Transcript Clinical Care - Chinook Primary Care Network

Clinical Protocol
Implementation
The details matter
Mike Davies, MD FACP
Goal
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Do a better job in a better way.
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In healthcare in the past, we could only measure
activity and assume quality. Today, we can
measure quality.
Why are Toyotas more reliable than Fords?
Why are Toyotas more reliable than
Fords?
Components of Excellent Clinical
Care: Cost, Quality, Access
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Cost
Access (satisfaction)
No waiting
 Courtesy – especially in making appointments
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Technical Quality
Access
 Prevention
 Chronic Disease Care
 Specific care often invisible to patients
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Quality is Measurable
Six Sigma – 99.99966% performance level
Creating Intellectual Capital
Five Sigma – 99.977% performance level
Competitive Breakthrough
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Four Sigma – 99.370% performance level
Continuous Improvement
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Three Sigma – 93.32% performance level
Compliance
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Two Sigma – 69.2% performance level
Capability
·
One Sigma – 31% performance level
Control
< One Sigma - < 31% performance level
Containment
·
Six Sigma = 3.4 per
million units
Five Sigma = 230 per
million units
Four Sigma = 6,210 per
million units
Three Sigma = 66,800 per
million units
Two Sigma = 308,000 per
million units
One Sigma = 690,000 per
million units
Mistakes add up…..
Form
Apply
Record
F/U +
Reset
Step 1
Step 2
Step 3
Step 4
Step 5
95%
95%
95%
95%
95%
95%
95%
65%
95%
95%
50%
50%
50%
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50%
What is a protocol?
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“Agreed-upon way of transmitting information
between two entities”
Checklist
Standard
Clear delineation of responsibility
Why a Protocol?
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Standardize
Systematize
Simplify
Clarify
Assign responsibility
Ultimately to improve reliability
HOW should we change?
WHAT strategies work????
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Effects of Quality Improvement Strategies
for Type 2 DM on Glycemic Control.
Shojania, K., et al. JAMA 2006; 296: 427-440.
Strategies Used
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Audit and Feedback
Clinician Education
Clinician Reminders (paper based)
Facilitated information to Clinicians
Patient Education
Promotion of self management
Patient Reminder Systems
Continuous Quality Improvement
Strategies Used Continued
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Case Management
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Coordinated Dx, Rx, and ongoing management
Team Changes
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“shared care” (routine visits with additional team member)
Multidisciplinary teams (in ongoing management)
Expansion or revision of roles (nurse or pharmacist plays
active role in monitoring and/or adjusting medications)
Results
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66 trials reduced A1C 0.42% overall
2 approaches stood out (26 studies)
Team approaches did 33% better
 Case management did 22% better
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1 strategy stood out (11 studies)
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Nurse or pharmacy makes some independent
med changes (by protocol)
 Reduces A1C 0.96%
Note
I’m told good dental care will decrease
Hgb A1C by 1 point also….
WHAT is the GOAL?
Questions….
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Can you identify all the diabetic patients?
Do you know what services those patients should be
offered in a given year?
Do we provide the right care for every single one?
Do you have a system for tracking?
How are we doing?
Core Measures
Goal
% Adult DM Patients on Panel with > 2 HgbA1C Tests done in
past 12 months
> 95%
% Adult DM Patients on Panel with > 2 Hgb A1C readings < 7
in past 12 months
>90%
% Adult DM Patients on Panel with dilated eye exam in past 24
months
TBD
% Adult DM Patients on Panel with foot exam in past 12
months
TBD
Harder Questions
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Does the doctor-room-patient episodic visit
work?
How does the red-zone relationship work in
changing patient behavior?
Does the patient have any goals?
Is the patient motivated to change?
Can we reach this kid?
Sample Protocol Steps
1.
2.
Instruct/set goals on Diet
Instruct/set goals on Exercise
Current Drug Guidelines
D+E
D+E+MF
D+E+BI+MF
D+E+MF+SU
D+E+BI+MF+SU
?? Insulin ??
Targeted Tissues
Insulin
Secretagogues
Pancreatic
ß Cells
Alpha
Glucosidase
Inhibitors
Intestine
Insulin
Sensitizers
Metformin
Liver
Glitazones
Peripheral
Tissues
Metformin (Glucophage)
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Decrease liver glucose production, increases glucose uptake by
the muscles and supresses appetite (side effect)
Eliminated via kidney
Biguanides include:
 Glucophage® (metformin)
 Glucophage XR® (extended release metformin)
Metformin Special
Considerations:
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Cannot be used in patients with hepatic or renal
insufficiency or congestive heart failure
Associated with increased risk for lactic acidosis
Other drugs (eg, digitalis and quinidine) can enhance
the effect of metformin
Side effects: gastrointestinal discomfort; a metallic taste
Sample Protocol Steps
1.
2.
3.
