An Innovative Approach to the Stroke Patient Care Continuum

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1 An Innovative Approach to the Stroke Patient Care Continuum Introductions May 8, 2012 Presented By: Nancy McAlexander RN BSN Clinical Services Patient Care Units All Private Rooms- 32 Med/Surg 16 ICU 20 PINS 8 Neuro/Stroke 12 Oncology 16 Orthopedic 9 Labor/Delivery 16 Post Partum 7 NICU 4 CDTU Diagnostic Advanced diagnostic imaging Uses less invasive procedures Online access to results Digital environment Physicians can immediately view patient images from various locations Reduces time between exam and therapy Shortens hospital stay Cath Lab Cath Lab with Flat Panel technology Accredited Echocardiography Lab 2 Non-Invasive Echocardiography and Vascular rooms Procedure Center 4 major operating rooms MIS suites with voice activation technology 2 minor operating rooms 8 PACU beds 20 private peri-op rooms Lab Lean processes ( 1st In / 1st Out) Work Standardization Positive Patient ID at bedside Emergency Services 18 private rooms, including: 4 Clinical Decision Treatment Units (CDTUs) 3 advanced treatment bays Accredited Chest Pain Center Accredited Primary Stroke Center 1

2 Session Objectives 1. Describe the rapid cycle approach to process improvement for care of the Stroke patient 2. Examine a process for improving coordination of care for the stroke patient 3. Identify trigger and care plan tools that guide the health care team in the care and recovery of the stroke patient Methodology Model Rapid Cycle PDSA (Plan, Do, Study, Act) P A D S 2

3 Rapid Cycle PDSA Pre-Planning Phase F O C U S Find a process to improve Organize a team Clarify the current knowledge of the process Understand dprocess variation Select a strategy for implementation F O C U S F Rapid Cycle PDSA Find a process to improve Objective: Within 100 days identify efficiencies and eliminate waste in providing evidence based care to specific population Top 10 High Cost Low Quality Diagnosis across Alegent Health system Assigned ownership to individual campus Reviewed per case data for: -Diagnostic services provided and cost - Pharmacy services provided and cost -Lab services provided and cost -Emergency Room services provided and cost -Rehabilitation services provided and cost -Mortality/Co-morbidities -Use of consultants (ie. Neurology) -Length of Stay -Readmissions 3

4 Program Development Crimson Data DRG 064, 064, 066 AH System BMMC IMC LKS Mercy Midlands Top Decile Volume CMI Avg Risk of Mortality Avg Severity Level Re admissions 30 day any 9.28% 7.73% 8.55% 9.28% 16.18% 0.00% 7.72% Re admission 30 day same 0.84% 1.10% 0.85% 1.03% 0.00% 0.00% 1.20% Re admission 3 day any 2.53% 2.21% 2.56% 2.06% 4.41% 0.00% 1.60% Complications of Condition 0.42% 0.55% 0.85% 0.00% 0.00% 0.00% 0.89% Complications of Care 0.21% 0.00% 0.85% 0.00% 0.00% 0.00% 0.43% Mortality Rate 7.38% 8.29% 6.84% 5.15% 10.29% 0.00% 4.27% Mortality O/E Ratio Charges $26,732 $25,841 $26,771 $27,473 $ $19,194 $24,616 % Cases Above Avg Charge 43.88% 43.65% 42.74% 45.36% 48.53% 18.18% 30.77% LOS Consultants Used

5 Average LOS and Charges by MD $8,000 $7,800 $7,600 Total Charges vs LOS $7,400 $7, $7,000 $6,800 $6, Avg Total Charges Average LOS $6,400 $6, $6, Total Charges vs Diagnostic Charges $8,000 $7,800 Total Charges vs Lab Charge $700 $7,600 $7,400 $600 $7,200 $7,000 $6,800 $6,600 $500 $400 Avg Total Charges Avg Lab Charge (1682/1745) $6,400 $300 $6,200 $6,000 $200 5

6 O Rapid Cycle PDSA Organize a team Chief Operating Officer Chief Nursing Executive Chief Quality Officer Chief Financial Officer Physician Champions: Emergency Room Hospitalists Neurology Radiology Operations Directors/Managers from the following departments: Emergency Room Inpatient Units Diagnostics Laboratory Rehabilitation Services (PT, OT, ST) Quality Pharmacy C Rapid Cycle PDSA Clarify the current knowledge of the process (picture of the wall with stickies) 6

