Merging the Rothman Early Warning (R-Warning) and Interdisciplinary Plans of Care (IPOC) to Impact Patient Safety

Transcription

1 Merging the Rothman Early Warning (R-Warning) and Interdisciplinary Plans of Care (IPOC) to Impact Patient Safety Terris Kennedy, RN, PhD, CNO Susan Tanner, RN, MSN System Director Clinical Information Systems Riverside Health System

2 Objectives Describe the Rothman Index and its evolution as an R-Early Warning & Explain how Nursing Documentation is Critical Describe the Mapping of EMR Data in Obtaining the Rothman Score Describe how standardizing care across the continuum can result in enhanced Patient Safety Explain how R-Warning and IPOC supports Clinical Success and Patient Safety Identify R-Warning Metrics

3 About Us

4 To care for others as we would care for those we love to enhance well- being and improve health

5

6 Riverside by the Numbers 2011 Data People Physicians = (392 Employed by the Riverside Medical Group) Employees = Hospitals Hospital Beds = 984 Acute Care, Community (4) 5 in April, 2013 Behavioral Health/Substance Abuse - Children, Adolescent, Adult (1) Physical Rehabilitation (1) Discharges = 25,461 Patient Days = 121,337 4 ED/Trauma Centers = 111,584 Visits Births = 3,230

7 Riverside by the Numbers 2011 Data Outpatient Visits = 103,000 (excludes diagnostics) PACE Centers = 6 Long Term Care Centers = 10 Resident Days = 329,256 Beds = 968 Retirement Communities = 3 Assisted Living Units = 306 Independent Living Units = 350 Total Post Acute Beds = 2,306

8 Riverside is a fully integrated health system. We recognize the importance of addressing the full continuum of care to best meet the needs of our patients.

9 What is R-Warning and the Rothman Index?

10 Rothman Index Evolution Turning Loss into Meaning - Family loss inspires the Rothman brothers to investigate data available in the hospital EHR Investigation and Discovery - Research leads to Rothman Index with clear correlation of specific clinical indicators and patient outcomes - Scientific validation with 250,000 lives in multiple settings From Research to Product - Validation complete, clinical partners identified - Evolution from a grant-funded LLC to incorporated entity with broad-based product launch in Dec Fully integrated with multiple EMRs

11 What is the Rothman Index? A numerical value derived from existing clinical data using a defined algorithm Uses nursing assessments, vital signs and labs Represented as a data point on a graph in the record Instant access to pertinent information The Index is updated frequently as new data are available Information over time to visualize changes in patient condition Reflects a patient s condition in light of treatment

12 Clinical Implications Nursing Assessments If the first nursing assessments taken upon admission correlate with in-hospital mortality and The last nursing assessments taken prior to discharge correlate with post-discharge mortality then It is reasonable to infer that all nursing assessments gathered throughout the patient s stay contain significant clinical information (Rothman et al., 2012)

13 Rothman Index R-Warning Overview Existing EHR Data Vital Signs Lab Values Nursing Assessments Rothman Index Score Opportunities for Earlier Intervention US Patent Nos. 8,092,380; 8,100,829; 8,355,925; 8,403,847 and 8,454,506; and other foreign patents pending PeraHealth, reproduced with permission

14 Has this Patient Gotten Better or Worse in the Last Five Days? 30-Jul 31-Jul 31-Jul 31-Jul 1-Aug 1-Aug 1-Aug 2-Aug 2-Aug 3-Aug 12:07 7:25 8:00 14:46 0:00 8:00 22:30 4:15 16:25 0:20 Temperature F Systolic BP Diastolic BP Heart Rate Respiration Rate Oximetry Heart Rhythm SR= SR= SR= SR= SR= SR= SR= SR= SR= SR= Braden Cardiac met not met met met not met not met not met not met met not met Food met met met met not met not met not met not met not met not met Gastrointestinal met met met met met met met met not met not met Genito-urinary met met met met not met not met not met not met not met not met Musculo-skeletal not met not met not met not met not met not met not met not met not met not met Neurological met met not met not met not met not met not met not met not met not met Peripheral-vasc not met not met met met not met not met not met not met not met not met Psycho-social met met met not met not met not met not met not met not met not met Respiratory met not met not met not met not met not met not met not met not met not met Safety met met not met not met not met not met not met not met not met not met Skin not met not met not met not met not met not met not met not met not met not met BUN Creatinine WBC HGB Chloride Sodium Potassium PeraHealth, reproduced with permission

15 Root Cause Analysis: An Unexpected Death A 50-point fall over 12 hours 46 year old male, foot ulcer admitted PeraHealth, reproduced with permission

