The CNS Role and Outcomes Management Evelyn Taverna

The CNS Role and Outcomes Management Evelyn Taverna, RN, MS, CCRN, CNS Guest Lecturer: N 226 February 19, 2003 California Pacific Medical Center

Overview Purpose: to extend the traditional role of case management to patient population based clinical resource management Develop systems to manage patients across the continuum - from inpatient to extended care to home health Create teams to effectively manage and integrate departmental activities in a cost effective, outcome driven manner California Pacific Medical Center

Population Based Teams Cardiology Cardiovascular Surgery Medicine Neurology/Neurosurgery Obstetrics Oncology Pediatrics Pulmonary Surgery/Orthopedics California Pacific Medical Center

Team Members Clinical Nurse Specialists RN Case Managers Social Workers Administrative Assistants Data Analysts Quality Coordinators Physician Champions California Pacific Medical Center

CPMC Quality & Clinical Resource Management Model CLINICAL MANAGEMENT QUALITY MANAGEMENT RESOURCE MANAGEMENT Clinical Nurse Specialist Population Based OUTCOMES MANAGEMENT Case Manager UR PHYSICIANS HOSPITALISTS DISCHARGE PLANNING Social Worker Patient/Family Based Administrative Assistant Support UTILIZATION MANAGEMENT California Pacific Medical Center STAFF MANAGEMENT DEPARTMENTS SOCIAL SERVICES

Quality & Clinical Resource Management Model CLINICAL NURSE SPECIALISTS Cardiology, Cardiac Surgery, Interventional Endoscopy, Medicine, Neonatal, Neurology/Neurosurgery, Oncology, Pediatrics, Perinatal, Pulmonary, Surgery/Ortho Quality Improvement Focus Resource Management Clinical Management Outcomes Management • Benchmarking • Protocols • Quality, cost, service • MD comparisons • Best practice guidelines • Data analysis/research • LOS/level of care • Clinical consultation • Clinical effectiveness • Cost/resource analysis • Staff education • PI projects • Resource utilization • Complex case review California Pacific Medical Center • Sutter initiatives

The CNS as Team Leader Masters prepared expert nurse clinician Manage clinical resources Define care requirements (best practices) Monitor their impact on outcome achievement 60% of time actively involved with patients Daily interaction with patients, families, clinical staff, nurses, and physicians Continually evaluate patient care needs Individuals and aggregate population Seek opportunities for improvement California Pacific Medical Center

Project Selection External Sources/Needs Mandatory – JCHAO Core Measures & Standards State Requirements - OSHPD Sutter Initiatives Press-Ganey Patient Satisfaction Survey VHA Programs Internal Sources California Pacific Medical Center

Project Selection External Regulatory Requirements JCAHO CORE Measures - 2002 CHF Perinatal Outcomes JCAHO CORE Measures – 2003 Community Acquired Pneumonia California Pacific Medical Center

Project Selection JCAHO Standards Pain Management – Jackie Phan, CNS Patient Safety- Gail Guthrie, CNS & Phyllis Erickson, CNS Medication Error Reduction – Evelyn Taverna, CNS California Pacific Medical Center

Project Selection External Requirements California CABG Outcomes Reporting Program (CCORP) – Jill Ley, CNS Crusade Study & National Registry for Myocardial Infarction (NRMI) – Evelyn Taverna, CNS ACOS Accreditation – Alice Mack, CNS National Practice Recommendations: AHA, AHCPR, etc. California Pacific Medical Center

Developing Clinical Questions Institutional Sources Quality committees Performance Improvement teams Product lines Clinician Sources Clinical observations New products/techniques Evidence-based practices California Pacific Medical Center

Current Projects Medication Error Reduction Coumadin dosing project Range-dosing protocol Patient controlled analgesia protocol New Procedures Bariatric surgery outcomes Continuous renal replacement therapy Off-pump CABG outcomes Outcomes Management Interventional endoscopy database Plavix research and practice change VBAC – California Best Pacific practice Medical Center

Current Projects Medication Error Reduction Coumadin dosing project Range-dosing protocol Patient controlled analgesia protocol New Procedures Bariatric surgery outcomes Continuous renal replacement therapy Off-pump CABG outcomes Outcomes Management Interventional endoscopy database Plavix research and practice change VBAC – California Best Pacific practice Medical Center

Benchmarking Resources Agency for Health Care Policy & Research(AHCPR) AHA, ACC VHA CMRI HBSI Fathom Midas NRMI 4 Crusade California Pacific Medical Center

