Nurses Blending Caring Practice with Teaching to Improve Medication Communication 2018 NICHE Conference Date: Thursday, April 12, 2018 Session: 1 Time: 1:30-2:45 Track: Health, Wellness and Transitions Intermediate Cardiac Care Unit Cindy Rivet MS, RN, CNL, CVN, NE-BC Clinical Manager of CCU/PCU Disclosures The speakers have no relevant financial or nonfinancial relationships to disclose The Miriam Hospital The Miriam Hospital is a 247 bed, private, not-for-profit, community, teaching hospital, affiliated with Brown University, located in Providence, RI Founding partner of Lifespan, a comprehensive health care system Has more than 2300 employees 870 physicians 50 full-time house staff (medical school graduates) 700 registered nurses Five time recipient of the Magnet Award for Excellence in Nursing NICHE member since 2008 1
Care Environment The Coronary Care Unit 9 bed medical teaching high level intermediate care unit, specializing in the complex needs of cardiovascular patients Staff Clinical Manager Clinical Nurse Leader Master s Student for duration of pilot project Advanced Practice Manager 19 RNs 4 Licensed Independent Practitioners 6 CNAs 4 Secretaries Quality Improvement/Quality Assurance Data Analysis CCU HCAHPS scores Medication Communication & Quietness of Environment were lowest scores Decided to focus on Medication Communication Multiple types of medications are prescribed during and after hospitalization Cardiac medications are high on the list of those that can cause serious harm Patients with cardiovascular disease are at a higher risk for errors and adverse drug events after discharge Hospital Priorities 2
Professional Practice Model Method/Measure of Success Consistently provide medication information to patients in a way that is understandable during their hospital stay Promote safe medication- taking behaviors after discharge Earlier recognition of adverse drug events Improve medication adherence after discharge Reduced patient re-admissions Show improvement in HCAHPS scores Literature Patient reported measures are strongly correlate with better patient outcomes and largely represent nurse and physician communicationbased care Higher hospitallevel patient satisfaction is associated with lower 30-day riskstandardized readmission rates (Boulding, Glickman, Manary, Schulman & Stalin, 2011, p. 46) (Bartlett Ellis, Bakoyannis, Haase, Boyer & Carpenter, 2016, p. 1149) 3
Baseline Data 3 rd Quarter : April-June 2016 Top-Box Always Percentile Rank by Received Date Overall Communication about Medications 26 th percentile o Staff describe medicine side effects = 12 th percentile o Staff tell you what new medication is for = 55 th percentile o Patient understood purpose of medication = 66 th percentile Goal: 50 th percentile in the Overall Medication Communication Domain during pilot project Med-COMM Project CCU s project was designed to increase patient satisfaction with medication communication 5 Components: 1. Tailored medication education sheets for CCU patient population 2. Signage in patient rooms 3. Nursing specific intervention 4. Collaboration between RNs, MDs & LIPs, Pharmacy 5. Daily Leadership rounds Tell me and I forget. Teach me and I remember. Involve me and I learn ~Benjamin Franklin~ Project Approval/Resources Approval by: Pharmacy Nursing Executive Committee Patient Experience Committee CCU Quality Improvement/Assurance Committee Utilized: Lifespan Print Shop Lifespan Interpreter Services 4
Tailored Medication Sheets Collaborated with Pharmacy-Omnicell utilization list Tailored to CCU patient population/highly administered medications Sorted by Drug Class 1. Medication name 2. Purpose 3. How often to take medication 4. Side effects Patient centered language and graphics Handout to patients on admission to CCU o Promotes on-going discussion about medications and patient involvement in Plan of Care 5
Patient Rooms Addition of signage above white-board: As part of our goal to provide you with excellent care and prepare you for a safe discharge, we want to ensure you know your medications and their possible side effects. Always Ask if you have questions or concerns. 6
