Authors (including presenting author) :
Lau LW(1), Ko WC(1), Wong YN(1), Yim SL(1), Yiu YY(1), Wong TW(1), Sin SK(1), Tse C(1), Ho K(1), Cheung F(2), Yeung D(2), Ng TH(3), Chung R(3), Hung SC(4), Lee T(4), To CT(4)
Affiliation :
(1)Community Nursing Service, Yan Chai Hospital(YCH), (2)Physiotherapy Department, YCH, (3)Occupational Department, YCH, (4)Department of Medicine, YCH
Introduction :
According to the latest World Health Organization facts, COPD was the 3rd leading cause of death worldwide, caused 3.23 million deaths in 2019 (WHO,2022)and becomes the 9th leading cause of death in Hong Kong (CHP,2022).
Objectives :
1. Enhance COPD management in community 2. Improve quality of life 3. Reduce unnecessary emergency admission and decrease medical burden.
Methodology :
Admitted COPD patients (via Hospital Admission Risk Reduction Program for the Elderly score ≥ 0.2) will be assessed and invited to join the COPD Program upon hospital discharge. An unique training plan will be carried out by multi-disciplinary team on home visit. Community Nurse(CN): empowered disease management and exacerbation care by educational kit: [慢阻肺病自強錦囊]、 self-monitoring of COPD Care & Action Plan sheets. Using smartphone/iPad to review inhalation video by using tailor-made QR code information sheet. Physiotherapist(PT): reinforced patient’s breathing technique, rehabilitation exercise and Professional Resistance Bands (THERABAND) to strengthen muscle power. Occupational Therapist(OT): educated energy-saving technique, assisted in home modification and/or home oxygen therapy. Geriatrician: provided case conference and medical support by phone or fast tract clinic. Besides, advancement in using of HA Go Apps - Smart Patient - COPD to consolidate their knowledge.
Result & Outcome :
Result: From July 2019 to October 2022, 165 clients recruited with 1286 home visits provided by multi-disciplinary team. mMRC Grade, CAT Score, Inhaler Technique, A&E attendance and Unplanned Hospital Readmission were evaluated respectively. The satisfactory results were as follows: ● mMRC Grade: Improved 4.6% (average from 2.1 to 2.0) ● CAT Score: Improved 14.0% (average from 15.6 to 13.4) ● Overall Inhaler technique: Improved 22.5% (average from 14.0 to 19.1) ● Pre/post numbers of A&E Attendance (<28days): Decreased to 55.2% (143 to 64) ● Unplanned Hospital Readmission (<28days): Decreased to 57.9% (133 to 56) Conclusion: All parameter shown that COPD patients have significant benefit on self-care in the disease. Multi-disciplinary team support and new learning mode on smart technology would definitely enhance patient interest and practice on disease management in the community.
