Resource optimization through process re-engineering of inhalational therapy unit at a tertiary care public hospital

Background: Salaries, supplies and machinery account for bulk of public funding necessitating efficient utilisation. Studies suggest that process re-engineering helps improve cost, quality, service, and speed. Disbanded once and re-commissioned, a centralized Inhalational Therapy Unit (ITU) banked and provided portable mechanical ventilators to the inpatient wards. A demand for new ventilators from ITU led to the present study involving its critical review and cost analysis.Methods: An interventional study was conducted at a large tertiary care public hospital in India from April 2015 to June 2015. Critical review of process of providing portable ventilators and cost analysis were conducted. Review of records of and interview with ITU personnel and nursing staff were carried out. Fundamental rethinking and radical redesign of the process was done with attention to human resource, costs, space and actual medical equipment utilization. Two fundamental questions of process re-engineering were deliberated upon: “Why do we do what we do?” “And why do we do it the way we do?” Fundamental rethinking for new process was organized around the outcome.Results: Average utilization coefficient was 6.2% (3.3% to 12.1%). Ventilators utilized per day were 1.43. Expenditure on salaries was INR 315000 per month and INR 10500 per day. Low utilization offered low value for expenses incurred. All activities in ITU focused on “provision of ventilators” (outcome) and the old rule was, “If one needed a ventilator one must contact ITU”. Since nurses were using the “outcome” and performed activities of arranging, they were handed-over the ventilators (based on utilisation patterns). ITU was disbanded, human resource and space were re-allocated to various hospital areas (costs tied were done away with) with no adverse effect on hospital functioning.Conclusions: Process re-engineering led to improved healthcare delivery, curtailed delays in hospital processes, optimised costs involved in human resources and medical equipment.

Acute exacerbations of asthma occurring frequently time to check your techniques

Background: Asthmatics form a predominant section of patients in OPD. If poorly controlled the frequency of attacks requiring an emergency department visit adds to the burden. It was noticed that the patients who were on inhalational therapy had poor control despite the absence of other factors which could lead to exacerbations. Hence author evaluated the inhalational techniques.Methods: A prospective study undertaken in the department of medicine in tertiary care hospital in Dakshina Kannada District, Karnataka enlisting 25 patients admitted with acute exacerbation of bronchial asthma. The patients were assessed for their symptoms, signs and recurrent attacks along with their cough severity index and inhaler scores and the observations were tabulated.Results: Of the twenty-five, 15 were on inhalation therapy with various modes of deliveries. There were 15 males and 10 females from ages 20 to 50years. The number of attacks of asthma was higher in those not on inhalation therapies than those using inhalation therapies. Also, the level/severity of cough, measured as Cough Severity Index, was assessed among the two groups. Those on inhalation therapy had a lower grade of cough than those not on therapy . Mean AEC was 94 among those on inhalation therapy and 209 among those not on therapy. Inhalational score was calculated for each patient. There is a strong negative correlation of -0.709 between inhalation score and recurrent attacks, which is statistically significant (p=0.003). Lower inhalation scores were associated with recurrent attacks.Conclusions: Recurrent exacerbations in an asthmatic patient on inhalation therapy are due to improper inhalational technique. It was suggested that it is wise to spend time with the patients in authors OPD set up and teach them the correct techniques of using inhalational therapy hence reducing frequency of attacks and cost of health care in such patients.

Efficacy of ciclesonide, budesonide and beclomethasone dipropionate in moderate persistent bronchial asthma: a comparative study

Background: The objective of the present study was to compare the efficacy and adverse effects of ciclesonide with that of budesonide and beclomethasone dipropionate in moderate persistent cases of bronchial asthma.Methods: This was an open label, randomized parallel group study done in Government General and Chest Hospital, Hyderabad for a period of 12 weeks. Each group had 20 patients. Group A was given ciclesonide inhalational therapy 160 mcg once daily. Group B was given budesonide inhalational therapy 400 mcg twice daily. Group C was given beclomethasone dipropionate inhalational therapy 400 mcg twice daily.Results: Symptomatic improvement was observed in all three groups. At end point, mean FEV1 in ciclesonide treatment group improved by 23.84% compared with 15.24% in budesonide and 12.93% in beclomethasone treatment groups. At end point, mean FVC value in ciclesonide treatment group improved by 6.44% compared with 1.5% in budesonide and 1.06% in beclomethasone groups. Mean FEV1/FVC also improved by 16.56% in ciclesonide group compared with 13.68% in budesonide and 11.93% in beclomethasone groups. No adverse effects were reported in any of the treatment groups.Conclusions: This study showed that ciclesonide is superior to budesonide and beclomethasone in improving lung function, decreasing symptoms and need for rescue medication in moderate persistent asthma.

Possibilities to prevent acute exacerbation of chronic obstructive pulmonary disease using inhalational therapy. A Report of Expert Panel of Russian Respiratory Society

An impact of acute exacerbation of COPD (AECOPD) on the course and the prognosis of chronic obstructive pulmonary disease depends on severity of the exacerbation. Moderate and severe exacerbations are considered as clinically significant events. Clinical studies investigating a role of inhalational therapy for the risk of AECOPD differed significantly in important parameters and the patients involved were not fully described in the real clinical practice. Tiotropium alone did not demonstrate any benefit over other inhalational therapies, such as inhaled corticosteroid/long-acting β2-agonist (ICS/LABA) combinations and long-acting muscarinic antagonist (LAMA)/LABA combinations, for risk reduction of moderate to severe exacerbations. A benefit of tiotropium/olodaterol combination over tiotropium for the reduction of risk of clinically significant exacerbations was first shown in DYNAGITO study; patients’ groups in this study did not differ in a rate and a spectrum of adverse events including cardiovascular events. An efficient bronchodilating therapy should be administered to all patients with COPD as it could improve dyspnea and prevent exacerbations. Further escalation of treatment in patients with frequent exacerbations of COPD should be personalized according to clinical course and causes of AECOPD.

Knowledge, attitude, practices of inhalational therapy among nursing staff posted at tertiary care teaching hospital

Background: Inhalational therapy for patients with chronic respiratory disorder can greatly benefit. Nurses are one of the major components of health care system of hospital and have an important role in education and training of patients. This study was planned to assess knowledge, attitude, and practices of inhalational therapy among nurses.Methods: This questionnaire based cross sectional study was conducted after taking permission from the institutional ethics committee in all the nurses of a tertiary care teaching hospital. This questionnaire consists of few socio-demographic questions and other questions for assessing level of knowledge, attitudes, and practices related to inhalational therapy. Incompletely filled questionnaire were excluded out for data analysis. Data was interpreted in percentage.Results: Total 344 (87.31%) questionnaires were analysed. 334 (97.09%) have heard the term inhalational therapy and 310 (90.12%) responded that it is preferred in respiratory disease. 117 (34.01%) nurses could not mention single side effect of inhalational therapy. 178 (51.74%) nurses always assess/observe the patient and 211 (61.34%) always train the patients for correct inhalational technique. 165 (47.97%) nurses responded that knowledge of inhaler use came from attending meetings, courses or workshops organized by scientific bodies. 163 (47.38%) nurses considered ‘Disease to be treated’ the most important variable while prescribing an inhalational device.Conclusions: The knowledge of inhalational therapy was satisfactory while the demonstration of inhaler techniques to patients was moderate in this study. So regular training courses and workshop should be conducted for the nurses about inhalational therapy practical approach.