What you need to know about Care Delivery at Temple!

2013 TUHS House Staff Orientation

Case StudyPatient X is a 72 year old

History of Present Illness: • chest pain, shortness of breath, palpitations, pedal edemaPast Medical History:• hypertension, diabetes, atrial fibrillation, renal failure, heart failure, and frequent falls Exam: • blood pressure 180/98, heart rate 112, respiratory rate 26, pulse oximetry 95% 2L,

afebrile• lungs- rales 2/3 bilat; irreg/irreg heart rhythm and rate; 2+ pedal edema; R Foot with

erythema, warmth, tenderness; unsteady gaitAncillary testing:• Chest x-ray- CHF; BNP 2115; Creatinine 5.6Admitted to Floor. Put on IV lasix, 02, imdur, beta blocker, and hydralazine. Also started on IV vanco

Care Delivery IssuesHeart Failure: Core Measure ComplianceHeart Failure Disease Navigation ProgramDocumentation- “acute or chronic”, “systolic or diastolic”

Renal Failure:Acute on ChronicNephrology consultationWill need Dialysis- complicates care and discharge planning

Cellulitis in a Diabetic:Manage glucose during an infectionPatient ends up with osteomyelitis- will require 6 weeks of intravenous antibiotics-this will complicate discharge planning- to home or to a skilled nursing facility

Gait Instability:History of falls. Fell while in hospital.Importance of “out of bed” and physical therapy to prevent deconditioning and falls and to improve function and safety. Will need fall assessments, physical therapy- in hospital and post discharge

Complex patient. Will need coordinated team effort to ensure safe and effective patient-centered care

Care Delivery Team

Review Assessments and Roles of:1. Physician 2. Nursing 3. Case Management 4. Social Work 5. Physical Therapy And how they all coordinate as a TEAM in providing Safe, Effective, Efficient, Timely, and Patient-Centered Care

Physician Assessment/Role

• Clinical Assessment, treatment plan, and documentation

• Plan for the Day, Stay, and Way• Work Rounds• Multi-disciplinary Rounds• Coordination of Care with Team• Medication Reconciliation• Patient and Family education• Transitions of Care

Accountable Care Unit ModelEach Unit is geographic and has a:• Unit Based Medical Director who has oversight for the clinical,

service, and cost outcomes of the Unit• Partnered management with nurse manager/UBMD leaders and

structured multidisciplinary roundingAccountable for:• Efficiency of care• Patient throughput• Decreasing variation• Use of clinical care guidelines• Management of utilization• And teaching

Interdisciplinary Plan of Care - IPOC

• Focus : IPOC is patient focused and disciplines add to the IPOC as they become involved in the patient’s care

• Where : The IPOC is located in the Care Plan tab of the Medical Record

Falls Prevention • Any patient designated Low Risk or High Risk are

placed in the Fall Prevention Program- Morse Scale used to assess fall risk

• The yellow armband (At Fall Risk) is placed on the same arm as the patient ID band

• The Fall Risk Magnet is placed by the patient name on the locator board outside the patient’s room and on the door frame.

• Use of low rise bed and or bed alarms• Assure assistance and supervision are provided with

elimination, transfers and ambulation• Provide patient/family education• Recommend referral to PM&R for safe ambulation and

transfer techniques

What happens if a patient does fall?

• A Midas Incident/Event report must be done. It needs specific information about the fall: Where, when, how,

injuries?• Post Fall Assessment to be completed by the team • Falls are tracked and trended because of the Midas report• The data is used to help us improve care

Level 1-1:1 Supervision-Suicide PrecautionsPatient an immediate threat to selfStaff must be within arm’s length of patient-including when in bathroom

Level 2-Field of Vision/Visual ObservationPatient danger to self or othersAt risk for elopementStaff must be in same room/areaVisual contact with patient at all times2:1 observation permitted

Level 3-Enhanced Safety ObservationPatient has delirium/dementia without violent behaviorMay have impulsive behavior requiring more frequent observationStaff must observe whereabouts, behavior, and patient condition every 30 minutes

Level 4-Fall PrecautionsMorse scale to identify fall riskStaff must observe whereabouts, behavior, and patient condition every 60 minutesCollaborative effort to reduce fallsNotify RN if you assess any changes in patient’s mobility

Close Observation

Telemetry & Pulse Oximetry• Two classifications for telemetry

– Class I (e.g. a-fib, a-flutter, certain medications)• If the patient needs to be transported, he/she must be on a

cardiac monitor and accompanied by nurse or doctor (or both)