16 Patient Condition is Changing PeraHealth, reproduced with permission

17 R-Warning Decline Time Rothman Index Braden Cardiac Food GI GU Musculo Neuro Perivasc Psych Safety Skin 07: Fail Pass Pass Pass Fail Pass Fail Pass Pass Fail 07: Fail Pass Pass Pass Fail Pass Fail Pass Pass Fail 08: Pass Pass Pass Pass Fail Fail Pass Pass Fail Fail 11: Pass Pass Pass Pass Fail Fail Pass Fail Fail Fail 12: Pass Pass Pass Pass Fail Fail Pass Fail Fail Fail 13: Pass Pass Pass Pass Fail Fail Pass Fail Fail Fail 14: Pass Pass Pass Pass Fail Fail Pass Fail Fail Fail 15: Pass Pass Pass Pass Fail Fail Pass Fail Fail Fail 16: Pass Pass Pass Pass Fail Fail Pass Fail Fail Fail 20: Fail Fail Pass Fail Fail Fail Fail Fail Fail Fail PeraHealth, reproduced with permission

18 Build and Implementation

19 Architecture Overview USER WORKSTATION EMR Database Local OR Citrix Index Viewer DLL HL7 Interface Vital Signs Lab Results Nursing Assessments Demographic Data Unit/Patient Graphs can be accessed through EMR via an External Link R-WARNING APPLICATION & DATABASE SERVER(S) Translator Rules Processor (RI Computation) R-Warning Database Servers(s) can be physical or virtual, in either local or hosted environment

20 Mapping EMR Data Vital Signs Lab Results Assessments Demographics** Temperature* Systolic Blood Pressure Diastolic Blood Pressure Heart Rate Respiration Rate Oxygen Saturation BUN Creatinine WBC Hemoglobin Chloride Sodium Potassium Braden Scale* Fall Risk Shift Heart Rhythm* Body Systems Integumentary Name Date of Birth* Patient IDs Location Admission/Discharge Date/Time Discharge Disposition Diagnosis Provider Name Patient Type Almost 200 findings interfaced!

21 Met and Not Met Within Normal/Defined Limits Statements Charting by Exception Example: Cardiac Heart Tones Click Deficit Distant Gallop Irregular Murmur Regular Rub S1 S2 S3 S4 Split Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Normal Abnormal Normal Normal Abnormal Abnormal Abnormal

22 Swim Lane Alerts 3 months of data analyzed prior to live Three levels of alert Rule Name Definition Mortality LOS (days) Patient Visits that Trigger Rule Very High Acuity RI % % High Acuity sensitive to slower changes Medium Acuity sensitive to rapid changes Falls 40% within last 24 hours Falls 30% Within last 6 hours 14.2% % 11.8% % Note: 6,858 historical visits Overall mortality is 2.6% Average LOS is 3.9 days

23 While Live in the Dark Code Blue

24 Practice Guidelines and Optimization

25 RHS 2014 Commitments Focus Area #3 Safety, Quality, Service Experience 3.2 Improve health outcomes through a commitment to evidence-based practice and reliability of performance as demonstrated by improved transitions in care, compliance with preventive care measures and integration of predictive tools to manage the health of defined populations cared for by our team members. Readmissions Preventive measures R-Warning implementation 3.3 Instill a culture of patient safety and high reliability at the point of care delivery, as evidenced by an increased number of days between serious safety events driven by the Patient Safety Coaches observations of demonstrated safety behaviors.

26 Background What is Interdisciplinary Care Planning? Interdisciplinary care planning occurs when the team collaboratively synthesizes the information and reaches consensus around treatment and goals for the patient. (Gage) Interdisciplinary Plan of Care (IPOC) A written plan based on data gathered during assessment that identifies care needs and treatment goals, describes the strategy for meeting those needs and goals, outlines the criteria for terminating any interventions, and documents progress toward meeting the plan's objectives. (Gage) Gage M. Ten steps to a patient-driven interdisciplinary care plan. Aspens Advis Nurse Exec 1998;13:6-8.

27 Guiding Principles POC Development Subject Matter Experts (SMEs) must be open to the ideas/suggestions of other facilities represented. This is the way we have always done it is not what we need. This will be a collaborative effort of our facilities. Subject Matter Expert s for your area and facility, you are representing the viewpoint of your entire clinical discipline throughout the design process. Keep in mind what is important when caring for YOUR patients in your experience. In the event of a discussion where two or more members cannot come to an agreement, the evidence will prevail.

