a report to the patient safety committee of arizona general hospital l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
A Report to the Patient Safety Committee of Arizona General Hospital PowerPoint Presentation
Download Presentation
A Report to the Patient Safety Committee of Arizona General Hospital

Loading in 2 Seconds...

play fullscreen
1 / 66

A Report to the Patient Safety Committee of Arizona General Hospital - PowerPoint PPT Presentation


  • 199 Views
  • Uploaded on

A Report to the Patient Safety Committee of Arizona General Hospital. Prepared by Members of the University of Missouri-Columbia Interdisciplinary Workgroup for the CLARION INTERPROFESSIONAL CASE COMPETITION SPRING 2005. INTRODUCTIONS. Ashley Mahon Accelerated Option BSN, RN Program

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'A Report to the Patient Safety Committee of Arizona General Hospital' - Ava


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
a report to the patient safety committee of arizona general hospital

A Report to thePatient Safety Committeeof Arizona General Hospital

Prepared by Members of the

University of Missouri-Columbia Interdisciplinary Workgroup

for the CLARION INTERPROFESSIONAL CASE COMPETITION

SPRING 2005

introductions
INTRODUCTIONS
  • Ashley Mahon
    • Accelerated Option BSN, RN Program
    • UMC School of Nursing
  • Russell McCulloh
    • 4th Year, MD Program
    • UMC School of Medicine
  • Kevin Norris
    • 3rd Year, PT Program
    • UMC School of Health Professions
  • Brian Stout
    • 3rd Year, MHA/MBA Dual Degree Program
    • UMC Schools of Medicine & Business
presentation overview
PRESENTATION OVERVIEW
  • Case Overview
  • Methods of Analysis
  • Major Findings
  • Specific Findings
    • Recommendations/Action Plan
    • Tracking Indicators
    • Cost Analysis
  • Systems Issues
  • References/Acknowledgments
case overview
CASE OVERVIEW
  • Arizona General Hospital:
    • Tertiary care center
    • 620 bed-facility
    • 97 Behavioral Health Beds
  • AGH Values:
    • Dignity
    • Collaboration
    • Stewardship
    • Excellence
case overview6
CASE OVERVIEW
  • Part of Southwest HC System (SWH)
    • Flagship for HC delivery in Maricopa Co.
    • 10 affiliated clinics
  • Clinical Expertise Centers of Excellence
    • Behavioral Health
    • Women’s Health
    • Rehabilitation
    • Cardiovascular services
    • Neuroscience
    • Oncology
    • Orthopedics
    • Spine Care
case overview7
CASE OVERVIEW
  • 36 year old female
  • 20 year history of schizophrenia
  • Admitted for decreased mental status
  • Treated for suspected overdose
  • Self-administered medication overdose in hospital
  • 3-week stay in BHU
  • Discharged to home
  • Readmitted seven weeks later for relapse of psychotic symptoms and alcohol intoxication
methods
METHODS
  • Investigation:
    • Identification of Major Events
    • Causal Flow Analysis
    • Root-Cause Analysis (VA-NCPS)
    • Identification of Contributing Factors
  • Remediation:
    • Literature Review
    • Development of Recommendations
    • Progress Assessment
    • Cost Analysis
    • Extrapolation
major findings
MAJOR FINDINGS
  • Three adverse events were identified:
    • Self-Induced Clozaril Overdose
    • Job/Coverage Loss & Rehospitalization
    • Self-Extubation*
  • Self-Induced Overdose:
    • Unsuccessful suicide attempt
    • Near-miss of a reportable JCAHO sentinel event:

“Any suicide of a patient in a setting where the

patient is housed around-the-clock”

self induced overdose rca
Self-Induced Overdose RCA
  • Root Cause Statement:

“Level of patient observation and

access to potentially toxic medications

resulted in increased possibility

of self-induced overdose.”

