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1. From the NICU to Primary Care: Improving the Quality of the Transition
Virginia A. Moyer, MD, MPH
Professor of Pediatrics, Baylor College of Medicine
Chief, Section of Academic General Pediatrics
Chief Quality Officer, Medicine
Texas Childrens Hospital
2. Cartoon:
3. Overview Care transitions
Patient safety challenge
Literature
HFMEA
Definition
Description
AHRQ Planning Grant
NICU to ambulatory follow-up
Process
Results
HFMEA
Qualitative
Next steps
4. Background Patient Safety literature increasingly acknowledges potential risks of care transitions
Adult literature reveals significant vulnerabilities
Proactive evaluation of error-prone health care processes can inform interventions to prevent adverse patient outcomes before they occur
5. Care Transitions Sometimes called handoffs
Movement of patients between health care practitioners and settings
Shift changes
ER to hospital
OR to post-op or ICU
ICU to floor
One facility to another
6. Hospital to Home Prolonged time period during handoff
Unclear lines of responsibility
Lack of patient understanding of health care problems
Lack of readiness for self-care responsibilities
Lack of information for follow-up provider
7. Pediatric Care Transitions Inpatient to ambulatory setting
Pediatric literature relatively silent except for measuring follow-up appointments
Focus has been on lack of compliance by caregivers rather than on systematic issues around discharge
28% of children discharged from a pediatric ICU (not a NICU) did not receive timely medical follow-up
8. Research in Adults 19% of patients had identifiable adverse events in the first 3 weeks home
73% of older patients misused at least one medication
>1 medical error per discharge summary
9. Research in the NICU
10. FMEA: Failure Mode and Effects Analysis
11. What is a FMEA?The technique involves identifying potential mistakes before they happen to determine whether the consequences of those mistakes would be tolerable or intolerable Potential failures are identified in terms of failure modes
For each mode the effect on the total system is studied.
12. Why FMEA? Powerful approach for proactive risk assessment
Used in other high risk industries such as aerospace, aviation, nuclear industry
13. HFMEA Process
Team generates a flow diagram of main process and sub-processes
Team brainstorms about all potential errors at each step (failure modes)
Each is scored for probability it will occur (frequency) and potential severity if it did occur (severity)
Frequency score x severity score = hazard score
High-risk failure modes identified as well as related causes or contributory factors
14. AHRQ Planning Grant Conduct HFMEA on NICU to ambulatory care transitions
Conduct retrospective review to confirm or modify HFMEA findings
Conduct qualitative assessment of the process to accomplish the HFMEA
15. Setting: Texas Childrens Hospital NICU
78 Level III beds, 62 Level II beds
>200 VLBW (<1500gm) babies per year, many other babies with complex congenital abnormalities
Special Needs Primary Care Clinic
Housed at main campus
>100 children on home ventilators; 24-7 coverage
TCPA
42 private practices, including 5 Medical Homes
Shared electronic record with TCH
TCHP
TCH-owned Medicaid Managed Care Plan, ~230,000 kids
16. Our Project Perform a HFMEA for the transition in care from NICU to ambulatory follow up
Use multiple methods to see if our predictions are correct
Revise the HFMEA
Develop a mitigation plan to address the identified risks
17. It takes a team
Virginia Moyer, MD, MPH Principal Investigator
Karen Finkel, RN, BSN Patient Safety Office
Hardeep Singh, MD, MPH Patient Safety Researcher (VAH)
Lu-Ann Papile, MD Neonatologist
Jochen Profit, MD Neonatologist
Charleta Guillory, MD Neonatologist
Marcia Berretta, MSW Social Worker
Teresa Duryea, MD Pediatrician
Lori Sielski, MD Pediatrician
Jan Mort, RN Baylor NICU nurse
Carol Carrier, RN
Adam Kelly, PhD Survey researcher (VAH)
Myrna Khan, PhD Patient Safety researcher (VAH)
Eric Thomas, MD, MPH Patient safety guru (UT-H)
Joseph DeRosier creator of HFMEA (VAH)
18. Process Diagram
19. NICU to Ambulatory Care Diagram
21. Our HFMEA Results
Team identified 114 potential failure modes within the discharge process
Final model included 40 high-failure modes and 75 high-risk causes
22. HFMEA Results Common issues present across most failure modes and causes:
Clinicians act in isolation resulting in lack of standardized, coordinated, comprehensive plan of care
Parents/caregivers inadequately prepared for home care and management of fragile infants
Community providers lack required knowledge and skills to manage medically complex infants
23. Multiple Methods to confirm the HFMEA Self-reporting of events (using TCH reporting system)
Electronic triggers for possible adverse events
ER visits within one month of discharge
Readmissions within one month
Missed appointments within one month
Questionnaire for parents/caregivers
the Care Transitions Measure
24. Retrospective Review Charts reviewed using a trigger methodology to confirm or add to HFMEA findings (N=88)
Failures documented for 14 of 35 sub-steps predicted to have errors, in 1-10 cases each
Documentation in current medical records system inadequate to systematically collect reliable data
Documentation unavailable for majority of patients for 19 of the 35 sub-steps.
