Evidence-Based Practice and Case Management

The delivery of high-quality, up-to-date nursing care using an evidence-based practice approach has become increasingly important as the population ages and technological advancements are made. EBP is something that is commonly heard and practiced in the medical field, but is not always understood. There are many definitions for evidence-based practice, but Melnyk and FineoutOverholt (2011, p. 4) describe EBP as evidence that “takes into consideration a synthesis of evidence from multiple studies and combines it with the expertise of the practitioner and patient preferences and values.” This definition suggests that patient perspectives, clinical knowledge and medical research are interconnected and rely on each other to find the best practice for individualized, positive patient outcomes.
This paper will discuss the importance of the use of EBP by case managers for patients who are battling chronic obstructive pulmonary disorder (COPD). Best nursing practices will be reviewed, including published guidelines for COPD. Finally, appraisal of clinical pathways to guide EBP will be discussed.
Identify and Discuss Best Practices

COPD is a chronic, lifelong disease that greatly affects the day to day lives of those who suffer from it. Early diagnosis, intervention and management can significantly improve symptoms and patients’ quality of life. Sethi (2018) reports that “primary care providers’ main focus is to provide treatment to reduce patients’ symptoms and improve their quality of life.” Because COPD differs from person to person, the provider must use an individualized approach

to treatment by identifying the symptoms that affect patients’ activities of daily living and quality of life and devise a treatment plan around those symptoms.
Sethi (2018) identifies three primary care best practices for COPD management.

Encouraging patients to self-manage COPD by smoking cessation and healthy lifestyles is the first best practice. Smoking is the number one cause of COPD and smoking cessation is imperative to decreasing disease burden and acute exacerbation risk (CDC, n.d.). The case manager is available to educate the patient on the benefits of smoking cessation and risks associated with continued smoking. A referral can be placed by the case manager for a smoking cessation program, and the case manager can facilitate communication with the provider for pharmaceutical intervention to assist with smoking cessation.
The second best practice discussed is routine monitoring of the patient for signs of acute exacerbation or changes in symptoms, evaluating treatment outcomes and assessing treatment goals. Routine monitoring of the patient allows the provider to assess for signs of worsening disease or acute exacerbation and treat them before the patient would require hospitalization. A patient assessment for barriers related to management and treatment of COPD must be completed to ensure patient compliance with routine monitoring. Barriers to treatment include access to healthcare to increase incident of early diagnosis and effective disease management, compliance to treatment recommendations, risk reduction of hospital admissions and re- admissions and other psychosocial issues or concerns (Sethi, 2018). An example of a barrier to treatment is transportation. If a patient does not have reliable means of transportation, they may not be able to keep all recommended follow-up appointments for routine monitoring.
Monitoring and encouraging compliance of pharmaceutical intervention is the third best practice Sethi (2018) discussed. The patient must receive education on use of all prescribed

medication treatments for COPD management. Education should include the reason why the patient takes the medication, how the drug works, dosing and schedule and administration instructions. The patient should be able to demonstrate understanding of the use of medications via demonstration or teach-back, such as proper technique for using an inhaler.
Incorporating a case manager into the care of patients with COPD can assist in identifying the barriers to treatment and developing interventions to overcome barriers. Once barriers are identified and interventions are developed, the patient and case manager can create a plan to carry out treatment recommendations (Kilpatrick, Wilson, & Wimpenny, 2014). The case manager will have frequent contact with the patient, giving them ample opportunity to assess for changes in symptoms, evaluating treatment outcomes, medication management and assessing treatment goals.
Evaluating Published Guidelines

