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Safe and Effective Prescription of Exercise in Acute Exacerbations of Chronic Obstructive Pulmonary Disease:… Kan, Debbie; Macapagal, Paolo; Yoon, Tae Il; Bakshi, Param; Beattie, Colin 2011-08

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Safe and Effective Prescription of Exercise in Acute Exacerbations of Chronic Obstructive Pulmonary Disease: A Consensus of Experts       An Interim Report  Debbie Kan, Paolo Macapagal, Tae Il Yoon, Param Bakshi, Colin Beattie Co-supervisors: Dr. Darlene Reid and Dr. Pat Camp  Consultant group: Alison Hoens and SAFEMOB group  Outline ? Introduction  ? Purpose  ? Methods ? Results to date ? Discussion Introduction ? COPD Defn - a progressive, partially reversible disease state characterized by airflow limitation, shortness of breath and frequent exacerbations ? Includes emphysema, chronic bronchitis, and may also include elements of asthma (American Thoracic Society, 1995; O?Donell, 2007) Introduction  ? COPD is predicted to rise from the 4th to the 3rd leading cause of death by 2030 (World Health Organization, 2008)  ? Each acute exacerbation further accelerates the decline in pulmonary function (Lawati & FitzGerald, 2008)  Purpose Areas of controversy: Researchers Study Design Sample Size Type of Physical Activity Initiation of Physical Activity Eaton et al., 2008 RCT 97 supervised walking, upper and lower limb strengthening Mean 2.6 days post-admission Yohannes et al., 2003 RCT 110 supervised walking three times daily with a PT or nurse 2 days post-admission Kirsten et al., 1998 RCT 29 6-min treadmill walk tests and five walking sessions/day 6-8 days post-admission ? Inconsistency on type of physical activity and timing of interventions ? FITT? Research Question ? The Burning Question: ? What are the parameters for prescription of safe and effective physical activity in hospitalized patients with an acute exacerbation of COPD (AECOPD)? Objective ? Through the use of the Delphi technique, there will be a consensus among an expert panel (PTs, MDs, RTs, RNs, and COPD patients) representing clinicians, academics, and patients on parameters to prescribe safe and effective PA for AECOPD patients.  METHODS Methods ? Research design: ? Use of the Delphi method to obtain a consensus among clinicians, academics, and patients with COPD ? What is the Delphi process? ? ?Systematic series of questionnaires interspersed with controlled feedback? ? Increasing popularity in nursing and allied health care literature  Powel, C. (2003), Okoli, C. & Pawlowski, S.D. (2004).  Participant Selection ? 3 stakeholder groups ? Clinicians (RN, RT, PT, MD) ? Academics (PT, MD, RT) ? Patients ? No sample calculation ? Optimal size not established, range from 4 to 3000 (Campbell, 2002)     Inclusion/Exclusion Criteria Subgroup Inclusion Criteria Exclusion Criteria Clinicians ?Currently working in an acute care setting ?At least 3 years experience with COPD patients ?Currently practicing in   Canada ?Practice leaders or   administrators Academics ?Hold a teaching or research    role specializing respiratory   area ?Currently practicing in   Canada  Patients ?Are a member of a self-interest group ?Have COPD and have had an acute exacerbation of COPD in the past  ?Patients with dementia   or severe cognitive   impairments ?Palliative patients ?Patients who are   medically unstable Recruitment Process Expert Panel Clinicians Pool: Nationwide large (>400 beds) and small (<200 beds) hospitals; delegate  conference list Contact: PT Practice leaders, Nurse PCC, Team leaders, floor managers Academics Pool: Major Canadian Universities with PT, MD and BScN programs Contact: Professors Patients Pool: Nationwide COPD self interest groups (ie. Better Breathers, COPD Canada) Contact: Chapter Presidents Study Design QUESTIONNAIRE DEVELOPMENT AND RECRUITMENT ?Brainstorming ?Draft questionnaire produced ? Piloted with local academics for validity ?Recruitment process ?Finalized questionnaire sent ROUND 1: Parameter Identification (7 weeks) ? Questionnaire 1: Broad open ended questions  ? Analysis: Statements from panellists to be categorized  and codified ROUND 2: Agreement of Classifications (predicted 12 weeks) ? Questionnaire 2: Panel presented with results from round 1  ? Analysis:  ? Review and revise if necessary ROUND 3: Rating of Parameters (predicted 8 weeks) ?Questionnaire 3: Likert Scale of statements from round 2  ?Analysis: Determination of consensus Piloting ? Researchers developed preliminary questionnaire and operational terms ? A brief pilot of the questionnaire was sent out to 3 local PT?s  for review. ? Questionnaire was revised to include: ? Case study ? Glossary of terms ? Generate leading questions for safe parameters  Questionnaire Development  ? Operational terms: ? Safe: An exercise or physical activity intervention within your clinical setting that:  ?  