Care Delivery

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Care Delivery

Category : Articles

Care Delivery 2 NUR: 555

The aim of this assignment is to provide an evaluation of the National Institute for Health and Clinical Excellence (NICE) (2010) guidelines for Chronic Obstructive Pulmonary Disease (COPD). COPD is a term used to describe a variety of conditions which includes asthma, chronic bronchitis and emphysema. COPD is characterised by airflow obstruction. It is usually a long term progressive disease which does not change over several months and is not fully reversible (NICE 2010). The main cause of COPD is cigarette smoking (Doherty and Lister 2008). However, occupational exposures, air pollution and hereditary problems are also factors that may contribute to a person developing COPD (British Lung Foundation 2012). Due to the word limitation and volume of the guidelines related to COPD, only one chapter will be discussed. This discussion will include the strengths and weaknesses of inhaler technique and patient compliance. This assignment will then be concluded by drawing key points together.

NICE (2010) guidelines provide a framework for diagnosing and managing COPD and are based on current evidence for best practice, which healthcare professional should take into account fully when utilizing their clinical judgement. Healthcare professionals have a responsibility in the development and implementation of the NICE guidelines. However, the guidance does not override the individual responsibility. There is evidence to suggest that these guidelines are not often adhered to. This will now be discussed further.

Patient education is essential in the management of COPD, it not only involves teaching it promotes learning by helping patients and their family or carer/s to improve knowledge, increase self-confidence and to take responsibility of the disease (Nault and Sedeno 2006). This can be achieved by taking actions that allow the prevention and management of early disease exacerbation (Nault and Sedeno 2006). NICE (2010) clinical guideline one hundred and one was developed to support and manage stable COPD. Chapter 1.2 states that patients should only be prescribed inhalers after they have received training and have demonstrated the correct technique in using the inhaler. Healthcare professionals should also check regularly that the patient is using their inhaler correctly.

The correct delivery of drugs by inhalation is paramount and according to Vincken et al (2010) is the preferred route of administering respiratory drugs for the treatment and management of COPD. Although the NICE (2010) guidelines for the management COPD also acknowledge that the preferred route is the inhalation of respiratory drugs, the guidelines do not address the characteristics of the inhaler devices needed to deliver these medicines (Vincken et al 2010). Tuition is part of the Integrated Care Pathway (ICP). However, patients fail to use it correctly as the correct inhaler technique can be lost over time (Hardwell et al 2011).

With effective inhalation of medication, asthma remains poorly controlled due to poor inhaler technique (Virchow et al 2008). An indication that patients are failing inhaler technique is that prescriptions are needed a lot more frequently (British Thoracic Society (BTS) 2006). According to BTS (2006) if symptom relief is not as expected when using bronchodilators, patients will usually inhale another dose. This could be an indication that the patient??™s inhaler technique needs to be readdressed or the patient??™s condition is deteriorating. BTS (2006) also suggests if the patient??™s technique is not corrected then their control of the condition will eventually deteriorate. NICE (2010) guidelines and Vincken et al (2010) state that the assessment of inhaler technique should be preformed yearly or at every visit to overcome this problem. In addition, the patient??™s inhaler should be changed to an inhaler that they can use more easily. However, NICE (2010) guidelines are not equipped to address the problem of inhaler misuse.

Toby et al (2012) suggests that people with asthma posed clinical issues regarding compliance. Almost a quarter of asthma patients reported that they had forgotten to take their medication or is unable to use their inhaler. Poor compliance contributes to the morbidity, mortality and expense associated with asthma. Although NICE (2010) guidelines make reference to education to improve the management of COPD a study by the World Health Organisation (WHO) (2012) found that both the healthcare provider and the patient affected compliance. Considine (2005) suggests that a positive relationship with patients was the most important factor in improving compliance. However, further studies by WHO (2012) which were carried out over a year found a ninety seven percent compliance rate at the start of treatment, but only fifty percent were still compliant after six months. Furthermore, there are few studies to guide healthcare professionals, by improving inhaler technique, patient education, offering clear instructions and choosing the correct therapy; patient compliance has been seen to improve (Considine, 2005).

NICE (2010) guidelines relating to COPD are clear and give a broad outline on how to manage the disease. The introduction of a local ICP helps guide healthcare professionals and patients through the clinical experience with a positive outcome (Anglesey Local Health Board (ALHB) 2008/2009). An ICP for COPD is a tool that uses evidence based guidelines and protocols (ALHB 2008/2009). NICE (2010) clinical guideline one hundred and one states that COPD care should be managed and delivered by a multidisciplinary team (MDT). Underlying factors in the management of COPD are that the MDT should work together to ensure that admissions and re-admissions to hospital are appropriate and to help and encourage patients to self-manage their own condition (Davis, 2005). Patients with COPD are usually diagnosed and managed in the community. However, patient may be referred to the occupational therapist, physiotherapist and respiratory specialist for advice if difficulties arise (McManus et al 2005).

In conclusion recommendations produced by NICE (2010) regarding inhaler techniques and compliance is paramount in a continuum of healthcare practice. Failure to educated effective technique and review compliance has a negative impact on the patient??™s health and healthcare providers. Guidelines are provided to help healthcare professionals structure care. They recommend that self management education, including action plans must be tailored to suit individuals needs. By doing these Healthcare professionals build up trust so patients do not fear embarrassment or anxiety if they are unable to manage their current inhaler. This in return achieves a better outcome for both the patient and the healthcare provider.


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Considine, J. (2005), The role of nurses in preventing adverse events related to respiratory dysfunction, Journal of Advanced Nursing Vol. 49, No. 6 pp. 624-633

Davis. N. (2005) Integrated Care Pathways. Cardiff: National Leadership and Innovation Agency Healthcare. Available from
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Hardwell, A., Barber, V., Hargadon, T., McKnight, E., Holmes, J. and Levy, M. L. (2011), Technique training does not improve the ability of most patients to use pressurised metered-dose inhalers (pMDIs). Primary Care Respiratory Journal Vol. 20, No.1, pp. 92-96

National Institute for Health and Clinical Excellence (2010) Quick reference guide: Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care. Available from
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McManus, T.E., Marley, A.M and Kidney, J.C. (2005) The Mater Hospital Muiltiprofessional Care Pathway for Acute Exacerbation of Chronic Obstructive Pulmonary Disease. Journal of Integrated Care Pathways Vol. 9 pp.32-36

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Vincken, W., Dekhuijzen, R. and Barnes, P. (2010), The ADMIT series ??“ Issues in Inhalation Therapy,
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Virchow, J.C., Crompton, G.K., Dal Negro, R., Pedersen, S., Magnan, A., Seidenberg, J. and Barnes, P.J. (2008) Importance of Inhaler Devices in the Management of Airway Disease, Respiratory Medicine, Vol. 102, No. 1, pp. 10-19

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