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) was created as a “pocketbook” or guide for healthcare professionals who work with COPD patients. The GOLD literature reviews what COPD is, diagnosis and assessment of COPD, evidence supporting prevention and maintenance therapy/management of stable COPD and acute exacerbations, and COPD and comorbidities. Utilizing published guidelines in healthcare ensures that healthcare providers throughout the state, country and world are using the most up-to-date and effective evidenced-based practices.
Guidelines for diagnosis of COPD include consideration of any patient presenting with “dyspnea, chronic cough or sputum production, history of recurrent lower respiratory tract infections and/or a history of risk exposures” (GOLD, 2020). Spirometry is the most reliable and

objective measurement of limited airflow, and is required in the diagnosis of COPD. A chest X- ray will not aid in diagnosing COPD but it may help rule out other causes of respiratory distress, such as pneumonia or cardiovascular abnormalities (GOLD, 2020). Monitoring a patient’s pulse oximetry is imperative. If the SpO2 drops below 92%, arterial blood gasses should be collected for further assessment.
The goals of assessment of COPD include impact of the disease on patient’s overall health, determining acuity or extent of limited airflow and the risk for poor patient outcomes, such as acute exacerbation requiring hospitalization or death. Identifying severity of airflow is completed by evaluating levels of spirometry, and severity is graded as mild (GOLD 1), moderate (GOLD 2), severe (GOLD 3) or very severe (GOLD 4). The higher the grade, the higher level of airflow restriction and increased incident of COPD symptoms (GOLD, 2020). The GOLD guide recommends using the COPD Assessment Test (CAT) and the COPD Control Questionnaire (CCQ) to assess and grade symptoms. Healthcare professionals are able to gather objective data with the CAT and subjective data with the CCQ, allowing for a well-rounded, comprehensive assessment.
The GOLD pocket guide lists many key points for evidence supporting prevention and maintenance therapy, with the first recommendation being smoking cessation. Because smoking is the number one cause of COPD, cessation is key to COPD management and positive patient outcomes. Care providers can use pharmacologic measures and psychosocial support, such as counseling or support groups, to aid in smoking cessation (GOLD, 2020). Other preventative measures include lifestyle and activity changes, initial pharmacotherapy, self-management education, and managing comorbidities. Staying up-to-date on influenza and pneumococcal vaccinations will decrease incident of respiratory infections that increase the risk COPD

complications. Patient education is an important step in self-management. Explaining the etiology and pathophysiology of the disease, treatment measures with rationale, and daily lifestyle changes will allow the patient to make informed decisions on care and increase compliance.
Management of COPD is aimed to reduce the severity and frequency COPD symptoms and acute exacerbation. Pharmacologic interventions include short and long-acting bronchodilators, used to decrease inflammation and airway obstruction. Anti-inflammatory agents are not typically recommended, though may be uses in certain situations. Use of antibiotic therapy can be helpful if an underlying infection is causing increased COPD symptoms. The provider should demonstrate and routinely assess proper use of an inhaler. Because COPD symptoms differ from patient to patient, the care provider must develop individualized treatment plans.
Non-pharmacologic interventions for COPD management include pulmonary rehabilitation, supplemental oxygen and surgical interventions. Pulmonary rehabilitation can assist in increasing lung capacity and improving activity tolerance, which in turn improves symptom management and quality of life. Supplemental oxygen therapy can improve acute symptoms and long-term survival rates (GOLD, 2020). Depending on a patient’s extent of disease and functional status, surgical intervention may be appropriate to minimize COPD symptoms. It is important to consider negative outcomes related to surgical intervention for patients with chronic illness, and ensure that the benefit outweighs the risk.
COPD exacerbation is defined as “an acute worsening of respiratory symptoms that results in additional therapy” (GOLD, 2020, p. 40). Prompt identification and treatment of COPD exacerbations increases the likelihood of positive patient outcomes. The goal for

treatment of acute exacerbations is to minimize negative impacts for the patient and prevent future events from occurring. Because symptoms of COPD mirror symptoms related to other respiratory illnesses, the provider must rule out differential diagnoses, such as respiratory tract infections.
Pharmacologic intervention for acute COPD exacerbation includes initial treatment with short-acting beta2-antagonists with short-acting anticholinergics to promote bronchodilation and decrease work of breathing. Short-term use of corticosteroids can be used to minimize inflammation and work of breathing. If infection is present, antibiotic therapy should be initiated to shorten recovery time. Non-invasive mechanical ventilation should be the initial mode of ventilation for patients presenting with acute respiratory failure. This reduces work of breathing and need for intubation and improves gas exchange (GOLD, 2020). Measures for risk reduction of future exacerbation should be implemented as soon as possible.
Appraising Clinical Pathways

