Hospitalist attitudes toward the assessment and management of dyspnea in patients with acute cardiopulmonary diseases

A Retrospective, Descriptive Study of Dyspnea Management in a Multidisciplinary Interstitial Lung Disease Clinic

Background: Fibrotic interstitial lung diseases (F-ILDs) have a high symptom burden with progressive dyspnea as a primary feature. Breathlessness is underrecognized and undertreated primarily due to lack of consensus on how to best measure and manage it. Several nonpharmacologic and pharmacologic strategies are published in the literature, however there is a paucity of real-world data describing their systematic implementation. Objectives: We describe the types of breathlessness interventions and timing of implementation in our multidisciplinary collaborative care (MDC) ILD clinic and the impact of our approach on dyspnea trajectory and acute care use in ILD. Methods: A retrospective, observational study of deceased ILD patients seen in our clinic (2012-2018) was conducted. Patients were grouped by baseline medical research council (MRC) grade and dyspnea interventions from clinic enrolment until death were examined. Healthcare usage in the last 6 months of life was collected through Alberta's administrative database. Results: Eighty-one deceased ILD patients were identified. Self management advice was provided to 100% of patients. Pulmonary rehabilitation (PR) and home care (HC) referrals were made in 40% and 57% of patients, respectively. Eighty percent were treated with oxygen and 53% with opioids during the study. MDC-initiated referral to PR and HC, oxygen and opioid prescriptions were provided a median of 13, 9, 11, and 4 months prior to death, respectively. Stepwise implementation of interventions was observed more commonly in MRC 1-2 and concurrent implementation in MRC 4-5. Conclusions: Our clinic's approach allows early and systematic dyspnea management.

Professionals', patients' and families' views on the use of opioids for chronic breathlessness: A systematic review using the framework method and pillar process

BACKGROUND

In combination with non-pharmacological interventions, opioids may safely reduce chronic breathlessness in patients with severe illness. However, implementation in clinical practice varies.

AIM

To synthesise the published literature regarding health professionals', patients' and families' views on the use of opioids for chronic breathlessness, identifying issues which influence implementation in clinical practice.

DESIGN

Systematic review and synthesis using the five-stage framework synthesis method.

DATA SOURCES

Three electronic databases (MEDLINE, Embase via OVID, ASSIA via Proquest) were searched (March 2020) using a predefined search strategy. Studies were also citation chained from key papers. Papers were screened against a priori eligibility criteria. Data were extracted from included studies using the framework synthesis method. Qualitative and quantitative data were synthesised using the pillar process. Included studies were critically appraised using the Mixed-Methods Appraisal Tool.

RESULTS

After de-duplication, 843 papers were identified. Following screening, 22 studies were included. Five themes were developed: (i) clinician/patient characteristics, (ii) education/knowledge/experience, (iii) relationship between clinician/family, (iv) clinician/patient fear of opioids and (v) regulatory issues.

CONCLUSIONS

There are significant barriers and enablers to the use of opioids for the symptomatic reduction of chronic breathlessness based on the knowledge, views and attitudes of clinicians, patients and families. Clinicians' interactions with patients and their families strongly influences adherence with opioid treatment regimens for chronic breathlessness. Clinicians', patients' and families' knowledge about the delicate balance between benefits and risks is generally poor. Education for all, but particularly clinicians, is likely to be a necessary (but insufficient) factor for improving implementation in practice.

Attitude change and increased confidence with management of chronic breathlessness following a health professional training workshop: a survey evaluation

BACKGROUND

Clinicians and people living with chronic breathlessness have expressed a need to better understand and manage this symptom. The aim of this study was to evaluate a 3-day health professional training workshop on the practical management of chronic breathlessness.

METHODS

Workshop design and delivery were based on current understandings and clinical models of chronic breathlessness management, principles of transformative learning, and included sessions co-designed with people living with breathlessness. Registrants were invited to complete pre and post-workshop surveys. Pre and 1-week post-workshop online questionnaires assessed familiarity and confidence about workshop objectives (0[lowest]-10[highest] visual analogue scale), attitudes and practices regarding chronic breathlessness (agreement with statements on 5-point Likert scales). Post-workshop, participants were asked to describe implementation plans and anticipated barriers. Baseline familiarity and confidence were reported as mean (SD) and change examined with paired t-tests. Pre-post attitudes and practices were summarised by frequency/percentages and change examined non-parametrically (5-point Likert scale responses) or using a McNemar test of change (binary responses).

