california pacific medical center the cns role and outcomes
TRANSCRIPT
California Pacific Medical Center
The CNS Role and Outcomes Management
The CNS Role and Outcomes Management
Evelyn Taverna, RN, MS, CCRN, CNSGuest Lecturer: N 226
February 19, 2003
Evelyn Taverna, RN, MS, CCRN, CNSGuest Lecturer: N 226
February 19, 2003
California Pacific Medical Center
Overview Purpose: to extend the traditional role of case management to patient population based clinical resource managementDevelop systems to manage patients across the continuum - from inpatient to extended care to home healthCreate teams to effectively manage and integrate departmental activities in a cost effective, outcome driven manner
California Pacific Medical Center
Population Based Teams
CardiologyCardiovascular SurgeryMedicineNeurology/NeurosurgeryObstetricsOncologyPediatricsPulmonarySurgery/Orthopedics
California Pacific Medical Center
Team MembersClinical Nurse SpecialistsRN Case ManagersSocial WorkersAdministrative AssistantsData AnalystsQuality CoordinatorsPhysician Champions
California Pacific Medical Center
CPMC Quality & Clinical Resource
Management Model
Clinical Nurse
Specialist Population
Based
Case Manager
Social Worker
Patient/Family
Based
Administrative Assistant
Support
QUALITY MANAGEMEN
T
CLINICAL MANAGEMEN
T
RESOURCE MANAGEMEN
T
OUTCOMES MANAGEMEN
T
DISCHARGE PLANNING
SOCIAL SERVICES
UTILIZATION MANAGEMEN
T
UR PHYSICIANS HOSPITALISTS
STAFF MANAGEMENT DEPARTMENT
S
California Pacific Medical Center
Quality & Clinical Resource Management
Model
CLINICAL NURSE SPECIALISTS
Cardiology, Cardiac Surgery, Interventional Endoscopy, Medicine, Neonatal,
Neurology/Neurosurgery, Oncology, Pediatrics, Perinatal, Pulmonary, Surgery/Ortho
Quality Improvement Focus
Clinical Management
• Protocols
• Best practice guidelines
• Clinical consultation
• Staff education
• Complex case review
Resource Management
• Benchmarking
• MD comparisons
• LOS/level of care
• Cost/resource analysis
• Resource utilization
Outcomes Management
• Quality, cost, service
• Data analysis/research
• Clinical effectiveness
• PI projects
• Sutter initiatives
California Pacific Medical Center
The CNS as Team Leader
Masters prepared expert nurse clinician Manage clinical resources
Define care requirements (best practices)Monitor their impact on outcome achievement
60% of time actively involved with patients
Daily interaction with patients, families, clinical staff, nurses, and physicians
Continually evaluate patient care needs Individuals and aggregate populationSeek opportunities for improvement
California Pacific Medical Center
Project SelectionExternal Sources/Needs
Mandatory – JCHAO Core Measures & StandardsState Requirements - OSHPDSutter InitiativesPress-Ganey Patient Satisfaction SurveyVHA Programs
Internal Sources
California Pacific Medical Center
Project SelectionExternal Regulatory Requirements
JCAHO CORE Measures - 2002CHF Perinatal Outcomes
JCAHO CORE Measures – 2003Community Acquired Pneumonia
California Pacific Medical Center
Project SelectionJCAHO Standards
Pain Management – Jackie Phan, CNSPatient Safety- Gail Guthrie, CNS & Phyllis Erickson, CNSMedication Error Reduction – Evelyn Taverna, CNS
California Pacific Medical Center
Project Selection External Requirements
California CABG Outcomes Reporting Program (CCORP) – Jill Ley, CNSCrusade Study & National Registry for Myocardial Infarction (NRMI) – Evelyn Taverna, CNSACOS Accreditation – Alice Mack, CNSNational Practice Recommendations:
AHA, AHCPR, etc.
