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Evidence-Based Practice and Case Management

Evidence-Based Practice and Case Management

As the population ages and technological advances are made, the delivery of high-quality, up-to-date nursing care using an evidence-based practice approach is becoming increasingly important. EBP is a term that is frequently heard and used in the medical field, but it is not always understood. There are many definitions of evidence-based practice, but Melnyk and FineoutOverholt (2011, p. 4) define it as evidence that “considers a synthesis of evidence from multiple studies and combines it with the practitioner’s expertise and patient preferences and values.” This definition implies that patient perspectives, clinical knowledge, and medical research are inextricably linked and rely on one another to determine the best practice for individualized, positive patient outcomes.

This paper will discuss the significance of using EBP by case managers for patients suffering from a chronic obstructive pulmonary disease (COPD). Best nursing practices, including published COPD guidelines, will be examined. Finally, clinical pathways for guiding EBP will be evaluated.

Best Practices should be identified and discussed.

COPD is a chronic, lifelong disease that has a significant impact on the lives of those who suffer from it. Early diagnosis, intervention, and management can improve symptoms and patient’s quality of life significantly. According to Sethi (2018), “the main focus of primary care providers is to provide treatment to reduce patients’ symptoms and improve their quality of life.” Because COPD varies from person to person, the provider must take an individualized approach to treatment, identifying the symptoms that interfere with patients’ activities of daily living and quality of life and designing a treatment plan around those symptoms.

Sethi (2018) identifies three best practices for COPD management in primary care. The first best practice is to encourage patients to self-manage their COPD through smoking cessation and healthy lifestyle choices. Smoking is the leading cause of COPD, and quitting is critical to reducing the disease burden and acute exacerbation risk (CDC, n.d.). The case manager is available to educate the patient on the benefits of quitting smoking as well as the risks of continuing to smoke. A referral for a smoking cessation program can be made by the case manager, and the case manager can facilitate communication with the provider for pharmaceutical intervention to aid in smoking cessation.

Routine monitoring of the patient for signs of acute exacerbation or changes in symptoms, evaluation of treatment outcomes, and assessment of treatment goals is the second best practice discussed. Routine patient monitoring enables the provider to detect signs of worsening disease or acute exacerbation and treat them before the patient requires hospitalization. To ensure patient compliance with routine monitoring, a patient assessment for barriers related to COPD management and treatment must be completed. Access to healthcare to increase the incidence of early diagnosis and effective disease management, compliance with treatment recommendations, risk reduction of hospital admissions and re-admissions, and other psychosocial issues or concerns are all barriers to treatment (Sethi, 2018). Transportation is an example of a treatment barrier. If a patient lacks reliable transportation, they may be unable to attend all recommended follow-up appointments for routine monitoring.

The third best practice Sethi (2018) discussed is monitoring and encouraging compliance with pharmaceutical intervention. All prescribed medication treatments for COPD management must be taught to the patient. The reason why the patient is taking the medication, how the drug works, the dosing and schedule, and administration instructions should all be covered in education. The patient should be able to demonstrate an understanding of medication use through demonstration or teach-back, such as proper inhaler technique.

Incorporating a case manager into the care of COPD patients can help in identifying treatment barriers and developing interventions to overcome them. Once the barriers have been identified, and interventions have been developed, the patient and case manager can develop a plan to implement the treatment recommendations (Kilpatrick et al., 2014). The case manager will have frequent contact with the patient, giving them ample opportunity to evaluate treatment outcomes, medication management, and treatment goals.

Evaluating Publicly Available Guidelines

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) was established to serve as a “pocketbook” or guide for healthcare professionals who work with COPD patients. The GOLD literature examines what COPD is, how it is diagnosed and assessed, evidence for prevention and maintenance therapy/management of stable COPD and acute exacerbations, and COPD and comorbidities. Using published guidelines in healthcare ensures that healthcare providers across the state, country, and world are employing the most current and effective evidence-based practices.