does not contribute to further deterioration of patient?s health status  ?  does not increase risk of personal injury to attending health care professionals. ?  Effective: An exercise or physical activity intervention that: ?  can be implemented with the usual resources and practitioner experience  ?  maintain high patient compliance ? optimize patient health status Round 1 Data Analysis ? Round 1: codifying and classification of statements  Raw Data Collected Results/Discussion Participant selection ? 139 people contacted ? 57 academics, 56 clinicians, 26 patients ? 33 consent forms received ? 29 participants included post screen for inclusion/exclusion criteria Stakeholder Group Composition Healthcare Discipline Stakeholder Group Academics Clinicians Patients          MD 4 2 N/A          PT 4 4 N/A          RN 0 6 N/A          RT 1 1 N/A Total 9 13 7 Stakeholder Group Distribution Stakeholder Group Western Canada  (BC, AB, MB, SK)  Eastern Canada  (ON, QB, NS, NB, PE, NF) Academics 4 5 Clinicians 12 1 Patients 4 3 Total 20 9 Stakeholder Group Diversity ? Years teaching/researching ? Range: 4-30, mean = 18.6, std dev = 10.5 Academics ? Years of working w/ COPD  ? Range: 3-32, mean = 12.1, std dev = 8.9 ? # of beds  ? Range: 40-780, mean = 350.0, std dev = 220.0 Clinicians ? Years since Dx:  ? Range: 4-11, mean = 7.1, std dev = 3.1 Patients Self-Reported Consensus Stakeholder Group(s) Mean Self-Report Consensus Standard Deviation Self-Reported Consensus Safe Effective Safe Effective Academic 87.2 78.3 6.7 9.0 Clinician 83.5 79.2 9.4 9.3 Patient 89.3 79.3 9.3 15.4 Academic & Clinician 85.0 78.9 8.5 9.0 Academic, Clinician & Patient 86.0 79.0 8.7 10.5 Round 1 Responses ? Over 1000 responses  QUESTION 1.  What outcomes or measures related to walking are necessary prior to discharge? QUESTION 2.  What outcomes or measures related to activities of daily living are necessary prior to discharge? Question 4.  Please provide the guidelines and measures that must be considered in order to maintain safe exercise, focusing on CARDIAC STATUS.    Question 1 ? Outcome Measures Related to Walking  ? Answers provided by the panel that were related to outcomes of walking/functional ambulation, with or without a gait aid: Question Response Frequency Question 1 Be able to complete a predetermined # of stairs 16 A predetermined distance is required 7 Substantial household ambulation is necessary 6 Able to complete 6 minute walk test 5 Able to maintain SpO2 during ambulation 4 Other related to walking/ambulation 6 Other related to signs and symptoms 16 Other related factors  10 Question 2 ? Outcome Measures Related to ADLs ? Answers provided by the panel related to performance of ADLs (with or without adaptive aids): Question Response Frequency Question 2 Able to bath and maintain personal hygiene 17 Able dress independently 8 Basic meal preparations 7 Able to toilet independently 6 Patient able to transfer independently from bed to chair, sit to stand 5 Able to feed independently 5 Make sure patient is able to manage 02 equipment and medications 4 Other  29 Question 4 ? Measures Related to Cardiac Status ? Answers provided by the panel related to heart rate at rest:     ? Answers provided by the panel related to heart rate during activity:     HR (min) Frequency HR (max) Frequency 40 1 100 3 50 2 110 1 55 1 120 3 125 1 HR (min) Frequency HR (max) Frequency - - 120 1 - - 125 1 - - 130 1 Question 4 ? Measures Related to Cardiac Status ? Answers provided by the panel related to blood pressure at rest:      SBP (min) Frequency SBP (max) Frequency 70 1 130 1 80 3 140 2 90 5 145 1 100 2 150 1 - - 160 4 - - 180 1 - - 200 5 Question 4 ? Measures Related to Cardiac Status ? Answers provided by the panel related to blood pressure at rest:      ? During activity: similar variability  ? Answers provided by the panel related to cardiac precautions/contraindications     DBP (min) Frequency DBP (max) Frequency 40 2 90 2 50 2 95 2 60 1 100 1 85 1 110 4 - - 120 1 Patient Responses ? Patients displayed significant difficulty with answering questions ? Very few numeric values ? Often deferred from answering the question with ?I don?t know?  Round 2 ? In Process? ? 28 participants remain ? 25 out of 28 responses ? No comments on misrepresentation of answers ? Panellists surprised with number or responses Discussion/Implications ? Expert panel was multidisciplinary ? 28 panellists  ? Higher n ? potentially more robust results ? ?additional recruitment  ? limited by timeline  ? Over 1000 line items analysed in round one, reflecting a wide variety of practice standards and knowledge      Discussion/Implications ? Expert panel representation: ? Western Canada : Eastern Canada = approx. 2:1 ? Representation vs. Representative ? Clinical Practice Guidelines (CPGs) generalizable? ? Clinician Group 12:1 (West:East) ? Providing a brief case study ? Answers may have been general ? Why not more elaborate?   