Multidisciplinary Performance Improvement. Improving patient outcomes by decreasing VTE through interprofessional collaboration

Transcription

1 Multidisciplinary Performance Improvement Improving patient outcomes by decreasing VTE through interprofessional collaboration

2 Goals & Objectives Define interprofessional collaboration Describe methods to leverage interprofessional collaboration to impact patient outcomes through the alignment of quality and education initiatives Describe the impact of an interprofessional team on VTE

3 VTE In the United States Alone Over 2 million new cases of DVTs occur annually. 1/10 go on to die of a PE. 200, 000 deaths annually which is more than Breast CA, MVC, and AIDS COMBINED! VTEs are one of the most preventable conditions. Only 40% of patients have appropriate prophylaxis. The risk for developing VTE varies between 10 85% (depending on reason for admission). The rate of fatal pulmonary embolus more than doubles between the ages of 50 and 80. 3

4 VTE = Never Event VTE Prophylaxis= An Always Event Effective October 1, 2008, CMS no longer pays hospitals at a higher rate for the increased costs of care that result when a patient is harmed by one of the listed conditions if it was hospital acquired. Instead, they will be paid as if the secondary diagnosis was not present. These are referred to as Never Events Chemical prophylaxis reduces the incidence of VTE by 50 65%. American College of Chest Physicians (ACCP) and other societal guidelines exist to guide VTE prevention efforts. American Society of Health System Pharmacists (ASHP) supports a National Educational Quality Initiative on Preventing VTEs. 4

5 Annual/Ongoing Costs to Treat VTE $11,000 per DVT episode per patient $17,000 per PE episode per patient Recurrence increases hospitalization costs by 20% Complications of anticoagulation Time lost from work Quality of life: post thrombotic syndrome and pulmonary HTN

6 The Perfect Storm..Sandy s Story Late 40 s Comorbidities Breast Cancer (in treatment) HTN BMI 34 Falls off horse trailer knee injury Total Knee Replacement Cleared by Physical Therapy Instructions keep leg elevated Knee immobilizer Crutches DC Plan F/U with ortho in 2 weeks Pharmacy continue home meds

7 The Perfect Storm..Sandy s Story Home day 3 Comfy on the couch Knee immobilized Day 4 Up to bathroom Couch to bed Reports to nurse on call Back of leg hurts Day 5 Ortho office Lower extremity US negative No orders Day 6 Feels SOA, doesn t feel right Calls PCP might be a virus

8 The Perfect Storm..Sandy s Story Day 7 Restless, confused, SOA Increased difficulty breathing 911 :Condition Critical + Femoral DVTs Massive bilateral pulmonary emboli Family informed prognosis was poor She may die without emergent intervention tpa Massive clot removed from left pulmonary artery, multiple smaller clots removed from both pulmonary arteries. Day 8 13 Complicated ICU stay Lifetime Medication management Coumadin SE of anticoagulants Limited mobility

9 The Impact of an Interprofessional team on quality outcomes

10 Interprofessional VTE Committee Liz Carlton, RN, Director: Quality, Safety & Regulatory Compliance Jeff Beasley, DO, Assistant Professor General and Geriatric Medicine Lauren Gray, RN, Nursing Informatics Michael Moncure, MD, Associate Professor Trauma and Critical Care Rashaad Chothia, MD, Internal Medicine Resident Sneha Phadke, DO, Internal Medicine Resident Chris Wittkopp, Director Quality Outcomes, Public Reporting Organizational Improvement Tim Williamson, MD, Associate Professor Pulmonary & Critical Care Medicine Vishal Jain, MMBS, Internal Medicine Resident Michelle Homan, DO, Internal Medicine Resident Chad Fisher, RNFA, Department of Orthopedic Surgery Tony Wiedal, RN, IV Therapy Nurse Anup Kasi, MBBS, Internal Medicine Resident Karthik Vamanan, MD, Assistant Professor Vascular Surgery Heather Cunningham, MD, Internal Medicine Resident Nancy Page, RN, Quality Outcomes Coordinator Organizational Improvement Theresa King, MD, Assistant Professor General and Geriatric Medicine Randy McMillen, PharmD, Clinical Pharmacist Samaneh Wilkinson, PharmD, Pharmacy Assistant Director Sue Pingleton, MD, Joy McCann Professor of Women in Medicine and Science Director, Quality and Professional Development Continuing Medical Education Kim Sanders, Manager, Continuing Education

11 Interprofessional Interprofessional collaborative practice: multiple health workers from different professional backgrounds work together with patients, families, and communities to deliver the highest quality of care(who, 2010) Interprofessional teamwork: The levels of cooperation, coordination and collaboration characterizing the relationships between professions in delivering patient centered care Interprofessional team based care: Care delivered by intentionally created, usually relatively small work groups in health care, who are recognized by others as well as by themselves as having a collective identity and shared responsibility for a patient or group of patients

12 Interprofessional collaboration Advantages: Shared professional competence and experience Collective responsibility Interprofessional communication Increase in resource availability Partnerships

13 Interprofessional collaboration Potential barriers Communication difficulties Time Commitment Resistance Differing professional views Lack of collaborative skills Lack of resources Role ambiguity and duplication of effort Level of experience

