Evaluation of a self-management plan for chronic obstructive pulmonary disease.

We hypothesized that the use of an Action Plan might assist self-management for patients with chronic obstructive pulmonary disease (COPD). A pilot process and randomized, controlled study were undertaken to evaluate an Action Plan that provided advice on management of usual care and exacerbations, together with a booklet on self-management. Fifty six subjects with COPD recruited through general practitioners (GPs) completed the 6 month study, 27 in the control group and 29 in the intervention group. The control group received usual care from their GP, and the intervention group received a booklet and Action Plan from their practice nurse plus a supply of prednisone and antibiotic from their GP. The two groups were demographically similar with a mean age of 68 yrs. The resources were well received by GPs, practice nurses and intervention group subjects. After 6 months, there were no differences in quality of life scores or pulmonary function. There were significant changes in self-management behaviour in the intervention group compared to controls. In response to deteriorating symptoms, 34 versus 7% (p=0.014) initiated prednisone treatment and 44 versus 7% (p=0.002) initiated antibiotics. Subjects in the intervention group readily adopted self-management skills but did not show any difference in quality of life or lung function parameters. A larger, prospective, controlled, clinical trial of this approach is warranted.

Asthma management at Christchurch Hospital: compliance with guidelines.

AIM: To audit compliance with guidelines for the assessment and management of adult patients admitted to Christchurch Hospital with acute asthma. METHODS: An asthma admission form and management guidelines, based on international consensus statements, were designed for use by resident staff at Christchurch Hospital. Compliance with these guidelines was audited during the winter of 1994 by means of retrospective case record review. RESULTS: One hundred and forty three admissions were screened. The form was used in 99 patients (69%), of which 97 had records available for audit. Sixty two patients were admitted under general medical services and 35 under respiratory specialist services. The median age was 34 years (range 14-84) and 77% were female. The history including interval status was adequately documented in over 95% of cases. Peak flow rate was recorded on admission in 93 patients (96%) and spirometry in 62 (64%). During the acute phase of treatment 528 items were prescribed, of which 382 (72%) were appropriate according to the guidelines. The major area (55%) of nonguideline prescribing was the use of nebulised ipratropium in addition to salbutamol for mild or moderate asthma. Written evidence of asthma education was present in 42 (43%). In 34 patients (35%) there was specific reference to the introduction of an asthma action plan. Of the 33 smokers only 17 appeared to have been given smoking cessation advice. Discharge prescribing complied with the guidelines in 71%. The most common variation from the guidelines for discharge therapy related to the manner of prednisone dose reduction. The readmission rate at 1 month was 11%. CONCLUSIONS: The introduction of an asthma admission form enhanced the quality of clinical data gathering by junior staff. Compliance with management guidelines was adequate. Specific sections pertaining to the use of chest radiographs, arterial blood gases and the prescribing of ipratropium and prednisone will be reviewed in updated guidelines.

A community-wide promotion of asthma self-management in New Zealand.

Asthma affects approximately 9% of young adults in New Zealand, with evidence of an increase in prevalence over recent years. Morbidity and mortality from this condition have caused widespread concern. In response to identified deficiencies in asthma management, initiatives to promote self-management using an asthma action plan were promoted throughout the Canterbury region in 1991 as part of a regional pilot study. A resource kit was prepared and self-management principles were promoted to general practitioners in discussion workshops. A community-wide promotion of the action plan was followed by a process and outcome evaluation. The plan and associated resources were well received by doctors and patients. Seventy-seven percent of doctors responding to a questionnaire had used the plan, and of these, 94% indicated that they would continue to use the plan in the future. Patients who obtained a completed plan experienced a greater reduction in nocturnal waking with asthma and improved self-management skills.

An audit of the assessment and management of patients admitted to Christchurch Hospital with chronic obstructive pulmonary disease.

AIM: To audit the assessment and management of patients admitted to hospital with chronic obstructive pulmonary disease (COPD) during three months of the winter of 1992. METHODS: Consensus management guidelines were developed as the basis for the audit. Consecutive cases were audited by review of the case notes. Half were admitted initially under a respiratory physician and half under a general physician. Ninety-five cases were audited. RESULTS: The overall standard of medical assessment was adequate but a number of deficiencies were identified. The mean duration of stay in hospital was nine days. In the emergency department the use of pulse oximetry in preference to arterial blood gas analysis led to failure to diagnose significant ventilatory failure in five cases. Initial assessment by junior medical staff failed to include comment about level of consciousness in 50% of cases and chest hyperinflation in 40%. Oxygen therapy was given in 87% of cases, but was not prescribed in one third and was often not adequately monitored. Peak flow monitoring was performed on admission in 74% of cases and arterial blood gas measurement in 81%. Over 90% of patients were given nebulised bronchodilator therapy with both nebulised ipratropium bromide and salbutamol. Antibiotics were given in 77% of cases. Corticosteroids were given in 95% of cases, usually orally. Sedatives were prescribed inappropriately in six cases where there was acute ventilatory failure. Four patients died in hospital, none unexpectedly. Three patients were mechanically ventilated and all survived to leave hospital. There was no discharge summary in the case records in 29% of cases. CONCLUSIONS: Standards of assessment and treatment were adequate. Several areas were identified where improvements are required, particularly in the prescribing and monitoring of oxygen therapy. Hospital-wide guidelines for the management of COPD are to be developed.