Transcript Document

What you need to know about
Care Delivery at Temple
2014 TUHS House Staff Orientation
Care Delivery Team
Review Assessments and Roles of:
1. Physician
2. Nursing
3. Physical Therapy
4. Case Management
5. Social Work
And how they all coordinate as a TEAM in providing
Safe, Effective, Efficient, Timely, and PatientCentered Care
Physician Role
• Clinical assessment, treatment plan, and
documentation of care
• Medication reconciliation
• Patient and family education
• Transitions of care
• Work rounds (teaching rounds)
• Multi-disciplinary rounds -Care Coordination
Accountable Care Unit (ACU) Model
Each unit is “geographic” and has:
• Unit Based Medical Director (UBMD) who has
oversight for and accountability for unit
•
•
•
•
•
Efficiency of care
Patient throughput
Decreasing variation
Use of clinical care guidelines
Support of patient safety and quality initiatives
• Partnered management with nurse
manager/UBMD leaders and structured
multidisciplinary rounding- in transition
Interdisciplinary Plan of Care
• Goal:
– Patient focused
– Disciplines add to the IPOC as they become
involved in the patient’s care
• Where : The IPOC is located in the Care
Plan tab of the Medical Record
Department of Nursing
Telemetry & Pulse Oximetry
• Two classifications for telemetry
– Class I (e.g. a-fib, a-flutter, certain medications)
• If the patient needs to be transported, he/she must be on a
cardiac monitor and accompanied by nurse or doctor (or both)
– Class II (e.g. other diagnoses requiring monitoring)
• The patient can be transported off telemetry without a nurse or
doctor
• All patients requiring telemetry will have IV access
• Pulse Oximetry:
– Verify the physician order for continuous pulse oximetry
– The order must include acceptable range for saturations
Duration of Telemetry
• Patients eligible for removal of telemetry monitoring
will be reviewed at shift report
– Criteria for removal have been established under
the direction of the Cardiology Medical Director
• If a patient meets criteria for removal after 48 hours on
telemetry, then an order must be obtained to
discontinue telemetry
• House staff/resident will be notified
– Attending physician has the option of reordering
telemetry
Falls Prevention
• Any patient designated Low Risk or High Risk is
placed in the Fall Prevention Program
- Morse Scale used to assess fall risk
• The yellow armband (At Fall Risk) is placed on the
same arm as the patient ID band
• A Fall Risk Magnet is placed by the patient name on
the locator board outside the patient’s room and on
the door frame.
• Interventions:
– Use of low rise bed and or bed alarms
– Assure assistance and supervision are provided with elimination, transfers
and ambulation
– Provide patient/family education
– Recommend referral to PM&R for safe ambulation and transfer techniques
What happens if a patient
does fall?
• A Midas Incident/Event report must be entered. It
needs specific information about the fall: Where,
when, how, and whether there is injury?
• Post Fall Assessment to be completed by the team
• Falls are tracked and trended through the Midas
report
• The data is used to help us improve care
Close Observation
Level 11:1 Supervision-Suicide Precautions
Patient who is an immediate threat to
self: Staff must be within arm’s
length of patient-including when in
bathroom
Level 2Field of Vision/Visual Observation
Patient danger to self or others or
at risk for elopement: Staff must be
in same room/area with visual
contact with patient at all times.
2:1 observation permitted
Level 3Enhanced Safety Observation
Patient has delirium/dementia without
violent behavior (may have impulsive
behavior requiring more frequent
observation): Staff must observe
whereabouts, behavior, and patient
condition every 30 minutes
Level 4Fall Precautions
Morse scale to identify fall risk: Staff
must observe whereabouts, behavior,
and patient condition every 60 minutes.
Notify RN if you assess any changes in
patient’s mobility.
When and Why Should Physical
Therapy be Ordered?
• Is the patient at his functional mobility baseline?
• Will medical treatment alone restore the patient to his
baseline level?
• Have there been attempts to mobilize the patient prior
to therapy referral
• Is patient able to participate in therapy?
• Do you plan to transfer to a SNF or Rehab within the
next 48 hours for PT services?
