The CNS Role and Outcomes Management

California Pacific Medical Center

The CNS Role and Outcomes Management

Evelyn Taverna, RN, MS, CCRN, CNSGuest Lecturer: N 226

February 19, 2003


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


Population Based Teams

CardiologyCardiovascular SurgeryMedicineNeurology/NeurosurgeryObstetricsOncologyPediatricsPulmonarySurgery/Orthopedics


Team MembersClinical Nurse SpecialistsRN Case ManagersSocial WorkersAdministrative AssistantsData AnalystsQuality CoordinatorsPhysician Champions


CPMC Quality & Clinical Resource

Management Model

Clinical Nurse

Specialist Population

BasedCase

ManagerSocial

Worker

Patient/Family Based

Administrative Assistant

Support

QUALITY MANAGEMEN

T

CLINICAL MANAGEMEN

T

RESOURCE MANAGEMEN

TOUTCOMES

MANAGEMENT

DISCHARGE PLANNING

SOCIAL SERVICES

UTILIZATION MANAGEMEN

T

UR PHYSICIANS HOSPITALISTS

STAFF MANAGEMENT DEPARTMENT

S


Quality & Clinical Resource Management

ModelCLINICAL NURSE SPECIALISTS

Cardiology, Cardiac Surgery, Interventional Endoscopy, Medicine, Neonatal,

Neurology/Neurosurgery, Oncology, Pediatrics, Perinatal, Pulmonary, Surgery/Ortho

Quality Improvement Focus

Clinical Management• Protocols• Best practice guidelines • Clinical consultation• Staff education• Complex case review

Resource Management• Benchmarking• MD comparisons• LOS/level of care• Cost/resource analysis• Resource utilization

Outcomes Management• Quality, cost, service• Data analysis/research• Clinical effectiveness• PI projects• Sutter initiatives


The CNS as Team LeaderMasters prepared expert nurse clinician Manage clinical resources

Define care requirements (best practices)Monitor their impact on outcome achievement

60% of time actively involved with patientsDaily interaction with patients, families, clinical staff, nurses, and physicians

Continually evaluate patient care needs Individuals and aggregate populationSeek opportunities for improvement


Project SelectionExternal Sources/Needs

Mandatory – JCHAO Core Measures & StandardsState Requirements - OSHPDSutter InitiativesPress-Ganey Patient Satisfaction SurveyVHA Programs

Internal Sources


Project SelectionExternal Regulatory Requirements

JCAHO CORE Measures - 2002CHF Perinatal Outcomes

JCAHO CORE Measures – 2003Community Acquired Pneumonia


Project SelectionJCAHO Standards

Pain Management – Jackie Phan, CNSPatient Safety- Gail Guthrie, CNS & Phyllis Erickson, CNSMedication Error Reduction – Evelyn Taverna, CNS


Project Selection External Requirements

California CABG Outcomes Reporting Program (CCORP) – Jill Ley, CNSCrusade Study & National Registry for Myocardial Infarction (NRMI) – Evelyn Taverna, CNSACOS Accreditation – Alice Mack, CNSNational Practice Recommendations:

AHA, AHCPR, etc.


Developing Clinical Questions

Institutional SourcesQuality committeesPerformance Improvement teamsProduct lines

Clinician SourcesClinical observationsNew products/techniquesEvidence-based practices


Current ProjectsMedication Error Reduction

Coumadin dosing project Range-dosing protocolPatient controlled analgesia protocol

New ProceduresBariatric surgery outcomesContinuous renal replacement therapyOff-pump CABG outcomes

Outcomes ManagementInterventional endoscopy databasePlavix research and practice changeVBAC – Best practice


Current ProjectsMedication Error Reduction

Coumadin dosing project Range-dosing protocolPatient controlled analgesia protocol

New ProceduresBariatric surgery outcomesContinuous renal replacement therapyOff-pump CABG outcomes

Outcomes ManagementInterventional endoscopy databasePlavix research and practice changeVBAC – Best practice


Benchmarking Resources

Agency for Health Care Policy & Research(AHCPR)AHA,ACCVHACMRI

HBSI FathomMidasNRMI 4Crusade


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 costmaintain quality outcomesimprove service


