NYSARC TRC QUALITY INITIATIVE. Reducing ER Admissions

Transcription

1 NYSARC TRC QUALITY INITIATIVE Reducing ER Admissions

2 QUALITY IMPROVEMENT PROJECT- REDUCING ER ADMISSIONS Identification of a High Risk Concern: Complaint from one of the local hospitals that TRC had a high number of individuals who were using the emergency room to address respiratory infections..

3 QUALITY IMPROVEMENT PROJECT- DATA COLLECTION Identify what data to collect Emergency Room Visits Hospitalizations Infection Control Information Trending Analysis Who, when, where, what Discharge Information Educational Information

4 QUALITY IMPROVEMENT PROJECT- DATA COLLECTION Identification of methodology for collecting data Therap Electronic Record System General Event Records T-logs Hospital Portal ER/Hospital Admission Diagnosis Discharge information TRC PCO Portal/Electronic Health Record (Alscripts) Pre and Post Visit information

5 QUALITY IMPROVEMENT PROJECT- ANALYSIS QUERIES Why are people going to the ER? Who are the people going to the ER? Are there options to going to the ER? What are the steps to getting to the ER? Who makes the decision?

6 QUALITY IMPROVEMENT PROJECT HOW OFTEN IS THE EMERGENCY ROOM USED? QUARTERLY ER VISITS (1st thru 3rd qtr include Under Auspices & Community - 4th Qtr Under Auspices Only) Total ER Visits ER Visits W/O Admissions Hospitalizations 20 0 JAN - MAR APRIL - JUNE JULY - SEPT OCT - DEC

7 QUALITY IMPROVEMENT PROJECT- WHO MAKES THE DECISION? Who % Non-licensed staff 28% RN on Call/RN Site Nurse 67% Provider Contacted 5%

8 WHY ARE PEOPLE GOING TO THE ER? G-tube, J-tube related Falls Respiratory difficulties/distress Gastrointestinal symptoms Urinary Issues Seizures Deaths Miscellaneous

9 INFECTION CONTROL What types of infections were occurring within the Residential programs Identify primary categories to determine trends Eyes Ears Gastrointestinal Urinary Respiratory Skin Nasal/Oral

10 INFECTION CONTROL 6% 7% 14% 5% 0% Eyes - 23 Ears - 18 Gatrointestinal - 1 Urinary - 85 Respiratory Skin % Nasal/Oral %

11 PROFILES Identify who (currently) were the individuals who were experiencing respiratory infections and where were they living. Profiles included the following complicating factors Medical profile with multiple complicating diagnoses and conditions Pulmonary, Cardiac, Gastrointestinal, Neurological, Endocrinological, Orthopedic scoliosis, kyphosis impinging on cardiac and pulmonary function Past history of antibiotic resistance

12 PROFILES CONT D Multiple ports and medically invasive openings in their skin which makes them more vulnerable to developing infections Close personal care from support staff Behaviors that compromised health inserting hand in mouth, drooling, etc. that put individuals at high risk to transmit/contract infections Communication/following direction compromised non-verbal or unable to articulate how they are feeling so it is difficult to diagnose illness Inability to participate in infection control measures and/or respiratory etiquette

13 PROFILES CONT D Individuals (who went to day program) attended with other participants from multiple residences Staff assigned to different sites and exposed to multiple other participants Participants travel via bus where other participants are being transported, who also come from multiple sites

14 TARGET SITES/POPULATION Identify where individuals were living to determine if there were specific individuals who utilized the Emergency Room more frequently. Identification of top 3 sites Identified top users

15 FINDINGS FOR THE TARGETED SITE High Hospitalization/Rehospitalization rate High utilization of emergency room Under-utilization of primary medical staff Cost of uncovered medical expenses exceeds $150,000/year

16 ANALYSIS Problem Statement- The agency will reduce the number of ER visits and hospital admissions due to respiratory infection. How do we currently measure the number of infections and the number of ER visits/admissions? Therap-GERs, t-logs How do we track and trend the data now? Number of infections, type and category of infections, visits to ER, who was admitted

17 CAUSATIVE FACTORS What are the primary causative factors? Poor communication among primary care providers, specialists, health and community providers, patients, and advocates/staff Failure to catch problems early

