1、A Report to the Patient Safety Committee of Arizona General Hospital,Prepared by Members of the University of Missouri-Columbia Interdisciplinary Workgroup for the CLARION INTERPROFESSIONAL CASE COMPETITION SPRING 2005,INTRODUCTIONS,Ashley Mahon Accelerated Option BSN, RN Program UMC School of Nursi
2、ng Russell McCulloh 4th Year, MD Program UMC School of Medicine Kevin Norris 3rd Year, PT Program UMC School of Health Professions Brian Stout 3rd Year, MHA/MBA Dual Degree Program UMC Schools of Medicine & Business,She “might be trouble” -Bus Driver,PRESENTATION OVERVIEW,Case Overview Methods of An
3、alysis Major Findings Specific Findings Recommendations/Action Plan Tracking Indicators Cost Analysis Systems Issues References/Acknowledgments,CASE OVERVIEW,Arizona General Hospital: Tertiary care center 620 bed-facility 97 Behavioral Health Beds AGH Values: Dignity Collaboration Stewardship Excell
4、ence,CASE OVERVIEW,Part of Southwest HC System (SWH) Flagship for HC delivery in Maricopa Co. 10 affiliated clinicsClinical Expertise Centers of Excellence Behavioral Health Womens Health Rehabilitation Cardiovascular services Neuroscience Oncology Orthopedics Spine Care,CASE OVERVIEW,36 year old fe
5、male 20 year history of schizophrenia Admitted for decreased mental status Treated for suspected overdose Self-administered medication overdose in hospital 3-week stay in BHU Discharged to home Readmitted seven weeks later for relapse of psychotic symptoms and alcohol intoxication,METHODS,Investigat
6、ion: Identification of Major Events Causal Flow Analysis Root-Cause Analysis (VA-NCPS) Identification of Contributing Factors Remediation: Literature Review Development of Recommendations Progress Assessment Cost Analysis Extrapolation,MAJOR FINDINGS,Three adverse events were identified: Self-Induce
7、d Clozaril Overdose Job/Coverage Loss & Rehospitalization Self-Extubation*Self-Induced Overdose: Unsuccessful suicide attempt Near-miss of a reportable JCAHO sentinel event:“Any suicide of a patient in a setting where the patient is housed around-the-clock”,Self-Induced Drug Overdose,Self-Induced Ov
8、erdose Timeline,Self-Induced Overdose Flow Diagram,Self-Induced Overdose RCA,Root Cause Statement:“Level of patient observation and access to potentially toxic medications resulted in increased possibilityof self-induced overdose.”Three contributing factors domains were identified,Care Team Communic
9、ation,Care Team Role Definition,Policies & Procedures,Self-Induced Overdose Ishikawa,Self-Induced Overdose: Contributing Factors,Care Team Communication Parallel and informal evaluation and communication of self-harm risk Informal assumption of polysubstance abuse Care Team Roles Medication identifi
10、ed solely by ER staff Primary focus on only physical health aspects of admission Policies & Procedures Persistent access to patient of potentially toxic medications PMH gathered solely from patients medication bottle,Self-Induced Overdose: Recommendations,Care Team Communication AMR “tab” dedicated
11、to psychosocial issues1 Care Team Roles All pt home meds are to be ID by pharmacist2 Policies & Procedures Develop a standard protocol for evaluation & management of all overdose patients3 Establish procedures for pts. at possible risk for self harm1,4 Establish security procedures for the intake, s
12、torage, and disposition of pt home meds2 Similar policy for potentially harmful pt. items2,Self-Induced Overdose: Tracking Indicators,Suspected overdose patients assessed for self-harm risk* Employees scoring 70% or greater on knowledge assessment of behavioral health training courses* Home medicati
13、ons stored securely*All indicators are percentage-based; goals for implementation are to be set at 100% compliance,Self-Induced Overdose: Cost Analysis,Incurred costs Room sitters (personnel-dependent) Time/resource demands for training personnel re: new assessment procedures Monitoring/ongoing risk
14、 assessment Cost-neutral measures AMR changes covered by IT contract Estimated savings Reduced risk of emergent intervention,Self-Induced Overdose: Dollars and Sense,Job/Coverage Loss and Rehospitalization,Job/Coverage Loss & Rehospitalization Timeline,Job/Coverage Loss & Rehospitalization Flow Diag
15、ram,Job/Coverage Loss & Rehospitalization RCA,Root Cause Statement : “Level of social services involvement led to the patients job & coverage loss and ultimately resulted in patients relapse & readmission to the hospital.”Three contributing factor domains were identified,Care Team Communication,Inad
16、equate Social Services,AMR Usage,Job/Coverage Loss & Rehospitalization Ishikawa,Job/Coverage Loss & Rehosp.: Contributing Factors,Care Team Communication: Care teams engaged in parallel and informal communication Coordination of Social Services: Patient assigned to HCC Currently defined roles for HC
17、C and SW HCC only involved near end of pts stay AMR Usage: Hospital staff unfamiliar with documenting psycho-social information into the AMR Incomplete integration of AMR with organizational culture,Job/Coverage Loss & Rehosp.: Recommendations,Care Team Communication Psych team and SW make daily rou
18、nds together for all primary diagnoses of mental illness, psychosis, and drug overdose5 Fully integrated multi-disciplinary teams Coordination of Social Services Redefine the role of the HCC6,7,8 Automatic referral to SW in cases with primary dx. of mental illness, psychosis, or drug overdose AMR Us
