Inpatient pulmonary rehab creates new patient niche

Goal is to reduce acute admissions

A subacute pulmonary rehabilitation program that includes yoga, singing, and videotapes of comedies, along with traditional rehab components, is generating new patients for Peterson Rehabilitation Hospital and Geriatric Center in Wheeling, WV.

The chief goal of the program is to reduce acute hospital admissions for patients with chronic obstructive lung disease, a common condition in the northern West Virginia coal mining and steel mill region surrounding the hospital, says Elizabeth Sproull, RNC, MEd, administrator/director of nursing.

Although the facility is not yet in a heavily concentrated managed care area, the administration is preparing for managed care by looking for new sources of patients, Sproull says.

"At some point in the future, we know we are not going to get paid for the typical orthopedic rehab cases that are the bread and butter of any rehab unit. We have been looking for new sources of patients," she says.

Sproull began exploring inpatient pulmonary rehabilitation by talking with hospitals that operate similar programs. The health system to which the rehab hospital belongs has an outpatient pulmonary rehabilitation program with a waiting list. It also has a high incidence of patients with respiratory problems. About 40% of pulmonary patients admitted to the acute care hospital are on their third or fourth admission for exacerbation of the disease, Sproull explains.

Another factor in the decision to develop an inpatient pulmonary unit was that the local health maintenance organization’s criteria for determining if patients should be hospitalized included a section on subacute pulmonary rehabilitation. Sproull is still negotiating with the HMO to set up a program for its patients’ needs.

So far, all the patients have been under Medicare. The hospital is able to admit them under the diagnosis of debility, Sproull says.

After determining there were enough patients to justify setting up an inpatient pulmonary program, Peterson’s administration assembled a design team. Included were staff from various therapy departments, a pulmonologist, a physiatrist, and a representative from the durable medical equipment (DME) company the hospital uses.

The team worked for three months to develop the program and objectives. The subacute pulmonary program is set up to last four weeks, but it can be shortened for patients with less severe debilitation.

"If this is a person who walks from the bed to the recliner and sits 12 hours a day, it will take them six weeks. If it’s someone who stays out of bed, gets dressed, and tries to fix something to eat, we can cut the program to two or three weeks. It all depends on how far the disease has progressed," Sproull says.

Patients who smoke also go through a smoking cessation program led by the respiratory therapy department. The program includes use of nicotine patches, if appropriate.

Patients referred to the program are evaluated by a respiratory therapist who gets them to sign a contract in which they agree to quit smoking and participate in the rehab program and the outpatient program following discharge.

If patients are not willing to participate, they are deemed inappropriate for the program. One patient signed himself out after four days in the program because he didn’t like having to do things for himself and attend therapy sessions. He returned to the emergency department less than 24 hours later.

"Many of these patients are used to sitting in a chair all day with the remote control in their hand, being waited on by their family because they can’t breathe. In order to be admitted to this program, they have to be willing to make a lifestyle change," Sproull explains.

Before patients are discharged, they have to move into a private self-care room where they must bathe and dress themselves, do their own bronchial treatments, and perform other activities of daily living before they go home.

Treatment objectives are handled by a team that includes physical therapy, occupational therapy, nursing, respiratory therapy, speech therapy, social services, psychology, recreation therapy, dietetics, and a DME representative.

All members of the nursing and therapy staff have completed a 10-week inservice education program designed by the committee that developed the program. Included in the two-hour sessions were anatomy and physiology, information about chronic obstructive lung disease, available treatments, measurement of functional ability, and equipment demonstrations.

Physical and occupational therapy work on tolerance and strength training, self-care activities, pacing, work conservation, and energy conservation. The speech therapist teaches breathing support methods to help patients who have trouble breathing while chewing and swallowing. Education for the patient and family is a major component of the treatment plan. (For more on patient education, see the related story, p. 119.)

One of the first patients who went through the program told Sproull that before the rehab program, her anxiety level was about a nine on a scale of one to 10 and that she called the doctor and emergency department constantly because she was afraid she wasn’t going to be able to catch her breath. At the end of the program, she estimated that her anxiety level had dropped to a three.

Now, when she has trouble breathing, instead of panicking, she has the knowledge to adjust her oxygen, change her breathing patterns, and deal with the problem, Sproull says.

The rehab center is working with physicians to track the number of phone calls patients make before and after going through the program.