18 CAUSATIVE FACTORS, CONT D Under-utilization of Primary Care Provider Respiratory Therapist RN Housekeeping staff

19 CAUSATIVE FACTORS, CONT D Human performance factors that contributed to event Limited education of the hospitalists at the hospital with the population and services within OPWDD programs Inconsistent Triage skills to make valid determination to send to ER Moderate compliance with using PPE properly, not engaging in hand washing routinely

20 CAUSATIVE FACTORS, CONT D Equipment /device factors that contributed to event Under utilization of respiratory prevention equipment Staff knowledge gaps in using, storing and cleaning equipment Toothbrushes, personal hygiene supplies,o2, oximeters, inhalers, etc.

21 CAUSATIVE FACTORS, CONT D Education Uncertain who was trained on infection control procedures and what they were trained on Need for increased PPE Training Frequency and demonstration regarding PPE donning and doffing of equipment Policies Lack details on post infection procedures Unclear direction to staff on when to contact the RN

22 CAUSATIVE FACTORS, CONT D Other factors Inconsistent discharge instructions Minimal collaboration in working with the hospitalists to better understand our population

23 STRATEGIES AND INTERVENTIONS It is not about one single dramatic action, but about trying things to see if they work. Life is a series of experiments.

24 STRATEGIES AND INTERVENTIONS, CONT D What strategies do you propose to impact the results? Utilization of TRC Primary Care Office Regular visits to the home by the Primary Care Provider to catch problems early Initiate interventions on site vs visit to ER Ensure follow up after ER visit/admission 24/7 On call medical triage, support and decision making Nursing Visits to the Primary Care Office Utilization of Urgent Care

25 STRATEGIES AND INTERVENTIONS, CONT D Utilization of Respiratory Therapist Regular visits to the home Introduce and increase use of the SMART vest Provide instruction on the cleaning of all respiratory type equipment Ventilators -keep ventilator system off the floor Nebulizers take advantage of the eligibility to obtain more than one neb kit a month Oximeters - clean with alcohol between uses

26 STRATEGIES AND INTERVENTIONS, CONT D Enhanced Discharge Planning Transitional care model (hospital to home) designed to promote patient safety and satisfaction, improve quality of life, and reduce preventable re-hospitalizations and ER visits.

27 STRATEGIES AND INTERVENTIONS, CONT D Enhanced Discharge Planning, cont d Provided staff with To Go Packets Emergency Room Visit Guidelines Emergency Room Discharge Log Work with hospital social workers to increase understanding of our population with hospitalists

28 STRATEGIES AND INTERVENTIONS, CONT D Post Discharge Protocol On site visit by TRC primary care provider and respiratory therapist post discharge within 48 hours Personal Hygiene Equipment - Change all oral hygiene equipment, toothbrushes and tools, nebulizers, and any personal oxygen equipment after antibiotics are finished

29 STRATEGIES AND INTERVENTIONS, CONT D Post Discharge Protocol cont d Review/revision of Care Plan/PONS Include instructions on oral care in the Plan of Care Identify target symptoms/side effects to monitor and what to do should they arise

30 STRATEGIES AND INTERVENTIONS, CONT D Policies/Procedures Protocols/Checklists for sterilization of all oxygen equipment, nebulizers, oximeters, ventilator systems, inhalers, toothbrush replacement Care Plans/PONS Specific to Individual for Respiratory concerns When to contact the RN Clear discharge summary

31 STRATEGIES AND INTERVENTIONS, CONT D QOL Identify clear goals and objectives for improving and providing access to quality relationships and engagement Increase in community involvement/engagement Decrease staff turnover rates

32 STRATEGIES AND INTERVENTIONS, CONT D Education and Workforce Development Triage Training Telephone Triage Protocols for Nurses Julie K. Briggs; OPWDD Triage Training Infection Control for the Non-Infection Control Nurse Introduction to Infection Control Infection Transmission and Precautions Infection Control and Management Microbiological and Laboratory Testing Common Infectious Agents Within an OPWDD Program

33 STRATEGIES AND INTERVENTIONS, CONT D Education and Workforce Development cont d Instructional Workshop with the Respiratory Therapist Infection Control Practices/Standard Protections Hand Washing Basics Personal Protective Equipment Curriculum with hands on use of PPE Cough Hygiene Sanitizing Equipment and Environment

34 EDUCATION HAND WASHING Hand Hygiene for Transmission Control One of the easiest and most effective ways to control transmission hand washing

35 EDUCATION HAND WASHING, CONT D Hand Washing Basics: How: Generally best to wash hands with plain soap and water Antibacterial soap is no more effective at killing germs than is regular soap Do it right!

