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California Pacific Medical Center The CNS Role and Outcomes Management Evelyn Taverna, RN, MS, CCRN, CNS Guest Lecturer: N 226 February 19, 2003 Evelyn.

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Presentation on theme: "California Pacific Medical Center The CNS Role and Outcomes Management Evelyn Taverna, RN, MS, CCRN, CNS Guest Lecturer: N 226 February 19, 2003 Evelyn."— Presentation transcript:

1 California Pacific Medical Center The CNS Role and Outcomes Management Evelyn Taverna, RN, MS, CCRN, CNS Guest Lecturer: N 226 February 19, 2003 Evelyn Taverna, RN, MS, CCRN, CNS Guest Lecturer: N 226 February 19, 2003

2 California Pacific Medical Center Overview Purpose: to extend the traditional role of case management to patient population based clinical resource management Develop systems to manage patients across the continuum - from inpatient to extended care to home health Create teams to effectively manage and integrate departmental activities in a cost effective, outcome driven manner

3 California Pacific Medical Center Population Based Teams Cardiology Cardiovascular Surgery Medicine Neurology/Neurosurgery Obstetrics Oncology Pediatrics Pulmonary Surgery/Orthopedics

4 California Pacific Medical Center Team Members Clinical Nurse Specialists RN Case Managers Social Workers Administrative Assistants Data Analysts Quality Coordinators Physician Champions

5 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 MANAGEMENT CLINICAL MANAGEMENT RESOURCE MANAGEMENT OUTCOMES MANAGEMENT DISCHARGE PLANNING SOCIAL SERVICES UTILIZATION MANAGEMENT UR PHYSICIANS HOSPITALISTS STAFF MANAGEMENT DEPARTMENTS

6 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

7 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 population Seek opportunities for improvement

8 California Pacific Medical Center Project Selection External Sources/Needs Mandatory – JCHAO Core Measures & Standards State Requirements - OSHPD Sutter Initiatives Press-Ganey Patient Satisfaction Survey VHA Programs Internal Sources

9 California Pacific Medical Center Project Selection External Regulatory Requirements JCAHO CORE Measures - 2002 CHF Perinatal Outcomes JCAHO CORE Measures – 2003 Community Acquired Pneumonia

10 California Pacific Medical Center Project Selection JCAHO Standards Pain Management – Jackie Phan, CNS Patient Safety- Gail Guthrie, CNS & Phyllis Erickson, CNS Medication Error Reduction – Evelyn Taverna, CNS

11 California Pacific Medical Center Project Selection External Requirements California CABG Outcomes Reporting Program (CCORP) – Jill Ley, CNS Crusade Study & National Registry for Myocardial Infarction (NRMI) – Evelyn Taverna, CNS ACOS Accreditation – Alice Mack, CNS National Practice Recommendations: AHA, AHCPR, etc.

12 California Pacific Medical Center Developing Clinical Questions Institutional Sources Quality committees Performance Improvement teams Product lines Clinician Sources Clinical observations New products/techniques Evidence-based practices

13 California Pacific Medical Center Current Projects Medication Error Reduction Coumadin dosing project Range-dosing protocol Patient controlled analgesia protocol New Procedures Bariatric surgery outcomes Continuous renal replacement therapy Off-pump CABG outcomes Outcomes Management Interventional endoscopy database Plavix research and practice change VBAC – Best practice

14 California Pacific Medical Center Current Projects Medication Error Reduction Coumadin dosing project Range-dosing protocol Patient controlled analgesia protocol New Procedures Bariatric surgery outcomes Continuous renal replacement therapy Off-pump CABG outcomes Outcomes Management Interventional endoscopy database Plavix research and practice change VBAC – Best practice

15 California Pacific Medical Center Benchmarking Resources Agency for Health Care Policy & Research(AHCPR) AHA,ACC VHA CMRI HBSI Fathom Midas NRMI 4 Crusade

16 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 cost maintain quality outcomes improve service

17 California Pacific Medical Center Cardiology CNS Acute Coronary Syndrome CHF Pacemaker Study Atrial Fibrillation Complex patients clinical education discharge planning