7 U Rapid Cycle PDSA Understand process variation Emergency Department Neuro consults MRI vs CT Stroke Team alert Initiation of EBC orders TIA Discharge to home Outpt diagnostic testing Inpatient t Nursing Bed assignments Care Map Education Inpatient Hospital to Community Lack of coordination Rehabilitation Services Initial evaluations/treatment plan timeliness Patient Time vs. Charting/Prep time Patient refusals Care Management Social Services Role redesign Discharge Plan vs Placement Early intervention Facilitate nursing education Readmission Risks PT/OT/ST Workflow Lean Model PT, OT and ST Evaluation of patient to be completed within 4 hours of admission. Therapist to obtain order from MD immediately after evaluation for ongoing treatment during hospital stay. Therapy to collaborate with Care Management/Social Work on therapy needs/recommendations post discharge by Day 2 Key Learnings: Patient follow-up on refusals Charting (batching & duplication) Outdated guidelines Provide services as per Does patient treatment plan orders System Applicability: established between therapy and MD. require therapy services post discharge? Therapy to contact post discharge therapists (OP, SNF, HHC) to provide handoff report and status at discharge Meaningful Interdisc. Care Rounds Workflow Redesign Realtime Documentation Next Steps: Finalize current state Optimize workflow Implement Integrated Care model YES Measure of Success Safety Timely Effective Efficient Equitable Patient Centered Realtime Documentation (95%) X X X X X X New Eval Seen Same Day (95%) X X X X X X Increase Therapy Time (15%) X X X X X X 7

8 Rapid Cycle PDSA S Select a strategy for implementation 1. What are we trying to accomplish? 2. What changes can we make that will result in improvement? 3. How will we know that a change is an improvement? Emergency Department Strategies Pts w/ any neuro deficit is a Stroke pt until proven otherwise. Practitioner to see patient within 10 min of arrival. All neuro deficit pts receive swallowing screen in ED regardless of NPO status. Auto page to Stroke Team w/ initiation of CT orders. Manual page of tpa candidate pt with weight Manual page of tpa candidate pt with weight. Neurological consult ASAP. Core measure packet initiated. ED nurse holds accountability for patient until hand-off. 8

9 Nursing Strategies Dedicated Stroke Unit DVT prophylaxis initiated with Stroke alert Evidence Base Orders placed in physician chart Care path initiated Stroke packet and book placed at bedside All education coordinated by nurse coordinator Care Management Strategies Care Management coordinates the discharge plan. Social Worker focuses on discharge placement. Care Manager reviews care path daily for completion of activities. Review education record. Collaborates with inpatient / outpatient team (HC, SNF, Rehab Services, etc). Physician appointment made within 3-5 days post discharge. Follow-up phone call within hours of discharge. 9

10 Rehabilitation Strategies Stroke page received - Initial evaluation within 4 hours of page - After 6pm, evaluation completed next am Real-time documentation AM prep to therapy start time Creation of a Team Station concept Implementing the Action Plan PDSA (Plan, Do, Study, Act) Plan: based on theory/prediction P Act: adopt adapt abandon A D Do: small scale S Study: to learn 10

11 Rapid Cycle PDSA P Gap Analysis Prepared by Plan to Implement Date Completed: Sufficiency of process step (x = excessive, a = adequate, i = inadequate) Process Step EBC Existing Sufficiency Is it sufficient? Next Steps Order Set? Y/N x,a,i If not, why? What Who When Patient admission thru the ED Culture of "Every patient with a neuro deficit is a Stroke patient" until proven otherwise.. All neuro patients must be seen in 10 minutes by ED Provider. All ED patients must be entered into ADT within 5 minutes of arrival Use of EBC orderset Evaluation of Acute Stroke initiated with orders input within minutes. This triggers automatice page to Stroke Team. NIH scoring completed All tpa candidates must have weights taken and manual age to Stroke team within minutes of arrival. All metrics of lab and diagnostid results of 45 mintues from door to arrival must be met. tpa order to pharmacy if all inclusion criteria met for patient within minutes of door to arrival Neurologist notified by ED physician All neuro patients to receive swallowing screen regardless of NPO status. This mst be documented and reported at handoff P Plan to Implement 11

12 P Plan to Implement P Plan to Implement 12

13 P Plan to Implement XXXX X X x D Do Implement the Plan ABCD 2 Tool Stroke Order Tools set for Rollout Nursing Care Guidelines Roadmap for Patient & Family Stroke Patient Packet (Book) Core Measure Check List 13

14 ABCD2 Door to Needle Time 14

15 Clinical Practice Guidelines Evidence Based Care Order Sets Acute Evaluation of Suspected Stroke Acute Stroke Post tpa Alteplase (Activase) Acute Stroke Management Non-tPA Alteplase (Activase) Patient ONLY Acute Stroke Discharge Stroke Carepath 15