36 EDUCATION HAND WASHING, CONT D Hand sanitizers Not cleaning agents Easy and quick to use Cause less skin irritation Portable Must be at least 60% alcohol Place where there is no sink

37 EDUCATION HAND HYGIENE HAND HYGIENE Perform hand hygiene IMMEDIATELY after removing all PPE If hands are visibly contaminated during PPE removal, wash hands before continuing to remove PPE Wash hands with soap and water or use an alcohol-based hand rub Ensure that hand hygiene facilities are available at the point needed.

38 EDUCATION COUGH CONTROL Cough Hygiene For Transmission Control Educate individuals on source control Post signs Cover your Cough if appropriate Provide tissues and receptacles Provide alcohol-based hand rubs or sinks Offer masks to participants or personnel Social distancing - maintain 3 feet from others

39 EDUCATION EFFECTIVE USE OF PPE Don (put on) before contact with the individual, generally before entering the room Use carefully - don t spread contamination Remove and discard carefully, either at the doorway or immediately outside individual s room (remove face mask outside of room) Immediately wash hands

40 EDUCATION SEQUENCE FOR DONNING PPE Gown first Mask /Goggles or Respirator Goggles or Face shield Gloves

41 STRATEGIES AND INTERVENTIONS, CONT D Environmental Sanitization Engagement of the housekeeping staff Training Infection Control & Housekeeping Where Are We Headed Use of microfiber cloths Disinfecting agents Quaternary Disinfectant Cleaner (QUAT) Reduced disinfecting time from 10 minutes to 30 seconds

42 ANALYSIS Performance Measures: Number of visits to ER for respiratory reasons Admissions to hospital frequency, duration, individuals, sites Reason for ER visit/hospital admission

43 ANALYSIS, CONT D Identify who will look at metrics Identify method to determine if the number of ER visits decreased

44 QUALITY IMPROVEMENT PROJECT- ENHANCED HOME CARE FLOW CHART System Entry -Embedded primary care -Staff education/support -Ongoing medical evaluation RN Care coordination System Navigation -RN Care coordination -Reduced fragmentation -Person-centered planning Community Integration Improved community participation and socialization INTEGRATED CARE Improved healthcare outcomes Improved access to care Reduced costs system and program

45 QUALITY IMPROVEMENT PROJECT- EXPECTED OUTCOMES System Entry System Navigation Community Integration Reduce hospitalizations from baseline Reduce use of emergency room from baseline Provide 24/7 on call medical triage, support and decisionmaking Improve communication with primary care providers and specialists Reduce fragmentation and duplication of communication Reduce annualized staff turnover rates from 112% to 87% Establish weekly in-home visits with community volunteers Increase community engagement by participating in at least one community-based activity per month.

46 HOW OFTEN IS THE EMERGENCY ROOM USED? Total ER Visits in 2012 Total ER Visits in JAN - MAR APR - JUNE JULY - SEPT OCT - DEC TOTAL: 50 0 JAN - MAR APRIL - JUNE JULY - SEPT OCT - DEC TOTAL FOR 2013

47 HOW OFTEN IS THE EMERGENCY ROOM USED? Total ER Visits in 2014 Total ER Visits in JAN - MAR APR - JUN JULY - SEPT OCT - DEC TOTAL: 0 JAN - MAR APR - JUN JULY - SEPT OCT - DEC TOTAL:

48 HOW OFTEN IS THE EMERGENCY ROOM USED? ER Visits from 2012 to

49 What impacted the number for 2014: 30 new admissions to the Residential program Episodic care services 20 individuals transitioned within the program

50 ANALYSIS Next Steps in 2015: Case review with primary care physician Develop protocols to educate staff when individuals are repeat users 2 within 30 days 3 within 3 months Case reviews/debriefings for MH reasons intense behavior Follow ACO Standards to verify follow up with provider within 48 hours