Nurse s Role 1. Med-COMM Intervention** Establish dedicated uninterrupted time spent with patient/caregiver to discuss medications and answer questions for at least 5 minutes every shift Talk about medication, its purpose and at least 1 side effect Document in care plan under Discharge Planning Med- COMM intervention performed and include any pertinent information **Intervention is in compliance with Lifespan RN Standard Care Protocol for Patient Education Nurse s Role-Teach-Back Discharge process Ask clarifying questions to validate the patient s understanding of health information Patients who clearly understand their post-discharge planincluding how to take their medications-are 30% less likely to be readmitted or visit the emergency department than patients who lack this information. Peter et al, 2015, p.36 Staff Reminders Reminder cards placed on each computer workstation 7
Collaboration Collaborate with MDs & LIPs during patient care rounds for medication dosing revisions or additions CCU does not have a dedicated Pharmacist- shared with Specialty Care Unit & Medical Intensive Care Unit Nursing places a Pharmacy consult if education, more indepth than nursing can provide, is necessary CCU/Pharmacy Collaboration Early identification by RNs of patients who may benefits from PharmD consult: Complicated cases Non-compliance/Cost Issues History of frequent readmissions Starting new therapy Hours available: M-F 730a-3p Leadership Role Implement daily rounds to assess compliance New admissions to CCU 1. Do you have any medication questions? 2. Did your nurse teach you about your medications? Provide feedback to staff Monitor effectiveness of project through Press-Ganey HCAHPs data RN Compliance 8
Results- Project Implemented Oct 1, 2016 100 90 80 70 60 50 40 30 20 10 0 Domain: Med Comm Side Effects Understand Purpose New Medications HCAHPS Top-Box Percentile Rank by Received Date Baseline:April-June 2016 October-December 2016 Follow-Up: April-June 2017 October-December 2017 Overall Domain Goal: Raised to 75 th percentile after pilot project Overall Hospital Readmissions Implications Chair of Patient Experience Med Comm sub-committeereport out twice a year, monthly to Management Team Expanded use of cardiac teaching sheets throughout facility Translation of cardiac sheets into Spanish & Portuguese Development of Respiratory medication teaching sheets Respiratory sheets currently being translated into Spanish & Portuguese 9
Challenges/Limitations Overflow of medical patients into CCU Short length of stay Original pilot project only in English Increase in hospital acuity/census and change in patient demographic r/t closure of another local hospital which has impacted all Patient Experience Domains- Pharmacy focus on patients getting prescriptions filled Nurses struggle with educating patients on side effects and many patients get fixated on this information---potential for less adherence if scared of side effects Many hospital practitioners tell patients to call their PCP if they have questions about meds Next Steps Revising current cardiac sheets for Stroke/TIA patients Revising current Chemotherapy teaching sheets Analyzing overall hospital Omnicell medication utilization to develop tailored medication sheets for other drug classes/patient populations & service lines Modifying sheets for inclusion in Epic to be used at all Lifespan affiliates Summary A patient-centered approach to redesigning patient educational materials by reinforcing key concepts enhanced medication communication for our cardiovascular patients. This simple intervention which enhanced nurse-patient communication about medications will positively impact medication adherence and patient outcomes. 10
References Bartlett Ellis, R., Bakoyannis, G., Haase, J., Boyer, K., & Carpenter, J. (2016). Patient perceptions of provider and hospital factors associated with new medication communication. Western Journal of Nursing Research, 38(9), 1139-1154. Boulding, W., Glickman, S., Manary, M., Schulman, K., & Staelin, R. (2011). Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. The American Journal of Managed Care, 17(1), 41-48. Duffy, J., Baldwin, J., Mastorovich, MJ. (2007). Using the Quality-Caring Model to organize patient care delivery. JONA, 37(12), 546-551. Nelson, E.C., Batalden, P.B., & Godfrey, M.M. (2007). Quality by design: A clinical microsystems approach. San Francisco, CA: Jossey-Bass. Peter, D., Robinson, P., Jordan, M., Lawrence, S., Casey, K., & Salas-Lopez, D. (2015). Reducing readmissions using teach-back: Enhancing patient and family education. JONA, 45(1), 35-42. Special Thanks Nicole Hebert, MSN, RN, CNL,CEN Clinical Nurse Leader Master s Student at the time of Pilot Project Implementation-Capstone project Questions/Contact Information Cindy Rivet MS, RN, CNL, CVN, NE-BC Clinical Manager- Coronary Care Unit/Procedural Care Unit Crivet@lifespan.org 401-793-3673 164 Summit Avenue Providence, RI 02906 11