Guiding Protocolized Patient Care through Branching Logic. By Cindy Sparkman, BS, RRT-NPS and Mickey Roach, BS, RRT
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1 Guiding Protocolized Patient Care through Branching Logic By Cindy Sparkman, BS, RRT-NPS and Mickey Roach, BS, RRT
2 University of Utah 2
3 University of Utah FY2012 Hospitals and Clinics; 4 Hospitals 10 Community Clinics Total employees 8657 Total Respiratory Therapists Inpatient Admissions just over 30,000 Licensed Beds 728 Physicians 1,200 physicians 3
4 Objectives Attendees: 1. Will understand the value of electronic protocols in respiratory care 2. Will understand how to program branching logic codes for MediLinks protocols 3. Will understand how electronic protocols can improve patient care outcomes 4
5 Traditional Care MD writes Respiratory Therapy Order Respiratory Therapist performs task Every order flagged at 48 hours DC d at 72 hours 5
6 AARC STATEMENT AARC defines that the purposes of the TDP are: Deliver individualized diagnostic and therapeutic respiratory care to patients Assist the physician with evaluating patients respiratory care needs and to optimize the allocation of respiratory care services Determine the indications for respiratory therapy and the appropriate modalities for providing high-quality, cost-effective care that improves patient outcomes and decreases length of stay Empower respiratory care practitioners to allocate care using signs-and symptom-based algorithms for respiratory treatment 6
7 Research 25% of care misallocated, The Cleveland Clinic % of therapy over ordered, 11.8% of therapy under ordered, Shelledy DC, LeGrand TS, Peters JI, % Oxygen therapy over ordered, Brougher et al,
8 Misallocation Therapy not needed Patient needs therapy, but not receiving Another therapy more effective Wrong frequency 8
9 Consequences of Misallocation Prolonged duration of mechanical ventilation Prolonged ICU LOS Prolonged hospital LOS Increased cost 9
10 Process Assemble a team Review existing data on therapist driven protocols and RT procedures Design therapist driven protocols Integrate branching logic software and incorporate into the existing work flow Forcing Function Protocol drives the therapy Training, Implementation, and Roll out 10
11 Goals 1. To reduce misallocation of care and cost of care via therapist driven protocols 2. Improve The Exceptional Patient Care Experience 3. Monitor: Ventilator Days, ICU LOS, Hospital LOS, Number of therapies, Cost of care 11
12 TEAM Boaz Markewitz, MD, Medical Director Earl Fulcher, Respiratory Therapy Manager Cindy Sparkman, Respiratory Care Adult Care Coordinator Mickey Roach, Respiratory Care Computer System Adminstrator Jim Behnke, Ancillary Services Director Bob Goodsell, Respiratory Therapist Paul Kappelman, Respiratory Supervisor Steve Lafortune, Respiratory Therapist Linda Egbert, Quality & Patient Safety Specialist Jace Manning, Quality & Patient Safety Project Manager / Facilitator 12
13 University of Utah Protocols Developed a series of unique protocols for the University of Utah Hospital Lung Volume Expansion (LVE) Airway Clearance (AWC) Neuromuscular Bronchodilator Oxygen 13
14 Designing Protocols Patient population Evidence Based Medicine Strong Direction from Medical Director Robust electronic Programming- Medilinks 14
15 Designing Protocols Least Cost/ least invasive Moderate Cost/ moderately invasive Most Cost/Most invasive 15
16 New Procedures Ventilator/CPAP/Manual Hyperinflation Vest therapy for Non-CF Patients Cough Assist Intrapulmonary percussive ventilation The ability to choose between Therapep and EzPAP 18
17 Traditional Care MD writes Respiratory Therapy Order Respiratory Therapist performs task Every order flagged at 48 hours DC d at 72 hours 19
18 Current Care MD writes order-perform Care for 24 hours Enroll patient into Resp. Care Protocols Physician orders- RT To Assess and Treat, Preferred method Immediately Assess and Enroll into Respiratory Care Protocols Every patient/every unit with two exceptions CF and Pediatric 20