Cardiology CNSAcute Coronary SyndromeCHF Pacemaker Study Atrial Fibrillation Complex patients

clinicaleducationdischarge planning


Cardiology: AMI

ED chest pain protocolSTEMI and NSTEMI protocol

Crusade & NRMI 4 data – Focus on NSTEMI outcomes

IIb/IIIa inhibitor use and bleedinginterventional procedures

Sutter Cardiovascular Services InitiativeAMI task forceCHF committee

CHF ACE inhibitor use and discharge instruction outcomes & readmission


AMI Outcome Measures

1. Aspirin at arrival2. Beta blocker at arrival3. Median time to thrombolytic

therapy4. Median time to PTCA5. Aspirin prescribed at

discharge


AMI (cont.)6. Beta blocker prescribed at

discharge7. ACE I at discharge for LVSD8. Adult smoking cessation

advice9. Inpatient mortality10.Lipid-lowering agent at D/C


AMI StrategiesED Chest Pain Risk AssessmentAcute Coronary Syndrome Protocols/Order SetsAMI Standard of CareAMI Guide to Recovery


E m erg en c y D ep artm en tC h es t P a in R isk A ss es sm en t

S T/n ew L B B BIn it ia te A M I P ro toco l

C ath L ab o rTh rom b olytic

N S TE M I/U n s tab le A n g in aIn it ia te

A cu te C oroan ry S yn d rom e P ro toco l

C h es t P a in


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


AMI Case StudyPMH:

CAD, S/P angioplasty in 1989DiabetesHypertensionHypercholesterolemiaCurrent smoker

Medications:Atenolol and GlucophageAllergic to Aspirin and Motrin


AMI Case StudyPhysical Exam:

Vital stable with bradycardia of 58Oxygen sat 96% on 2 litersLungs clear, no JVD

Labs:Elevated cardiac markersGlucose – 295

EKG:ST elevation in inferior leads


AMI case studyInterventions:

PlavixNitroMorphineHeparinPrimary PTCA with GP IIb/IIIa inhibitor during/after PTCA

Door to balloon time = 100 min.


AMI case studyDischarge planning

Cardiac rehab (PT, OT, Dietary)Smoking cessation adviceStress managementAspirin, Plavix, Beta blocker, ACE I inhibitor, statin


ACUTE MYOCARDIAL INFARCTIONNRMI 4 DATA SUMMARY September 2002 Report7/1/01 – 6/30/02

INDICATOR CPMC

LIKE HOSPITALS

(173 centers)

CALIFORNIA

NATION(1228 centers)

Enrollment Yearly

Non Transfer-in

303260

55489 27330 186439

AGE 76 68 70 69ST and/or LBBB on 1st

EKG28% 27% 25% 27%

AMI patients Eligible for Reperfusion a

Treated Eligible AMI patients

Untreated Eligible AMI patients

42 pts.60% (25/42)40% (17/42)

71%29%

N/A

N/A

IV Thrombolysis 2 pt. 7% 13% 12%Door to Drug median min.

door to datadata to decisiondecision to drug

36 13176

338187

34 33

Door to Drug (<30 minutes)

0% 38% 44% 46%

Door to Dilation b

door to datadata to cath labcath lab to dilation

124 156841

10896138

116 105

Door to Dilation (<90 minutes)

11%(4/35)

33% 25% 36%

NSTEMI 62% 63% 65% 63%NSTEMI Eligible AMI

Patients Treated with GP 2b/3a

Inhibitor

36% 39% 27% 30%

Death 8.5% 10.0% 10.1% 9.7%Length of Stay 2002 1st Q 2002 2nd Q

4.14.4

4.84.8

3.93.9

4.04.0

Days in ICU 2.0 1.8 N/A N/A


ACUTE MYOCARDIAL INFARCTIONNRMI 4 DATA SUMMARY September 2002 Report7/1/01 – 6/30/02

INDICATOR CPMC

LIKE HOSPITAL

S(173

centers)CALIFORNIA

NATION(1228

centers)NSTEMI 62% 63% 65% 63%

NSTEMI Eligible AMI Patients

Treated with GP 2b/3a Inhibitor

36% 39% 27% 30%

Death 8.5% 10.0% 10.1% 9.7%Length of Stay 2002 1st Q 2002 2nd Q

4.14.4

4.84.8

3.93.9

4.04.0

Days in ICU 2.0 1.8 N/A N/A


ACUTE MIDEMOGRAPHICS AND RISK FACTORS

CPMCN =260

LIKE HOSPITALSN= 34920

CALIFORNIA

AGE >75 years

7659%

6836%

7042%

Clinical Presentation

Sx onset to door> 4 hrs

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


AMI Opportunities for

ImprovementEmergency Department:

Door to EKG timeChest pain Risk Assessment ProtocolCPK & Troponin utilization

Cath Lab:Door to Balloon time

Critical Care & TelemetryAnalysis of bleeding requiring interventionPatient Education materialCardiac Rehab


CARDIOLOGY SEVICE LINE 2001 – 2002DRG PMI/

AGECASES

2001LOS2001

CASES2002(Jan-June)

LOS2002

LOSCHANGE

2001-2002

DIRECT COST2001

DIRECTCOST2002

CHANGE2001-2002

YTD%

CHANGE

121AMI & Major Comp

1.55/80 106 5.45 118 6.29 + .84

122AMI

No Comp

1.24/66 63 3.51 27 4.04 + .53

123AMI

Expired

1.56/87 20 3.50 20 3.50 + .25

127Heart

Failure

.98/75 471 4.17 387 4.89 + .72

140Angina

.58/74 55 1.75 14 2.71 + .96

143Chest Pain

.52/67 219 1.53 203 1.52 - 0.1


CARDIOLOGY SERVICE LINECOST DATA2001 – 2002

DRG Critical Care

Med/Surg RT/Pul

Supplies Pharmacy PT Radiology Lab Other

121AMI &Major Comp

122AMINo

Comp

127Heart

Failure

140Angina

143Chest Pain


Congestive Heart Failure

System-wide PI ProjectHigh volume, high resource utilizationOpportunities for Improvement:

ACE Inhibitors on discharge for patients with Ejection Fraction < 40%Decreasing LOS and readmission rateStandardizing patient education materialsMedical and Nursing Staff Education


Ace Inhibitor on Discharge for EF < 40%

0.6

0.7

0.8

0.9

1.0

CALIFORNIA PACIFIC MEDICAL CENTER


Sutter Health CHF InitiativeCalifornia Pacific Medical Center - Discharge Instruction Rates

Goal: 90% of all patients discharged to home will be documentedas having received instructions on all education elements

0%

25%

50%

75%

100%

Meds Weight Diet Activity Follow-Up Sypmtoms Worse All Instructions

2001 CPMC(n=291) 2002Q1(n=72) Goal


Strategies CNS patient population oversightCHF patient education materialsWeight chartOne page - Tips for managing at homeCHF discharge sheet


Strategies for Improvement

Staff educationCNS follows CHF inpatientsChart alert to MD - document reason no ACE prescribedData posted in MD newsletter, MD lounge, cardiology unit.Data reported to Cardiology & Medicine & Nursing QA Committees.



Permanent Pacemaker Analysis 2002

Ann Edmonson RN, Quality Improvement

Jill Ley RN, Cardiac SurgeryEvelyn Taverna RN, Cardiology

James Mailhot MD, Cardiology QI Chair


Pacemaker ProjectIndicationsPacer typeVendorAnesthesia typeDuration of procedureComplications


Data Collection ProcessesSoftmed Report for ICD-9 Code 37.83

Dates: Jan, 2000 – May, 2002Data collection methods by LOS

If LOS > 1 day – medical record reviewIf LOS = 1 day – PCIS review

OP note, d/c summary, blood ordersAnesthesia type and OR time not recorded

Readmission screen for all patients


Indications for Pacemaker

0

20

40

60

80

100

120

SSS HB AF Other

# of patients


Pacemaker Complications

Lead DislodgementInfectionPneumothoraxPM TachycardiaHypotensionReprogrammingBleedingRV PerforationCVADeath


CNS ContributionsIdeally positioned to influence teamKnowledgeable about evidence based practicesImpact both processes and outcomes of careImproved outcomes documented:

Reduced LOS, complication ratesAppropriate use of resourcesDocumented cost savings

Links to quality improvement & credentialing


Achieving Continual Improvement

Format meetings and forums to continually review care deliveryImplement systems to obtain data: retrospective, concurrent, prospective Continually monitor defined indicatorsMultidisciplinary reviews - close the loopDetermine when to move on to the next project


Clinical Nurse Specialist

Ability to Blendclinical, research & financial aspects of outcomes managementwith a focus on quality, compassion & caring.


Documents

The CNS Role and Outcomes Management