Discussion/Implications ? Although we are unable to make conclusions on consensus at this point, some trends did emerge which potentially show some consistency within the panellists ? E.g., more overlap in answers for outcome measures regarding  functional ambulation and ADLs   ? Consensus on parameters ? Levels of consensus - 86.0% (SAFE) & 79.0% (EFFECTIVE) ? Results so far: increased variability in safe responses      and more overlap for effective responses  ? We suspect we may gain consensus on effective parameters more easily than safe   Discussion/Implications ? Will be interesting to see how panellists rate items in round 3 now that they have seen other?s responses.  ? Patient stakeholder group had difficulty answering Round 1 Questions. We expect them to make a greater contribution in subsequent round 3. Discussion/Implications ? Ultimate Goal: establish CPGs for a decision making tool to help guide safe and effective prescription of exercise with hospitalized patients suffering from acute exacerbations of COPD.  ? Not to be substitute for clinical decision making ? Help guide interventions with greater confidence Areas of Improvement ? Higher sample size. Recruitment was limited by deadlines. ? Establish a more geographically representative panel. ? Inclusion of disciplines that were too few (e.g., academic RN) or not included at all in this research study (e.g., OT). ? Add questions relating to appropriate type of physical activity for patients with AECOPD. QUESTIONS? Thank you! ? Dr. Pat Camp and Dr. Darlene Reid ? Research Supervisors ? Andrea Neufeld ? Research Assistant ? Pilot and Panellist Participants References Okoli, C., &Pawlowski, S.D. (2004). The Delphi method as a  research tool: an example,  design considerations and applications. Information & Management. 42; 15?29.   Lawati N.A., &FitzGerald, J.M. (2008). Acute exacerbation of  chronic obstructive pulmonary  disease. BC Medical Journal, 50(3); 138-142.   American Thoracic Society (1995). Standards for the diagnosis and  care of patients with  chronic obstructive pulmonar ydisease. American Journal of Respiratory Critical Care  Medicine, 152(5 Pt 2):S77-S121   Indulska, M., Recker, J., Rosemann, K., & Green, P. (2009).  Business Process Modeling: Current Issues and Future  Challenges. Advanced Information Systems Engineering -  CAiSE,556;, 501-514.   Powel, C. (2003). The Delphi technique: myths and realities.  Journal of Advanced Nursing.  41(4); 376?382.     References Eaton, T., Young, P., Fergusson, W., Moodie, L., Zeng, I., O'Kane, F., et al. (2009). Does early pulmonary rehabilitation reduce acute health-care utilization in COPD patients admitted with an exacerbation? A randomized controlled study.Respirology, 14(2), 230-238.  Kirsten, D. K., Taube, C., Lehnigk, B., Jorres, R. A., &Magnussen, H. (1998). Exercise training improves recovery in patients with COPD after an acute exacerbation. Respiratory Medicine, 92(10), 1191-1198.  Yohannes, A. M., & Connolly, M. J. (2003). Early mobilization with walking aids following hospital admission with acute exacerbation of chronic obstructive pulmonary disease. Clinical Rehabilitation, 17(5), 465-471.  Public Health Agency of Canada (2005). Chronic obstructive pulmonary disease (COPD) Facts and Figures. Retrieved at July 21, 2010 from World health Statistics. (2008). Reducing deaths from tobacco. France. World Health Organization  Timeline Key Elements Date of Completion August 13, 2010 Ethics submission Mid-October 2010 Ethics re-submitted End- November 2010 Ethics re-submitted 2nd time Mid- December 2010 Ethics Approved December 2010 Began recruitment and questionnaire development  February/March 2011 Round 1 distributed April/May 2011 Round 1 Analysis  End of June 2011 Round 2 distributed August 2011 Awaiting 3 responses from round 2 Round 3 ? Purpose: ? rank each item on Likert scale of 1-7      ? use data to calculate concensus ? 6-7 (agree and strongly agree) ? Consensus: ? Safe: 86%   (24/28) ? Effective: 79%  (22/28) 1 ? Strongly Disagree 2 ? Disagree 3 ? Somewhat Disagree 4 ? Neither Agree or Disagree 5 ? Somewhat Agree 6 ? Agree 7 ? Strongly Agree Delphi Technique Pros and Rationale PROS ?Achievement of consensus in an area of controversy/lack of evidence Anonymity allows for decrease group think phenomenon Allows for inclusion of experts from different geographical areas and fields Parameters for safe and effective exercise with AECOPD patients controversial Improvement over focus group/group interview methodology Can recruit representative panel; Answers more robust and generalizable Powel, C. (2003), Okoli, C. & Pawlowski, S.D. (2004).  Round 4 ? Potential round 4 ? Depends on results from round 3: ? an excessive amount of items achieve consensus ? panellists asked to rank their top 5-10  


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