The Communica3on Bundle Quality Measures

Transcription

1 The Communica3on Bundle Quality Measures Module I Day 1 1. Proxy decision- maker iden3fied AND documented in medical record within 24 hours 2. Presence or absence of advance direc3ve iden3fied AND documented in medical record within 24 hours 3. CPR status addressed AND documented in medical record within 24 hours 4. Pain assessment completed AND documented in medical record within 24 hours 5. Dyspnea assessment completed AND documented in medical record within 24 hours 6. ICU informa3onal brochure provided to family AND documented in medical record within 24 hours Module II Day 3 7. Family mee3ng scheduled, occurred, and documented within 3 days 8. Pa3ent prognosis discussed at the family mee3ng and documented 9. Pa3ent goals discussed at the family mee3ng and documented 10. Need for spiritual care was evaluated, provided and documented within 3 days

2 CommunicaBon Bundle Measurement Data AbstracBon Guidelines Exclusion Criteria: Post- op from elec3ve surgery with expected ICU admission ICU stay of <24 hours Boarding on the ICU Psychiatric/suicide admission (i.e. overdose, suicide ayempt) Day 1 1. Proxy decision- maker iden3fied AND documented in medical record within 24 hours Proxy decision- maker ideally this is the pa3ent s designated health care power of ayorney (DPOA), however can be any designated person Documenta3on includes name of decision- maker Documenta3on is recorded by a MD, NP, PA or RN 2. Presence or absence of advance direcbve iden3fied AND documented in medical record within 24 hours Advance direc3ve - a wriyen document in which the pa3ent has iden3fied specific wishes regarding treatment in the event that he/she cannot communicate those wishes Measure is met regardless of whether the document is physically in the chart Documenta3on is recorded by the MD, NP, PA or RN to whether or not the pa3ent has a wriyen advance direc3ve, as informed by the pa3ent or proxy decision- maker. Answer is YES or NO (No including all instances when informa3on is not available. UTO as an answer is unacceptable.

3 3. CPR status addressed AND documented in medical record within 24 hours CPR status clarify pa3ent/family wishes for the use of resuscita3ve measures if cardiopulmonary arrest occurs. Documenta3on is recorded by a MD, NP, or PA 4. Pain assessment completed AND documented in medical record within 24 hours 48,49 Pain assessment documenta3on reflects the policy that each hospital has established regarding ini3al assessment and reassessment. Methods of assessment include but not limited to: pa3ent self- report, physical examina3on, observa3on of pa3ent behavior, family member s report and physiological cues. Measure of pain intensity tool is u3lized, such as: A 0-10 scale for cogni3vely intact pa3ents. The Woong/ Baker FACES Pain Ra3ng Scale for cogni3vely intact, nonverbal or non- English speaking pa3ents. FLACC behavioral scale for cogni3vely impaired or pa3ents unable to communicate Documenta3on is recorded by MD, NP, PA or RN

4 5. Dyspnea assessment completed AND documented in medical record within 24 hours 50 Dyspnea assessment documenta3on should reflect the policy that each hospital has established regarding ini3al assessment and reassessment. Methods of assessment include but not limited to: pa3ent self- report, physical examina3on, observa3on of pa3ent behavior, family member s report and physiological cues. Dyspnea assessment may include: Onset of symptoms acute vs. chronic, frequency, severity, associated symptoms, exacerba3ng or allevia3ng factors, impact on mood, ac3vi3es of daily life, ability to eat or sleep. Concerns about specific therapeu3c interven3ons, as well as past and current treatment. Measure of Severity tool is u3lized such as 6. ICU informabonal brochure provided to family AND documented in medical record within 24 hours Brochure includes: ICU visita3on hours, ICU phone number Documenta3on is recorded by MD, NP, PA, or RN

5 Day 3 Quality Measures 7. Family meebng scheduled occurred and documented within 3 days Mee3ng held in a private area Presence of two disciplines Presence of either the surrogate decision maker and/or at least one family member Documenta3on includes who was present Documenta3on is recorded by MD, NP, PA, or RN 8. PaBent prognosis discussed at the family mee3ng and documented Prognosis expecta3ons for recovery and treatment op3ons Documenta3on is recorded by MD, NP, or PA 9. PaBent goals discussed at the family mee3ng and documented Goals summary of agreed upon pa3ent goals Documenta3on is recorded by MD, NP, or PA 10. Need for spiritual care was evaluated, provided and documented within 3 days Spiritual care pa3ents religious, spiritual and/or cultural preferences iden3fied Documenta3on is recorded by MD, NP, PA or