28 It Takes a Team & Goals Members: Nurses (managers and frontline), Physicians, Care Management, Respiratory Therapy, Information Technology, Decision Support, Quality, Education, palliative care, Non-acute team members, Vendor IPOC Goals Patient Safety Prevention Evidence-Based Patient Engagement Address Needs of the Vulnerable & Older Patient Working Transition Date Interdisciplinary Rounding/Conferencing Process Discharge Planning Steering Committee Clinical Staff

29 Supporting Financial and Clinical Success VOLUME VALUE R-Early Warning + IPOC Prioritized Physician Rounding Enhanced Cross Coverage Discharge Planning Margin Nursing Practice Support Proactive vs. Reactive RRT LOS Improvement Optimizing ICU Utilization Multiple Admissions/Palliative Care Use Reducing Harm - Drive early intervention Streamlining workflow Improved clinical communication and Best Practice Community Health Telemedicine, Post-Acute Care 30 Day Readmissions Reduction 1% of Medicare Revenue penalty Early patient discharge disposition to post acute care (SNF, Home Health)

30 Timeline for R-Warning + IPOC Dec Q14 2Q14 3Q14 4Q14 R-Warning Go Live Metrics Defined Standardize Code Blue & RRT Practices (June 1) Practice Guidelines (PG) Project Charter Education/Training (PG) Standardize Code Blue & RRT Review Processes (October 1) RI Hardwired in IPOC (Dec. 1) R-Warning Project Milestones RRT= Rapid Response Team PG= Practice (Usage) Guidelines RI= Rothman Index Riverside Care Difference Commitments Threshold: All facilities with R-Warning meet all four by year end Target: All facilities with R-Warning meet all four by designated deadlines Stretch: All facilities with R-Warning meet all four earlier than designated deadlines

31 R-Warning Toolkit

32 R-Warning Metrics Practice guidelines- (proxy measure- usage reports) Timeliness of RN shift assessment documentation Code Blue (Overall, ICU, Non-ICU) Rapid Response Team (RRT) calls Sepsis incidence Length of Stay (Arithmetic & Geometric) Mortality (3M methodology- Premier) ICU Readmissions All diagnosis Hospital Readmission (3M-Premier) Discharge disposition (% d/c home) Safety Moments/ Good Catches Shared Best Practices

33 R-Warning Usage Data PeraHealth, reproduced with permission

34 Hardwiring R-Warning into IPOC Rounding RHS Culture

35 The Difference Bringing R-Warning & IPOC Together Communication The sharing, imparting or interchange of thoughts, opinions, or information by speech, writing or technologic signs. Collaboration Individuals assuming complementary roles and cooperatively working together, sharing responsibility for problem solving, and making decisions to formulate and carry out plans based on data input. The Advisory Board Company 2012

36 Inpatient R-Warning Kiosk

37 Patient Board

38 Respiratory Rounding Prioritization

39 Plan of Care as the Communication Hub Order Sets Handoffs/ Care Transitions Patient/ Family Education Scope of Care IPOC Transition Instructions Policy/ Procedure Assessment

40 Nurse as Integrator Patient Advocate Information Source Information Giver Coordinator of care Coordinator of care team Pulls it all together for the patient

41 Measures and Metrics of Interest

42 Measures Include R-Warning with IPOC Baseline Data Ongoing Monitoring IPOC Presence, Use, Individualization (ehr Audit) Length of Stay (ALOS, All) Readmission Rate (30-Day All Dx, All Payer) Patient/Family Satisfaction Staff Satisfaction Physician Satisfaction Transition Setting (Referrals to Home Health) Key Clinical Quality Indicators (NDNQI Falls) Adverse Events (Midas patient/procedural)

43 Metrics of Interest

44 Goals 2015 Process Bring patient (physically) into rounds R-Warning Consistent Tool for all IPOC & Readmission Rounds Continue to update and enhance existing problems, add triggers Continue to revise plans and process based on effective utilization of the Rothman Index and measurement results

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46 Summary The integration of existing EMR data into a scientifically validated tool assists the interdisciplinary care team to proactively respond to subtle changes in patient condition with the goal of improving patient outcomes with improved timeliness of care.

47 References Bradley, E. H., Yakusheva, O., Horwitz, L. I., Sipsma, H., & Fletcher, J. (2013, September). Identifying patients at increased risk for unplanned readmission. Medical Care, 51(9), Marks, E. (2013, April 22). Complexity science and the readmission dilemma. JAMA Internal Medicine, 173(8), Rothman, M., Solinger, A., Rothman, S. & Findlay, G. (2012). Clinical implications and validity of nursing assessments: a longitudinal measure of patient condition from analysis of the electronic medical record. British Medical Journal Open, 2(4). doi: /bmjopen