Facilitatingoptimaldischargeplansforhighriskpatients促进高风险患者的最佳治疗方案课件

1、Timeline of ATU/AMS第1页，共36页。 2008 NPSG (selected) 1 - Improve accuracy of patient identification2 - Improve the effectiveness of communication among caregivers3 - Improve safety of using medicationsRequirement 3E: Reduce the likelihood of patient harm associated with the use of anticoagulation thera

2、pyNew/第2页，共36页。2008 NPSG (selected)8 - Accurately and completely reconcile medications across the continuum of care9 - Reduce the risk of patient harm resulting from falls13 - Encourage patients active involvement in their own care as a patient safety strategy15 - The organization identifies safety

3、risks inherent in its patient population第3页，共36页。 NQF Safety Standards Safe Practice 17: Evaluate each patient upon admission, and regularly thereafter, for the risk of developing DVT/VTE. Utilize clinically appropriate methods to prevent DVT/VTE.Safe Practice 18: Utilize dedicated anti-thrombotic (

4、anticoagulation) services that facilitate coordinated care management./第4页，共36页。Goal is to reduce incidence of surgical complications nationwide by 25% by 2010SCIP VTE1 Surgery patients with recommended VTE prophylaxis orderedSCIP VTE2 Surgery patients who received VTE prophylaxis within 24 hours af

5、ter surgery, see Other Resource: About the Project第5页，共36页。OSG Call to Action Sept 15, 2008/第6页，共36页。The Joint Commission Sentinel Alert Sept 24, 2008/SentinelEvents/SentinelEventAlert/第7页，共36页。第8页，共36页。Clinic overviewPatients = 4100+Mean age = 69 yrs, SD 13.65, range 20 - 100Common indications for

6、treatment:AF 57%VTE 15%Heart Valves 9%INR intensity ranges2 3 87%2.5 3.5 9%By request, selected othersAdmissions:75/month+ Reactivated patients 60% new referrals from inpatient (POE Consult referral)Discharges: 90/month第9页，共36页。Time in Therapeutic RangeTTR calculated using Rosendaal methodStrict ran

7、ge limits, eg. 2 3 and 2.5 3.5Using ALL INR data (induction, interruptions, etc)第10页，共36页。Percent INR tests out-of-rangeIn Range (2 3) = 60% Above 3 = 15% Below 2 = 25%Percent Very High 5 = 0.8% 7.5 = 0.2%Percent Very Low 1.3 = 0.3%第11页，共36页。Communication and Education for Patients and Physicians第12

8、页，共36页。Key elements for improvedpatient managementPatient focused, primary nurse modelPhysician Order Entry for AMS Consult Referral (nearly all data fields mandatory for submission, thus all critical info received)Dawn AC (patient management system for maintenance and transition patients)3 Interfac

9、es:ADT Interface (electronic notification for AMS patient admissions/discharges)Outbound message Interface (AMS icon/communication facilitator)Results Interface (electronic INR entry into Dawn AC from lab system)Hospital “buy in”Information System support (2 FTEs)Pharmacy support (AMS Discharge Rx)第

10、13页，共36页。AMS Communication with PatientsOne-time face-to-face educational visit with patient & family and primary nurseFollowed by telephone calls to patient for short period to review subsequent INR values, current dose instructions, and date of next INRThereafter, written instructions are mailed w

11、ith same information. Dose info communicated via # pills not mg. (finalizing plans to initiate email communications, when desired by patient)Telephone assessments more common than face-to-face visitsCommunication interventions are individualized to meet patient needs over time第14页，共36页。Patient Satis

12、faction“My ranking of this program: First Class Service.”“The anti-coag service is great. I go to Florida 3 months during the winter months and I am able to keep track of dosages and INR levels easily. My daughter calls in for me and lets me know if there are any changes in dosage to be made.” “I ha

13、ve nothing but praise and appreciation for the concern and care over the years.” “Knowing your clinic keeps a very close check on my Coumadin levels gives me a sense of security. Your reporting is prompt and directions clearly stated.” 第15页，共36页。Nursing Implications for Anticoagulated PatientsKnowle

