Transcript Presentation Title - MHA An Association of Montana Health

Reducing Readmissions
Cheryl Ruble, MS, RN, CNS
Montana Regional Meetings
Glendive Medical Center
Glendive, MT
Your Improvement Opportunity
• Do you know what your readmission rates are?
Overall? For specific clinical conditions?
• Compared to other hospitals in your area, state,
national? Should you compare to others or just
yourself?
• What’s possible?
Aim Statement
• Reduce overall readmissions by
20% from the 2010 baseline by
December 31, 2012
• By end of 2013, reduce
readmissions for heart failure
by 30%.
Outcome Measure
All cause
readmissions
within 30 days
Process Measure
All cause readmission can
include:
• DC phone calls
• Risk Assessment
completed
• Med-Rec completed on DC
• Percent of patients with
complete, customized
after care plan
• Percent patients with
completed DC education
Outcome Measure
Heart failure
patients –
readmission
within 30 days,
all cause
Readmission Reduction Drivers
AIM
Primary Driver
Secondary Driver
Risk assessment & stratification
Enhanced admission assessment
Identify high risk
patients
Multi-disciplinary care team to coordinate care
Patient/Caregiver knowledge of medications, symptoms, self-care
strategies
Identify and address patients’ health literacy and activation levels
Self-management skills
Use of teach-back to validate understanding
Reduce readmissions by
20% by 12/31/2013
Create a patient-centered record
Coordination of
information along the
care continuum
Timely communication with members of the care team who are not
hospital based
Medication reconciliation at admission, change in level of care, and
at discharge
Coordination with physician/other care provider to facilitate
resources and follow-up needs
Adequate follow-up and
community resources
Post-discharge calls and visits
Integrate organizations and Consider medical home capabilities.
Coordinate with skilled nursing facilities.
Determine community resources for vulnerable populations
Driver: Identify high risk patients
Risk Stratify: Identify High Risk Patients
and Communicate to all Providers
High Risk Patients
• Patient has been admitted two or more
times in the past year
• Patient is unable to teach-back, or the
patient or family caregiver has low
degree of confidence to carry out selfcare at home
Nielsen GA, Rutherford P, Taylor J. How-to Guide: Creating an Ideal Transition Home. Cambridge,
MA: Institute for Healthcare Improvement; 2009. Available at http://www.ihi.org.
Risk Assessment
• Use a validated
readmission risk
assessment tool
• Select an easy to
implement risk
assessment
Assessing Patient Risk
Project Red Risk Factors
• Depressive symptoms
• Limited health literacy
• Frequent hospital
admissions
• Unstable housing
• Substance abuse
http://www.hospitalmedicine.org/ResourceRoomRedesi
gn/RR_CareTransitions/PDFs/TARGET.pdf
Risk Stratification
• Low risk –
normal process
• Moderate risk –
enhanced
hospital process
• High risk –
enhanced
hospital process
+ community
intervention
Assessing Patient Risk
Project BOOST 8P
Screening Tool
–
–
–
–
–
–
–
–
Problem medications
Psychological
Principal diagnosis
Polypharmacy
Poor health literacy
Patient support
Prior hospitalization
Palliative care
http://www.hospitalmedicine.org/ResourceRoomR
edesign/RR_CareTransitions/PDFs/TARGET_screen
_v22.pdf
Driver: Self-Management Skills
Patient self management as goal
Primary Driver:
Self Management Skills
• Assess patient / caregiver knowledge:
of medications, symptoms, self-care
strategies
• Health literacy: Identify and address
patient’s health literacy and
activation level; use culturally
appropriate training materials and
clear written instructions using
health literacy concepts
• Teach-back: Use teach-back to
validate understanding; use patientcentered, culturally sensitive
educational tools
Medication Reconciliation
•Medication reconciliation
– Perform at a minimum on
admission & discharge
– List given to patient/care
giver clearly identifies
– For high risk patients,
work with home health or
other ambulatory providers
Medication Education
Project RED – After Hospital Care Plan Example
http://www.ahrq.gov/about/annualconf09/jack.htm
Assess Health Literacy
Health literacy measurement
tool, available in English and
Spanish, from AHRQ
Red Flags for Low Literacy in
Patients
• Frequently missed
appointments
• Incomplete registration forms
• Non-compliance with meds
• Unable to name meds, explain
purpose or dosing
• Identifies pills by looking at
them, not reading label
• Unable to give coherent,
sequential history
• Ask few questions
• Lack of follow through on tests
or referrals
Strategies to Improve Patient
Understanding
• Focus on “need to
know” & “need to do”
• Use ‘Teach Back’
• Demonstrate/draw
pictures
• Use clearly written
education materials
– 5th grade level or below
8 Tips for Clinicians
1. Use plain language
2. Limit info (2 – 4 points)
3. Be specific & concrete,
not general
4. Demonstrate, draw
pictures, use models
5. Repeat, summarize
6. Avoid Yes/No questions
• Open ended questions
7. Teach Back
8. Be positive
Teach Back is….
• Asking patients to repeat in their own words what
they need to know or do, in a non-shaming way.
• Not a test of the patient, but of how well YOU
explained a concept.
• A chance to check for understanding and, if
necessary, re-teach.
Teach Back Is…
• Ensuring agreement &
understanding
– Critical to achieving
adherence
• Associated with
improved patient
engagement in their
own care
“I want to make sure I
explained it correctly.
Can you tell me in your
own words how you
understand the plan?”
Teach Back Examples
• “I want to be sure I
explained everything
clearly. Can you please
explain it back to me so
I can be sure I did?”
• “What will you tell your
husband about the
changes we made to
your blood pressure
medicine?”
• “We’ve gone over a lot
of information about
getting more exercise in
your day. In your own
words tell me some of
the ways you can get
more exercise. How will
you make it work at
home?”
Teach Back Examples
• “Can you tell me how
you take each
medicine?”
• “When do you take
these medicines?”
• “Home much or how
many do you take?”
“Show me how many pills
you would take in 1 day.”
Teach-back
• Teach-Back guide from
Medicare Quality
Improvement
Organizations National
Coordinating Center for
the Integrating Care for
Populations and
Communities Aim (ICPCA)
• Train clinical staff, use “I”
statements
ASTHMA ZONES
Know your zone: Green, Yellow, or Red
Green Zone: All Clear
Green Zone Means