More about PT
PT is contraindicated if:
•
•
•
•
•
•
Spine not cleared from trauma/METS
X-rays/MRI pending
No clear Weight Bearing status
Patient with BEDREST activity orders
HgB <7
INR > 5
PT is not necessary if:
•
•
•
•
•
Safely discharging home
Want home PT for endurance or safety check
Want outpatient PT for chronic issues
Patient is baseline functionally
Want a walking pulse ox
Other PM&R Services
Occupational Therapy:
Upper extremity dysfunction
Hand/arm/shoulder splinting
Splint, boots, shoes
Activities of Daily Living
dysfunction
Acute Rehab assessment
Speech Pathology Services:
Diagnostic and therapeutic
services forDysphagia
Speech-Language dysfunction
Cognitive Impairments
Voice Disorders
Mobility Aides:
Trained aides to enhance
patient mobility. Prevent
patient debility that can cause
secondary complications
Physical Medicine and
Rehabilitation:
Consider early consult for
musculoskeletal related issues
or need for inpatient rehab.
CLINICAL RESOURCE
MANAGEMENT DEPARTMENT
Primary functions• Coordinate a safe and timely discharge plan
• Monitor and decrease length of stay
• Secure reimbursement for care
• Collaboration with the team
• Daily Accountable Care Unit interdisciplinary
rounds
What is needed from you?
• H & P MUST be in the medical record for all
members of the team to begin their work
• Document patient’s contact numbers in the
H & P if you interview care giver/community
representative
• Clearly documented plan of care
• Participation in unit based rounds
• Forms and prescriptions completed timely
• Communicate, Communicate, Communicate
How we can assist you?
• Case Managers and Social Workers can
assist you with developing the plan for a safe
transition to after care
• Consult with team to determine appropriate
level of care for transition
• Available as a resource to you and team
When to consult Social
Worker
• Patient incapable of
decision-making
• No next of kin
information
• Social Work to assess
provision of resources in
the community to local
health district and public
welfare office
• Suspicion of Domestic
Violence, Child or Elder
Abuse
• Patient admitted with a
psychiatric involuntary
(302) or voluntary (201)
need for continued
psychiatric treatment
when medically stable
• Patient has active drug
or alcohol issues
• Assistance in placement
of homeless patients
Case Management- Discharge
Planning Considerations
Home Care
• Visiting Nurse
• PT
• IV Therapy
• OT
• Speech
• Home care aide
• Home Hospice
Skilled Facility
Acute Rehabiltation
• Needs qualifying
• PT needs
diagnosis
• Wound Care
• Insurance
• Wound Vac
authorization
• IV antibiotic therapy
• PM&R team will
• Inpatient Hospice
provide physical,
• Needs insurance authorization occupational, and
speech therapies
Long Term Acute Care Hospital (LTACH)
• Daily Physician Assessment
• Ventilator weaning
• Complex wound care
Discharge Coordination
• Special Circumstances: Chronic Dialysis
– Skilled facility placement must be coordinated with the
dialysis Social Worker
– Patient agrees to hemodialysis site and Skilled Nursing
Facility
• Insurance authorization must be obtained
• Patient medically cleared for transfer is documented
• Final arrangements made, time of transport
communicated
• Transfer orders complete before time of discharge
Home Discharge Plan
• Patient has made progress in physical therapy
• Therapist recommends continued PT at Home
• Team modifies medication regime to insure
adherence
• Case Manager informed of plan and suggests
Visiting Nurse, PT, and Home Health Aide
• Home infusion arrangements
• Agency selected; must coordinate with hemodialysis
• Informs team, discharge instructions completed
Temple Access Center
Need an appointment for a patient
being discharged?
• Place an order in MIS (Computerized Physician
Order Entry system)- it goes to our Access Center
• 2 hour turn around time for referral in-system, 24
hour turn around for external referrals
• Access Center will make the appointment and
enter it directly into MIS in the discharge
instructions
Summary
• Temple patients are complex!
• Care delivery requires a
multidisciplinary approach and great
teamwork
• Take advantage of your Temple Teameveryone is here to help you provide
safe, efficient, effective, timely,
equitable and patient-centered care
• Welcome to your TUHS experience!