Facilitating optimal discharge plans for high risk patients …促进高风险患者的最佳治疗方案….ppt

Massachusetts General Hospital Anticoagulation Management Service,Lynn B.Oertel,MS,ANP,CACPClinical Nurse SpecialistPresented November 4,2008,Timeline of ATU/AMS,2008 NPSG(selected),1-Improve accuracy of patient identification2-Improve the effectiveness of communication among caregivers3-Improve safety of using medicationsRequirement 3E:Reduce the likelihood of patient harm associated with the use of anticoagulation therapy,New,http:/www.jointcommission.org/,2008 NPSG(selected),8-Accurately and completely reconcile medications across the continuum of care9-Reduce the risk of patient harm resulting from falls13-Encourage patients active involvement in their own care as a patient safety strategy15-The organization identifies safety risks inherent in its patient population,NQF Safety Standards,Safe Practice 17:Evaluate each patient upon admission,and regularly thereafter,for the risk of developing DVT/VTE.Utilize clinically appropriate methods to prevent DVT/VTE.Safe Practice 18:Utilize dedicated anti-thrombotic(anticoagulation)services that facilitate coordinated care management.,http:/www.qualityforum.org/,Goal is to reduce incidence of surgical complications nationwide by 25%by 2010SCIP VTE1 Surgery patients with recommended VTE prophylaxis orderedSCIP VTE2 Surgery patients who received VTE prophylaxis within 24 hours after surgery,www.qualitynet.org,see Other Resource:About the Project,OSG Call to Action Sept 15,2008,http:/www.surgeongeneral.gov/,The Joint Commission Sentinel Alert Sept 24,2008,http:/www.jointcommission.org/SentinelEvents/SentinelEventAlert/,Clinic overview,Patients=4100+Mean age=69 yrs,SD 13.65,range 20-100Common indications for treatment:AF 57%VTE 15%Heart Valves 9%INR intensity ranges2 3 87%2.5 3.5 9%By request,selected others,Admissions:75/month+Reactivated patients 60%new referrals from inpatient(POE Consult referral)Discharges:90/month,Time in Therapeutic Range,TTR calculated using Rosendaal methodStrict range limits,eg.2 3 and 2.5 3.5Using ALL INR data(induction,interruptions,etc),Percent INR tests out-of-range,In Range(2 3)=60%Above 3=15%Below 2=25%,Percent Very High 5=0.8%7.5=0.2%,Percent Very Low 1.3=0.3%,Communication and Education for Patients and Physicians,Key elements for improvedpatient management,Patient focused,primary nurse modelPhysician Order Entry for AMS Consult Referral(nearly all data fields mandatory for submission,thus all critical info received)Dawn AC(patient management system for maintenance and transition patients)3 Interfaces:ADT Interface(electronic notification for AMS patient admissions/discharges)Outbound message Interface(AMS icon/communication facilitator)Results Interface(electronic INR entry into Dawn AC from lab system)Hospital“buy in”Information System support(2 FTEs)Pharmacy support(AMS Discharge Rx),AMS Communication with Patients,One-time face-to-face educational visit with patient&family and primary nurseFollowed by telephone calls to patient for short period to review subsequent INR values,current dose instructions,and date of next INRThereafter,written instructions are mailed with same information.Dose info communicated via#pills not mg.(finalizing plans to initiate email communications,when desired by patient)Telephone assessments more common than face-to-face visitsCommunication interventions are individualized to meet patient needs over time,Patient Satisfaction,“My ranking of this program:First Class Service.”“The anti-coag service is great.I go to Florida 3 months during the winter months and I am able to keep track of dosages and INR levels easily.My daughter calls in for me and lets me know if there are any changes in dosage to be made.”“I have nothing but praise and appreciation for the concern and care over the years.”