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The CNS Role and Outcomes Management Evelyn Taverna, RN, MS, CCRN, CNS

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Presentation on theme: "The CNS Role and Outcomes Management Evelyn Taverna, RN, MS, CCRN, CNS"— Presentation transcript:

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

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 California Pacific Medical Center

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

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

5 CPMC Quality & Clinical Resource Management Model
CLINICAL MANAGEMENT RESOURCE MANAGEMENT Clinical Nurse Specialist Population Based Case Manager Social Worker Patient/Family Based Administrative Assistant Support QUALITY MANAGEMENT OUTCOMES MANAGEMENT STAFF MANAGEMENT DEPARTMENTS UR PHYSICIANS HOSPITALISTS DISCHARGE PLANNING SOCIAL SERVICES UTILIZATION MANAGEMENT California Pacific Medical Center

6 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 Resource Management Benchmarking MD comparisons LOS/level of care Cost/resource analysis Resource utilization Clinical Management Protocols Best practice guidelines Clinical consultation Staff education Complex case review Outcomes Management Quality, cost, service Data analysis/research Clinical effectiveness PI projects Sutter initiatives California Pacific Medical Center

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 California Pacific Medical Center

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 California Pacific Medical Center

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

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 California Pacific Medical Center

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. California Pacific Medical Center

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

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 California Pacific Medical Center

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 California Pacific Medical Center

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

16 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 California Pacific Medical Center

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

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 California Pacific Medical Center

19 California Pacific Medical Center
AMI Outcome Measures Aspirin at arrival Beta blocker at arrival Median time to thrombolytic therapy Median time to PTCA Aspirin prescribed at discharge California Pacific Medical Center

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

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 California Pacific Medical Center

22 California Pacific Medical Center

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

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 California Pacific Medical Center

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 California Pacific Medical Center

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. California Pacific Medical Center

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 California Pacific Medical Center

28 ACUTE MYOCARDIAL INFARCTION
NRMI 4 DATA SUMMARY September 2002 Report7/1/01 – 6/30/02 INDICATOR CPMC LIKE HOSPITALS (173 centers) CALIFORNIA NATION (1228 centers) Enrollment Yearly Non Transfer-in 303 260 55489 27330 186439 AGE 76 68 70 69 ST  and/or LBBB on 1st EKG 28% 27% 25% 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 Thrombolysis 2 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 34 Door to Drug (<30 minutes) 0% 38% 44% 46% Door to Dilation b data to cath lab cath lab to dilation 124 15 41 108 9 61 38 116 105 Door to Dilation (<90 minutes) 11% (4/35) 33% 36% NSTEMI 62% 63% 65% NSTEMI Eligible AMI Patients Treated with GP 2b/3a Inhibitor 39% 30% Death 8.5% 10.0% 10.1% 9.7% Length of Stay st Q 2002 2nd Q 4.1 4.4 4.8 3.9 4.0 Days in ICU 2.0 1.8 California Pacific Medical Center

29 ACUTE MYOCARDIAL INFARCTION NRMI 4 DATA SUMMARY September 2002 Report
7/1/01 – 6/30/02 INDICATOR CPMC LIKE HOSPITALS (173 centers) CALIFORNIA NATION (1228 centers) NSTEMI 62% 63% 65% NSTEMI Eligible AMI Patients Treated with GP 2b/3a Inhibitor 36% 39% 27% 30% Death 8.5% 10.0% 10.1% 9.7% Length of Stay st Q 2002 2nd Q 4.1 4.4 4.8 3.9 4.0 Days in ICU 2.0 1.8 N/A California Pacific Medical Center

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% 77/160 31% N/A Chronic renal Insufficiency 17% (45) 12% No CHF 57% (148) 75% Rales, JVD 15% (39) 16% Pulmonary edema 27% (71) 7% Cardiogenic Shock 1% (2) 1% California Pacific Medical Center

31 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 California Pacific Medical Center

32 California Pacific Medical Center
CARDIOLOGY SEVICE LINE 2001 – 2002 DRG PMI/ AGE CASES 2001 LOS 2002 (Jan-June) CHANGE 2001- DIRECT COST DIRECT COST YTD % 121 AMI & Major Comp 1.55/80 106 5.45 118 6.29 + .84 122 AMI No Comp 1.24/66 63 3.51 27 4.04 + .53 123 Expired 1.56/87 20 3.50 + .25 127 Heart Failure .98/75 471 4.17 387 4.89 + .72 140 Angina .58/74 55 1.75 14 2.71 + .96 143 Chest Pain .52/67 219 1.53 203 1.52 - 0.1 California Pacific Medical Center

33 California Pacific Medical Center
CARDIOLOGY SERVICE LINE COST DATA 2001 – 2002 DRG Critical Care Med/Surg RT /Pul Supplies Pharmacy PT Radiology Lab Other 121 AMI & Major Comp 122 AMI No Comp 127 Heart Failure 140 Angina 143 Chest Pain California Pacific Medical Center

34 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 California Pacific Medical Center

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

36 California Pacific Medical Center

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

38 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. California Pacific Medical Center

39 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 California Pacific Medical Center

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

41 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 California Pacific Medical Center

42 Indications for Pacemaker
# of patients California Pacific Medical Center

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

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 California Pacific Medical Center

45 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 California Pacific Medical Center

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

47 California Pacific Medical Center


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