19、age AMR “Tab” for psycho-social information Formal mechanism for staff feedback,Job/Coverage Loss & Rehosp.: Tracking Indicators,Staff satisfaction rate with AMR (20% increase from baseline) Voluntary exit survey for patients receiving Psych/SW team care Percent of pts. admitted with diagnosis of me
20、ntal illness, psychosis, or drug overdose, assessed by SW (100%) Percent of pts seen by HCC within:- 36 hours of admission (95%)- 48 hours of admission (100%) 5. Number of readmissions due to mental illness, psychosis, or drug overdose (10% reduction),Job/Coverage Loss & Rehosp.: Cost Analysis,Cost
21、Neutral Recommendations: AMR changes (provided through IT contract) Social Worker/Psych rounds Referral policies Incurred Costs Additional HCCs (case managers)9 Savings Reduce number of psych readmissions6 Reduced LOS by 10% with multi-disciplinary rounds5 Reduced per-patient cost of stay by up to 1
22、6% with multi-disciplinary rounds5,Job/Coverage Loss & Rehosp.: Dollars and Sense,Job/Coverage Loss & Rehosp.: Dollars and Sense,Self-Extubation,Self-Extubation Timeline,Self-Extubation Flow Diagram,Self-Extubation RCA,Root Cause Statement :“The level of sedation & agitation management increased the
23、 likelihood of patient self-extubation”Three major contributing factor domains were identified,Care Team Communication,Policies & Procedures,Scheduling,Self-Extubation Ishikawa,Self-Extubation: Contributing Factors,Care Team Communication: Time/location of pharmacist involvement Communication b/w fr
24、ont-line providers Policies & Procedures: Extent of behavioral assessment Availability/use of agitation management protocols Availability/use of sedation and weaning protocols Scheduling: Provider staffing-level in ICU,Self-Extubation: Recommendations,Care Team Communication: Ensure timely urine/ser
25、um toxicology screens in conjunction with overdose protocols Develop AMR flag for pharmacist consult in all cases involving drug overdose Policies & Procedures: Institute routine use of agitation management protocols by ICU staff (Ramsay)10 Institute use of sedation protocols in ICU11,12 Institute u
26、se of weaning protocols in ICU10,13 Scheduling: Evaluate adequacy of ICU staffing/training10,14,15,Self-Extubation: Tracking Indicators,Incidence of self-extubation (ICU) Length of ventilator support (ICU) ICU pt-nurse staffing ratios (1.5-1.7) Number of pts (per 100 intubated pts) that score below
27、3 on two consecutive hourly Ramsay Assessments (Zero) Percent of overdose pts whose records include RPh consult notes (100%) Percent of overdose pts whose urine/serum toxicology screens are ordered w/in 1 Hr of admit to ER (100%),Self-Extubation: Cost Analysis,Incurred Cost: Increased ICU Staffing?
28、Physician/RPh Consult Fees Implementation of protocols/training Monitoring/ongoing risk assessment Estimated Savings: Decreased LOS in ICU (Decrease of 3.5 days)16,17 Shorter Duration of Ventilator Support (Decrease of 2.5 days17; between 63 and 89% of SEs do not require reintubation10) Costs of Rei
29、ntubation (40% Decrease)11,Self-Extubation: Dollars and Sense,“The Big Picture”,Recommendation Summary,Communication AMR/organizational culture integration Policies and Procedures Expansion of care team member roles Supporting AGH mission and values Dignity Collaboration Stewardship Excellence,What
30、If,Psych would have been more actively involved in patient care? Risk for self-harm would have indicated need for 1:1 staffing and/or suicide observation in ICU and suicide observation in Ward 10A Pharmacy would have been more actively involved in patient care? Patient and drug ID would have been co
31、nfirmed Patient PMH might have been available Concerns over sedative interactions might have been dismissed,What If,Social Services would have been more actively involved in patient care? Patient job/coverage loss might have been avoided altogether Patient would have had access to local mental healt
32、h resources and “safety net” coverage All three domains had been aligned with delivery of acute care? No adverse events? Patient would have certainly left our institution better off than when she arrived (in many ways),Targeting Continuity of Mental Health Services,Within the Institution Mental Heal
33、th Services Pharmacy Social Services Acute/Chronic Care Within the Community: Provider/MCO Collaboration Partnerships Regional Leadership,Future Directions:,Increase pharmacy integration: Discharge Planning/Consultation18,19,20 Pharmacy and Therapeutics Committee18,19 Collaborative Drug Therapy18,19
34、 Medication Reconciliation21 Psychiatric Pharmacist22,23 Integrating social services & behavioral health: Functional Integration Team18 (AGH BHCE) Wellness Recovery Action Plans24 (WRAP) Ongoing collaboration between: AGH & community pharmacies AGH & satellite clinics SWH & ValueOptions25,26,Conclud
35、ing Remarks,Consistent with: Our institutional mission IOM & IHI vision of the future Our patients needs/rights to access & receive safe, reliable, and comprehensive care “It doesnt work to leap a twenty-foot chasm in two ten-foot jumps”-American Proverb,A Report to the Patient Safety Committee of A
36、rizona General Hospital,Prepared by Members of the University of Missouri-Columbia Interdisciplinary Workgroup for the CLARION INTERPROFESSIONAL CASE COMPETITION SPRING 2005,References,Dlugacz, Y.D., Restifo, A., Scanion, K., Nerlson, K., et al. (2003). Safety Strategies to Prevent Suicide in Multip
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