– Class II (e.g. other diagnoses requiring monitoring)• The patient can be transported off telemetry and without a nurse

or doctor• All patients requiring telemetry will have a patent IV access

• Pulse Oximetry:– Verify the physician order for both telemetry and continuous pulse

oximetry (pulse ox) – The order must include acceptable range for saturations

Discontinuing Telemetry• Patients eligible for removal of telemetry monitoring

will be reviewed at shift report– Criteria for removal has been established under the

direction of the Cardiology Medical Director• If patient meets criteria after 48 hours on telemetry,

then an order must be obtained to discontinue telemetry

• House staff/resident will be notified– Attending physician has the option of reordering

telemetry

TUH Clinical Escalation.url

Department of Nursing

CLINICAL RESOURCE MANAGEMENT DEPARTMENT

Primary functions-• Coordinate a safe and timely discharge plan• Secure reimbursement for care• Collaboration with the team• Daily Accountable Care Unit rounds• Review of medical record

What is needed from you?• H & P MUST be in the medical record for all

members of the team to begin their work • Document patient’s contact numbers in H & P if you interview care giver • Clear documented plan of care• Forms and prescriptions completed timely• Communicate, Communicate, Communicate

How we can assist you?• Case Managers and Social Workers can

assist you with developing the plan for a safe transition to after care

• Consult with team to determine appropriate level of care for transition

• Provide resources to you• Available as a resource to you and team

When to consult Social Worker• Patient incapable of decision-making• No next of Kin Information• Social Work to assess provision of resources in the

community to local health district and public welfare office

• Patient admitted with a psychiatric involuntary (302) or voluntary (201) need for continued psychiatric treatment when medically stable

• Patient has active drug or alcohol issues• Assistance in placement of Homeless patients

When and Why Should Physical Therapy be Ordered?

• Is the patient at his functional mobility baseline?

• Will medical treatment alone restore the patient to his baseline level?

• Have there been attempts to mobilize the patient prior to therapy referral

• Is patient able to participate in therapy?

• Do you plan to transfer to a SNF or Rehab within the next 48 hours for PT services?

More about PTPT is contraindicated if:

• Spine not cleared from trauma/METS• X-rays/MRI pending• No clear Weight Bearing status• Patient with BEDREST activity orders• HgB <7• INR > 5

PT is not necessary if:• Safely discharging home• Want home PT for endurance or safety check• Want outpatient PT for chronic issues• Patient is baseline functionally• Want a walking pulse ox

Other PM&R Services Occupational Therapy:Upper extremity dysfunctionHand/arm/shoulder splintingSplint, boots, shoesActivities of Daily Livi dysfunctionAcute Rehab assessment

Speech Pathology Services:Diagnostic and therapeutic services for-DysphagiaSpeech-Language dysfunctionCognitive ImpairmentsVoice Disorders

Mobility Aides:Trained aides to enhance patient mobility. Prevent patient debility that can cause secondary complications

Physical Medicine and Rehabilitation:Consider early consult for musculoskeletal related issues or need for inpatient rehab.

Case Management-Discharge Planning Considerations-Home Care• Visiting Nurse• PT• IV Therapy• OT• Speech• Home care aide• Home Hospice

Skilled Facility• PT needs• Wound Care• Wound Vac• IV antibiotic therapy• Inpatient Hospice• Needs insurance authorization

Acute Rehabiltation• Needs qualifying

diagnosis• Insurance

authorization• PM&R team will

provide physical, occupational, and speech therapies

Coming Back to our Patient

• Physical Therapy evaluation indicates patient would benefit from inpatient PT, not safe for home discharge

• Medical team indicates patient will be discharged on intravenous antibiotics

• Chronic Dialysis needed, new onset, Social Work needs to arrange for a unit to accept patient

Discharge Coordination• Skilled facility placement must be coordinated

with the dialysis Social Worker• Patient agrees to Hemodialysis site and Skilled

Nursing Facility • Insurance Authorization must be obtained• Patient medically cleared for transfer-documented• Final arrangements made, time of transport

communicated• Transfer orders complete before time of discharge

Alternative Discharge Plan

• Patient has made progress in physical therapy• Therapist recommends continued PT at Home• Team modifies medication regime to insure

adherence• Case Manager informed of plan and suggests

Visiting Nurse, PT and Home Health Aide• Home infusion arrangements • Agency selected; must coordinate with Hemodialysis• Informs team, discharge instructions completed

Temple Access CenterNeed an appointment for a patient being discharged?• Place an order in MIS (Computerized Physician

Order Entry system)- it goes to our Access Center• 2 hour turn around time for referral in-system/24

hours for external referrals• Access Center will make the appointment and

enter it directly into MIS in the discharge instructions

Summary• Patients are complex• Care Delivery requires a multidisciplinary approach and great teamwork

• Take advantage of your Temple Team- everyone is here to help you provide safe, efficient, effective, timely, equitable and patient centered care

• Welcome to your TUHS experience!