Place hospital logo here

Transcription

1 Place hospital logo here

2 Nurse-Driven Protocol for the Management of Patients in Alcohol/Substance Withdrawal Maimonides Medical Center (MMC) Sharon Hawthorne, RN, BSN, CCRN, SSN II Ariadne Williams, RN, MSN, CCRN, SSN I Laurie Wilson, RN, MSN, SSN I Christina Ycaza-Gutierrez, RN, BSN, CCRN, SSN II

3 Problem Higher number of Medical Intensive Care Unit (MICU) admissions with alcohol/substance abuse and withdrawal symptoms Resource intensive care and clinically challenging for RNs Staff need clear guidelines for clinical management

4 Baseline Data Large influx of emergency department patients in withdrawal who were prophylactically intubated due to oversedation; some ending up with a tracheostomy No quantifiable means to measure degree of patient s agitation Intensivists have varying approaches to medicating and managing these patients

5 Purpose To develop and implement a nurse-driven, evidence-based protocol using pharmacological and nonpharmacological interventions to manage patients with alcohol/substance abuse and to manage the symptoms of patients in withdrawal

6 Goals Early recognition and management of patients with withdrawal symptoms using the Richmond Agitation Sedation Scale (RASS) Decrease severity of symptoms Decrease ventilator (vent) days Decrease complications (falls, injury, ventilatorassociated pneumonia) Decrease MICU length of stay (LOS)

7 Action Plan Develop a pre- and post-survey tool to ascertain how staff feel about caring for symptoms of patients in withdrawal Develop and implement an algorithm of care Launch project and provide ongoing staff re-education Develop audit tool to track identified patients with delirium Recruit champions from day and night shifts

8 Project Timeline January 2014 March 2014 Literature review Pre-project survey, algorithm, slogan Project kickoff, giveaways, education Audit tool Data collection

9

10 Stop DTs, Fast D/C

11 ALGORITHM FOR MANAGEMENT OF PATIENTS IN ALCOHOL OR SUBSTANCE ABUSE WITHDRAWAL RASS Q 1 HOUR AND PRN RASS SCORE: SIGNS & SYMPTOMS OF WITHDRAWAL AGITATION RESTLESSNESS ANXIETY TACHYCARDIA DIAPHORESIS HAND TREMORS CONFUSION HEADACHE INSOMNIA HALLUCINATIONS YES IS PATIENT IN PAIN? PAIN MANAGEMENT Morphine Hydromorphone Fentanyl ON NURSING MEASURES Constant Watch Reorientation Decrease Stimulation Nutrition/Hydration Electrolyte Replacement Bowel/Bladder Program (Toileting) Timely Removal of Catheters Early Mobilization Sleep Promotion Environment Management Emotional Support Encourage Family Involvement MEDICATIONS Immediate Acting: Lorazepam IV Push PRN Dexmedetomidine IV Infusion Long Acting Oral Medications: Chlordiazepoxide Clonazepam Quetiapine Gabapantein Methadone Supplements: Folic Acid Mulitivitamin Thiamine LABS: Alcohol level CBC Liver Profile PT/INR Basic Metabolic Panel Magnesium Phosphorous Toxicology: Serum, Urine Serum Amylase, Osmolarity DIAGNOSTICS: EKG SWA Referral If RASS > -3, sustained in 4 hrs: Titrate medications starting with IV Precedex, then long acting medications ( dose &/or frequency)

12 Project Launch/Kickoff

13 Project Launch/Kickoff March 13, 2014

14 Grant Budget Breakdown $ for launch party food and festivities $1, for posters, water bottles, and bags $ $7, $1, Launch Party Supplies/Gifts Remainder

15 Project Timeline April Present: Re-educate staff Engage and ensure nurse/physician compliance Track patients and their progress Recruit champions Develop educational booklets for nurses and physicians Continue collecting and analyzing data

16 Blue & White Day April 30, 2014

17

18

19 Order Set

20

21 MMC Nursing Grand Rounds, October 22, 2014

22 Project Update Luncheon, October 22, 2014

23 Challenges Team members had schedule conflicts Patients not appropriately diagnosed on admission Obtaining pertinent data for the project Encouraging physicians to use protocol Motivating RNs to consistently enforce the nurse-driven protocol Restricted use of higher-priced medications due to budgetary constraints

24 Percent of Staff Answering "Always" 100% 80% 78% Survey 1 Survey 2 72% 60% 40% 50% 52% 20% 17% 15% 0% How well do you understand RASS? How often do you use RASS? How confident are you in managings a patient with DT/Withdrawal?

25 Percent of Staff Answering "Always" 100% 80% 60% Survey 1 Survey 2 65% 40% 20% 0% 16% How anxious or overwhelmed are you now when assuming care of a patient in DT/Withdrawal?