14 Goals Decrease VTE rates house wide Create standard order sets Increase staff awareness of the impact and importance of VTE screening & intervention Ensure evidence based management for VTE prophylaxis Identify trends and implement interventions Research Meet Meaningful Use and Core Measure requirements

15 Chart Review Forms

16 Themes The University of Kansas Hospital 16

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19 Best practice Education Awareness Integration

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22 Standardized order sets CPOE BPA

23 Interprofessional Team Approach Physician Screening Orders Decrease interruptions Education Nursing Screening Order implementation Decrease interruptions Mechanical interventions Progressive mobility Education Pharmacy Screening Order implementation Decrease interruptions Surveillance Education Physical Therapy Early progressive mobility Mechanical interventions Education

24 Physician Roles in VTE Prevention Promptly assess the patient Place and maintain appropriate orders Minimize disruptions and ensure continuity Utilize societal guidelines and the University of Kansas Hospital Risk Assessment Tool and Guidelines

25 The Pharmacist s Role in VTE Prevention Screening tool in EMR: Order implementation Decreased interruptions Education: Indications/contraindications Appropriate agent and dose Risks vs. benefits of VTE prophylaxis

26 The RN s Role in VTE Prevention VTE prophylaxis screening On admission Per shift Change in condition Transition of care RN to MD communication Medication Administration Initiation Timing Interruptions Home therapy and discharge teaching Mobility assessment and collaboration with PT Importance of mobility SCD utilization Clinical surveilance Postoperative patient review Screening Timing Interruptions

27 Role of PT in VTE Prevention Be aware of patient s risk factors for VTE Be aware of chemical prophylaxis or lack thereof Support, encourage, and provide patient mobility Encourage use of SCD s when patient is resting Instruct patient in risk factors, importance of mobility, and signs and symptoms of VTE 27

28 Physical Therapy s Role Mobilization When and how much is enough? Chandrasekaran et al,

29 What if Sandy s physician had. Utilized evidence based guidelines for VTE prevention? Started VTE mechanical and chemical prophylaxis within 24 hours of end of surgery Discharged on at least days of chemical prophylaxis Encouraged frequent ambulation Educated on signs and symptoms of DVT/PE

30 What if Sandy s pharmacist had. Noticed there was no VTE medication prophylaxis ordered Very high risk (10 20%) for VTE based on procedure alone No contraindications present Noticed 3 additional risk factors for VTE BMI > 29 Dx: Breast CA Age y/o Taken a moment to ensure that Sandy received the standard of care! VTE medication prophylaxis for total knee with 3 additional risk factors

31 What if Sandy s RN had. Screened to see if Sandy had appropriate VTE prophylaxis? Alerted the physician about the absence of VTE prophylaxis? Asked Sandy about her understanding of VTE prevention and her post/op care? Collaborated with PT to ensure Sandy had an effective plan in place to ensure early mobilization?

32 What if Sandy s physical therapist had. Informed her of the risk for post operative VTE? Instructed her in the importance of early post op ambulation to prevent VTE? Instructed her in the signs and symptoms of VTE? 32

33 What if Sandy s healthcare team had taken an interprofessional approach to her care? 33

34 VTE rates before initiatives The University of Kansas Hospital

35 Interprofessional Actions Chart Reviews Electronic Medical Record Best Practice Alert Order sets Timing of dose PICC Use algorithm Alternative VAD Education/training Pharmacy Education Active surveillance Nursing Quality initiative Quality & Safety Investigator focus Chart Reviews Physician Patient Safety Conference Service Specific Meetings Pediatric Focus Mechanical Compression Evaluation SCD vs AVI TED vs Gradiant Stockings Education Video CME VTE Sharepoint Data distribution Chairs Directors Managers Communication Plan Candy Cart Badge Buddy

36 Current State VTE Rates The University of Kansas Hospital

37 SUCCESS The extent to which different healthcare professionals work well together can affect the quality of the health care that they provide. Patients are recognized as the ultimate justification for providing collaborative care

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39 References Core Competencies for Interprofessional Collaborative Practice Sponsored by the Interprofessional Education Collaborative Report of an Expert Panel May resources/ipecreport.pdf Executive Summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence Based Clinical Practice Guidelines Chest February :2_suppl 7S 47S Qaseem et al, Venous Thromboembolism Prophylaxis in Hospitalized Patients: A Clinical Practice Guideline From the American College of Physicians Annals Internal Medicine 1 November (9): American College of Chest Physicians (ACCP). Prevention of venous thromboembolism. American College of Chest Physicians evidence based clinical practice guidelines (8th edition). Chest 2008 Jun;133(6 Suppl):381S 453S. [728 references] American Academy of Orthopaedic Surgeons (AAOS). American Academy of Orthopaedic Surgeons clinical guideline on prevention of symptomatic pulmonary embolism in patients undergoing total hip or knee arthroplasty. Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS); p. [49 references] Society of Hospital Medicine VTE Resource Guide: AHRQ Prevention of VTE Following Hip and Knee Reconstruction Synthesis of Guidelines :