“Knowing your clinic keeps a very close check on my Coumadin levels gives me a sense of security.Your reporting is prompt and directions clearly stated.”,Nursing Implications for Anticoagulated Patients,Knowledge of patient risk v.benefit of treatmentSafe and quality care management Know goal therapeutic INR range and treatment plan.Utilize systematic,standardized protocols and decision support tools.Monitoring Tracking and patient follow-upEffective communication and coordination of multiple care providersPatient&Family Education,include health literacy assessment,modification of risks,standardize curriculum&education materials,Achieving good outcomes is dependent upon:,AMS Patient Education Slide Show Standardized education curriculum content,individualized for patient-specific needs,Written materials support contentof slide show,AMS Brochure,Patient Education,To prepare for discharge,can patient Identify signs and symptoms of VTE(or bleeding)Describe action to take if occurs Identify warfarin managerRecite instructions for follow-up including:daily dose schedule,confirmation of pill size,date of next INR Describe plans for blood testing and future monitoringDescribe management and disposal of medications,especially sharps disposal per town regulations,2.Reminder of pill size,Dose Instruction Letter,1.INR result and Target Range,3.New weekly dose instructions(repeat schedule until next dose letter arrives),4.Date for next INR test,may see a message to skip 1 or 2 days(patients generally recd a phone call at the time),Dose Instruction with skip,If INR is high,Then,follow weekly dose instruction here,Compliance Process,Automated follow-up support by Dawn AC,details developed by AMSFive Stages a letter mailed to patients at each stage underscoring safety concernsFormal discharge letter sent with delivery confirmationCollaboration with referring physicians(possibly case management)at critical milestonesEmailed formal notices at Final and Discharge StagesCustomized letters/emails in Dawn ACHighly efficientBatch printed or emailedExcellent documentation trail,Reminder Letter for missed INR date,Dedicated line for calls,This informationneeded,or email same information,Auto-reschedule of INR Date,AMS Icon,Indicates patient is an active patient in AMSAppears on electronic medical records(1 in-patient,2 out-patient systems)Click on icon,new window displays critical data elements about the patient from AMS database,AMS icon CAS,LMR and OnCall,COMING NOVEMBER 7,Phase II AMS Icon,CPOE Consult Referral,Creates an electronic referral to AMSEfficient,user-friendly,fast turn aroundEnsures key clinical information provided since most fields mandatory,AMS Consult Referral,AMS Consult Referral,Outpatient Paper AMS Referral,Transition Pathway Services,Induction PathwaysNew Start Warfarin OnlyNew Start Warfarin with LMWHNew Start Warfarin with Fondaparinux,Bridging PathwaysResume Warfarin OnlyResume Warfarin with LMWHResume Warfarin with Fondaparinux,Communication Strategies,Transition PathwaysFloor by floor roll-outMulti-disciplinary approach(medicine,nursing,pharmacy,case management,target key leaders):Grand roundsInservice education sessionsPrint materials(newsletters)Main Corridor eventsElectronic resourcesPOECAS alertsAll user(select user group)Broadcast email messagesWeb page presence with multi-source access to key anticoag-specific documents via hyperlinks,Role Group Responsibilities,Referring PhysicianComplete referralOrder baseline lab workSubmit AMS Rx,AMS NurseReviews/confirms eligibility and seeks clarification,as needed“Meets and Greets”patientWritten instructions for pt.Assumes anticoag management day after discharge,Floor NurseObtain patient weightConduct medication discharge teachingCompletes discharge process and ensures patient leaves hospital with meds and instructions,Case Management/VNAsMay/may not be involvedCoordinates needs/services at home,Pharmacy Delivers AMS Rx to floor,E-Z Guide,Resources,Your Guide to Coumadin/Warfarin Therapy Agency for Healthcare Research and Quality,http:/www.ahrq.gov/consumer/coumadin.htmImportant information to know when you are taking:Coumadin and Vitamin K-http:/ods.od.nih.gov/factsheets/cc/coumadin1.pdfAre you at risk for a DVT Blood Clot-http:/www.preventdvt.org/OSG Call to Action,Sept 15,2008-http:/www.surgeongeneral.gov/The Joint Commission Sentinel Alert,Sept 24,2008-http:/www.jointcommission.org/SentinelEvents/SentinelEventAlert/Nursing Model for Anticoagulation Service http:/,Conclusion,Collaborative communication strategies across disciplines are needed to support and reinforce the patients treatment plan.Patient education about prevention,disease process and treatment is vital for successful outcomes.Detailed written reinforcements are critical elements.,