Facilitating optimal discharge plans for high risk patients …促进高风险患者的最佳治疗方案….ppt
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1、Massachusetts General Hospital Anticoagulation Management Service,Lynn B. Oertel, MS, ANP, CACP Clinical Nurse Specialist Presented November 4, 2008,Timeline of ATU/AMS,2008 NPSG (selected),1 - Improve accuracy of patient identification 2 - Improve the effectiveness of communication among caregivers
2、 3 - Improve safety of using medications Requirement 3E: Reduce the likelihood of patient harm associated with the use of anticoagulation therapy,New,http:/www.jointcommission.org/,2008 NPSG (selected),8 - Accurately and completely reconcile medications across the continuum of care 9 - Reduce the ri
3、sk of patient harm resulting from falls 13 - Encourage patients active involvement in their own care as a patient safety strategy 15 - The organization identifies safety risks inherent in its patient population,NQF Safety Standards,Safe Practice 17: Evaluate each patient upon admission, and regularl
4、y thereafter, for the risk of developing DVT/VTE. Utilize clinically appropriate methods to prevent DVT/VTE. Safe Practice 18: Utilize dedicated anti-thrombotic (anticoagulation) services that facilitate coordinated care management.,http:/www.qualityforum.org/,Goal is to reduce incidence of surgical
5、 complications nationwide by 25% by 2010 SCIP VTE1 Surgery patients with recommended VTE prophylaxis ordered SCIP VTE2 Surgery patients who received VTE prophylaxis within 24 hours after surgery,www.qualitynet.org, see Other Resource: About the Project,OSG Call to Action Sept 15, 2008,http:/www.surg
6、eongeneral.gov/,The Joint Commission Sentinel Alert Sept 24, 2008,http:/www.jointcommission.org/SentinelEvents/SentinelEventAlert/,Clinic overview,Patients = 4100+ Mean age = 69 yrs, SD 13.65, range 20 - 100 Common indications for treatment: AF 57% VTE 15% Heart Valves 9% INR intensity ranges 2 3 87
7、% 2.5 3.5 9% By request, selected others,Admissions: 75/month + Reactivated patients 60% new referrals from inpatient (POE Consult referral) Discharges: 90/month,Time in Therapeutic Range,TTR calculated using Rosendaal method Strict range limits, eg. 2 3 and 2.5 3.5 Using ALL INR data (induction, in
8、terruptions, etc),Percent INR tests out-of-range,In Range (2 3) = 60% Above 3 = 15% Below 2 = 25%,Percent Very High 5 = 0.8% 7.5 = 0.2%,Percent Very Low 1.3 = 0.3%,Communication and Education for Patients and Physicians,Key elements for improved patient management,Patient focused, primary nurse mode
9、l Physician Order Entry for AMS Consult Referral (nearly all data fields mandatory for submission, thus all critical info received) Dawn AC (patient management system for maintenance and transition patients) 3 Interfaces: ADT Interface (electronic notification for AMS patient admissions/discharges)
10、Outbound message Interface (AMS icon/communication facilitator) Results Interface (electronic INR entry into Dawn AC from lab system) Hospital “buy in” Information System support (2 FTEs) Pharmacy support (AMS Discharge Rx),AMS Communication with Patients,One-time face-to-face educational visit with
11、 patient & family and primary nurse Followed by telephone calls to patient for short period to review subsequent INR values, current dose instructions, and date of next INR Thereafter, written instructions are mailed with same information. Dose info communicated via # pills not mg. (finalizing plans
12、 to initiate email communications, when desired by patient) Telephone assessments more common than face-to-face visits Communication interventions are individualized to meet patient needs over time,Patient Satisfaction,“My ranking of this program: First Class Service.” “The anti-coag service is grea
13、t. I go to Florida 3 months during the winter months and I am able to keep track of dosages and INR levels easily. My daughter calls in for me and lets me know if there are any changes in dosage to be made.” “I have nothing but praise and appreciation for the concern and care over the years.” “Knowi
14、ng your clinic keeps a very close check on my Coumadin levels gives me a sense of security. Your reporting is prompt and directions clearly stated.”,Nursing Implications for Anticoagulated Patients,Knowledge of patient risk v. benefit of treatment Safe and quality care management Know goal therapeut
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