California Pacific Medical Center
Developing Clinical Questions
Institutional SourcesQuality committeesPerformance Improvement teamsProduct lines
Clinician SourcesClinical observationsNew products/techniquesEvidence-based practices
California Pacific Medical Center
Current ProjectsMedication Error Reduction
Coumadin dosing project Range-dosing protocolPatient controlled analgesia protocol
New ProceduresBariatric surgery outcomesContinuous renal replacement therapyOff-pump CABG outcomes
Outcomes ManagementInterventional endoscopy databasePlavix research and practice changeVBAC – Best practice
California Pacific Medical Center
Current ProjectsMedication Error Reduction
Coumadin dosing project Range-dosing protocolPatient controlled analgesia protocol
New ProceduresBariatric surgery outcomesContinuous renal replacement therapyOff-pump CABG outcomes
Outcomes ManagementInterventional endoscopy databasePlavix research and practice changeVBAC – Best practice
California Pacific Medical Center
Benchmarking Resources
Agency for Health Care Policy & Research(AHCPR)AHA,ACCVHACMRI
HBSI FathomMidasNRMI 4Crusade
California Pacific Medical Center
Influencing Physician Practice
The CNS is the “point person” for providing cost, service, and quality information to the Medical Staff to guide data driven practice changes which:
reduce cost variations decrease overall costmaintain quality outcomesimprove service
California Pacific Medical Center
Cardiology CNSAcute Coronary SyndromeCHF Pacemaker Study Atrial Fibrillation Complex patients
clinicaleducationdischarge planning
California Pacific Medical Center
Cardiology: AMI
ED chest pain protocolSTEMI and NSTEMI protocol
Crusade & NRMI 4 data – Focus on NSTEMI outcomes
IIb/IIIa inhibitor use and bleedinginterventional procedures
Sutter Cardiovascular Services InitiativeAMI task forceCHF committee
CHF ACE inhibitor use and discharge instruction outcomes & readmission
California Pacific Medical Center
AMI Outcome Measures
1. Aspirin at arrival2. Beta blocker at arrival3. Median time to thrombolytic
therapy4. Median time to PTCA5. Aspirin prescribed at
discharge
California Pacific Medical Center
AMI (cont.)6. Beta blocker prescribed at
discharge7. ACE I at discharge for LVSD8. Adult smoking cessation
advice9. Inpatient mortality10.Lipid-lowering agent at D/C
California Pacific Medical Center
AMI StrategiesED Chest Pain Risk AssessmentAcute Coronary Syndrome Protocols/Order SetsAMI Standard of CareAMI Guide to Recovery
California Pacific Medical Center
E m erg en cy D ep artm en tC h es t P a in R isk A ssessm en t
S T/n ew L B B BIn it ia te A M I P ro toco l
C ath L ab o rTh rom b o lytic
N S TE M I/U n s tab le A n g in aIn it ia te
A cu te C oroan ry S yn d rom e P ro toco l
C h es t P a in
California Pacific Medical Center
AMI Case Study
Mr. M is a 54 year old man admitted with c/o of chest pain which began while watching the 49’ers playoff game. Patient lives with wife and works in law enforcement.
Symptoms included:Constant, substernal chest pressure (5/10)Diaphoresis
California Pacific Medical Center
AMI Case StudyPMH:
CAD, S/P angioplasty in 1989DiabetesHypertensionHypercholesterolemiaCurrent smoker
Medications:Atenolol and GlucophageAllergic to Aspirin and Motrin
California Pacific Medical Center
AMI Case StudyPhysical Exam:
Vital stable with bradycardia of 58Oxygen sat 96% on 2 litersLungs clear, no JVD
Labs:Elevated cardiac markersGlucose – 295
EKG:ST elevation in inferior leads
California Pacific Medical Center
AMI case studyInterventions:
PlavixNitroMorphineHeparinPrimary PTCA with GP IIb/IIIa inhibitor during/after PTCA
Door to balloon time = 100 min.