RESULTS

Forty-seven of 55 registrants joined the study; 39 completed both pre and post-workshop questionnaires (35 female; 87% clinicians; median 8 years working with people with chronic breathlessness). Post-workshop, greatest gains in confidence were demonstrated for describing biopsychosocial concepts unpinning chronic breathlessness (mean change confidence = 3.2 points; 95% CI 2.7 to 4.0, p < 0.001). Respondents significantly changed their belief toward agreement that people are able to rate their breathlessness intensity on a scale (60 to 81% agreement) although only a minority strongly agreed with this statement at both time points (pre 11%, post 22%). The largest shift in attitude was toward agreement (z statistic 3.74, p < 0.001, effect size r = 0.6) that a person's experience of breathlessness should be used to guide treatment decisions (from 43 to 73% strong agreement). Participants' belief that cognitive behavioural strategies are effective for relief of breathlessness changed further toward agreement after the workshop (81 to 100%, McNemar test chi- square = 5.14, p = 0.02).

CONCLUSION

The focus of this training on biopsychosocial understandings of chronic breathlessness and involvement of people living with this symptom were valued. These features were identified as facilitators of change in fundamental attitudes and preparedness for practice.

Routine dyspnea assessment and documentation: Nurses' experience yields wide acceptance

Background

Dyspnea (breathing discomfort) is a common and distressing symptom. Routine assessment and documentation can improve management and relieve suffering. A major barrier to routine dyspnea documentation is the concern that it will have a deleterious effect on nursing workflow and that it will not be readily accepted by nurses. Nurses at our institution recently began to assess and document dyspnea on all medical-surgical patients upon admission and once per shift throughout their hospitalization. A year after dyspnea measurement was implemented we explored nurses’ approach to dyspnea assessment, their perception of patient response, and their perception of the utility and burden of dyspnea measurement.

Methods

We obtained feedback from nurses using a three-part assessment of practice: 1) a series of recorded focus group interviews with nurses, 2) a time-motion observation of nurses performing routine dyspnea and pain assessment, and 3) a randomized, anonymous on-line survey based, in part, on issues raised in focus groups.

Results

Ninety-four percent of the nurses surveyed reported administering the dyspnea assessment is “easy” or “very easy”. None of the nurses reported that assessing dyspnea negatively impacted workflow and many reported that it positively improved their practice by increasing their awareness. Our time-motion data showed dyspnea assessment and documentation takes well less than a minute. Nurses endorsed the importance of routine measurement and agreed that most patients were able to provide a meaningful rating of their dyspnea. Nurses found the patient report very useful, and used it in conjunction with observed signs to respond to changes in a patient’s condition.

Conclusions

In this study, we have demonstrated that routine dyspnea assessment and documentation was widely accepted by the nurses at our institution. Our nurses fully incorporated routine dyspnea assessment and documentation into their practice and felt that it improved patient-centered care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12912-016-0196-9) contains supplementary material, which is available to authorized users.

How well do patients and providers agree on the severity of dyspnea?

BACKGROUND

Understanding the severity of patients' dyspnea is critical to avoid under- or overtreatment of patients with acute cardiopulmonary conditions.

OBJECTIVE

To evaluate the agreement between dyspnea assessment by patients and healthcare providers and to explore which factors contribute to discordance in assessment.

DESIGN, SETTINGS AND PARTICIPANTS

Prospective study of patients hospitalized for acute cardiopulmonary diseases at an urban teaching hospital.

INTERVENTION AND MEASUREMENTS

A numerical rating scale (0-10) was used to assess dyspnea severity as perceived by patients and assessed by providers. Agreement was defined as a score within ±1 between patient and healthcare provider; differences of ≥2 points were considered over- or underestimations. The relationship between patient self-perceived dyspnea severity and provider rating was assessed using a weighted kappa coefficient.

RESULTS

Of the 138 patients enrolled, 33% had a diagnosis of heart failure, 30% chronic obstructive pulmonary disease, and 13% pneumonia; median age was 72 years, and 57% were women. In all, 96 patient-physician and 138 patient-nurses pairs were included in the study. The kappa coefficient for agreement was 0.11 (95% confidence interval [CI]: 0.01 to 0.21) between patients and physicians and 0.18 (95% CI: 0.12 to 0.24) between patients and nurses. Physicians underestimated patients' dyspnea 37.9% of the time and overestimated it 25.8% of the time, whereas nurses underestimated it 43.5% of the time and overestimated it 12.4% of the time. Admitting diagnosis was the only patient factor associated with discordance.

CONCLUSIONS

Agreement between patient perception of dyspnea and healthcare providers' assessment is low. Future studies should prospectively test whether routine assessment of dyspnea results in better patient outcomes. Journal of Hospital Medicine 2016;11:701-707. © 2016 Society of Hospital Medicine.