  • Three contributing factors domains were identified
self induced overdose contributing factors
Self-Induced Overdose:Contributing Factors
  • Care Team Communication
    • Parallel and informal evaluation and communication of self-harm risk
    • Informal assumption of polysubstance abuse
  • Care Team Roles
    • Medication identified solely by ER staff
    • Primary focus on only physical health aspects of admission
  • Policies & Procedures
    • Persistent access to patient of potentially toxic medications
    • PMH gathered solely from patient’s medication bottle
self induced overdose recommendations
Self-Induced Overdose:Recommendations
  • Care Team Communication
    • AMR “tab” dedicated to psychosocial issues1
  • Care Team Roles
    • All pt home meds are to be ID by pharmacist2
  • Policies & Procedures
    • Develop a standard protocol for evaluation & management of all overdose patients3
    • Establish procedures for pts. at possible risk for self harm1,4
    • Establish security procedures for the intake, storage, and disposition of pt home meds2
    • Similar policy for potentially harmful pt. items2
self induced overdose tracking indicators
Self-Induced Overdose:Tracking Indicators
  • Suspected overdose patients assessed for self-harm risk*
  • Employees scoring 70% or greater on knowledge assessment of behavioral health training courses*
  • Home medications stored securely*

*All indicators are percentage-based; goals for implementation are to be set at 100% compliance

self induced overdose cost analysis
Self-Induced Overdose:Cost Analysis
  • Incurred costs
    • Room sitters (personnel-dependent)
    • Time/resource demands for training personnel re: new assessment procedures
    • Monitoring/ongoing risk assessment
  • Cost-neutral measures
    • AMR changes covered by IT contract
  • Estimated savings
    • Reduced risk of emergent intervention
job coverage loss rehospitalization rca
Job/Coverage Loss & Rehospitalization RCA
  • Root Cause Statement :

“Level of social services involvement led to the patient’s job & coverage loss and ultimately resulted in patient’s relapse & readmission to the hospital.”

  • Three contributing factor domains were identified
job coverage loss rehosp contributing factors
Job/Coverage Loss & Rehosp.:Contributing Factors
  • Care Team Communication:
    • Care teams engaged in parallel and informal communication
  • Coordination of Social Services:
    • Patient assigned to HCC
    • Currently defined roles for HCC and SW
    • HCC only involved near end of pt’s stay
  • AMR Usage:
    • Hospital staff unfamiliar with documenting psycho-social information into the AMR
    • Incomplete integration of AMR with organizational culture
job coverage loss rehosp recommendations
Job/Coverage Loss & Rehosp.:Recommendations
  • Care Team Communication
    • Psych team and SW make daily rounds together for all primary diagnoses of mental illness, psychosis, and drug overdose5
    • Fully integrated multi-disciplinary teams
  • Coordination of Social Services
    • Redefine the role of the HCC6,7,8
    • Automatic referral to SW in cases with primary dx. of mental illness, psychosis, or drug overdose
  • AMR Usage
    • AMR “Tab” for psycho-social information
    • Formal mechanism for staff feedback
job coverage loss rehosp tracking indicators
Job/Coverage Loss & Rehosp.: Tracking Indicators
  • Staff satisfaction rate with AMR (20% increase from baseline)
  • Voluntary exit survey for patients receiving Psych/SW team care
  • Percent of pts. admitted with diagnosis of mental illness, psychosis, or drug overdose, assessed by SW (100%)
  • Percent of pts seen by HCC within:

- 36 hours of admission (>95%)

- 48 hours of admission (100%)

5. Number of readmissions due to mental illness, psychosis, or drug overdose (10% reduction)

job coverage loss rehosp cost analysis
Job/Coverage Loss & Rehosp.: Cost Analysis
  • Cost Neutral Recommendations:
    • AMR changes (provided through IT contract)
    • Social Worker/Psych rounds
    • Referral policies
  • Incurred Costs
    • Additional HCCs (case managers)9
  • Savings
    • Reduce number of psych readmissions6
    • Reduced LOS by 10% with multi-disciplinary rounds5
    • Reduced per-patient cost of stay by up to 16% with multi-disciplinary rounds5
self extubation rca
Self-Extubation RCA
  • Root Cause Statement :

“The level of sedation & agitation

management increased the likelihood

of patient self-extubation”

