Improving Transition Home through a Standardized Discharge Process. Christopher D. Baker, MD Associate Professor of Pediatrics May 10, 2016
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1 Improving Transition Home through a Standardized Discharge Process Christopher D. Baker, MD Associate Professor of Pediatrics May 10, 2016
2 Objectives Identify components of the Children s Hospital Colorado discharge process and Pediatric Respiratory Care Unit that may translate to local team s practice in Ohio Describe key aspects of the Children s Hospital Colorado High Fidelity Simulation training to increase parent/caregiver confidence prior to discharge
3 Ventilator Care Program VCP Mission: To provide quality inpatient-to-outpatient care for children with chronic respiratory failure Interdisciplinary Team: Pulmonary Neonatology Critical Care Cardiology ENT Rehabilitation Respiratory Care Nursing Developmental Therapies Social Work Case Management Part of the Pediatric Heart Lung Center
4 Ventilator Care Program Collaboration is key: Weekly rounds include rotating teams (Pulmonary, NICU, PICU) with Drs. Baker and Gien providing continuity and oversight An environment of mutual respect / learning Consult Pulmonary and ENT early NICU VCP rounds: Friday 11:30am-12:30pm; at bedside (w/ family) Pulmonary VCP rounds: Wednesday 1:30pm-2:30pm; rest of hospital
5 Ventilator Care Program CHCO VCP patient cross-section: 15+ chronically ventilated inpatients 100+ chronically ventilated outpatients Seven state region (many in rural setting) Pediatric Respiratory Care Unit (PRCU): chronically ventilated patients not in ICU Survival of chronically ventilated infants with severe BPD has markedly improved: Gien 2015, unpublished
6 Ready to Discharge Initiative Large-scale Quality Improvement efforts Safe and timely discharge after trach placement Initial areas of focus: Standardize patient/family education (Simulation) Optimize care coordination Improve patient outcomes Process mapping: Increase safety, improve efficiency, define roles, ensure that nothing gets overlooked
7 Process Mapping VCP Leadership team: MD, RT Director, (I/O) Advanced Practice Nurse, (I/O) Nurses Addition of Process Improvement Specialist to team Process map draft created early by team Regular meetings: twice/month monthly Small-group meetings: RT leads, Developmental Therapists, Case Managers / Social Work, Subspecialists Tell us what you do? methods vary, individual styles Post-it Notes Discuss what works? Show draft map edit with them, add what is missing Leadership team: created final version
8 Process Mapping Baker 2016 Pediatrics 137:e
9 Chronic Ventilation Road Map Simplifies the process map Outlines processes involved in transition home with chronic ventilation Conveys educational goals Summarizes the skills to be mastered before discharge (not Skills Checklist) Laminated in each child s room Demonstrates our vision to hospital staff, consultants, students, trainees
10 Baker 2016 Pediatrics 137:e
11
12 Patient and Family Education
13 Patient and Family Education Discharging chronically ventilated children to home requires extensive training and education of family and caregivers There are still challenges around adequately training caregivers for at-home emergencies
14 Performance-Based Education Interdisciplinary teaching collaborative, with Nursing and Respiratory Therapy taking the lead Teach-back Method Multiple modalities utilized (verbal, written, hands-on, repetition, videos) Education and teaching sessions are modified to address each family caregiver s learning needs (e.g., language barrier, inability to read, dyslexia) Timelines, checklists, color-coded medications
15 Educational Handouts Notebook for patients and families created by an interdisciplinary team Collection of individual handouts and checklists o The Breathing System o What is a Tracheostomy o What is Chronic Ventilation? o Modes of Ventilation o Bag trach ventilation o Routine Suctioning o Routine Tracheostomy change o Cleaning a Tracheostomy tube at home o Trach tie changes o Is my ventilated child sick? o Transporting my child who is ventilated o Emergency Tracheostomy changes
