. The article below describes a research study that was undertaken as a collaboration between Respiratory, Medicine, and Nursing. The main idea for the study came from a clinically expert Respiratory Therapist, who is the first author of the article. Medicine and Nursing respectively assisted in the implementation and the statistical analysis and writing of the article describing the study, which was undertaken at University Medical Center in Las Vegas.

Introduction

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States. Approximately 12 million Americans are currently diagnosed with COPD and an additional 12 million may remain undiagnosed. Recent advances in treatment for COPD offer improved opportunities for increases in our patients' quality and length of life; however, available data from the National Heart Lung and Blood Institute indicate many of those afflicted with COPD may not be receiving optimal treatment. (1)

At our large, urban, public medical center, the treatment of COPD continues to challenge our respiratory therapists (RT) physicians, and nurses. Of particular concern is the increasing numbers of RT hours required for the administration of bronchodilator therapy. Like most public and private medical centers, we were faced with a shortage of qualified RT personnel; therefore strategies to decrease RT treatment-related hours, without compromising patient care, needed to be explored. Consequently, our department created a new role for some of our RTs--that of Respiratory Care Coordinator (RCC). The focus of the RCC is to assist our physicians and nurses, as well as to educate and facilitate patient care.

After receiving specialized training and education, the RCCs were assigned to perform patient assessments and make 'best practice' recommendations to our resident physicians or nurse practitioners. This paper briefly describes a research study initiated by our RCCs under the close mentorship of our department's Medical Director and a doctorally-prepared nurse researcher. The purpose of which was to evaluate the RCC recommendations of tiotropium bromide inhalation powder (TB).

Best practice guidelines

Not unknown to most RTs, inhaled bronchodilator therapy is central in the treatment of COPD. When symptoms persist and are not adequately controlled with short-acting bronchodilator, the recent guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommend regular treatment with mono- or combination therapy with a long-acting bronchodilator. (1,2)

Why tiotropium bromide?

The clinical benefit of once-daily tiotropium, an anticholinergic agent has been established in comparative 1-year clinical studies versus placebo and ipratropium bromide, and in two 6-month studies versus salmeterol or placebo. Over all, tiotropium was found to be superior to these active agents in improving lung function. (3-6)

Tiotropium bromide inhalation powder is indicated once daily for the long-term, maintenance treatment of bronchospasm associated with COPD, including chronic bronchitis and emphysema. Patients taking TBP have a reduced requirement for the use of rescue short-acting beta 2-agonists inhalers. (7)

Method

A prospective non-randomized design was used for this study. Institutional review board (IRB) approval was obtained and patients were evaluated for study inclusion by four RCCs, under the direction/supervision of the Medical Director of the Respiratory Services Department. Patients were included in the study if they:

* had a documented admission diagnosis of COPD, not requiring mechanical ventilation,

* were already receiving respiratory therapy i.e. albuterol, ipratropium bromide, levalbuterol and duoneb via small volume nebulizers (SVNs),

* were referred by staff or staff physicians, and

* had no known contraindications to receiving TBP.

The RCCs examined the admitted COPD patients and assessed their need for the maintenance drug TBP. Additionally, education was provided to patients, family, and staff on this maintenance treatment for COPD patients. Additional education was provided to all appropriate patients related to smoking cessation. A Recommendation and Assessment form was developed and used for this study; patients were assessed and recommendations were given to the physician based on the assessment classification. This two-page form was designed by our Medical Center's Collaborative Practice Committee and was based on the AARC Guidelines.

Other treatments were not excluded (i.e. the combination of a B2-agonist and anticholinergics, theophylline, glucocorticosteroids, antibiotics, mucolytic, oxygen therapy). Additionally, not every patient admitted with a diagnosis of COPD was assessed, due to the large numbers of patients, the four RCC were not able to see every patient. Data were collected from June though August 2007.

Results

Data from 31 patients were used in this analysis. It was calculated that before TBP was ordered, 430 SVN treatments would have been routinely done. After TBP was ordered, only 113 treatments were required for the remainder of the study patients' hospitalization. A decrease of 312 treatments was noted. This represents a statistically significant (p [less than or equal to] 0.000) decrease (79%) in treatments required and given (Figure 1).

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

We also found a statistically significant difference (p [less than or equal to] 0.000) in time saved by RTs (Figure 2). The reduction in "non-beneficial" treatments decreased the need for RT in less critical situations, allowing extra time for patient education. The utilization timesavings of RTs were estimated to be over 156 hours of direct patient care. Time devoted to specifically educating COPD patients about maintenance medication and smoking cessation was approximately 11 hours and 20 minutes during the study period. Tables 1-3 respectively, display the specific data from all patients (N = 31) during each of the three study months.

Overall, feedback from the respiratory therapists, physicians, nurses and patients was positive. No adverse response from the patients or staff was reported.

Discussion and Conclusion

At our public medical center, large numbers of patients with a history of COPD are admitted for reasons other than COPD exacerbations. It was observed that because of this history of COPD, physicians were routinely ordering SVNs around the clock even when the patients were not in acute distress and demonstrated no clinical need. Moreover, these COPD patients were generally not on maintenance medication (TBP) for their disease. Our results suggest the use of RCCs and their recommendation of TBP is beneficial to both our COPD patients as well as our institution.

