Home Mechanical Ventilation In Norway

4 regional Health enterprisesOwned by the state

Ministry of Health and Care Services

Directorate of Health

Regional Health EnterprisesMunicipalities

- Municipal Health Service - Nursing, Care and Rehabilitation - Social Services

Hospitals

Ownership

National health RegistryNational centers of exelency

National guidelines

Health care system structure in Norway

LTMV in Norway 1990-2000

• Dedicated individual health professionals

• Lack of standard of care

• LTMV initiated after acute respiratory failure

Long term mechanical ventilation

• Includes – Dependent of mechanical ventilation– Partly or 24/7> 6 weeks – Out of hospital– Invasiv and noninvasive

• Not included– Cpap /bilevel /adaptiv servoventilation– Obstructive or sentral sleep apne syndrom or Cheyne

Stokes syndrom

< 5< 5

5 - 105 - 10

10 – 15 10 – 15

15 – 2015 – 20

Distribution of HMV patients by counties (n=340, july 2001)

Prevalence rates per 100 000 population

Prevalence rates per 100 000 population

Trends and Challenges in HMV in Norway 2000

• Increasing number of patients• Need of skills in respiratory care • Regional diversity• Non invasive ventilation dominating treatment modality• Ethical• Financial

National Centre of excellence for Home Mechanical Ventilation 2002

Expertise included: Pediatric Neurological Frontline service

Regions Coordinator

Project participantsResource Persons Physicians

(10%)Nurses (10%)

Physioterapist (10%)

SouthEast Physician (30%) 4 5 2 5

West Physician (20%) 2 2 3

Midt Physician (20%) 2 2 1 3

North Physician (20%) 1 2 1 3

Tasks for the HMV Centre• Competence

• Diagnostic and therapeutic procedures in adults

and children• Norwegian Registry of Patients receiving LTMV • Educating

• Health care professionals in hospitals • Care givers in the community

• Counseling and technical support• Equal access to treatment for the patients• Develop new knowledge • Establish national professional guidelines

• Registry's main purpose:

• Monitoring LTMV to contribute to a geographically equitable treatment

• Quality for patients treatment

• Research

• Register chaired by an academic committee with representatives from all four health regions

• 2012, the registry approved by the Ministry of Health as a national medical grade registry

National Registry for LTMV Established in 2002

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Home visits to the patient:by the Contact Nurse

• Customize ventilatory and pressure

support

• Replacing mask or ventilator

• Spot pulse oximetry, kapnometri

or art. blood gas sample

• Download ventilator data

• Education to caregivers in

the home / nursing homes

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Website

• Internal Website for the HMV Network for the participants in the network

• External Website for health care professional in the hospitals and health care givers in the community

• Communication of new research• Weekly news and information

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The coordinators and project participants assignments

• Organizing HMV facilities in each region• Ensuring quality of the national patient registry • Survey of regional resources and knowledge• Action Plan for implementation of the national

guidelines• Create education material

• Standardize training, teaching and checklists

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The national professional guidelines for long-term mechanical ventilation

(published 2012)

18

National guidelines for

LTMV

Interfaces - flowchart

Acute initiation of LTMV

Patient at risk

Acute respiratory failure

Intubation weaning

NIV

Referral for initiation of LTMV

Death

Starting LTMV

Patient care plan

Follow-up

Planned initiation of LTMV

Out-patient evaluation

Indication for LTMV?

Start treatment

Patient at risk

Follow-up

Controll in 3-12 months

YES

NO

Patient care plan

http://helsedirektoratet.no/publikasjoner/nasjonal-faglig-retningslinje-for-langtids-mekanisk-ventilasjon-ltmv

Ministry of Health and Care Services

Directorate of Health

Regional Health EnterprisesMunicipalities

- Municipal Health Service - Nursing, Care and Rehabilitation - Social Services

Hospitals

Ownership

National health RegistryNational centers of exelency

National guidelines

Health care system structure in Norway

Regional Survey and report 2011/2012

Regional plan of action2012/2013

Tidsskr Nor Laegeforen. 2009 Mar 26;129(7):628-31

Termination of mechanical ventilation in amyotrophic lateral sclerosis

Holmøy T, Aarrestad S, Engstrand P, Ottesen S, Syse A, Førde R.

Tidsskr Nor Laegeforen. 2009 Oct 22;129(20):2094-7.

Prevalence of home ventilation therapy in Norway]Tollefsen E, Gulsvik A, Bakke P, Fondenes O

Tidsskr Nor Laegeforen. 2012 May 15;132(9):1111-4.

Respiratory complications associated with spinal cord injury.

Tollefsen E, Fondenes O

Develop new knowledge

Laryngeal response patterns to mechanical insufflation-exsufflation in healthy subjects.

Andersen T, Sandnes A, Hilland M, Halvorsen T, Fondenes O, Heimdal JH, Tysnes OB, Røksund OD.

Am J Phys Med Rehabil. 2013 Oct;92(10):920-9.

[PubMed - in process]

The Norwegian version of the Severe Respiratory Insufficiency (SRI) questionnaire. Translation, adaptation and validation of The SRI Questionnaire.

A cross sectional survey including patients receiving long-term mechanical ventilation in Norway.

Markussen H, Lehmann S, Nilsen RM, Natvig GK.

International J of Nursing Practice .2013 accept Jun. 17.

“When the breath fail”

A six years closed cohort study of outcomes in patients requiring long-term mechanical ventilation (LTMV).

Heidi Markussen, Sverre Lehmann, Ove Fondenes, Roy Nilsen, Gerd- Karin Natvig

•The aims of these studies are to characterize and measure outcomes in LTMV in patents in the western region of Norway.

•Examines:

• Sociodemographic, physiological and clinical predictors for changes in HRQoL.

• Predictors of hospitalisations, treatment compliance, use of out-patient clinic and length of life in the six years period.

Projects

Visualizing the larynx during MI-E in ALS

Andersen, Tiina et al. Norwegian Centre of Excellence in Home Mechanical Ventilation, Bergen, Norway

Monitoring of Noninvasive Ventilation

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Project leader

Sigurd Aarrestad, MD Oslo UniverUllevål OUS og Regional koordinator Helse Sør-Øst Nasjonal kompetansetjeneste for hjemmerespiratorbehandling. NKH Haukeland US Prosjektmedarbeidere:Elin Tollefsen, seksjonsoverlege St. Olavs Hospital. Dr.med.Ole Henning Skjønsberg, Professor. Dr. Med. Lungemedisinsk avdeling Ullevål OUSAnne Louise Kleiven . Fagsykepleier. Lungemedisinsk avdeling Ullevål OUSMagnus Qvarfort. Overlege. Lungemedisinsk avdeling Ullevål OUS og NKHJean-Paul Janssens. Professor. Dr. Med. Genève. Sveits

Project ”Breathe" Quality assurance and standardization of training in

the use of LTMV Target group:

Adolescents receiving LTMV Caregivers without professional health care education

A collaborative National center of excellence in:

Home mechanical ventilation Neuromuscular diseases Telemedicine

2 year project (2013-2014) E-learning

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LTMV diagnosisdevelopment in Norway 2001-2010

LTMV in Norway (2010)

• Prevalence adults: 26,5 / 100.000

• Prevalence children: 8,1 / 100.000

• Tracheostomy: 6,7%

Challenges

• Full implementation of national guidelines in LTMV at the individual level to all health care professional

• Equal access to treatment in the country• Maintain or increase Health related Quality of life• Ethical issues• Increase research in the field of HMV• Lack of health professionals• Assess the possibilities for education in respiratory care