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Instruct/set goals on Diet
Instruct/set goals on Exercise
Order and monitor Glycohemoglobin every 2
months until goal then every 6 months thereafter
Metformin 500mg PO BID. Instruct to take with
meals. Max dose 850mg BID. Check Cr. yearly.
If > 1.4 notify provider.
Targeted Tissues
Insulin
Secretagogues
Pancreatic
ß Cells
Alpha
Glucosidase
Inhibitors
Intestine
Insulin
Sensitizers
Metformin
Liver
Glitazones
Peripheral
Tissues
‘Glitizones’ Special
Considerations:
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Response develops slowly
Liver function enzymes should be routinely
monitored in patients using these medications.
Drug should be discontinued in ALT is greater
than 2.5x Upper Limit of Normal.
May cause fluid retention
Sample protocol steps: Glyburide
or Glypizide
5.
6.
Add if Metformin does not achieve goal
Dose 2.5mg QD. Adjust in increments of
2.5mg PD to max of Glyburide 10mg BID or
Glypizide 20mg BID. Adjust AM dose first.
Sample protocol steps:
Glyburide/Glypizide or
Rosiglitazone
8.
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Rosiglitazone. Dose is 2-4mg QD. (Max dose is
8mg.) Use if Hgb A1C is > 8.5. D/C if no
improvement in 6 mo.
All patients on glitazones need baseline liver
function. CHF is contraindication. Major side
effect: weight gain
Sample protocol steps: Monitoring
& Adjusting Meds
10. Pt. to call RN (or vice versa) q 3-4 weeks to
review BS readings (goal is 70-120)
11. If pt. doesn’t call, RN attempts to call
12. Dose adjustments made based on Hgb A1C
and BS readings both q 2 months to goal set
by provider
Sample Protocol cont: Insulin
1.
2.
3.
Initial dose by provider (8-10 u of NPH in
AM and/or HS)
Instruct patient NPH insulin lasts 8-16 hrs.
Increase by 2 u every 3-5 days until AM
(insulin given in HS) or PM (insulin given in
AM) BS Goal of 70-120 is achieved
Sample Protocol cont:
Hypoglycemia
1.
2.
3.
Instruct patient to treat with 15 gm. CHO per
protocol.
Determine TIMING (night vs. before/after
meals). Discuss with provider
Determine if related to exercise. If due to
increased exercise, instruct patient to take
additional CHO before exercise
Tobacco Protocol
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Step 1: Screen for tobacco use
“Do you use tobacco currently?”
 If yes, continue questions and offer help. If no,
then move on to next step in process.
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Step 2: Document
Do you use
tobacco
currently?
NO
Stop
Yes
Are you interested in quitting?
Are you aware that tobacco is bad for
you?
“You should stop”
Would you like to see a video?
Would you like a brochure?
Would you like to learn about help
stopping by
using nicotine replacement or
Zyban?
Yes
Document
& Alert
Provider
Meds or
Further
Advice?
NO
Educate &
Document
Impact of Mental Illnesses (of which
Depression is the most prevalent)
Causes of Disability / United States, Canada, and Western Europe, 2000
(SOURCE: World Health Organization, 2001)
Mental Illnesses
Alcohol and Drug Use Disorders
Alzheimer’s Disease and Dementias
Musculoskeletal Diseases
Respiratory Diseases
Cardiovascular Diseases
Sense Organ Diseases
Injuries (Disabling)
Digestive Diseases
Communicable Diseases
Cancer (Malignant neoplasms)
Diabetes
Migraine
All Other Causes of Disability
0%
4%
8%
12%
16%
20%
24%
Depression
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10% of the population suffer from a depressive
disorder at some point in their lives
US spends $44 B per year in direct and indirect
costs related to depression
50% of patients with depression go undetected
or untreated
Most patients with depression don’t complete
adequate care
Steps to Implement a Protocol
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Identify a clinical focus area
Identify a high leverage clinical change within focus
Identify a measure of interest
Flow map the process
Identify the tasks
Assign right work to the right person
Develop the script
Commit the script to paper or computer
Steps to Implement a Protocol
Cont….
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PDSA
Remember to measure regularly
Continually improve
Focus on outcomes
Redesign and move forward
None of this happens without..
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ACCESS FIRST!
CONTINUITY!
TEAM UNDERSTANDING THEIR ROLES
AND GOALS!
Summary
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Good Clinical Care means developing high
reliability systems
Implementation of these requires teamwork
Flow map, Checklists, Staff roles all need to be
worked out
Measurement and feedback are needed
Do it well – our patients are depending on it!
Good References
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www.guidelines.gov
US Preventative Services Taskforce
[email protected]
 http://pda.ahrq.gov
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http://www.qmo.amedd.army.mil/pguide.htm
www.cancerboard.ab.ca
topalbertadoctors.org
www.health.gov.ab.ca