Transcript Patient Safety - Virginians Improving Patient Care and Safety

Increase the Safety of
Warfarin Therapy in the
Ambulatory Setting
Patient Safety, Satisfaction & Revenue
Stephanie Dougherty, RN, BSN
Patient Safety Fellow
Virginia Commonwealth University
VIPC&S May 15, 2003
1
History and Background
• 176 bed hospital with 12 Ambulatory Practices
and 145 physicians participating in Integrated
Delivery System
• Coumadin - one of the top 10 most dangerous drugs in
the ambulatory setting. Literature states combination
bleeding and embolic events runs 2- 20 % in traditional
office based management
• Adverse Event – lets Speak the Truth
2
Half Full Theory
3
Objectives
• a.. Create a culture in ambulatory care of
patient safety based on open communication
and human factor concepts
• b.. Implement an evidence based, systems
based, patient centered framework to decrease
variation in the management of Warfarin therapy
in the ambulatory setting
4
Objectives
• c.. Increase patient education, awareness, and
patient participation in managing healthcare
safety
• d.. Implement use of Pont-Of-Care INR testing
equipment in ambulatory setting to decrease
turn around time and increase patient/staff
satisfaction
5
Begin…
• Pilot patient safety project at two hospital owned
Ambulatory practices
• Began November to create the new process
• Conducted Failure Analysis - Flow Diagram or
What are we currently doing?
6
Flow Diagram
5-6 RN's to train
D/C from some
facility already on
Coumadin or
Cardiologist
Register-Sign in on
Nurse Unit
RN Chart in "Rack"
"Nurse of the Day"
all blood work for
nurse visits
RN picks up chart
and bring patient
back to lab
RN verify current
dose and
compliance with
regimen
Any missed doses
recorded on record
and reported to
M.D.
RN/LPN/MA draws
INR
PBFHC uses HMC
the "most" due to
Medicare for INR's
Paper log of PT/INR
(See lab draw log)
Lab voucher (one
copy stays with
chart) results are
pending
Faxed copy of
results
Recorded lab log
and placed with
chart in M.D. Box
(UP box
distinguishes urgent
Specimen and
voucher goes to
HMC lab
Extreme abnormals
are called from
HMC lab to PBFHC.
Otherwise HMC lab
faxes copy of results
to PB.
Abnormals get
placed on podum for
immediate
Verify M.D. is
present for follow-up
M.D. decides dose,
repeat visit & writes
orders.
See yellow
Anticoagulation
Form
He puts chart into
Nurse Box or into
RN's hands
RN calls to contact patient.
*Document where
communication is in process.
May write on lab sheet result.
Makes new appt. for follow-up.
If out of wack-assess.
Patient education-RN blood
draw
Conversation and assessment
& callls for nurse dose
booklet.
Patient on phone:
Set date now-front desk does
schedule. They want the RN
to set the date. There is a
recall list the patient can go on
so the patient does not have
to remember.
Cardiology managed
INR's?
PB faxes results to
cardiologist who then
contact the patients.
We tell the patient if they do
not hear from us within 24 hrs.
they need to call us.
Changes in RxMd/RN calls
pharmacy
7
DATA
• How are we managing our patient education?
• What best practice algorithm are we using?
• Is everyone doing the same thing - well?
• ( reference slide re data collection pre implementation)
8
What We Found…
• Found the following:
– Small “Snapshot Sample” of charts reviewed:
Only 13 % were in target range 80% of the time
– Use of a basic algorithm only at one practice
site- large amount of variation
– Interaction with patient usually a lab draw by
nurse or technician – did not have a Coumadin
focused assessment by nurse or physician
9
What We Found…
– PT/INR results arrive 1-2 days after
patient visit
– Physicians review stack of charts a the
end of the day for medication orders
– Needed standard for patient assessment
each visit
– Needed standardized education for
patients or staff - not sure of hospital
based patient education is remembered
10
What We Found
– Nurse time not billed
– Physician time not billed
– Heavy reliance on memory
 Many
steps in the process
11
Culture and Patient Safety
Concepts
• Cultivate Patient Safety Thinking- initiate
culture change- understand basics of error
and why changes to Coumadin
management need to be accomplishedstory telling
• Remove blame
• Look for roots of error in system- fatigue,
memory, vigilance, production pressure
12
Look Familiar?