  • Three major contributing factor domains were identified
self extubation contributing factors
Self-Extubation:Contributing Factors
  • Care Team Communication:
    • Time/location of pharmacist involvement
    • Communication b/w front-line providers
  • Policies & Procedures:
    • Extent of behavioral assessment
    • Availability/use of agitation management protocols
    • Availability/use of sedation and weaning protocols
  • Scheduling:
    • Provider staffing-level in ICU
self extubation recommendations
Self-Extubation:Recommendations
  • Care Team Communication:
    • Ensure timely urine/serum toxicology screens in conjunction with overdose protocols
    • Develop AMR flag for pharmacist consult in all cases involving drug overdose
  • Policies & Procedures:
    • Institute routine use of agitation management protocols by ICU staff (Ramsay)10
    • Institute use of sedation protocols in ICU11,12
    • Institute use of weaning protocols in ICU10,13
  • Scheduling:
    • Evaluate adequacy of ICU staffing/training10,14,15
self extubation tracking indicators
Self-Extubation:Tracking Indicators
  • Incidence of self-extubation (ICU)
  • Length of ventilator support (ICU)
  • ICU pt-nurse staffing ratios (1.5-1.7)
  • Number of pts (per 100 intubated pts) that score below 3 on two consecutive hourly Ramsay Assessments (Zero)
  • Percent of overdose pts whose records include RPh consult notes (100%)
  • Percent of overdose pts whose urine/serum toxicology screens are ordered w/in 1 Hr of admit to ER (100%)
self extubation cost analysis
Self-Extubation:Cost Analysis
  • Incurred Cost:
    • Increased ICU Staffing?
    • Physician/RPh Consult Fees
    • Implementation of protocols/training
    • Monitoring/ongoing risk assessment
  • Estimated Savings:
    • Decreased LOS in ICU (Decrease of 3.5 days)16,17
    • Shorter Duration of Ventilator Support (Decrease of 2.5 days17; between 63 and 89% of SEs do not require reintubation10)
    • Costs of Reintubation (>40% Decrease)11
recommendation summary
Recommendation Summary
  • Communication
  • AMR/organizational culture integration
  • Policies and Procedures
  • Expansion of care team member roles
  • Supporting AGH mission and values
    • Dignity
    • Collaboration
    • Stewardship
    • Excellence
what if
What If…
  • Psych would have been more actively involved in patient care?
    • Risk for self-harm would have indicated need for 1:1 staffing and/or suicide observation in ICU and suicide observation in Ward 10A
  • Pharmacy would have been more actively involved in patient care?
    • Patient and drug ID would have been confirmed
    • Patient PMH might have been available
    • Concerns over sedative interactions might have been dismissed
what if53
What If…
  • Social Services would have been more actively involved in patient care?
    • Patient job/coverage loss might have been avoided altogether
    • Patient would have had access to local mental health resources and “safety net” coverage
  • All three domains had been aligned with delivery of acute care?
    • No adverse events?
    • Patient would have certainly left our institution better off than when she arrived (in many ways)
targeting continuity of mental health services
Targeting Continuity of Mental Health Services
  • Within the Institution
    • Mental Health Services
    • Pharmacy
    • Social Services
    • Acute/Chronic Care
  • Within the Community:
    • Provider/MCO Collaboration
    • Partnerships
    • Regional Leadership
future directions
Future Directions:
  • Increase pharmacy integration:
    • Discharge Planning/Consultation18,19,20
    • Pharmacy and Therapeutics Committee18,19
    • Collaborative Drug Therapy18,19
    • Medication Reconciliation21
    • Psychiatric Pharmacist22,23
  • Integrating social services & behavioral health:
    • Functional Integration Team18 (AGH BHCE)
    • Wellness Recovery Action Plans24 (WRAP)
  • Ongoing collaboration between:
    • AGH & community pharmacies
    • AGH & satellite clinics
    • SWH & ValueOptions25,26
concluding remarks
Concluding Remarks
  • Consistent with:
    • Our institutional mission
    • IOM & IHI vision of the future
    • Our patients’ needs/rights to access & receive safe, reliable, and comprehensive care

“It doesn’t work to leap a twenty-foot chasm

in two ten-foot jumps”

