St. Mary’s General Hospital leads the way in community based chronic disease management


St. Mary’s General Hospital in Kitchener continues to take a leadership role in community based chronic disease management in Waterloo Region with the launch of Activation/Reactivation, a chronic obstructive pulmonary disease (COPD) management program.

Developed by Suzy Young – an Acute Care Nurse Practitioner at St. Mary’s, the goal of this intensive 3 week program is to provide COPD patients with the tools to develop personal strategies that will help them better manage their disease.

Over 900 COPD patients sought emergency care at St. Mary’s in 2006/07. “We need to help these patients develop the tools to manage their disease to prevent further admissions to hospital and most importantly improve their quality of life,” says Young. Readmission rates for COPD patients at St. Mary’s were 10 per cent within 29 days post discharge – highest among all Case Mix Groups.

The Activation/Reactivation program is coordinated by COPD Educators and has the capacity to accept 10 new referrals each week. “Referrals generally come from the hospital’s emergency department, inpatient units, and complementary outpatient programs,” Young explains. “Referrals can also be made by family physicians and urgent care clinics.”

Upon referral to the program each participant completes an assessment of their eligibility to join the program, and properly diagnose their condition. The assessment includes: spirometry, a Six Minute Walk Test, and the St. George Respiratory Questionnaire. Following the assessment participants take part in two education sessions and five exercise sessions over a three-week period.

Education sessions focus on topics such as personal medication strategies, smoking cessation, nutrition and the importance of exercise, and breathing/sputum clearance techniques. The exercise portion of the program is led by an exercise therapist and concentrates on strength and endurance, cardiovascular exercises, techniques for relaxation and energy conservation and the development of an action plan that will help the participant improve and maintain their quality of life.

Young emphasizes that to see the long-term benefits participants must continue with their exercise plan once they complete the program. “We have partnered with retirement villages, fitness facilities, and mall walking programs so that participants have options that would allow them to continue to exercise.”

Both the Six Minute Walk Test and St. George Respiratory Questionnaire are repeated six weeks after participants complete the program to measure whether the program has made an improvement in their quality of life. The number of visits (both scheduled and unscheduled) participants make to either the emergency department or their primary health-care providers for treatment of their symptoms will also be tracked.

St. Mary’s is the Centre of Excellence for Respiratory Care in Waterloo Region. The hospital’s Chest Program includes a 27-bed inpatient unit to care for patients with acute respiratory diseases, a 15-bed Short-Term Rehabilitation Unit and outpatient Airway Clinic that provides assessment, treatment and education.