13
Human Factors Evaluation
• Evaluated the intrinsic properties and constraints
•
•
•
•
of the current system
Noise, interruptions, vigilance, increased reliance
on memory
Cognitive factors: stress, workload, fatigue
Communication between staff
Staff Training
14
Goals from Objectives
• Decrease reliance on memory- patient, nurse ,
•
•
•
physician,
Decrease variation in assessment , dosing,
education, use of pharmacies
Minimize workspace management-streamline
process, use evidence based medical tools
Add Specific Color to the Coumadin
Management Tools – recognition easier than
recall
15
Goals from Objectives
• Increase patient participation and educationPatient becomes partner in co managing
Coumadin treatment
• Eliminate 1-3 three day wait for PT/INR
•
Laboratory results
Immediate results with Point of Care technology
testing equipment (CoaguCheck)
16
KEEP IT SIMPLE
• Real – Relevant - Simple- and ‘Fun
(Gosbee)
• Develop healthy respect for latent error in any
new system, process or design
• Training to Anticipate error- Error will emerge!!
( so ..look for it!)
17
Obstacles to Patient Learning
•
•
•
•
Difficulty comprehending
Memory( heavy reliance on)
“Rushed”
Minimal connection with concept of personal
responsibility for monitoring diet, exercise,
travel, communication re: doses missed, illness
or activity, and concommitant medications
18
Perceived Obstacles to change at
the sites
•
•
•
•
•
•
•
Things are ok here
This is too much paperwork
Not another “program”
What do you mean Patient Safety- we’re safe!
The doctors will never go for this
The patients won’t like it
We are doing too much already
19
Overcome perception of Change…
20
BEST PRACTICE
• Process & Tools
• Algorithm
• Patient education and increased understanding
•
of responsibility
Initial Nursing Assessment and Coumadin Visit
Assessment- drives the discussion –re: relevant
questions on diet, lifestyles, medications over
the counter medications, herbs, activity, illness
21
Tools
• Evidence Based Algorithm
• Anticoagulation Log
• Visit Assessment
• Follow-up Appointment
• Pont-of- Care INR Testing
22
Tools to Decrease reliance on MEMORY
and Facilitate Education
TOOLS: (see your handouts for copies)
• Announcement to Patients Let the
patients (and staff!) know there is a change a
coming’ - new Point of Care Testing and
Benefits
• “Blood for the lab tests is obtained via finger
stick - No more venipuncture”
• “Test results are available within minutes – No
more waiting days for results”
23
Tools continued
• “Immediate adjustment of drug dosage, if needed
– No more delay in appropriate therapy and a
decreased risk of complications”
• “Frequent interaction with our healthcare
professionals, which results in better control of
therapy and increased opportunity to discuss your
treatment or education needs”
24
Tools- Announcement
• Announcement- handed out in the lab draw area
3-4 weeks before the first patient starts on the
new INR Point of Care Testing/Education
• Generated interest and excitement
for the changes
25
Tools..
• Initial Assessment - leads discussion
with patient relative to Coumadin and
issues of concern
•
The Language we use through each piece
REINFORCES learning about Coumadin and
precatutions
26
Tools..
• Patient Responsibility discussion and
•
contract
Education checklist matching the patient
Guide to using Coumadin pamphlet from BristolMyers, Squib guides the nurse and patient
education- eliminates reliance on memory (see
handouts)
• The education process reinforces learning about
Coumadin management for the Patient AND the
Staff
27
Point of Care Testing
• Eliminates call back time – immediate results to
patient, nurse and physician
• Engaged practitioners in discussion on memory,
vigilance, pace, interruptions
28
Point of Care testing
• Our choice - CoaguChek S System ( Roche
•
•
•
Diagnostics- www.coaguchek.com)
Human factors designed with multiple benign
failure modes - Designed to minimize human
error
CLIA waived
A test system not impacted by lot –to –lot
reagent variability thereby minimizes the
chances of clinically significant changes in test
results.
29
Education to change culture
• Incident - literature review & root cause analysis
results
• All Staff Educated on Anticoagulation
Management via American Heart AssociationManagement of Oral Anticoagulation Therapy
(www.acforum.org)
30
National Quality Forum
• National Quality Forum- Patient Safety activity:
• Increase safety of anticoagulation management
is applicable to ambulatory setting.
• A recommended safe practice is to utilize
dedicated anticoagulation services that facilitate
coordinated care management services
31
NQF
• Examples of implementation:
• Staff Experienced in monitoring anticoagulation
•
•
•
•
therapy
Reliable patient scheduling and tracking
Accessible, accurate and frequent prothrombin
time (PT)/ Independent Normalized Ration (INR)
Patient Specific decision support and interaction
Ongoing patient education
32
Narrow the holes of Swiss
Cheese
• Use of appropriate Technology
• Improved clinician knowledge and error
•
•
awareness
Continuous improvement
Evidenced based Medicine for the
Anticoagulation Algorithm
33
New Improved Process
Patient Registers
and completes
visit assessment
Nurse reviews
patient information
and performs INR/
PT Test
INR results are
immediate
Review and
discuss INR with
patient/family
MD evaluates
assessment and
INR results: writes
orders
Next visit
appointment
scheduled
•
Dramatic increase in patient satisfaction
•
More personal time between nurse and
patient better education and relationship
•
Patient ownership of Coumadin self
management
34
How much is this going to cost?