18 California Pacific Medical Center Cardiology: AMI ED chest pain protocol STEMI and NSTEMI protocol Crusade & NRMI 4 data – Focus on NSTEMI outcomes IIb/IIIa inhibitor use and bleeding interventional procedures Sutter Cardiovascular Services Initiative AMI task force CHF committee CHF ACE inhibitor use and discharge instruction outcomes & readmission

19 California Pacific Medical Center AMI Outcome Measures 1. Aspirin at arrival 2. Beta blocker at arrival 3. Median time to thrombolytic therapy 4. Median time to PTCA 5. Aspirin prescribed at discharge

20 California Pacific Medical Center AMI (cont.) 6. Beta blocker prescribed at discharge 7. ACE I at discharge for LVSD 8. Adult smoking cessation advice 9. Inpatient mortality 10. Lipid-lowering agent at D/C

21 California Pacific Medical Center AMI Strategies ED Chest Pain Risk Assessment Acute Coronary Syndrome Protocols/Order Sets AMI Standard of Care AMI Guide to Recovery

22 California Pacific Medical Center

23 AMI Case Study Mr. M is a 54 year old man admitted with c/o of chest pain which began while watching the 49ers playoff game. Patient lives with wife and works in law enforcement. Symptoms included: Constant, substernal chest pressure (5/10) Diaphoresis

24 California Pacific Medical Center AMI Case Study PMH: CAD, S/P angioplasty in 1989 Diabetes Hypertension Hypercholesterolemia Current smoker Medications: Atenolol and Glucophage Allergic to Aspirin and Motrin

25 California Pacific Medical Center AMI Case Study Physical Exam: Vital stable with bradycardia of 58 Oxygen sat 96% on 2 liters Lungs clear, no JVD Labs: Elevated cardiac markers Glucose – 295 EKG: ST elevation in inferior leads

26 California Pacific Medical Center AMI case study Interventions: Plavix Nitro Morphine Heparin Primary PTCA with GP IIb/IIIa inhibitor during/after PTCA Door to balloon time = 100 min.

27 California Pacific Medical Center AMI case study Discharge planning Cardiac rehab (PT, OT, Dietary) Smoking cessation advice Stress management Aspirin, Plavix, Beta blocker, ACE I inhibitor, statin

28 California Pacific Medical Center ACUTE MYOCARDIAL INFARCTION NRMI 4 DATA SUMMARY September 2002 Report7/1/01 – 6/30/02 INDICATORCPMC LIKE HOSPITALS (173 centers) CALIFORNI A NATION (1228 centers) Enrollment Yearly Non Transfer-in 303 260 5548927330186439 AGE76687069 ST and/or LBBB on 1 st 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 IV Thrombolysis2 pt.7%13%12% Door to Drug median min. door to data data to decision decision to drug 36 13 17 6 33 8 18 7 3433 Door to Drug (<30 minutes)0%38%44%46% Door to Dilation b door to data data to cath lab cath lab to dilation 124 15 68 41 108 9 61 38 116105 Door to Dilation (<90 minutes) 11% (4/35) 33%25%36% NSTEMI62%63%65%63% NSTEMI Eligible AMI Patients Treated with GP 2b/3a Inhibitor 36%39%27%30% Death8.5%10.0%10.1%9.7% Length of Stay 2002 1 st Q 2002 2 nd Q 4.1 4.4 4.8 3.9 4.0 Days in ICU2.01.8N/A

29 California Pacific Medical Center ACUTE MYOCARDIAL INFARCTION NRMI 4 DATA SUMMARY September 2002 Report 7/1/01 – 6/30/02 INDICATORCPMC LIKE HOSPITALS (173 centers) CALIFOR NIA NATION (1228 centers) NSTEMI62%63%65%63% NSTEMI Eligible AMI Patients Treated with GP 2b/3a Inhibitor 36%39%27%30% Death8.5%10.0%10.1%9.7% Length of Stay 2002 1 st Q 2002 2 nd Q 4.1 4.4 4.8 3.9 4.0 Days in ICU2.01.8N/A