No cough, wheeze, or shortness of breath
Sleeping through the night
Can do usual activities
Don’t need quick-relief (rescue) medicine most
days
or Peak Flow:______________ as instructed




Yellow Zone: Caution
Yellow Zone Means: Warning

Cough, wheeze, or shortness of breath, chest
tightness
 Waking at night due to asthma symptoms
 Can do some but no all usual activities
 Using more quick-relief (rescue) medicine more
frequently
 No improvement in your symptoms after
medications were started
or Peak Flow:______________

Red Zone: Medical Alert
Red Zone Means: Emergency
 Very short of breath, ribs show
 Quick-relief (rescue) medicine has not helped
• If you have trouble walking or talking
• Your lips or fingernails are blue
• You are feeling faint
or Peak Flow:______________



Your symptoms are under control
Continue taking your medications as ordered
Continue activity as tolerated
Keep all doctor appointments
Your symptoms may mean that you need a
change in your medications
Call your doctor_____________________
number_____________________
Call your Home Care Nurse 24 hour
number___________________________
Tell your home care nurse if you call or see your doctor
This indicates that you need to be seen by a
doctor right away- NOW!
 Call 911 or go to the nearest emergency
room
COPD ZONES
Know your zone: Green, Yellow, or Red
Green Zone: All Clear
Green Zone Means









Able to do usual activities
No new symptoms
No chest pain
Your usual medications are controlling your symptoms
Your symptoms are under control
Continue taking your mediations as ordered
Continue activity as tolerated
Use pursed lip breathing as instructed
Keep all doctor appointments
Yellow Zone: Caution
Yellow Zone Means: Warning