As the third leading cause of death in the United States, COPD has significant consequences – from poor patient outcomes to cost of healthcare for individuals and medical facilities alike. The guidelines reviewed in the last section of this document support prevention, diagnosis and management of COPD, which have been shown to significantly increase quality of life and reduction in healthcare utilization when implemented (Plishka et al., 2016). Clinical pathways (CPWs), also referred to as care plans, are tools that can be used to fill the gap between recommended guidelines and clinical practice. CPWs “bring the best available evidence to a range of healthcare professionals by adapting evidence-based clinical guidelines to a local context and detailing the essential steps in the assessment and care of patients” (Plishka et al.,

2016, p. 2). Summarized, CPWs assist healthcare professionals in the implementation of guidelines into their daily practice.
CPWs provide a structured plan of care by detailing the steps for treatment and standardizing care in a specific population (Plishka et al., 2016). The CPW will differ slightly for each patient to individualize care as needed, but will follow standard guidelines and algorithms to identify the best plan for treatment. A study completed by Nishimura et al. (2011) evaluating effects of CPWs for acute exacerbation of COPD (AECOPD) concluded that CPWs improved the quality of care for patients hospitalized with AECOPD.
Case managers offer a specific skill set for the creation and utilization of CPWs for patients, in both inpatient and outpatient care settings. Management of COPD is life-long and treatment modalities may change based on the symptoms the patient is experiencing or severity of disease. The case manager can complete education and compliance monitoring with the patient, as well as routinely monitor for changes in the patient’s health status. The case manager will recognize and recommend the most up-to-date evidence-based practice to care providers, and ensure all clinicians involved in the patient’s care are aware of the patient’s ordered treatments by facilitating communication between providers.
Conclusion

Clinical guidelines are created to provide healthcare practitioners with the most up-to- date, evidence-based best practices for patient care. Unfortunately, there is a gap between creation and distribution of the guidelines and use in everyday practice. Case managers can assist in minimizing this gap by identifying best practices and following clinical guidelines when

creating CPW for care. CPWs offer steps to care and standardization of treatment, while still allowing room for individualized treatment planning.

References

Melnyk B M, Fineout-Overholt E (2011) Evidence-Based Practice in Nursing and Healthcare: a guide to best practice. 2nd edn. Wolters Kluwer Lippincott Wilkins & Williams, Philadelphia.
Sethi, S. (2018). Effective management of COPD in primary care: Challenges and opportunities.

American Journal of Managed Care 4(5), p. 34-37.

CDC (n.d.). COPD Homepage for Clinicians. Retrieved September 28, 2020 from https://www.cdc.gov/copd/for-clinicians.html
Global Initiative for Chronic Obstructive Pulmonary Disease. (2020). GOLD 2020. https://goldcopd.org/wp-content/uploads/2020/03/GOLD-2020-POCKET-GUIDE-
ver1.0_FINAL-WMV.pdf

Plishka, C., Rotter, T., Kinsman, L., Hansia, M. R., Lawal, A., Goodridge, D., Penz, E., & Marciniuk, D. D. (2016). Effects of clinical pathways for chronic obstructive pulmonary disease (COPD) on patient, professional and systems outcomes: protocol for a systematic review. Systematic reviews, 5(1), 135.
Nishimura, K., Yasui, M., Nishimura, T., & Oga, T. (2011). Clinical pathway for acute exacerbations of chronic obstructive pulmonary disease: method development and five

years of experience. International journal of chronic obstructive pulmonary disease, 6, 365–372.