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The Perioperative Experience. Patient & Nursing Education Anemia Management and Intra-operative Data Collection September 21, 2013 . For patient centered care. Fight On. . Patient Blood Management (PBM) at USC An Evolving Program with New Directions! . Learning Objectives for SABM .

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the perioperative experience

The Perioperative Experience

Patient & Nursing Education

Anemia Management

and

Intra-operative Data Collection

September 21, 2013

For patient centered care.

Fight On.

learning objectives for sabm
Learning Objectives for SABM

Define meaningful Patient Blood Management (PBM) data essential to reporting patient outcomes

Establish the growing role of nursing practice in optimal PBM in a variety of settings

Identify strategies for educating and training healthcare professionals in PBM

Define & Communicate meaningful PBM data that is essential to quality reporting in a format that may correlate w patient outcomes

Establish the growing role of nursing practice in optimal PBM in a variety of settings

data tracking difficulties with pbm
Data Tracking Difficulties with PBM

Real Time Intra-op data not well collected from paper or even Electronic Medical Records (EMR) computed formats

What – No clear definition of what data is important

Who – No consistent designee(s)

How – No consistent mechanism

Where – No clear pathway into which to feed the data

surgical timeout
Surgical Timeout

Prior to commencement of operation

A confirming event for patient safety & global intra-op awareness

Multi-disciplinary coordinated effort in OR to Identify

Correct Patient, Surgeon, Anesthesia

Antibiotics

Correct Site and Laterality

Allergies

Procedure

Documentation for Quality record keeping

pbm timeout why not new variation on old theme
“PBM Timeout”Why Not?--New Variation on Old Theme

Perform near completion of surgery

Allows for a multi-disciplinary coordinated effort in OR to identify input from Nursing/Anesthesia/Surgery in real time data format

Goal:

Accurately capture important data elements in an operative EMR module – the Intra-op PBM Dashboard – written as a Power Form

Intra–operative PBM Dashboard, then uploads dataset into hospital EMR

EMR then query–able for all loaded PBM data

Allows accurate collection & tabulation of important clinical variables that historically never had a good capture mechanism and usually have to do chart reviews to identify

data tracking difficulties with pbm problems solved
Data Tracking Difficulties with PBMProblems Solved

No clear definition of what data is important

We define the important variables to track

No consistent time, no consistent designee(s)

Near Completion of Case

Nursing – Anesthesia – Surgery

No consistent mechanism

PBM Timeout

No clear pathway into which to feed the data

Intra–op Dashboard (Power Form) to the EMR

patient blood management timeout institutional implementation of a new process
Patient Blood Management Timeout Institutional Implementation of a New Process
  • Circulating Nurse is Captain of both timeouts and responsible for accurate data entry
  • Functional efficiency of the Power Form and the Intra–op Dashboard
  • Do a walk through of the process
process walkthrough pbm intra op dashboard implementation
Process Walkthrough PBM Intra-op Dashboard Implementation

PBM Committee identifies important clinical variables and develops mock–up of the module

Intra-op module presented to OR Committee as well as IT and EMR Committee’s for acceptance of process and creation of the Power Form that integrates with EMR

Quality Committee approval for a process that must be monitored and reported

OR Charge Nurse is key for OR Committee to approve the role of nursing here and to develop the nursing competencies to direct the process and supply the data entry

slide20

Establish the Growing Role of Nursing Practice in Optimal PBM in a Variety of SettingsAnemia Management Program – Patient MarketingPACE – Outpatient Clinics – ICU’s – CRNA’s Physician Offices – Interventional Radiology

nursing as the driving force for cultural change in patient blood management

Nurses and NPs have most immediate patient contact (inpatient and outpatient)

In addition, Nurses and NP’s are the managers of the services provided at the major Patient–Entry Portals

Nursing Council for PBM–New Concept here as well

Nursing managers that oversee hospital service service lines to develop Power Form templates specific to their service line

Submission to the PBM Cmte for approval and IT for creation

Nurses define workflow for Site-Specific power form

Nursing as the Driving Force for Cultural Change in Patient Blood Management
slide22

Council of Nurse Managers of hosp service

lines. Develop EMR power forms & define

workflow pathways for completion. Educate

staff while quality monitors performance

Hospital Culture Transformation

Continuing Education

QA Responses to Fallouts

Critical Clinical Pathways

ANH-AMP-Tx Guidelines

QA Structures

Data Tracking & Sorting

Universal Credentialing Practices

Hospital Based Committee Integration

EMR Integration of TFS & PBM Data Metrics

Departmental-Service Line & Programmatic Involvement

Nursing Advisory Council

anemia pbm public enemy 1
AnemiaPBM Public Enemy #1

Anemia

Leads to Transfusion

Often correctible in a short period of time

Nevertheless, accompanies many patients to the OR

And now we can track that in our Dashboard

And it can become a fallout by service line or even by MD

And it can become a PI project

Nevertheless,

Insurance authorization for ESAs for anemia correction can be difficult, so cannot put pressure on service lines or physicians to correct anemia without some type of institutional effort to centralize and soften the problem

anemia management program amp centralized institutional response to pre operative patient anemia
Anemia Management Program (AMP)Centralized Institutional Response to Pre-operative Patient Anemia