 Your symptoms may indicate that you need an adjustment of
your medications
 Call your doctor_____________________
number_____________________
• You should consult or see your doctor within 24-48 hours
 Call your Home Care Nurse 24 hour
number___________________________
Tell your home care nurse if you call or see your doctor
If you have any of the following signs and symptoms:
Increased cough and/or discolored sputum production
Increased in shortness of breath with usual activity level
Increase in the amount of quick relief medications used
Change in usual energy level: increase in either fatigue
or restlessness
RED ZONE: MEDICAL ALERT
RED ZONE Means: Emergency
 Severe or unusual shortness of breath: shortness of
breath at rest
 Unrelieved chest pain
 Wheezing or chest tightness at rest
 Need to sit in chair to sleep if you don’t normally
 New or increased confusion
 This indicates that you need to be evaluated by a
doctor right away – NOW!
Go to the nearest emergency room or call 911
DIABETES ZONES
Know Your Zones – Green, Yellow, or Red
Green Zone: All Clear
Green Zone Means
Average blood sugars are typically between 80 and
150.
Most fasting blood sugars are between 80 and 120.
No decrease in your ability to maintain normal
activity level
No ketones in your urine ( if Type 1)
Your symptoms are under control
Continue taking your medications as prescribed
Continue to follow your diet
Keep you doctor appointments
Continue to have your A1c measured every 3 to 6
months and monitor your blood sugars
Yellow Zone: Caution
Yellow Zone Means: Caution
Average blood sugars are between 150 and 250.
Most fasting blood sugars are over 150.
Two or more blood sugar readings less than 70 in
the past week
Two or more blood sugar readings above 200 in the
past week
Trace to small amounts of ketones in your urine ( if
Type 1)
Difficulty maintaining normal activity level
Nausea, not able to keep food down or eat normally
Your symptoms mean that you may need an
adjustment in your medications
Call your doctor ____________________
Number:_____________________
RED ZONE: Medical Alert
RED ZONE MEANS: Emergency
Average blood sugars are above 250.
Most fasting blood sugars are over 200
Two or more events in the past week when blood sugar
was less than 60.
You are unable to stay awake even during the day
Individual is not responsive, has passed out
This indicates that you need to be evaluated by a
doctor right away – NOW!
Name:_________________________
Number:_______________________
Call 911: if individual is unresponsive
Home health 24 hour number:______________
Please tell your home care nurse if you call or go see
your doctor
PNEUMONIA ZONES
Know your zone: Green, Yellow, or Red
Green Zone: All Clear
Green Zone Means





 Your infection is being treated
 The medications are working that helps fight the infection
 Increase your activities slowly; it may take several weeks
before you feel normal.
 Make sure to go to your doctor as directed
Having slight to no shortness of breath
Temperature below 100
Slight cough
No chest pain
You are able to drink liquids and eat normally
Yellow Zone: Caution
Yellow Zone Means: Warning