35
Financial Analysis
Total Number of Tests
Practice
PBFHC
DVFHC
RFHC
CFHC
Tests / Week
15
15
15
Annual Tests
780
780
780
10
520
Total
55
2,860
36
Financial Analysis
Medicare Reimbursement
INR Testing
Outside Laboratory
• Annual Tests: 2,860
• Nurse Visits: $67,524.60
• INR Tests: $15,701.40
• Annual Tests: 2,860
• Venipuncture: $8,580
Annual Revenue: $83,226
Annual Revenue: $8,580
37
Financial Analysis
Supply Costs
POC INR Testing
•
•
•
•
Annual Tests: 2,860
Strips: $14,128.40
Control Costs: $1,086.80
Lancets: $572
Annual Supply Costs:
Outside Laboratory
• Annual Tests: 2,860
• Venipuncture Supplies: $0.22
Annual Supply Costs:
$629
$15,787
38
Financial Analysis
Nursing Costs
INR Testing
Outside Laboratory
• Annual Tests: 2,860
• Time Cost (15 min. per test):
• Annual Tests: 2,860
• Time Cost (20 min. per test):
$715
• Annual Nursing Time: 715 hrs.
• Salary w/ Benefits per hr.:
$22.32
$943.80
• Annual Nursing Time: 944 hrs.
• Salary w/ Benefits per hr.:
$22.32
Annual Nursing Costs:
Annual Nursing Costs:
$15,959
$21,066
39
Financial Analysis
Total Annual Expenses
POC- INR Testing
• Supply Costs: $15,787
• Depreciation on INR machines:
$960
• Nursing Time: $15,959
• NJ State Lab
Compliance: $460
• Increased Lab License
Expense: $800
Outside Laboratory
• Supplies for
Venipuncture: $ 629
• Nursing Time: $21,066
TOTAL Expense:
$21,695
TOTAL Expense:
$33,966
40
Financial Analysis
Profit / (Loss) Statement
INR Testing
Outside Laboratory
• Annual Tests: 2,860
• Revenue: $83,226
• Expenses: $33,966
• Annual Tests: 2,860
• Revenue: $8,580
• Expenses: $21,066
Profit:
Only Loss:
$12,486
$49,260
41
Patient Outcomes
• Patient and Practitioners discovering
relationships between the diets of patients with
noted sometimes large variation in INR results
• The education and assessment time spent with
patient- we are finding new medications added,
missed doses, changes in level of wellness
42
Patient Satisfaction
• 100% satisfaction from the Patients – they
•
•
•
were ASKING for the new process
If they need to be re stuck they are saying –”it’s
OK- go ahead. Better than the vein”
New algorithm is being used as standard among
physicians and residentsError in dosing already intercepted with the
algorithm
43
Patient Outcomes
• Patient and Nurse schedules next
appointment before patient leaves
• Missed appointments are tracked and
followed up promptly- there have not been
any missed appointments with this new
process for the INR testing and
assessment
44
Patient Safety continues
• Patient leaves with a copy of the new
orders and the new appointment date
• Patients are now calling in to discuss the
addition of new antibiotics from other
MD’s and what to do about the Coumadin
dose
45
Physician Satisfaction
• Physicians are seeing the time spent on the
education and assessment of each patient and
are pleased and impressed with the patient’s
positive reaction
• This process slows down the Production –
devotes time to relationship- and is creating an
interactive patient safety dynamic with patients
at the center of the care
46
Go Global..
Speak the Truth Softly
• Original plan was for 3 owned sites to implement
• Now up to 5 – plan to offer this to all 12 owned
practices and the 145 physicians in our
Integrated Delivery System
• Data collection underway to capture the success
and other opportunities for improvement
47
About Patient Safety …Overcome this..!!!
48
Acknowledgements
• Dr.Kryzkowski- who showed us that we have an opportunity to
improved safety
• Dr. Roksvaag, Dr, Shlimbaum, Dr. Kozakowski, Lawrence
Grand, Claire Long and Dr. Pickoff– for showing leadership,
support and blessings
• Dr. Jacky Fein for her support in changing culture through
education
• Patty Musselman, Mary Shurts, Betty Cronce, Bonnie Adaire
– for their belief in patient safety as a number one priority and who
supported this process over all the obstacles
• Karen Swisher and Dr. Eric Silfen- for Patient Safety
Fellowship and mentoring
• Dr. Kim Thorne- Northbay Medical Center – who shared with
us all her successful clinic tools
49
Thank you!
Stephanie Dougherty. RN, BSN
Patient Safety Officer- Risk Manger
dougherty.stephanie@hunterdonhealthcare.
org
50