-American Proverb

a report to the patient safety committee of arizona general hospital57

A Report to thePatient Safety Committeeof Arizona General Hospital

Prepared by Members of the

University of Missouri-Columbia Interdisciplinary Workgroup

for the CLARION INTERPROFESSIONAL CASE COMPETITION

SPRING 2005

references
References
  • Dlugacz, Y.D., Restifo, A., Scanion, K., Nerlson, K., et al. (2003). Safety Strategies to Prevent Suicide in Multiple Health Care Environments. Joint Commission Journal on Quality and Safety, 29(6), 267-278.
  • Harry S. Truman Memorial Veterans Hospital- Pharmacy operations and drug procedures. December 30, 2004.
  • Harry S. Truman Memorial Veterans Hospital- Prevention and management of disturbed behavior. April 22, 2004.
  • Harry S. Truman Memorial VeteransHospital- Management of suicidal policy. April 26, 2004.
  • Curley, C., McEachern, K. E., Speroff, T. (1998). A Firm Trial of Interdisciplinary Rounds on Impatient Medical Wards: An Intervention designed using continuous quality improvement. Med Care, 36(8), AS4-AS12.
  • Cox, W.K., Penny, L.C., Statham, R.P., Roper, B.L. Admission intervention team: medical center based intensive case management of the seriously mentally ill. Care Management Journals, 4(4), 178-184.
references59
References
  • Rubin, A. Is Case Management Effective for People With Serious Mental Illness? A research review. Health & Social Work, 17(2), 138-150.
  • Wickizer, T.M., Lessler, D. Do Treatment Restrictions Imposed by Utilization Management Increase the Likelihood of Readmission for Psychiatric Patients? Medical Care, 36(6), 844-850.
  • 2003 Case Management Salary Survey Results. In: Advance for Providers of Post-Acute Care. May/June 2003, 51-54.
  • Maccioli GA et al. (2003). Clinical practice guidelines for the maintenance of patient physical safety in the intensive care unit: Use of restraining therapies-American College of Critical Care Medicine Task Force 2001-2002. Critical Care Medicine. 31(11), 2665-2676.
  • Wagner IJ. (1998). A sedation protocol to prevent self-extubation. Chest. 113(5),1429.
  • Powers J. (1999). A sedation protocol for preventing patient self-extubation. Dimensions of Critical Care Nursing. 18(2), 30-4.
references60
References
  • Razek T et al. (2000). Assessing the need for reintubation: a prospective evaluation of unplanned endotracheal extubation. Journal of Trauma-Injury Infection and Critical Care. 48(3), 466-9.
  • Bray K et al. (2004). British Association of Critical Care Nurses position statement on the use of restraint in adult critical care units. BACCN Nursing in Critical Care. 9(5), 1-19.
  • Martin B and Mathisen L. (2005). Use of physical restraints in adult critical care: A bicultural study. American Journal of Critical Care. 14, 133-142.
  • Ramsay MAE. (2005). How to use the Ramsay Score to address the level of ICU sedation. Referenced Wed Document. Available at: http://5jsnacc.umin.ac.jp/How%20to%20use%20the%20Ramsay%20Score%20to%20assess%20the%20level%20of%20ICU%20Sedation.htm. Accessed on March 23rd, 2005.
  • Kress JP, Pohlman AS, and Hall JB. (2002). Sedation and analgesia in the intensive care unit. American Journal of Respiratory Critical Care Medicine. 166, 1024-1028.
references61
References
  • IHI 100,00 Lives Campaign. (2004). Getting Started Kit: Prevent Adverse Drug Events (Medication Reconciliation). The Institute for Health Improvement. Available at www.ihi.org.
  • Paone D, Levy R, and Bringewatt R. (1999). Integrating pharmaceutical care: a vision and a framework. The National Chronic Care Consortium & The National Pharmaceutical Council. Available at www.npcnow.org/resources/PDFs/IPCvisionpaper.pdf.
  • Saunders, S.M., Tierney, J.A., et al. (2003). Implementing a pharmacist-provided discharge counseling service. AMJHSP, 60, 1101-1103.
  • Rosen CE and Holmes S. (1978). Pharmacist’s impact on chronic psychiatric outpatients in community mental health. American Journal of Hospital Pharmacy. 35(6), 704-8.