Influencing Physician Practice The CNS is the “point person” for providing cost, service, and quality information to the Medical Staff to guide data driven practice changes which: reduce cost variations decrease overall cost maintain quality outcomes improve service California Pacific Medical Center

Cardiology CNS Acute Coronary Syndrome CHF Pacemaker Study Atrial Fibrillation Complex patients clinical education discharge planning California Pacific Medical Center

Cardiology: AMI ED chest pain protocol STEMI and NSTEMI protocol Crusade & NRMI 4 data – Focus on NSTEMI outcomes IIb/IIIa inhibitor use and bleeding interventional procedures Sutter Cardiovascular Services Initiative AMI task force CHF committee CHF ACE inhibitor use and discharge instruction outcomes & readmission California Pacific Medical Center

AMI Outcome Measures 1. Aspirin at arrival 2. Beta blocker at arrival 3. Median time to thrombolytic therapy 4. Median time to PTCA 5. Aspirin prescribed at discharge California Pacific Medical Center

AMI (cont. ) 6. Beta blocker prescribed at discharge 7. ACE I at discharge for LVSD 8. Adult smoking cessation advice 9. Inpatient mortality 10. Lipid-lowering agent at D/C California Pacific Medical Center

AMI Strategies ED Chest Pain Risk Assessment Acute Coronary Syndrome Protocols/Order Sets AMI Standard of Care AMI Guide to Recovery California Pacific Medical Center

California Pacific Medical Center

AMI Case Study Mr. M is a 54 year old man admitted with c/o of chest pain which began while watching the 49’ers playoff game. Patient lives with wife and works in law enforcement. Symptoms included: Constant, substernal chest pressure (5/10) Diaphoresis California Pacific Medical Center

AMI Case Study PMH: CAD, S/P angioplasty in 1989 Diabetes Hypertension Hypercholesterolemia Current smoker Medications: Atenolol and Glucophage Allergic to Aspirin and Motrin California Pacific Medical Center

AMI Case Study Physical Exam: Vital stable with bradycardia of 58 Oxygen sat 96% on 2 liters Lungs clear, no JVD Labs: Elevated cardiac markers Glucose – 295 EKG: ST elevation in inferior leads California Pacific Medical Center

AMI case study Interventions: Plavix Nitro Morphine Heparin Primary PTCA with GP IIb/IIIa inhibitor during/after PTCA Door to balloon time = 100 min. California Pacific Medical Center

AMI case study Discharge planning Cardiac rehab (PT, OT, Dietary) Smoking cessation advice Stress management Aspirin, Plavix, Beta blocker, ACE I inhibitor, statin California Pacific Medical Center

ACUTE MYOCARDIAL INFARCTION NRMI 4 DATA SUMMARY INDICATOR CPMC September 2002 Report 7/1/01 – 6/30/02 LIKE HOSPITALS (173 centers) CALIFORNI A NATION (1228 centers) Enrollment Yearly Non Transfer-in 303 260 55489 27330 186439 AGE 76 68 70 69 ST and/or LBBB on 1 st EKG 28% 27% 25% 27% AMI patients Eligible for Reperfusion a Treated Eligible AMI patients Untreated Eligible AMI patients IV Thrombolysis Door to Drug median min. 42 pts. 60% (25/42) 40% (17/42) 71% 29% N/A 2 pt. 7% 13% 36 13 17 6 33 8 18 7 Door to Drug (<30 minutes) 0% 38% Door to Dilation b door to data to cath lab to dilation 124 15 68 41 108 9 61 38 door to data to decision to drug 34 N/A 12% 33 44% 116 Door to Dilation (<90 minutes) 11% 33% 25% (4/35) California Pacific Medical Center 46% 105 36%

ACUTE MYOCARDIAL INFARCTION NRMI 4 DATA SUMMARY September 2002 Report 7/1/01 – 6/30/02 INDICATOR NSTEMI Eligible AMI Patients Treated with GP 2 b/3 a Inhibitor Death CPMC Days in ICU NATION (1228 centers) 62% 63% 65% 63% 36% 39% 27% 30% 10. 1% 9. 7% 4. 1 4. 4 4. 8 3. 9 4. 0 2. 0 1. 8 N/A 8. 5% Length of Stay 2002 1 st Q 2002 2 nd Q LIKE HOSPITALS CALIFOR (173 NIA centers) California Pacific Medical Center