 You may need to adjust your medications
 Call your doctor to discuss your symptoms
Fever over 101
Have an increase in shortness of breath
Have an increase in coughing
Your sputum changes color
You are not taking in liquids
Feeling more tired than when you were in the hospital
Doctor: ___________________________
Phone: _________________________
Call your Home Care Nurse 24 hour
number___________________________
RED ZONE: MEDICAL ALERT
RED ZONE Means: Emergency
 Very difficult time breathing
 Your breathing does not get any better if you sit or lay
down
 Having chest pain
 Feeling more confused or having trouble thinking
 Coughing up blood
 You need to be seen by a doctor NOW!
 Call 911 or go to the nearest Emergency
room.
Resources
• HRET’s Preventable Readmissions
http://hret-hen.org/preventable-readmissions
• State Action on Avoidable Rehospitalizations (STAAR) Initiative,
http://www.ihi.org/IHI/Programs/StrategicInitiatives/STateAction
onAvoidableRehospitalizationsSTAAR.htm
• Project RED (Re-Engineered DC)
http://www.bu.edu/fammed/projectred/index.htlm Brian Jack,
MD
• Project BOOST (Better Outcomes for Older adults through Safe
Transitions)
http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_C
areTransitions/CT_Home.cfm Mark Williams, MD, FHM
Resources
• Transitional Care Model http://www.transitionalcare.info
Mary D. Naylor, PhD, RN, FAAN
• Patient Activation Measure
http://www.insigniahealth.com/solutions/patientactivation-measure
• INTERACT II http://www.interact2.net/
• Hospital 2 Home sponsored by the American College of
Cardiology and the Institute for Healthcare Improvement
http://www.h2hquality.org/
Finding and Reducing ADEs
Cheryl Ruble, MS, RN, CNS
Montana Regional Meetings – Barrett
Memorial Hospital
Dillion, MT
What is an ADE?
What is an ADE?
• Any injury
resulting from
medical care
involving
medication use.
AHRQ
But be careful…..
• The occurrence
of an ADE does
not necessarily
indicate an error
or poor quality
of care
AHRQ
What is a Medication Error?
What is a Medication Error?
• Any error
occurring in the
medication use
process
ISMP
So how is an ADE and a Med
Error Different?
Well what is An ADR?
WHO:
“Any response to a drug which is noxious
and unintended, and which occurs at doses
normally used in man for prophylaxis,
diagnosis, or therapy of disease, or for the
modification of physiological function.”
• All ADRs are ADEs
• All ADEs are not necessarily ADRs
All
ADEs
ADRs
So how is an ADE and a Med
Error Different?
ADE Adverse BOTH Medication
Med Error
Drug Event
Error
Why do we care?
• Harm and Death
>770,000 patients
per year
• Costs
Up to $5.6M per
hospital annually
Up to $32,000 per
patient
AHRQ
So what is an ADE again?
• Any injury
resulting from
medical care
involving
medication use.
AHRQ
What do they look like?
What do they look like?
How do we find them?
How do we find them?
•
•
•
•
Voluntary reports
Triggers
RCA’s
Electronic data
mining from
EMR’s
Voluntary Reports
• Does it work?
• Why?
• Why not?
The key…
• Make it SAFE
• Make it EASY
• Make it MEANINGFUL
Triggers
• Does it work?
• Why?
• Why not?
CLUES
How Did We Get Started?
• RRT’s & ICU nursing staff tipped us off
• All RRT’s reviewed by the Critical Care CNS
• Large portion were respiratory in nature and required
transfer to ICU
• Causative factor – over use of sedatives & analgesics
in post-op patients
• Of note – these were not found in occurrence reports
What Did We Test?
• Revision of work flow & assessment of patient
readiness for discharge from PACU to floor.
• ICU, PACU, and ortho unit nurses involved
What’s Our Data Show?
• We virtually eliminated RRTs due to over sedation/
analgesic use post recovery.
• It became a rare event.
What Did We Learn?
• Communication between departments is crucial
• Not about the who but how – at first there was
finger pointing between department staff
• Led us to think what about other rescue meds?
Rescue Meds
Other Triggers
Key Tips
• Always involve staff to identify the problem, design a
solution, test and implement.
• Use what you have –
– RRT forms/audits,
– automated medication dispensing reports – use of rescue
meds
– Use other reports such as blood product usage
• Consider unanticipated pulls from your automated
medication dispensing
RCA’s
• Does it work?
• Why?
• Why not?
Mining EMR’s
• Does it work?
• Why?
• Why not?
Lab & Pharmacy Data
•
•
•
•
How do you get it?
Does it work?
Why?
Why not?
What do we do with them
when we find them?
• Aggregate
• Analyze
• Look for system
defects
• Fix the system
• We are about what
and how not who
AIM
Primary Driver
Secondary Drivers
Use the ISMP
Assessment tool to
assess capacity
Awareness,
Readiness &
Education
Create awareness
of HAMs
Assess clinical
knowledge
Reduce harm from ADEs
due to high-alert
medications (HAMs)
Implement
quarterly ISMP
action agenda
Standardize Care
Processes
Develop standard
order sets
Allow nurses to
administer rescue
drugs per protocol
Sequence
implementation by
drug class
AIM
Primary Driver
Secondary Drivers
Implement
effective med rec
processes
Where appropriate,
create outpt clinics
for HAM f/up
Use flow sheets
that follow pt
through care
Avoid errors during
care transitions
Reduce harm from
ADEs due to high-alert
medications (HAMs)