COPD is diagnosed in any patient who has “dyspnea, chronic cough or sputum production, history of recurrent lower respiratory tract infections, and/or a history of risk exposures,” according to guidelines (GOLD, 2020). Spirometry is the most reliable and objective method of measuring restricted airflow and is required in the diagnosis of COPD. A chest X-ray cannot be used to diagnose COPD, but it can help rule out other causes of respiratory distress, such as pneumonia or cardiovascular abnormalities (GOLD, 2020). It is critical to monitor a patient’s pulse oximetry. If the SpO2 falls below 92%, arterial blood gases should be collected for analysis.

The assessment of COPD aims to determine the disease’s impact on the patient’s overall health, the acuity or extent of limited airflow, and the risk of poor patient outcomes, such as acute exacerbation requiring hospitalization or death. Spirometry levels are used to determine the severity of airflow, and severity is graded as mild (GOLD 1), moderate (GOLD 2), severe (GOLD 3), or very severe (GOLD 4). (GOLD 4). The higher the grade, the greater the level of airflow restriction and the likelihood of COPD symptoms (GOLD, 2020). To assess and grade symptoms, the GOLD guide suggests using the COPD Assessment Test (CAT) and the COPD Control Questionnaire (CCQ). Healthcare professionals can use the CAT to collect objective data and the CCQ to collect subjective data, allowing for a well-rounded, comprehensive assessment.

The GOLD pocket guide includes many key points for evidence supporting prevention and maintenance therapy, with smoking cessation being the first recommendation. Because smoking is the leading cause of COPD, quitting is essential for COPD management and positive patient outcomes. To aid in smoking cessation, healthcare providers can use pharmacologic measures as well as psychosocial support, such as counseling or support groups (GOLD, 2020). Other preventive measures include lifestyle and activity modifications, initial pharmacotherapy, self-management education, and comorbidity management. Maintaining current influenza and pneumococcal vaccinations will reduce the occurrence of respiratory infections, which increase the risk of COPD complications. Patient education is a critical component of self-management. Explaining the disease’s etiology and pathophysiology, treatment measures with rationale, and daily lifestyle changes will enable the patient to make informed care decisions and increase compliance.

COPD management aims to reduce the severity and frequency of COPD symptoms as well as acute exacerbations. Short and long-acting bronchodilators, which are used to reduce inflammation and airway obstruction, are examples of pharmacologic interventions. Anti-inflammatory medications are not usually advised, but they may be used in certain circumstances. If an underlying infection is causing increased COPD symptoms, antibiotic therapy may be beneficial. The provider should demonstrate and assess the proper use of an inhaler on a regular basis. Because COPD symptoms vary from patient to patient, treatment plans must be tailored to each individual.

Non-pharmacologic COPD management interventions include pulmonary rehabilitation, supplemental oxygen, and surgical interventions. Pulmonary rehabilitation can help to improve activity tolerance and lung capacity, which in turn improves symptom management and quality of life. Supplemental oxygen therapy has been shown to improve both acute symptoms and long-term survival rates (GOLD, 2020). Surgical intervention to reduce COPD symptoms may be appropriate depending on a patient’s disease severity and functional status. Negative outcomes associated with surgical intervention for patients with chronic illness must be considered to ensure that the benefit outweighs the risk.

An exacerbation of COPD is defined as “an acute worsening of respiratory symptoms requiring additional therapy” (GOLD, 2020, p. 40). Early detection and treatment of COPD exacerbations increase the likelihood of favorable patient outcomes. The goal of treating acute exacerbations is to minimize negative effects on the patient while also preventing future events. Because COPD symptoms are similar to those of other respiratory illnesses, the provider must rule out other possibilities, such as respiratory tract infections.

In the treatment of acute COPD exacerbations, short-acting beta2-antagonists are combined with short-acting anticholinergics to promote bronchodilation and decrease the work of breathing. Corticosteroids can be used in the short term to reduce inflammation and work of breathing. If an infection is present, antibiotic therapy should be started immediately to reduce recovery time. For patients with acute respiratory failure, non-invasive mechanical ventilation should be the first mode of ventilation. This reduces the amount of work required to breathe and the need for intubation while also improving gas exchange (GOLD, 2020). Measures to reduce the risk of future exacerbation should be put in place as soon as possible.