26 5 Number of Falls in MICU /2013-2/2014 3/2014-8/2014

27 Outcomes Data Pre- Project* Post- Project** Change Total Number of Patients Total Patient Days in MICU Average LOS in MICU Days Total Patient Days at MMC 1, Average LOS at MMC Days Total Number of Vented Patients Total Vent Days Average Vent Days per Patient Days Total Number of Trached Patients Patients *September 2013 February 2014 **March 2014 August 2014

28 Average LOS -MICU ALOS MICU Pre and Post Algorithm Implementation (September August 2014) (N=125) 6.79 Sept 2013-Feb 2014 (N=71) (Pre-Implementation Period) 5.48 March 2014-Aug 2014 (N=54) (Post-Implementation Period)

29 ALOS in Hospital ALOS in Hospital Pre and Post Algorithm Implementation (September August 2014) (N=125) Sept 2013-Feb 2014 (N=71) (Pre-Implementation Period) March 2014-Aug 2014 (N=54) (Post-Implementation Period)

30 Average Vent Days Average Vent Days Pre- and Post-RASS Implementation (September August 2014) (N=125) 7.02 Sept 2013-Feb 2014 (N=71) (Pre-Implementation Period) 5.29 March 2014-Aug 2014 (N=54) (Post-Implementation Period)

31 % Trached Patients 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% % Trached Patients Pre- and Post-Algorithm Implementation (September August 2014) (N=125) 15.5% Sept 2013-Feb 2014 (N=71) (Pre-Implementation Period) 1.9% March 2014-Aug 2014 (N=54) (Post-Implementation Period)

32 % Vented Pts Requiring Trach 25% % Vented Patients Requiring Trach Pre- and Post-Algorithm Implementation (September August 2014) (N=125) 22.9% 20% 15% 10% 5% 0% Sept 2013-Feb 2014 (N=71) (Pre-Implementation Period) 4.2% March 2014-Aug 2014 (N=54) (Post-Implementation Period)

33 Fiscal Impact of Protocol Implementation Outcome Estimated Cost Savings Decreased vent days by 1.73 $950 $39,444 Decreased MICU LOS by 1.3 days $9,500 $666,900 Decreased MMC LOS (outside the MICU) by 3.59 days $800 $155,088 Decreased falls by 1 (CMS, 2012) $9,491 $9,491 Decreased patients with tracheostomy from 11 to 1 $5,563 $55,630 Estimated cost based on hospital s calculations Savings based on 54 total patients and 24 ventilated patients during post-project implementation

34 Overall Fiscal Impact Estimated cost savings for 6 months after implementation of protocol: $926,553 Therefore, potential annual savings: $1,853,106

35 How Do We Plan to Sustain Our Project? Order set created for physician convenience, so that most commonly used medications and nursing interventions are available with one click Increased nurse satisfaction (reflected in the post-survey) should encourage staff to advocate for use of the protocol

36 What We Have Learned Recognition of individual strengths Success requires shared ownership of responsibilities Collaboration promotes improved patient outcomes We can effect change in our professional nursing practice by investing in projects that are evidence-based Networking with colleagues outside nursing expands our knowledge Dedicated staff who work as a team make the difference!

37 Special Thanks Marian Altman, RN, MS, CNS-BC, ANP, AACN CSI New York Faculty Debbie Brinker, RN, MSN, CNS, AACN CSI New York Faculty Adrienne Olney, AACN CSI Academy Program Manager Camille Scarciotta, RN, MSN, CCRN, Vice President of Nursing and CSI Coach, MMC Thomas Smith, DNP, RN, FAAN, Senior Vice President and Chief Nursing Officer, MMC Dorothy Jean Graham-Hannah, MPA, MSN, BSN, RN, BC, Vice President of Nursing, MMC Yizhak Kupfer, MD, FCCP, Director of Critical Care and Pulmonary Medicine Rosamaria Poska, RN, BSN, CCRN, Former Nurse Manager of MICU Sameh Samy, Director of Quality Outcomes, Performance Improvement Hannah Bodenstein, Assistant Director MIS - Systems & Procedures And especially the entire MICU team

38 References Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1): Barr J, Pandharipande PP. The pain, agitation, and delirium care bundle: synergistic benefits of implementing the 2013 Pain, Agitation, and Delirium Guidelines in an integrated and interdisciplinary fashion. Crit Care Med. 2013;41(9 Suppl 1):S99- S115. Cassidy EM, O Sullivan I, Bradshaw P, Islam T, Onovo C. Symptom-triggered benzodiazepine therapy for alcohol withdrawal syndrome in the emergency department: a comparison with the standard fixed dose benzodiazepine regimen. Emerg Med J. 2012;29(10):

39 References Awissi DK, Lebrun G, Fagnan M, et al. Alcohol, nicotine, and iatrogenic withdrawals in the ICU. Crit Care Med. 2013;41(9 Suppl 1):S57-S68. Eschel M, Greenlief J. Really soon: a change in practice for the care of patients with alcohol withdrawal syndrome. Crit Care Nurse. 2014;34(2). Hayes B. Dexmedotomidine (Percedex) as an adjunct to benzodiazepines for ethanol withdrawal. Acad Life Emerg Med Research Triangle Institute for Center for Medicare & Medicaid Services. Analysis report: Estimating the incremental costs of hospital-acquired conditions (HACs) Payment/HospitalAcqCond/index.html. Accessed April 1, (Click Incremental Updated Cost Report.)