California Pacific Medical Center
AMI case studyDischarge planning
Cardiac rehab (PT, OT, Dietary)Smoking cessation adviceStress managementAspirin, Plavix, Beta blocker, ACE I inhibitor, statin
California Pacific Medical Center
ACUTE MYOCARDIAL INFARCTIONNRMI 4 DATA SUMMARY September 2002 Report7/1/01 – 6/30/02
INDICATOR CPMC
LIKE HOSPITALS
(173 centers)
CALIFORNIA
NATION(1228 centers)
Enrollment Yearly
Non Transfer-in
303260
55489 27330 186439
AGE 76 68 70 69
ST and/or LBBB on 1st EKG
28% 27% 25% 27%
AMI patients Eligible for Reperfusion a
Treated Eligible AMI patients
Untreated Eligible AMI patients
42 pts.60% (25/42)40% (17/42)
71%29%
N/A
N/A
IV Thrombolysis 2 pt. 7% 13% 12%
Door to Drug median min.door to data
data to decisiondecision to drug
36 13176
338
187
34 33
Door to Drug (<30 minutes)
0% 38% 44% 46%
Door to Dilation b
door to datadata to cath labcath lab to dilation
124 156841
1089
6138
116 105
Door to Dilation (<90 minutes)
11%(4/35)
33% 25% 36%
NSTEMI 62% 63% 65% 63%
NSTEMI Eligible AMI Patients
Treated with GP 2b/3a Inhibitor
36% 39% 27% 30%
Death 8.5% 10.0% 10.1% 9.7%
Length of Stay 2002 1st Q 2002 2nd Q
4.14.4
4.84.8
3.93.9
4.04.0
Days in ICU 2.0 1.8 N/A N/A
California Pacific Medical Center
ACUTE MYOCARDIAL INFARCTIONNRMI 4 DATA SUMMARY September 2002 Report7/1/01 – 6/30/02
INDICATOR CPMC
LIKE HOSPITAL
S(173
centers)CALIFORNIA
NATION(1228
centers)
NSTEMI 62% 63% 65% 63%
NSTEMI Eligible AMI Patients
Treated with GP 2b/3a Inhibitor
36% 39% 27% 30%
Death 8.5% 10.0% 10.1% 9.7%
Length of Stay 2002 1st Q 2002 2nd Q
4.14.4
4.84.8
3.93.9
4.04.0
Days in ICU 2.0 1.8 N/A N/A
California Pacific Medical Center
ACUTE MIDEMOGRAPHICS AND RISK FACTORS
CPMCN =260
LIKE HOSPITALSN= 34920
CALIFORNIA
AGE >75 years
7659%
6836%
7042%
Clinical Presentation
Sx onset to door> 4 hrs
48% 77/160 31% N/A
Chronic renal Insufficiency
17% (45) 12% N/A
No CHF 57% (148) 75% N/A
Rales, JVD 15% (39) 16% N/A
Pulmonary edema 27% (71) 7% N/A
Cardiogenic Shock 1% (2) 1% N/A
California Pacific Medical Center
AMI Opportunities for
ImprovementEmergency Department:
Door to EKG timeChest pain Risk Assessment ProtocolCPK & Troponin utilization
Cath Lab:Door to Balloon time
Critical Care & TelemetryAnalysis of bleeding requiring interventionPatient Education materialCardiac Rehab
California Pacific Medical Center
CARDIOLOGY SEVICE LINE 2001 – 2002
DRG PMI/AGE
CASES2001
LOS2001
CASES2002(Jan-June)
LOS2002
LOSCHANGE
2001-2002
DIRECT COST2001
DIRECTCOST2002
CHANGE2001-2002
YTD%
CHANGE
121AMI & Major Comp
1.55/80 106 5.45 118 6.29 + .84
122AMI
No Comp
1.24/66 63 3.51 27 4.04 + .53
123AMI
Expired
1.56/87 20 3.50 20 3.50 + .25
127Heart
Failure
.98/75 471 4.17 387 4.89 + .72
140Angina
.58/74 55 1.75 14 2.71 + .96
143Chest Pain
.52/67 219 1.53 203 1.52 - 0.1
California Pacific Medical Center
CARDIOLOGY SERVICE LINECOST DATA2001 – 2002
DRG Critical Care
Med/Surg RT/Pul
Supplies Pharmacy PT Radiology Lab Other
121AMI &Major Comp
122AMINo
Comp
127Heart
Failure
140Angina
143Chest Pain
California Pacific Medical Center
Congestive Heart Failure