Anemia Management Program

Piggybacks off the OIC cost and personnel center – low $

Authorizations for ESA’s

Infusions, injections, oral therapies

Hyper–augmentation

JW procedures

Conventional Hospital Program Structure

Medical Director

Nurse Manager

P&P’s, Pathways, Order Sets

Visits registered into EMR for inclusion in PBM Dashboard

pbm business and operational impacts
PBM Business and Operational Impacts

Allays administrative concerns:

Reduced inpatient stay

Blood product utilization

Shifts cost of anemia therapeutics to reimbursable outpatient setting

Facilitates physician concerns:

“One-stop-shop” anemia Rx eliminates operational inefficiencies

Increase patient satisfaction:

Public increasingly aware of transfusion risks

Market program and transfusion alternatives directly to patients

outpatient marketing to patients
Outpatient Marketing to Patients

SMART THING!

Pharmaceutical companies did market directly to patients – even if the medication required a prescription

Once we have directly sparked patient interest and involvement – that will often trump the resistance to old ways of practice which can then drive the agenda towards modern PBM

Patient then will mention to anesthesia in PACE clinic that they want conservation practice

objective
OBJECTIVE

Identify strategies for educating and training healthcare professionals in PBM

education as a tool for cultural change clinical non clinical staff as targets

Applicable to Personnel Types

Nurses, CRNAs, NPs, Nurse Managers

Physicians

Residents

Staff – Unit Clerks, Pharmacy, Blood Bank, Pre-operative Assessment & Clinical Education (PACE)

Administration – Quality Admitting, ER, Professional Committee’s

Education as a Tool for Cultural change Clinical & Non-Clinical Staff as Targets
education as a tool for cultural change services as targets

Hospital based service lines where the action is:

Focus educational attention here.

Many--Nurse Managed

Admitting – ER – Outpatient Department – Transfer Center - PACE

OR – OR Scheduling – Blood Bank – AMP

ICU – Interventional Radiology

Pharmacy – Perfusion Services

Education as a Tool for Cultural Change Services as Targets
nursing education

Credentialing for TFS and PBM as a condition of employment

NPs belong in credentialing piece in same fashion as physicians

Nursing competencies as part of healthstream

Re-take test in circumstances where there is a fallout (TFS particularly)

Staff education falls in with nursing education

Nursing Education
competency module
Competency Module
  • ANCILLARY

Laboratory

Pharmacy

Perfusion Services

specialty or service line credentialing or competency module

All nurses take a general nursing test

Nurses who work for particular hospital based svc would have to take test that included dashboard material for that service line

Make it a condition of employment or referral

Define Fallouts

Fallouts trigger administrative response from PBM program- retake the module for both the offending person as well as the service line manager

Specialty or Service Line Credentialing or Competency Module
slide39

Site Specific Data-Form designed by Nurse Mgrs+ QA + PBM Committee

Model for Data Form creation that generates EMR Powerforms

To IT for creation of Powerforms into EMR

Dashboard supported by EMR

Re-educational processes for individual or Service Line fallouts

Implementation

Workflow Defined

Quality & Nurse Mgrs do Oversight + define fallouts

Functional Process at Site Specific Location

Education for Competencies

multi entry points
Multi-Entry points

Demonstration of the multiple entry points from Institutional Site Specific Locations into the EMR via Powerforms

slide41

Interventional Radiology

Critical Care

Anemia Mgmt Program

Operating Room

Pharmacy

Blood Bank

Donation (PAD, Directed, Unpaid) donor Centers

Clinical Dataforms Fed into Cerner as Powerforms

Other Clinical?

Laboratory

PBM Dashboard (from EMR)

Financial Data

Utilization Review Data

model for pbm derivative from tfs
Model for PBM Derivative from TFS

PBM Critical Pathway for Detailed Analysis of Actual Blood (Product) and Blood Product Costs within the Institution

Followed by Institutional Response to

Interrogated Data

slide43

Metrics of Performance

Physician

Service Line Department

Hosp-based Svc

Fallouts

Institutional Pressure

PBM & Quality Cmte Driven Queries

PBM Dashboard (from EMR)

questions
Questions?

Thank you!

Yolee Casagrande, RN, MSN

Nurse Director

Evaluation & Treatment Clinic (ETC), Observation Unit, Infusion Center, Women’s Health Services, and Department of Surgery Clinics

323 442 9696