30 California Pacific Medical Center ACUTE MI DEMOGRAPHICS AND RISK FACTORS CPMC N =260 LIKE HOSPITALS N= 34920 CALIFORNIA AGE >75 years 76 59% 68 36% 70 42% Clinical Presentation Sx onset to door > 4 hrs 48% 77/16031%N/A Chronic renal Insufficiency 17% (45)12%N/A No CHF57% (148)75%N/A Rales, JVD15% (39)16%N/A Pulmonary edema27% (71)7%N/A Cardiogenic Shock1% (2)1%N/A

31 California Pacific Medical Center AMI Opportunities for Improvement Emergency Department: Door to EKG time Chest pain Risk Assessment Protocol CPK & Troponin utilization Cath Lab: Door to Balloon time Critical Care & Telemetry Analysis of bleeding requiring intervention Patient Education material Cardiac Rehab

32 California Pacific Medical Center CARDIOLOGY SEVICE LINE 2001 – 2002 DRGPMI/ AGE CASES 2001 LOS 2001 CASES 2002 (Jan- June) LOS 2002 LOS CHANGE 2001- 2002 DIRECT COST 2001 DIRECT COST 2002 CHANGE 2001- 2002 YTD % CHAN GE 121 AMI & Major Comp 1.55/801065.451186.29+.84 122 AMI No Comp 1.24/66633.51274.04+.53 123 AMI Expire d 1.56/87203.50203.50+.25 127 Heart Failure.98/754714.173874.89+.72 140 Angina.58/74551.75142.71+.96 143 Chest Pain.52/672191.532031.52- 0.1

33 California Pacific Medical Center CARDIOLOGY SERVICE LINE COST DATA 2001 – 2002 DRGCritical Care Med/SurgRT /Pul SuppliesPharmacyPTRadiologyLabOther 121 AMI & Major Comp 122 AMI No Comp 127 Heart Failure 140 Angina 143 Chest Pain

34 California Pacific Medical Center Congestive Heart Failure System-wide PI Project High volume, high resource utilization Opportunities for Improvement: ACE Inhibitors on discharge for patients with Ejection Fraction < 40% Decreasing LOS and readmission rate Standardizing patient education materials Medical and Nursing Staff Education

35 California Pacific Medical Center Ace Inhibitor on Discharge for EF < 40%

36 California Pacific Medical Center

37 Strategies CNS patient population oversight CHF patient education materials Weight chart One page - Tips for managing at home CHF discharge sheet

38 California Pacific Medical Center Strategies for Improvement Staff education CNS follows CHF inpatients Chart alert to MD - document reason no ACE prescribed Data posted in MD newsletter, MD lounge, cardiology unit. Data reported to Cardiology & Medicine & Nursing QA Committees.

39 California Pacific Medical Center California Pacific Medical Center Permanent Pacemaker Analysis 2002 Ann Edmonson RN, Quality Improvement Jill Ley RN, Cardiac Surgery Evelyn Taverna RN, Cardiology James Mailhot MD, Cardiology QI Chair

40 California Pacific Medical Center Pacemaker Project Indications Pacer type Vendor Anesthesia type Duration of procedure Complications

41 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 review If LOS = 1 day – PCIS review OP note, d/c summary, blood orders Anesthesia type and OR time not recorded Readmission screen for all patients

42 California Pacific Medical Center Indications for Pacemaker # of patients

43 California Pacific Medical Center Pacemaker Complications Lead Dislodgement Infection Pneumothorax PM Tachycardia Hypotension Reprogramming Bleeding RV Perforation CVA Death

44 California Pacific Medical Center CNS Contributions Ideally positioned to influence team Knowledgeable about evidence based practices Impact both processes and outcomes of care Improved outcomes documented: Reduced LOS, complication rates Appropriate use of resources Documented cost savings Links to quality improvement & credentialing

45 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

46 California Pacific Medical Center Clinical Nurse Specialist Ability to Blend clinical, research & financial aspects of outcomes management with a focus on quality, compassion & caring.

47 California Pacific Medical Center


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