16 Educational Videos Videos parallel print materials in both English and Spanish 4 of 11 videos completed Current Titles: (on DVD, YouTube, CHCO website) Bagging - How to Manually Ventilate Your Child Emergency Airway Care Accidental Decannulation Emergency Airway Care Plugged Tracheostomy Tube Emergency Airway Care Ventilator Malfunction
17 Educational Videos Bagging - How to Manually Ventilate Your Child
18 Tracheostomy CPR Class In the past 5 years at CHCO, 4 VCP patients have had a cardiopulmonary arrest at home Of those 4, only 1 of them received timely CPR with compressions AHA CPR Anytime curriculum coupled with a tracheostomy CPR class. All primary caregivers attend the class
19 High Fidelity Simulation (SIM) Recreate emergent clinical scenarios in a safe artificial setting Advantages: No direct risk to patients Reflective learning Debrief with family Potential to decrease errors during crisis management Assessment of caregiver comfort level pre and post simulation
20 High Fidelity Simulation (SIM) Takes ~90 minutes (+debriefing) Two Complex Scenarios: Plugged tracheostomy requires suctioning the trach Ventilator malfunction requires full CPR and calling 911 To date, caregivers of 45+ children (82+ caregivers) have completed high-fidelity simulation
21 High Fidelity Simulation (SIM) Simulation scheduled during week before discharge (to confirm or reinforce skills) SIM provided for all families before discharge serves to identify gaps in understanding Caregiver feedback largely positive Limitations: cost/time, novel vs. lacking evidence Tofil 2013 Clinical Pediatrics 52:1038
22 Care Coordination
23 Care Coordination and the EMR Technical Optimization: Order sets (fresh trach, established trach, admission) Consult Order Patient Lists Standard note templates Ventilator Care Action Plan Enhanced Assessments: Alignment with RN, RT, & Case Management
24 Improved Chronic Ventilation Rounds Weekly interdisciplinary rounds Project the patient s chart and pertinent information Discharge Readiness Report Keeps team focused on discharge goals Allows team to see/edit discharge criteria Allows all team members to see progress toward discharge
25 Discharge Readiness Report
26 Care Coordination and the EMR VCP Consult Advisory
27 Care Coordination and the EMR Admission Order Set
28 Care Coordination and the EMR Admission Order Set (cont)
29 Care Coordination and the EMR Patient List
30 Telemedicine: Discharge Care Conference
31 QI Metrics / Outcomes
32 Data analysis Compare length of stay (LOS) parameters: Overall LOS Trach placement to hospital discharge PRCU transfer to discharge Pre-/Post-intervention study groups: Before Ready to Discharge Initiative: 3/2011 to 2/2013 After Ready to Discharge Initiative: 3/2013* to 12/2014 (*2 months after formal meetings began Jan 2013)
33 Decreased Overall Length of Stay Results: Baseline mean LOS (n=18): 249 days (8.3 months) Post-project mean LOS (n=30): 143 days (4.8 months) 42% reduction in overall LOS (p=0.002) Baker 2016 Pediatrics 137:e
34 Decreased Time in PRCU Results: Baseline mean PRCU LOS (n=18): 112 days (3.7 mo) Post-project mean PRCU LOS (n=12): 50 days (1.7 mo) 55% reduction in time after ICU transfer (p=0.001) Formal Project initiation Baker 2016 Pediatrics 137:e
35 Patient Outcomes Before/After Standardized Discharge Process Baker 2016 Pediatrics 137:e
36 SUMMARY VCP: quality inpatient-to-outpatient care Collaboration: interdisciplinary team it s the people, not the map Education: families and providers Learning through many modalities: hands-on sessions, handouts, videos, SIM, repetition, repetition, repetition Outcomes: improved using a team approach Partnership: It takes a village!
37 FUTURE DIRECTIONS Clinical: Improved partnerships with private duty nursing agencies (PDN) Standardization of PDN education, skills maintenance High-fidelity simulation: Expansion from VCP to all tracheostomy patients Additional education videos Use of SIM to train homecare nurses Telemedicine: In-home visits (current pilot) Remote consultation Barriers: site of practice, payer reform, licensing
38 Discussion / Questions Christopher.Baker@UCDenver.edu
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