16 Roadmap TIA / Stroke Path Your Road to Rehabilitation and Recovery Emergency Department Admission Day 1 Inpatient Goals Inpatient Goals Discharge Goals HOME (KEYS to preventing readmission).best Care Order set.clot Busters.Swallow eval.stroke Scale.PT/OT /Speech Consult.Neuro Consult.Blood Thinners.DVT Prophylaxis.Neuro Changes?.LDL/Cholesterol.Discuss Discharge Plan.Neuro Stable.Stroke Edu Packet done.medication Education.Follow up Appts..Rehab Therapy.Stroke Medications.Signs of Stroke.Follow up Phone call.discharge Instructions GOALS: Patient Milestones: Roadmap 16

17 Patient Education Stroke Checklist 17

18 Follow up Phone Call S Study the Results DRG Stroke Scorecard (Lakeside) DRG 064, 065, 066 Pilot Started on August 22 Quality Lakeside Data Owner Data Source Baseline* Target July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June YTD Process Metrics ED Physician i usage of EBO Nancy M. Pulsecheck TBD 100% 42% 33% 75% 60% 92% 100% 86% 100% 62% ED Dysphagia Screening Nancy M. Pulsecheck?? 58% 100% 27% 40% 100% 100% 92% 83% 100% 100% 92% I/P Appointments 3 5 Days (IP) Nancy M. Soarian TBD 100% na na 10% 75% 43% 50% 67% 33% 44% I/P D/C Phone Call w/in hrs Nancy M. Soarian TBD 100% na na 0% 75% 50% 50% 67% 0% 63% I/P F/U Phone Call (10 Day) Nancy M. Soarian TBD 100% 75% 75% 67% 0% 50% Outcome Metrics Core Measure Fallouts Nancy M. Mi da s TBD Discharge Info (Y8AA&Y8AB) Mike V. HealthStream Overall Rating (H30) Mike V. HealthStream Readmissions (30 Day) B. Newby Mi da s 6.32% 0.00% 0.00% 0.00% 0.00% 14.29% 0.00% 2.08% ALOS Reduction Amy K. DSS # of cases Financial Cost Reductions Lakeside Data Owner Data Source Baseline* Target July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June YTD LOS Amy K. $ 88,617 $7,385 $2,467 $2,056 $2,467 $1,439 $1,850 $1,644 $1,028 $12,951 Testing*** Amy K. $ 4,221 $352 Pharmacy Amy K. $0 * Baseline was from July 2010 through June 2011 (unless otherwise stated) ** Baseline was from April, May and June and included only cases that coded out with a final diagnosis of Stroke *** Includes a 20% reduction in overall utilization and only includes direct variable costs Total $92,838 $7,736 $2,467 $2,056 $2,467 $1,439 $1,850 $1,644 $1,028 $0 $0 $0 $0 $0 $12,951 18

19 Other Measures of Success Stroke Center Performance Measures Last Door to Needle Time 42 minutes CT Order to Begin: 96% have CT initiated within 25 min of order CT Order to Results: 93% of patients have results reported within 45 min Lab Order to Final Results: 89% of patients have lab results reported within 45 min Emergency Room Measures Stroke Packet initiated in the ED went from 47% to 100% compliance Use of EBC Order Set for Evaluation of Stroke in the ED went from 33% to 100% Dysphagia Screening completed in ED went from 58% to 100% 100% of tpa candidates have the CT ordered using the CT Head Protocol Inpatient Nursing Use of Inpatient EBC Order Set has went from 64% to 80% (all physicians) Use of Inpatient EBC Order Set by Hospitalists went from 64% to 100% Core Measure Variances- No variance since December 5, 2011 (153 days) All Stroke measures have remained at or above the GWTG top decile. Rehabilitation Services Real Time Documentation went from 102 minutes after therapy to 12 minutes (88% improvement) AM Prep Time to Therapy Start Time went from an average of 55 minutes to 10 minutes (73% improvement) A Act to Hold the Gain CELEBRATE THE SUCCESSES!!!! Ongoing Physician, Nurse and Staff Education Communication of updates to processes Maintain current and evidence based treatment Understanding and utilizing Roadmap for patient milestones Consistent patient communication through the care continuum including during and after hospital stay Changing physician behavior Explore potential for Neurology telemedicine All Neuro Deficits treated as Stroke until ruled out Periodic review of gap analysis Use of Care Path and Roadmap during bedside shift reporting Ongoing monitoring and reporting of metrics hospital wide 19

20 Evaluation Do you have any of the following symptoms after listening to this presentation? Sudden and severe headache Severe weakness/numbness of face, arm or leg on one side of the body Sudden loss of vision in one eye Sudden loss of balance or coordination- trouble walking Sudden slurred speech or difficulty speaking Sudden confusion Sudden dizziness If you checked one or more of the above you may be having a stroke.or possibly just the effects of a listening to a presentation about stroke?????? Questions 20

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