References

(1.) National Heart Lung and Blood Institute [NHLBI]. http://www.nhlbi.nih.gov/

(2.) Rabe KF, Hurd S, Anzueto A, Barnes PJ, Buist SA, Calverley P et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2007; 176: 533-555.

(3.) de Torres, J.P. Pinto-Plata, V., Ingenito, E. Bagley, P., Gray A. and Berger R., et al., Power of outcome measurements to detect clinically significant changes in pulmonary rehabilitation of patients with COPD, Chest 121 (2002), pp. 1092-1098.

(4.) Casaburi R, Mahler DA, Jones PW, et al. A long-term evaluation of once daily-inhaled tiotropium in chronic obstructive pulmonary disease. Eur Respir J 2002; 19: 209-216.

(5.) Vinchen W, van Noord JA, Greefhorst APM, et al. Improved health outcomes in patients with COPD during 1 years treatment with tiotropium. Eur Respir J 2002-; 19: 209-216.

(6.) Donohue JF, van Noord JA, Bateman ED, et al. A 6-month, placebo-controlled study comparing lung function and health status changes in COPD patients treated with tiotropium and salmeterol. Chest 2002; 122: 47-55

(7.) Brusasco V, Hodder R, Miravitles M, Korducki L, Towse L, Kesten S. Health outcomes following treatment for six months with once daily tiotropium compared with twoce daily salmeterol in patients with COPD. Thorax 2003; 58: 399-404

(8.) SPRIVIA HandiHaler (tiotropium bromide inhalation powder), package inserts Boehringer Ingelheim.

Table 1. June 2007 Patient Assessments for Tiotropium Bromide
Inhalation Powder (Spiriva)

                                          SVN TX
                        Recommended     scheduled
          Original TX      SVN TX        for the
           frequency     frequency      length of
            without     with SPIRIVA   stay without
Patient     SPIRIVA     (once daily)     SPIRIVA

1             Q6            PRN              8
2             PRN           PRN              6
3             Q6             Q6              8
4             Q4            PRN             30
5             Q4            PRN              6
6             Q4            PRN              6
7             Q4            PRN             24
8             Q4            PRN             30
9             Q6            MDI              8
10            Q4            PRN             12
11            Q4            PRN             12
12            Q4            PRN             24
13            Q4            PRN             24
14            Q3            PRN              6

            Actual SVN
             TX given         Total
          for the length   decrease in
          of stay after       SVN TX      Time (hours)
             SPIRIVA          after       saved in the
           (once daily)      SPIRIVA      utilization
Patient    recommended     (once daily)      of RT

1               3                5            2.5
2               1                5            2.5
3               3                5            2.5
4               8               22             11
5               1                5            2.5
6               1                5            2.5
7               0               24             12
8               7               23           11.5
9               0                8              4
10              1               11            5.5
11              1               11            5.5
12              2               22             11
13              3               18              9
14              0                6              3

TX = treatment; SVN = small volume nebulizers; Q3 = every three
hours; Q4 = every four hours; Q6 = every six hours;
RT = Respiratory Therapist; PRN = per required need

Table 2. July 2007 Patient Assessments for Tiotropium Bromide
Inhalation Powder (Spiriva)

                                          SVN TX
                        Recommended     scheduled
          Original TX      SVN TX        for the
           frequency     frequency      length of
            without     with SPIRIVA   stay without
Patient     SPIRIVA     (once daily)     SPIRIVA

1             TID           PRN              6
2             Q4            MDI              6
3             Q4            MDI             12
4             PRN           PRN              2
5             Q4            PRN             28
6             Q6            PRN              4
7             Q6            PRN             16

            Actual SVN
           TX given for       Total
          the length of     decrease
            stay after      in SVN TX     Time (hours)
             SPIRIVA          after       saved in the
           (once daily)      SPIRIVA      utilization
Patient    recommended     (once daily)      of RT

1               2               4               2
2               0               6               3
3               4               8               4
4               0               2               1
5              12              16               8
6               1               3             1.5
7               7               9             4.5

TX = treatment; SVN = small volume nebulizers; TID = 3 times daily;
Q4 = every four hours; Q6 = every six hours; RT = Respiratory
Therapist; PRN = per required need

Table 3. August 2007 Patient Assessments for Tiotropium Bromide
Inhalation Powder (Spiriva)

                        Recommended       SVN TX
          Original TX      SVN TX       scheduled
           frequency     frequency     for the length
            without     with SPIRIVA   of stay without
Patient     SPIRIVA     (once daily)     SPIRIVA

1             Q6            PRN             16
2             Q6            PRN             18
3             Q4            PRN              6
4             Q4            PRN              6
5             Q4            PRN             12
6             Q2            PRN             24
7             Q4            PRN             12
8             TID           PRN             24
9             Q4            TID             18
10            QID           MDI             16

            Actual SVN
           TX given for       Total
          the length of    decrease in
            stay after        SVN TX      Time (hours)
             SPIRIVA          after       saved in the
           (once daily)      SPIRIVA      utilization
Patient    recommended     (once daily)      of RT

1               0               16              8
2              18                0              0
3               1                5            2.5
4               2                4              2
5               2               10              5
6               2               22             11
7               5                7            3.5
8              10               14              7
9              10                8              4
10              8                8              4

TX = treatment; SVN = small volume nebulizers; TID = 3 times daily;
QID = 4 times daily; Q4 = every four hours; Q6 = every six hours;
RT = Respiratory Therapist; PRN = per required need