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Prescribing the right treatment for your COPD patients is critical, but what if your patients don’t grasp how to use the respiratory inhalers they’re given? It’s a frightening thought, and even more frightening when you learn how astonishingly high the rate of device misuse is. Studies have found that when it comes to inhalers, improper use is as high as 88%.1,2
RT, Owner
Kauffman Consulting, LLC
Medical Director, Swedish Edmonds Urgent Care
Director, Complex Care Management for Vituity
The problem isn’t that patients are simply incapable. Rather, they’re often sent home without the clear training and directions they need.
The onus, says Dr. Amy Shaheen, UNC’s Director of Population Health Services, is on providers to properly educate and train clinicians – to set them up for success when the time comes to train patients.
“One thing that we've really struggled with is training the trainers,” Shaheen says. “When you're training hundreds and hundreds of trainers for thousands and thousands of patients – we have 35,000 COPD patients in our system – it's a really tricky thing to do well.”
Shaheen recommends following these steps to ensure COPD clinicians are adequately prepared:
Once your practice has designated specific employees to be responsible for training on specific inhalers, you should conduct regular checks to ensure the trainers are still up to speed on how to properly use them.
“We actually have a little checklist, and we do an annual quality assurance to make sure that the trainers actually know how [to operate them],” Shaheen says.
Just as you should check up on clinicians to make sure they’re continuing to use proper technique when training patients, it’s crucial to regularly follow up with patients, too.
“Respiratory therapists should have multiple encounters with patients,” Drummond says. “If you look at the most successful inpatient programs, they involve a respiratory therapist, because they have teachable moments multiple times during the patient's hospitalization. I think that's really the place to initiate that training and then [do] a delayed teach-back in the clinic at that 10- to 14 day-encounter.”
A real-practice study3 compared a hypothetical cohort of 100 COPD patients making at least one critical inhaler error with 100 COPD patients with no inhaler errors. The study found that the errors resulted in a yearly excess of:
In a perfect world, every practice would have a full-time respiratory therapist who could properly demonstrate inhaler use and reinforce that education at follow-up appointments. One alternative in the absence of such an expert is to teach patients virtually.
“There are a lot of resources where you can at least do inhaler education videos, and make those easy for people to find in the workflow,” says Drummond. “When you don't have the opportunity to have a certified trainer, you can at least show the patient in a standardized way how the inhaler is supposed to be used.”
Dr. Brad Drummond wanted to find a way to decentralize his clinic’s COPD resources to make them available to a larger scope of COPD patients.
“Most COPD patients in our state and most COPD patients in our healthcare plan aren't seen in our COPD clinic,” Drummond explains. “They're cared for by primary care providers outside of our system or inside of the system. So one of our efforts has been to think about how can we decentralize resources, because it's nice if you have everything in this little clustered ivory tower, but that only helps a very small portion of the population.”
Drummond and his team built a site that features helpful tools, like inhaler identification cards, device education videos, a directory of pulmonary rehab centers in the state, and links to helpful resources.
“If you're in with a patient and you're starting them on a certain device, you can, with basically three clicks, get to an educational video that's developed for patient level training,” Drummond says.
The site receives about 100 hits a month – “which doesn't sound like a lot, but it isn't something that we branded or broadcast anywhere, that’s just sort of grassroots use,” Drummond explains, adding that the average user is on the website for 4 to 5 minutes at a time, “which tells us that they're actually using the website.”.
Respiratory therapist Garry Kauffman is working on a virtual tool that takes things one step further than pre-recorded videos. He’s toying with a system that would allow clinicians to regularly touch base with patients on live video calls to ensure that they’re using their inhalers properly.
“We're just missing [the misuse] because we're not investing that time,” Kauffman says.
Dr. Bobbie Kumar is working on a similar virtual solution, inspired by Amazon’s Alexa: an app that would connect patients with an expert when they have questions or need assistance.
“I think that it would be entirely useful to have something like that, where they could do a Skype or a FaceTime or a video call to provide that education and ensure that the questions are being answered,” Kumar says. “[We could] also take that information back to the primary care and back to the care team to let them know that this question was asked, this was what was done, and this is how we should go forward.”
Even the most well-intentioned initial education session can fall short, so the key is to continue chipping away until patients achieve device mastery.
“We can't expect a patient who's got chronic illness, who's getting a new inhaler for the first time, and probably with multiple delivery systems, to get it all in one fell swoop,” Drummond says.
Whether it’s increasing emphasis on clinician training, implementing routine education follow-ups and check-ins, or taking advantage of new teaching technology, tackling inhaler misuse isn’t as daunting as it may seem, and making it a priority will reduce the biggest hidden danger to effective COPD treatment.
References
1. Liang CY, Chen YJ, Sheu SM, Tsai CF, Chen W. Misuse of inhalers among COPD patients in a community hospital in Taiwan. Int J COPD. 2018:13:1309-1316.
2. Khassawneh BY, Al-Ali MK, Alzoubi KH, et al. Handling of inhaler devices in actual pulmonary practice: metered-dose inhaler versus dry powder inhalers. Respir Care 2008;53(3):324-328.
3. Roggeri A, Micheletto C, Roggeri DP. Inhalation errors due to device switch in patients with chronic obstructive pulmonary disease and asthma: critical health and economic issues. Int J COPD 2016:11(1): 597—602