19 Protocol Workflow Tools in MediLinks 21
20 Assessment Orders Report This report typically lists scheduled re-assessments orders 22
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23 Into Airway Clearance Diamond AC Is this a Neurology or Neurosurgical patient? Artificial Airway Present? Perform Therapep Frequency and re-assessment interval determined by triage score Which tx is pt able to perform effectively? Therapep? EzPAP? Neither? Does patient have a productive cough? 25
24 How charting a therapy will generate the initial assessment order 26
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27 A 24 hour assessment order code is embedded as a charge code on the branch code associated with this prompt 29
28 Assessors find the PIP (Patient Information Panel very helpful Template branches are completed as normal 30
29 In the sign/finish screen the INITIAL 24 HR assessment order is generated and will automatically post to the patient s orders upon signing 31
30 The order entry window opens automatically allowing user to modify the start date/time. Typically this will be 24 hours out for the initial assessment 32
31 Example of how the INITIAL Assessment order automatically posts to the assessor RT who is assigned to the patient when the worklist is built for the following days 33
32 RESPIRATORY THERAPY PROTOCOL Patient's identity (Name and Medical Record Number) verified via wristband. INITIAL RESPIRATORY ASSESSMENT PATIENT ASSESSMENT Respirations: Increased RR Level of Consciousness: Alert, oriented, cooperative Breath Sounds: Decreased bilaterally Cough: Strong, non-productive Level of Activity: Ambulatory (walks in hall) with assistance Oxygen Required for SPO2 >90%: 1-3 lpm or FIO2 < 40% or chronic cpap/bipap at home settings Example of what we want the initial assessment charting to produce: CHART ASSESSMENT Pulmonary Status: Current smoker > 1 Pk/Day Surgical Status: Lower abdominal surgery Chest X-Ray: Clear TRIAGE SCORE: 9 Patient complains of pain with deep breathing and coughing Lung Volume Expansion Indications: Upper abdominal surgery LUNG VOLUME EXPANSION PROTOCOL Patient has atelectasis by X-ray Patient does not have an artificial airway Patient is able to perform effective EzPAP therapy. CARE PLAN: The assessment template will generate: The assessment results Triage Score Care Plan Recommended Tx Frequency (based on triage score) Reassessment interval (based on triage score) To automatically DC last assessment order Perform EzPAP Recommended frequency: TID, re-assess in 24 hours. 34
33 The initial 24 hr assessment order is automatically DC d The NEXT assessment order generated from the INITIAL ASSESSMENT charting displays here in the Sign & Finish screen 35
34 The new order entry window again opens automatically allowing user to put in the new date/time as needed 36
35 In the treatment screen, the initial 24 hr assessment order is automatically DC s The new 2 ND Assessment order posts to the assessor RT who is assigned to the patient when the next day s worklist is built 37
36 A Embed Assessment order as a CHARGE CODE in Code Definition Tab and CODING: In the branch code containing the care plan, selection of the calculated Triage Score will determine the next re-assessment interval + it will DC the last assessment order automatically Freq. statements 38
37 B Embed Assessment orders to be DC D in the Charges/Observations/DC Order tab (DC Order column) 39
38 RESPIRATORY THERAPY PROTOCOL Patient's identity (Name and Medical Record Number) verified via wristband. PATIENT ASSESSMENT Respirations: Increased RR Level of Consciousness: Lethargic, follows commands Breath Sounds: Decreased unilaterally Cough: Strong, productive Level of Activity: Ambulatory (walks in hall) with assistance Oxygen Required for SPO2 >90%: 1-3 lpm or FIO2 < 40% or chronic cpap/bipap at home settings CHART ASSESSMENT Pulmonary Status: New diagnosis of pulmonary disease Surgical Status: No Surgery Chest X-Ray: Any abnormality i.e.: opacity, effusion, or atelectasis of one lobe Patient Physical Assessment (6 assessment elements) Chart Assessment (3 assessment elements) TRIAGE SCORE: 11 Patient complains of some intermittent shortness of breath Airway Clearance Indications: Excessive secretions Chest X-Ray findings: Atelectasis AIRWAY CLEARANCE PROTOCOL Patient does not have an artificial airway Patient has a productive cough Protocol / Care Plan Section Patient is able to perform effective TheraPEP Therapy. CARE PLAN: Perform TheraPEP Therapy Recommended Frequency: TID, reassess in 24 hours 40