New insulin orders
from parenteral to
enteral
Include pharmacist
on rounds
Use alerts for
dosage limits
Decision Support
Monitor
overlapping meds
given to a patient
Use alerts to avoid
multiple
narcotics/sedatives
Double checks by
pharmacy and
nursing
AIM
Primary Driver
Secondary Drivers
Minimize nurse
distraction during
med administration
Standardize
concentrations and
dosing options
Timely lab results
Reduce harm from
ADEs due to highalert medications
(HAMs)
Prevention of
Failure
Different locations,
labels, packaging for
LASA meds
Perform
independent double
checks
Use visual cues for
HAMs at bedside
Allow pt mgmt of
insulin
Set limits on high
dose orders
AIM
Primary Driver
Secondary Drivers
Prepackages Heparin
infusion
Reduce the number
of heparin
concentrations
Use of LMWH versus
unfractionated
heparin
Reduce harm from
ADEs due to highalert medications
(HAMs)
Prevention of
Failure Continued
Automatic nutrition
consults for pts on
warfarin
Use of table drug-todrug conversion
doses
Use fall prevention
programs
Use dosing limits
Prepackages Heparin
infusion
AIM
Primary Driver
Secondary Drivers
Access Culture of
Safety using AHRQ
Safety Survey
Use error reporting
system
Use of technology to
alert key staff when
rescue drug used
Identification &
Mitigations of
Failure
Administer meds on
time
Analyze override
patterns
Reduce harm from
ADEs due to highalert medications
(HAMs)
Use “Smart” pumps
Understand PCA
device errors
Smart Use of
Technology
Link order sets to lab
values
Use of proper levels
of alerts
Educate staff on
device use
consequences
Awareness, Readiness, Education,
Standard Care Processes
• Getting Started:
– Is the organization
ready?
– Does the organization
have the capacity?
– Is the organization
willing?
Awareness, Readiness, Education,
Standard Care Processes
• Assess clinical knowledge of
staff
• Create awareness of HAM’s
most likely to cause ADE
CLUES
• Access culture of safety
Driver: Standardize the Care
Process
“If you can’t describe your process, you don’t have one.”
W. Edwards Deming
“Every system is perfectly designed to get the results it gets.”
Paul Batalden, Dartmouth
“Standardize what is standardizable and no more”
Brent James, MD, Intermountain Health
“Quality is the absence of unexplained variation.”
David Nash, MD, Editor, American Journal of Medical Quality
Protocols
• Standard order sets for
high priority HAMs
– Start with the drug class
with greatest
opportunity
• Nurse administered
rescue drugs
• Allow for “opt out”
• Make it easy to use
What does it have to do with
readmissions?
• In one study 1 of 8
readmissions was due to
an ADE
• Note…if we eliminated
those we would be 60%
of the way to our goal of
a 20% reduction in
readmissions
• Causes:
– Failure to monitor
– Drug- Drug interactions
Guharoy, 2007
Avoid Errors During Care
Transitions
How can we prevent discharge
related ADE’s that lead to
readmissions?
How?
• Get the meds right!
• Monitor meds
• Minimize drug-drug
interactions
• Reconciliation
• Did the patient really
get the outpatient rx’s
filled:
– PA’s approved
– affordable
What matters most?
• Checking out the
patient 24-28 hours
post discharge to see
that they are
completely
reconciled…that all
issues related to med
rec are resolved
The Pill Mill
Dr. Suess’ You’re Only Old Once! A Book for Obsolete Children
How do we do that?
• Call them
• Visit them
• Have them visit
you
Driver: Prevention of Failure
• Medication errors are the
most frequent cause of
ADEs
• It goes beyond the mind
numbing recitation of the
5 rights – right med, right
patient, right dose, right
time, right route
• System design in crucial!
Set the clinician up for
success!
MED
ERROR
NOT DISTURB
REDUCTION
ZONE
Driver: Identification &
Mitigation of Failure
• Prompt identification
and actions to reduce
harm
• Understanding failure
and taking broad
system view is crucial
• Opportunities for
learning and system redsign
Culture of Safety
Do you have a non-punitive environment?
The Human Mind
Aoccdrnig to rschearch at Cmabrigde
Uinervtisy, it deosn’t mttaer in what oredr
the ltteers in a word are, the olny
iprmoetnt tihng is that the frist and lsat
ltteer be at the rghit pclae. The rset can be
a total mses and you can still raed it
wouthit a porbelm. This is bcuseae the
huamn mnid deos not raed ervey lteter by
istlef, but the word as a wlohe.
Amzanig huh?
Resources
•
•
•
•
•
•
•
2011 Institute for Safe Medication Practices (ISMP) Medication Safety Self
Assessment® for Hospitals
http://ismp.org/selfassessments/Hospital/2011/pdfs.asp
Institute for Healthcare Improvement High-Alert Medication Safety (Improvement
Map)
http://app.ihi.org/imap/tool/#Process=b8541097-7456-4aab-a885-38c31950e6bf
http://www.cshp.org/uploads/file/Shared%20Resources/2012/guideline_anticoag
ulants_2.21.12.pdf
Federico, Preventing Harm from High-Alert Medications, The Joint Commission
Journal on Quality and Patient Safety, 33(9), 537-542
Agency for Healthcare Research and Quality Hospital Survey on Patient Safety
Culture http://www.ahrq.gov/qual/patientsafetyculture/hospsurvindex.htm
Miller et al, Bar code Medication Administration Technology: Charcterization of
High-Alert Medication Triggers and Clinician Workarounds, The Annals of
Pharmacotherapy 2011 Feb Vol 45, 162-168