Improving Transition Home through a Standardized Discharge Process Christopher D. Baker, MD Associate Professor of Pediatrics May 10, 2016
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
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
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
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patients not in ICU Survival of chronically ventilated infants with severe BPD has markedly improved: Gien 2015, unpublished
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
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
Process Mapping Baker 2016 Pediatrics 137:e20150637
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
Baker 2016 Pediatrics 137:e20150637
Patient and Family Education
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
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
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
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
Educational Videos Bagging - How to Manually Ventilate Your Child
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
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
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
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
Care Coordination
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
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
Discharge Readiness Report
Care Coordination and the EMR VCP Consult Advisory
Care Coordination and the EMR Admission Order Set
Care Coordination and the EMR Admission Order Set (cont)
Care Coordination and the EMR Patient List
Telemedicine: Discharge Care Conference
QI Metrics / Outcomes
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)
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:e20150637
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:e20150637
Patient Outcomes Before/After Standardized Discharge Process Baker 2016 Pediatrics 137:e20150637
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!
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
Discussion / Questions Christopher.Baker@UCDenver.edu