14、dge of patient risk v. benefit of treatmentSafe and quality care management Know goal therapeutic INR range and treatment plan. Utilize systematic, standardized protocols and decision support tools.Monitoring Tracking and patient follow-upEffective communication and coordination of multiple care pro

15、vidersPatient & Family Education, include health literacy assessment, modification of risks, standardize curriculum & education materialsAchieving good outcomes is dependent upon:第16页，共36页。AMS Patient Education Slide Show Standardized education curriculum content, individualized for patient-specific

16、 needs第17页，共36页。Written materials support contentof slide showAMS Brochure第18页，共36页。Patient Education To prepare for discharge, can patient Identify signs and symptoms of VTE (or bleeding)Describe action to take if occurs Identify warfarin managerRecite instructions for follow-up including: daily do

17、se schedule, confirmation of pill size, date of next INR Describe plans for blood testing and future monitoringDescribe management and disposal of medications, especially sharps disposal per town regulations第19页，共36页。2. Reminder of pill sizeDose Instruction Letter1. INR result and Target Range3. New

18、 weekly dose instructions (repeat schedule until next dose letter arrives)4. Date for next INR test第20页，共36页。may see a message to skip 1 or 2 days (patients generally recd a phone call at the time)Dose Instruction with skipIf INR is high Then, follow weekly dose instruction here第21页，共36页。Compliance

19、ProcessAutomated follow-up support by Dawn AC, details developed by AMSFive Stages a letter mailed to patients at each stage underscoring safety concernsFormal discharge letter sent with delivery confirmationCollaboration with referring physicians (possibly case management) at critical milestonesEma

20、iled formal notices at Final and Discharge StagesCustomized letters/emails in Dawn ACHighly efficientBatch printed or emailedExcellent documentation trail 第22页，共36页。NonCompliance Process DNA StageINR rescheduled inRN ReminderMD EmailIif no INR 3 DAYS after scheduled date,then next INR in.2 weeks2if

21、no INR 1 DAY afterscheduled date, then next INR in 1 week3if no INR 1 DAY afterscheduled date, then next INR in 1 weekFinalif no INR 1 DAY afterscheduled date, then next INR in 1 weekDischargeNoticesent via Certified MailPatient Discharged(DNA = Did Not Attend)第23页，共36页。Reminder Letter for missed IN

22、R dateDedicated line for callsThis informationneeded or email same informationAuto-reschedule of INR Date第24页，共36页。AMS IconIndicates patient is an active patient in AMSAppears on electronic medical records (1 in-patient, 2 out-patient systems)Click on icon, new window displays critical data elements

23、 about the patient from AMS database第25页，共36页。AMS icon CAS, LMR and OnCallCOMING NOVEMBER 7Phase II AMS Icon第26页，共36页。CPOE Consult ReferralCreates an electronic referral to AMSEfficient, user-friendly, fast turn aroundEnsures key clinical information provided since most fields mandatory 第27页，共36页。AM

24、S Consult Referral第28页，共36页。AMS Consult Referral第29页，共36页。Outpatient Paper AMS Referral第30页，共36页。Transition Pathway ServicesInduction PathwaysNew Start Warfarin OnlyNew Start Warfarin with LMWHNew Start Warfarin with FondaparinuxBridging PathwaysResume Warfarin OnlyResume Warfarin with LMWHResume Wa

25、rfarin with Fondaparinux第31页，共36页。Communication StrategiesTransition PathwaysFloor by floor roll-outMulti-disciplinary approach (medicine, nursing, pharmacy, case management, target key leaders):Grand roundsInservice education sessionsPrint materials (newsletters)Main Corridor eventsElectronic resou

26、rcesPOECAS alertsAll user (select user group) Broadcast email messagesWeb page presence with multi-source access to key anticoag-specific documents via hyperlinks第32页，共36页。Role Group ResponsibilitiesReferring PhysicianComplete referralOrder baseline lab workSubmit AMS RxAMS NurseReviews/confirms eligibility and seeks clarification, as needed“Meets and Greets” patientWritten instructions for pt.Assumes anticoag management day after dischargeFloor NurseObtain patient weightConduct medication discharge teachingCompletes discharge process and ensures patient leaves hospital wi