Use of inhaled devices during a hospital exacerbation of COPD: a summary of an interdisciplinary audit held at ICS Maugeri Pavia, Italy (March-June 2019).

To date treatment protocols in Respiratory and or Internal departments across Italy for treatment of chronic obstructive pulmonary disease (COPD) patients at hospital admission with relapse due to exacerbation do not find adequate support in current guidelines. Here we describe the results of a recent clinical audit, including a systematic review of practices reported in literature and an open discussion comparing these to current real-life procedures. The process was dived into two 8-hour-audits 3 months apart in order to allow work on the field in between meeting and involved 13 participants (3 nurses, 1 physiotherapist, 2 internists and 7 pulmonologists). This document reports the opinions of the experts and their consensus, leading to a bundle of multidisciplinary statements on the use of inhaled drugs for hospitalized COPD patients. Recommendations and topics addressed include: i) monitoring and diagnosis during the first 24 h after admission; ii) treatment algorithm and options (i.e., short and long acting bronchodilators); iii) bronchodilator dosages when switching device or using spacer; iv) flow measurement systems for shifting to LABA+LAMA within 48 h; v) when nebulizers are recommended; vi) use of SMI to deliver LABA+LAMA when patient needs SABA <3 times/day independently from flow limitation; vii) use of DPI and pre-dosed MDI to deliver LABA+LAMA or TRIPLE when patient needs SABA <3 times/day, with inspiratory flow > 30 litres/min; viii) contraindication to use DPI; ix) continuation of LABA-LAMA when patient is already on therapy; x) possible LABA-LAMA dosage increase; xi) use of SABA and/or SAMA in addition to LABA+LABA; xii) use of SABA+SAMA restricted to real need; xiii) reconciliation of drugs in presence of comorbidities; xiv) check of knowledge and skills on inhalation therapy; xv) discharge bundle; xvi) use of MDI and SMI in tracheostomized patients in spontaneous and ventilated breathing.

Tele-assistance in patients with amyotrophic lateral sclerosis: long term activity and costs.

PURPOSE: To describe i) nurse's utilisation and associated costs during 4-year tele-assistance in amyotrophic lateral sclerosis (ALS) ii) optimal time for initiating tele-assistance. METHOD: 73 ALS patients after hospital discharge were followed up on voice by phone calls conducted by a nurse through a clinical card which was tested for feasibility, efficacy and utility. Number of patients simultaneously assisted/month, calls/patient, fixed and variable costs were calculated. RESULTS: Time between disease's diagnosis and the beginning of tele-assistance was 720 ± 971 days. ALS patients' percentage managed by nurses through tele-assistance increased over time by 628%. Tele-assistance integrated care (TAIC) followed up patients with a total of 5073 telephone calls. Steady state activity was reached at the 3rd year employing 5 ± 3 calls/pt/month (time/call 64 ± 44 min). Implementing the card was feasible, useful and effective by operator. Survival from diagnosis of ALS was 1224 ± 1150 days. Survival was related to tracheotomy. CONCLUSION: TAIC is a feasible tool to manage up to 25 ALS patients/month/nurse and costs about €105.00 per patient per month. Tele-assistance is proposed at 2/3 of time course of the disease.

At home and on demand mechanical cough assistance program for patients with amyotrophic lateral sclerosis.

OBJECTIVE: To establish a cost-effective telephone-accessed consultation and mechanical in-exsufflation (MI-E) and manually assisted coughing, oximetry feedback program for 39 patients with amyotrophic lateral sclerosis. DESIGN: Rapid access to healthcare consultation and to MI-E was provided to treat episodes of distress as a result of secretion encumbrance not reversed by suctioning and associated with a decrease in oxyhemoglobin saturation (SpO(2)) baseline. Avoided hospitalizations, defined by relief of respiratory distress and return of SpO(2) baseline to >or=95% by continuous ventilator use and assisted coughing, were recorded. Patient satisfaction was queried at 6 mos, and a cost analysis was performed of continuous vs. on demand MI-E use. RESULTS: Thirty-nine patients made a total of 1661 calls in 7.46 +/- 5.8 mos of follow-up. Twenty-seven patients had 66 home care visits by a respiratory therapist for a total time commitment of 89.7 +/- 99.3 min/patient/mo. Twelve patients, all ventilator users, were also brought mechanical in-exsufflators for mechanically assisted coughing for 47 respiratory episodes. Thirty hospitalizations were avoided. Seventy-five percent of the patients were extremely satisfied. Mean monthly cost per patient for on-demand telephone consultation, professional home healthcare visits, and MI-E as deemed necessary was euro403 +/- euro420 or 59% less than for continuous MI-E rental. Hospitalization costs were also spared. CONCLUSIONS: An on-demand consult and MI-E access program can avoid hospitalizations for patients with amyotrophic lateral sclerosis with significant cost savings.

Tele-assistance in chronic respiratory failure: patients' characterization and staff workload of 5-year activity.

BACKGROUND: The issue of how to optimize the routine use of tele-assistance (TA) in the clinical care remains to be addressed. Skills and costs of human resources represent the major component to care for chronic patients with TA. METHODS: We investigated (1) the change in patient population, mortality, and staff utilization/cost during the first 5-year activity of a TA program (24-h availability of a call center, pulse oxygen device, and second medical opinion) dedicated to chronic respiratory failure patients and (2) the staff time dedicated to each new patient admitted to the service. RESULTS: Three-hundred and ninety-six patients (age 64 +/- 17 years; 296 men) were reviewed across 5 years of activity. Patients followed/year increased over time, particularly for amyotrophic lateral sclerosis subjects. Calls/month dramatically increased from 60 to 290, with a 5-year number of calls equal to 12.952. The doctor's time dedicated to TA decreased over time, whereas the nurse's time increased allowing a cost saving of 39% when compared with budgeted salary costs. The number of home ventilated patients did not change, remaining over 78%. The mortality rate increased over time (from 6% to 11%). Both chronic obstructive pulmonary disease (COPD) and No-COPD patients used the TA service more frequently during the winter, and COPD used it also in the summer. CONCLUSIONS: A stable TA service dedicated to chronic respiratory failure may be reached after 4 years. Across years, (1) number of patients increased, with COPD and ventilated subjects being the most representative; (2) calls varied during seasons; (3) doctor's workload decreased, saving salary costs; and (4) each new enrolled patient may require 73 and 27 min/month of nurse and doctor, respectively.