  • Kaushal R and Bates DW. (2005). Chapter 7: The clinical pharmacist’s role in preventing adverse drug events. AHRQ Patient Safety Manual. Available at www.ahrq.gov/clinic/ptsafety/chap7.
references62
References
  • Arizona State Hospital. Wellness Recovery Action Plans (WRAP). http://www.azdhs.gov/azsh/patient_programs.htm.
  • ACP-ASIM. (2000). Pharmacist Scope of Practice. Position Paper. American College of Physicians – American Society of Internal Medicine. www.acponline.org/hpp/pospaper/pharm_scope.pdf.
  • ValueOptions of Arizona. Assertive Community Treatment (ACT). http://www.valueoptions.com/arizona/en/programs/act.htm
  • ValueOptions of Arizona. Contract implementation fact sheet: Recovery for adults with serious mental illnesses. Available at: http:// www.valueoptions.com/arizona/en/publications/fact_sheet_adult.pdf.
data sources for cost analyses
Data Sources for Cost Analyses
  • A - University Health System Consortium Clinical Database; January through December 2004 (Drawn from 9 geographically dispersed academic medical centers, bed size from 616 to 692, average # of beds = 660; when applicable, adjusted for 620 bed institution)
  • B - Annual Salary from: 2003 Case Management Salary Survey Results. Published in: Advance for Providers of Post-Acute Care; May/June 2003, 51-54.
  • C - University of Missouri Health Care, University Hospital; January through December 2004. (Identified at group request by the UMHC Office of Clinical Effectiveness; when applicable, adjusted for 620 bed institution)
  • D - Medicare Fee Schedule – 2004 (Intubation – Endotracheal Emergency – Code 31500)
acknowledgments
Acknowledgments
  • Kristofer Hagglund, PhD. Dean of Health Policy. School of Health Professions. University of Missouri-Columbia.
  • Kathryn Nelson, MHA. Patient Safety Officer. Office of Clinical Effectiveness. University of Missouri-Columbia Hospital.
  • Betty Nikodim. Senior Analyst. Office of Clinical Effectiveness. University of Missouri-Columbia Hospital.
  • Tim Anderson, RN. Patient Safety Manager. Harry S. Truman Memorial Veterans Hospital. Columbia, MO.
  • Barb Aston, MSW. Social Worker (Retired). Mid-Missouri Mental Health Center.
  • Kathryn Burks, RN, PhD. Faculty Advisor. University of Missouri-Columbia Sinclair School of Nursing.
  • Charles Brooks, MD, FACP. Residency Director. Department of Internal Medicine. UMC School of Medicine.
  • Rachel Haverstick, MA. Executive Staff Assistant. Center for Health Care Quality. University of Missouri-Columbia.
acknowledgments65
Acknowledgments
  • Laurel Despins, MS, APRN, BC, CCRN. Project Director. Office of Clinical Effectiveness. Clinical Nurse Specialist, Medical-Neurosurgical ICU. University of Missouri-Columbia.
  • Mark Kruse. Medical Records. Harry S. Truman Memorial Veterans Hospital. Columbia, MO.
  • Rebecca Wirth, MSW. Social Worker. Harry S. Truman Memorial Veterans Hospital. Columbia, MO.
  • Deborah Hurley. Human Resource Associate. Department of Health Management and Informatics. UMC School of Medicine.
  • Jane Bostick, RN, PhD. Faculty Advisor. UMC Sinclair School of Nursing.
  • Linda Headrick, MD. Sr. Associate Dean for Education. University of Missouri-Columbia School of Medicine.
contact information
Contact Information
  • Presenter Contact information:
    • Ashley Mahon: aem7ee@mizzou.edu
    • Russell McCulloh: rjm42b@mizzou.edu
    • Kevin Norris: kdn337@mizzou.edu
    • Brian Stout: bjs13e@mizzou.edu
  • UMC CLARION group was coordinated through the University of Missouri-Columbia Center for Health Care Quality (CHCQ)
    • For more information, please contact:

Rachel Haverstick, Executive Staff Assistant.

UMC Center for Health Care Quality

Medical Sciences Building, MA128

University of Missouri-Columbia. Columbia, MO 65211

Voice: (573) 882-8905

Fax: [573] 884-0474

Email: haverstickr@missouri.edu.