39 Example of Assessment Protocol Data Entry PROMPT Assessor selects from the list of pre-defined descriptors for the one that best matches the physical assessment of the patient for each assessment element 41
40 EXAMPLE OF BRANCH CODING FOR ASSESSMENT OF RESPIRATIONS Assign a value to each assessment element in List Choice 42
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42 EXAMPLE OF BRANCH CODING FOR ASSESSMENT OF LEVEL OF CONCIOUSNESS Each assessment category is coded similarly 44
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52 How to Code the Protocol Algorithm 54
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61 Once again the re-assessment order associated with the care plan is generated back into the work flow 63
62 RESPIRATORY THERAPY PROTOCOL Patient's identity (Name and Medical Record Number) verified via wristband. PATIENT ASSESSMENT Respirations: Increased RR Level of Consciousness: Lethargic, follows commands Breath Sounds: Decreased unilaterally Cough: Strong, productive Level of Activity: Ambulatory (walks in hall) with assistance Oxygen Required for SPO2 >90%: 1-3 lpm or FIO2 < 40% or chronic cpap/bipap at home settings CHART ASSESSMENT Pulmonary Status: New diagnosis of pulmonary disease Surgical Status: No Surgery Chest X-Ray: Any abnormality ie: opacity, effusion, or atelectasis of one lobe TRIAGE SCORE: 11 Patient complains of some intermittent shortness of breath Airway Clearance Indications: Excessive secretions Chest X-Ray findings: Atelectasis AIRWAY CLEARANCE PROTOCOL Patient does not have an artificial airway Patient has a productive cough Patient is able to perform effective TheraPEP Therapy. CARE PLAN: Perform TheraPEP Therapy Recommended Frequency: TID, reassess in 24 hours 64
63 Goals 1. To reduce misallocation of care and cost of care via therapist driven protocols 2. Improve The Exceptional Patient Care Experience 3. Monitor: Ventilator Days, ICU LOS, Hospital LOS, Number of therapies, Cost of care 65
64 OUTCOMES 66
65 OUTCOMES 67
66 Measured Outcomes Bronchodilator ICU Length of Stay Length Of Stay Vent Days All Pts Vent Pts Non-Vent Vent Non-Vent All Pt Vent Pre protocol Pre Pre Mean protocol Mean protocol Mean n n n 573 Post Protocol Mean n 1991 Post Protocol Post Protocol Mean Mean n n 1203 p(statistically significant) < p(statistically p(statistically < significant) < < < significant) <0.0001
67 Measured Outcomes Airway Clearance/Lung Volume Expansion Airway Clearance/Lung Length Of Stay Volume Expansion Vent Days ICU Length of Stay Pre protocol All Pts Mean n 598 Vent Pts Non-Vent Vent Non-Vent All Pts Vent Pre Pre protocol Mean protocol Mean n n 430 Post Protocol Mean n 2255 Post Protocol Post Protocol Mean Mean n n 1406 p(statistically significant) p(statistically p(statistically significant) < significant) 0.018
68 Sample Mean Measured Outcomes 60 Airway 50 Clearance/Lung Volume 40 Expansion X-Bar Chart of ICU Days Hospital ALOS- Critical Care Units Sample All ICUs
69 Take Home Points Protocols programmed into Mediserve s MediLinks reduces variability and improves patient outcomes. The ability to automate features allows therapists to focus their time and energy on patients, instead of order reconciliation. Data captured can be utilized to monitor outcomes more effectively. 71
70 Questions 72
71 Want More Information? Contact Your MediServe ASM! Today s presentation will be available on the Client Portal later this week! 73
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