A pediatric-adapted care transitions measure developed and validated.
25. Qualitative Analysis of the HFMEA Process The team members felt that the group functioned extremely well, with a high level of involvement and many new insights gained in the process.
The team encountered difficulty applying the HFMEA scoring system to the identified failure modes
The severity descriptions did not seem to fit the types of failure modes identified
Frequency descriptions did not seem sufficiently granular
The group modified both descriptions before it proceeded with scoring.
Some group members were concerned that scoring severity and frequency at the same time allowed for gaming of the scores
At the end of the process, the group scored one set of failure modes independently to determine whether this would significantly alter the scores (it did not).
26. Safe Passages The final step of the HFMEA is the development of a mitigation plan
We addressed the three major themes that were identified in the HFMEA:
Lack of a standardized discharge plan
Inadequate parent/caregiver preparation
Lack of knowledge and skills by community-based health care providers
27. Safe Passages We based the intervention on the Care Transitions Intervention (Coleman et. al.), adapted for a pediatric population.
Enhanced Personal Health Record
Health Coach
Just In Time Information for community-based health care providers
28. Enhanced Personal Health Record Existing discharge plan is ad hoc
Existing standard discharge information limited to a single sheet of paper with diagnoses, medications and appointments written in by hand.
Note that for many of our babies, the paper chart weighs more than the baby.
29. Enhanced Personal Health Record Welcome, Helpful Information about the Newborn Center, and Important Numbers
Journaling and Care Pages
Tips for Choosing Insurance and Pediatrician for Your Baby
Resources and Support
Ronald McDonald House
Key People, Equipment and Medical Terminology Glossary
Your Babys Development, Nutrition, and Feeding
Premature Babies Immunization Schedule
Breastfeeding Your Baby
Newborn Feeding- Bottle Feeding and Formula Preparation
Safety and Education
Medication Safety
Giving Oral Medicines
How to Give a Subcutaneous Injection
Crib Safety
Signs and Symptoms of Illness
Crying
Colic
Preventing Infection
RSV
Synagis
Planning for Discharge Checklist
Calendar with Follow-Up Appointments
30. Health Coach A technically expert individual who takes the role of sensitive coach, teacher and facilitator to foster the development of parents into competent caregivers for their fragile infants.
Masters prepared health educator, available at the hours parents are able to be present in the NICU.
Available to staff as a resource person
31. Just-in-Time information for primary care providers Capitalized on new Evidence Based Guidelines program at Texas Childrens
One page summaries of evidence based guidelines for common problems
Transition from premature formula, oxygen weaning, growth of premature infants, management of gastrostomy, management of tracheostomy, chronic lung disease
and much, much more.
Sent home with infant and also faxed to provider at the time of discharge
32. Research Design Concurrent Cohort Study over 1 year
NICU is divided into geographically distinct pods
One NICU III pod and its usual step-down Level II pod comprise the intervention group
Other pods comprise the control patients
IRB did not require patient/parent consent beyond verbal consent at the time of enrollment
But did require written consent for the evaluation of PCP compliance with JIT protocols
33. Progress to date Recruitment of intervention babies is close to on-schedule (n~50 at 6 months)
Recruitment of control babies is behind (n~40) because 2 control units were closed for low census
Very few refusals to participate, very high rate of response to phone surveys
Moderate level of difficulty recruiting PCPs to the J-I-T intervention, so numbers are low.
34. Outcome Evaluation Primary outcome is adverse events within 31 days of discharge (death, ER visit, readmission, missed appointments)
Care Transitions Measure Neo: administered by phone 2-3 days after discharge and again at 31 days
Comfort level and satisfaction of PCPs with common post-NICU problems
Adherence to guidelines by PCPs
35. Deliverables Toolkit
Manual for the Health Coach
Enhanced Discharge Binder (to be converted to electronic format if and when our EMR implementation actually happens)
JIT information sheets (to be converted
)
CTM-Neo - validated tool to evaluate the quality of the NICU discharge experience
36. References The Care Transitions ProgramSM http://www.caretransitions.org accessed January 18, 2007.
Coleman EA, Berneson RA. Lost in transition: Challenges and Opportunities for improving the quality of transitional care. Ann Int Med. 2004 Oct 5; 141(7):533-536.
DeRosier J, Stalhandske E, Bagian JP, Nudell T. Using health care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system. Jt Comm J Qual Improv. 2002 May;28(5):248-267, 209.
Forster AJ, Clark HD, Menard A, et al. Adverse events among medical patients after discharge from hospital. CMAJ. 2004; 170:345-349.
McPherson ML, Lairson DR, Smith EO, Brody BA, Jefferson LS. Noncompliance with medical follow-up after pediatric intensive care. Pediatrics 2002;109(6):94.
Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003 Aug;18(8):646-51.
Philibert I. Leach DC. Re-framing continuity of care for this century. Qual Saf Health Care. 2005 Dec;14(6):394-396.
Roy CL, Poon EG, Karson AS, Ladak-Merchant Z, Johnson RE, Maviglia SM, Gandhi TK. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005;143(2):121-8.
37. Questions?