System-wide PI ProjectHigh volume, high resource utilizationOpportunities for Improvement:
ACE Inhibitors on discharge for patients with Ejection Fraction < 40%Decreasing LOS and readmission rateStandardizing patient education materialsMedical and Nursing Staff Education
California Pacific Medical Center
Ace Inhibitor on Discharge for EF < 40%
0.6
0.7
0.8
0.9
1.0
CALIFORNIA PACIFIC MEDICAL CENTER
California Pacific Medical Center
Sutter Health CHF InitiativeCalifornia Pacific Medical Center - Discharge Instruction Rates
Goal: 90% of all patients discharged to home will be documentedas having received instructions on all education elements
0%
25%
50%
75%
100%
Meds Weight Diet Activity Follow-Up Sypmtoms Worse All Instructions
2001 CPMC(n=291) 2002Q1(n=72) Goal
California Pacific Medical Center
Strategies CNS patient population oversightCHF patient education materialsWeight chartOne page - Tips for managing at homeCHF discharge sheet
California Pacific Medical Center
Strategies for Improvement
Staff educationCNS follows CHF inpatientsChart alert to MD - document reason no ACE prescribedData posted in MD newsletter, MD lounge, cardiology unit.Data reported to Cardiology & Medicine & Nursing QA Committees.
California Pacific Medical Center
California Pacific Medical Center
Permanent Pacemaker Analysis 2002
Ann Edmonson RN, Quality Improvement
Jill Ley RN, Cardiac SurgeryEvelyn Taverna RN, Cardiology
James Mailhot MD, Cardiology QI Chair
California Pacific Medical Center
Pacemaker ProjectIndicationsPacer typeVendorAnesthesia typeDuration of procedureComplications
California Pacific Medical Center
Data Collection Processes
Softmed Report for ICD-9 Code 37.83
Dates: Jan, 2000 – May, 2002
Data collection methods by LOS If LOS > 1 day – medical record reviewIf LOS = 1 day – PCIS review
OP note, d/c summary, blood ordersAnesthesia type and OR time not recorded
Readmission screen for all patients
California Pacific Medical Center
Indications for Pacemaker
0
20
40
60
80
100
120
SSS HB AF Other
# of patients
California Pacific Medical Center
Pacemaker Complications
Lead DislodgementInfectionPneumothoraxPM TachycardiaHypotensionReprogrammingBleedingRV PerforationCVADeath
California Pacific Medical Center
CNS Contributions
Ideally positioned to influence teamKnowledgeable about evidence based practicesImpact both processes and outcomes of careImproved outcomes documented:
Reduced LOS, complication ratesAppropriate use of resourcesDocumented cost savings
Links to quality improvement & credentialing
California Pacific Medical Center
Achieving Continual Improvement
Format meetings and forums to continually review care delivery
Implement systems to obtain data: retrospective, concurrent, prospective
Continually monitor defined indicators
Multidisciplinary reviews - close the loop
Determine when to move on to the next project
California Pacific Medical Center
Clinical Nurse Specialist
Ability to Blendclinical, research & financial aspects of outcomes managementwith a focus on quality, compassion & caring.
California Pacific Medical Center