ACUTE MI DEMOGRAPHICS AND RISK FACTORS CPMC N =260 AGE >75 years LIKE HOSPITALS N= 34920 CALIFORNIA 76 59% 68 36% 70 42% 48% 77/160 31% N/A Chronic renal Insufficiency 17% (45) 12% N/A No CHF 57% (148) 75% N/A Rales, JVD 15% (39) 16% N/A Pulmonary edema 27% (71) 7% N/A Cardiogenic Shock 1% (2) 1% N/A Clinical Presentation Sx onset to door > 4 hrs California Pacific Medical Center

AMI Opportunities for Improvement Emergency Department: Door to EKG time Chest pain Risk Assessment Protocol CPK & Troponin utilization Cath Lab: Door to Balloon time Critical Care & Telemetry Analysis of bleeding requiring intervention Patient Education material Cardiac Rehab California Pacific Medical Center

CARDIOLOGY SEVICE LINE 2001 – 2002 DRG PMI/ AGE CASES 2001 LOS 2001 CASES 2002 (Jan. June) LOS 2002 LOS CHANGE 20012002 121 AMI & Major Comp 1. 55/80 106 5. 45 118 6. 29 +. 84 122 AMI No Comp 1. 24/66 63 3. 51 27 4. 04 +. 53 123 AMI Expire d 1. 56/87 20 3. 50 +. 25 127 Heart Failure . 98/75 471 4. 17 387 4. 89 +. 72 55 1. 75 14 2. 71 +. 96 219 1. 53 203 1. 52 - 0. 1 140 Angina 143 Chest Pain . 58/74. 52/67 DIRECT COST 2001 California Pacific Medical Center DIRECT COST 2002 CHANGE 20012002 YTD % CHAN GE

CARDIOLOGY SERVICE LINE COST DATA 2001 – 2002 DRG Critical Care Med/Surg RT /Pul Supplies Pharmacy PT 121 AMI & Major Comp 122 AMI No Comp 127 Heart Failure 140 Angina 143 Chest Pain California Pacific Medical Center Radiology Lab Other

Congestive Heart Failure System-wide PI Project High volume, high resource utilization Opportunities for Improvement: ACE Inhibitors on discharge for patients with Ejection Fraction < 40% Decreasing LOS and readmission rate Standardizing patient education materials Medical and Nursing Staff Education California Pacific Medical Center

Ace Inhibitor on Discharge for EF < 40% California Pacific Medical Center

California Pacific Medical Center

Strategies CNS patient population oversight CHF patient education materials Weight chart One page - Tips for managing at home CHF discharge sheet California Pacific Medical Center

Strategies for Improvement Staff education CNS follows CHF inpatients Chart alert to MD - document reason no ACE prescribed Data posted in MD newsletter, MD lounge, cardiology unit. Data reported to Cardiology & Medicine & Nursing QA Committees. California Pacific Medical Center

California Pacific Medical Center Permanent Pacemaker Analysis 2002 Ann Edmonson RN, Quality Improvement Jill Ley RN, Cardiac Surgery Evelyn Taverna RN, Cardiology James Mailhot MD, Cardiology QI Chair California Pacific Medical Center

Pacemaker Project Indications Pacer type Vendor Anesthesia type Duration of procedure Complications California Pacific Medical Center

Data Collection Processes Softmed Report for ICD-9 Code 37. 83 Dates: Jan, 2000 – May, 2002 Data collection methods by LOS If LOS > 1 day – medical record review If LOS = 1 day – PCIS review OP note, d/c summary, blood orders Anesthesia type and OR time not recorded Readmission screen for all patients California Pacific Medical Center

Indications for Pacemaker # of patients California Pacific Medical Center

Pacemaker Complications Lead Dislodgement Infection Pneumothorax PM Tachycardia Hypotension Reprogramming Bleeding RV Perforation CVA Death California Pacific Medical Center

CNS Contributions Ideally positioned to influence team Knowledgeable about evidence based practices Impact both processes and outcomes of care Improved outcomes documented: Reduced LOS, complication rates Appropriate use of resources Documented cost savings Links to quality improvement & credentialing California Pacific Medical Center

Achieving Continual Improvement Format meetings and forums to continually review care delivery Implement systems to obtain data: retrospective, concurrent, prospective Continually monitor defined indicators Multidisciplinary reviews - close the loop Determine when to move on to the next project California Pacific Medical Center

Clinical Nurse Specialist Ability to Blend clinical, research & financial aspects of outcomes management with a focus on quality, compassion & caring. California Pacific Medical Center

California Pacific Medical Center