Evaluating Clinical Pathways

COPD has significant consequences as the third leading cause of death in the United States, ranging from poor patient outcomes to the cost of healthcare for individuals and medical facilities alike. The guidelines discussed in the final section of this document advocate for COPD prevention, diagnosis, and management, which have been shown to significantly improve quality of life and reduce healthcare utilization when implemented (Plishka et al., 2016). Clinical pathways (CPWs), also known as care plans, are tools for bridging the gap between recommended guidelines and clinical practice. CPWs “bring the best available evidence to a diverse range of healthcare professionals by adapting evidence-based clinical guidelines to a local context and detailing the critical steps in patient assessment and care” (Plishka et al., 2016, p. 2). In summary, CPWs assist healthcare professionals in incorporating guidelines into their daily practice.

CPWs provide a structured plan of care that details treatment steps and standardizes care in a specific population (Plishka et al., 2016). The CPW will vary slightly for each patient in order to individualize care as needed but will follow standard guidelines and algorithms to determine the best treatment plan. Nishimura et al. (2011) concluded that CPWs improved the quality of care for patients hospitalized with AECOPD in a study evaluating the effects of CPWs on AECOPD.

Case managers have specialized skills in the development and implementation of CPWs for patients in both inpatient and outpatient settings. COPD management is ongoing, and treatment modalities may change depending on the patient’s symptoms or the severity of the disease. The case manager can educate and monitor the patient’s compliance, as well as routinely monitor for changes in the patient’s health status. By facilitating communication between providers, the case manager will identify and recommend the most recent evidence-based practice to care providers, as well as ensure that all clinicians involved in the patient’s care are aware of the patient’s ordered treatments.

Conclusion

Clinical guidelines are developed to provide the most up-to-date, evidence-based best practices for patient care to healthcare practitioners. Unfortunately, there is a chasm between the creation and dissemination of guidelines and their application in practice. Case managers can help to close this gap by identifying best practices and adhering to clinical guidelines when developing care plans. CPWs provide care steps and treatment standardization while still allowing for individualized treatment planning.

References

Melnyk B M, Fineout-Overholt E (2011) Evidence-Based Practice in Nursing and Healthcare: a guide to best practice. 2nd ed. Wolters Kluwer Lippincott Wilkins & Williams, Philadelphia.

Sethi, S. (2018). Effective management of COPD in primary care: Challenges and opportunities. American Journal of Managed Care 4(5), p. 34-37.

CDC (n.d.). COPD Homepage for Clinicians. Retrieved September 28, 2020, from https://www.cdc.gov/copd/for-clinicians.html

Global Initiative for Chronic Obstructive Pulmonary Disease. (2020). GOLD 2020. https://goldcopd.org/wp-content/uploads/2020/03/GOLD-2020-POCKET-GUIDE- ver1.0_FINAL-WMV.pdf

Plishka, C., Rotter, T., Kinsman, L., Hansia, M. R., Lawal, A., Goodridge, D., Penz, E., & Marciniuk, D. D. (2016). Effects of clinical pathways for chronic obstructive pulmonary disease (COPD) on patient, professional and systems outcomes: protocol for a systematic review. Systematic reviews, 5(1), 135.

Nishimura, K., Yasui, M., Nishimura, T., & Oga, T. (2011). Clinical pathway for acute exacerbations of chronic obstructive pulmonary disease: method development and five years of experience. International journal of chronic obstructive pulmonary disease, 6, 365–372.

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What are utilization and case management? How is this related to managed care and quality care and control issues?

Evidence-Based Practice and Case Management

Evidence-Based Practice and Case Management

How do APNP  clinical expertise and patient management skills provide a foundation for utilization and case management? Provide an example of how case management improves patient care outcomes. Use an EBP research article to support your case. Provide detailed examples

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