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ASTHMA CARE PROCESSMODEL AND EDUCATION
DOCUMENTATIONKarmella Koopmeiners RN MS FNP, Nurse Specialist
Primary Children’s Medical Center (PCMC) and
Intermountain Healthcare
100 North Mario Capecchi Drive
Salt Lake City, Utah 84113
e-mail: [email protected]
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Mission Statement
To Provide Excellent Asthma Care For ChildrenThrough Improved Documentation of
Education and the Revised CPMPrimary Children’s Medical Center (PCMC) is a 289-bed teaching
hospital providing 80% of inpatient services for children. US Newsand World Report recently ranked it as one of the nation’s best
children’s hospitals, recognizing them in 7/10 pediatric
subspecialties.
Intermountain Healthcare (IH)
Intermountain Healthcare has 22 facilities, 5 of the 9 rural facilities arecertified by Medicare as Critical Access Hospitals (4/Utah,1/Idaho).
These facilities recognize their stewardship in the community and
are committed to sharing information and strive to reduce costs
to consumers of healthcare while maintaining the quality of
healthcare services
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Vision Statements
• The asthma team is a multidisciplinary team of healthcare professionals committed to providingextraordinary care for pediatric patients. This isaccomplished through improved patient and staffeducation, communication, clinical excellence and
evidence-based practice using NHLBI and NAEPPguidelines.
• We support a patient/family centered approach;
including self-monitoring tools and participation inasthma care. We promote a collaborative effort acrossthe continuum of care by partnering with primary carefor a more proactive, preventative approach toimprove the utilization of resources measured by
patient outcomes.
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Incidence- 23 million-9.4% of children, 7.3% of adults Prevalence-only chronic illness-across the age spectrum
Impact-disproportionately low-income, American Indian
Best Practices –NAEPP Guideline #3 patient education
Costs- U.S. (2007) Total-19.7 billion
25% or 5 billion preventable by managing symptoms
Direct costs-(2010) 1,500 hospital D/C @ $16.2 million,(2009)-7,259 ED visits-$21.9 million =
$7.3 million treat-release,$14.7 million treat-admit visits
Indirect cost- absenteeism, presenteeism at work/school
Return On Investment(ROI) = dollars saved andexpenses avoided/ dollars invested
Source: Utah Department of Health (UDOH)
Background Information
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PCMC Asthma Team
Clinical Nurse Specialists (Advanced Practice Nurses)
Karmella Koopmeiners, Kate Thompson
Data Team -Tanya Stout, Rebecca Baggaley
Educators-Rebecca Bawden RN, Brandon Andersen RT
Physicians-Bern Fassl-Physician and Project Leader, BryanStone, Flory Nkoy-Research Team Leader
Research Team
Sarah Halbern, Eun Hea Kim, Allison Wilcox RN
Respiratory Clinical Expanded Roles (RNs)Anna Pate CMU, Alison Kohutek IMSU, John Mohr RTU
Riverton Care Unit
Michelle Hofmann, Kristina McKinley, Kim Young RN
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Asthma Team Roles and ResponsibilitiesPROVIDER
Pt/family education and
documentation of the
revised CPM is complete
• Act as a resource to
staff for pt/ family
education and CPM
guidelines
• Reviews pediatric
questionnaire and
completes themedication
reconciliation process
• Completes admission
orders including
chronic control table
• Using the revised CPM
coordinates the plan
of care (POC) with theteam
• Completes discharge
orders and discharge
instructions (DOADI)
with modification in
the home
management plan of
care (HMPC)
REGISTERED NURSE
Coordinates , provides and
documents education and
revised CPM documentation
• Provides education to pt
/family based on needs
assessment and reinforces
medications and skills
based on observations
• Documents education
provided and pt/familyresponse to education
• Reviews pediatric
questionnaire with the pt/
family including
medication reconciliation
and chronic control table
• Ensure medication
reconciliation process isdocumented and asthma
admit orders complete
• Recommends step-up
therapy (change in home
management plan)
• Reviews discharge teaching
instructions (DOADI) with
the pt/family
RESPIRATORY THEARIPST
Provides, documents
education , assists with CPMcompletion
• Provides individual
instruction on equipment
(i.e., spacer, MDI, peak
flow, nebulizer) and other
needs unique to the
patient /family
• Reviews patient/family
technique and evaluates
the return demonstration
of skills
• Reviews needs assessment
and completes
documentation on the
teaching outline
• Reinforces the concepts
taught by the team
• Assists pt/family with
pediatric questionnaire• Communicates and
collaborates with the team
about educational needs
of the patient and revised
CPM implementation
• Recommends changes in
the home management
plan of care (HMPC)
CLINICAL EXPANDED
ROLE/EDUCATORS
Provide clinic expertise
in asthma
• Develops and revises
education content
and documents (job
aides , handouts,
schedules etc.)
• implements,
evaluates revisedCPM and provides
unit staff education
• Conducts audits of
documentation of
education, revised
CPM and provides
feedback to the staff
and teams• Act as a resource,
consultant and liaison
with providers and
teams for education
and revised CPM
development and
evaluation
CLINICAL NURSE
SPECIALIST
Advanced Practice Nurse
leaders in asthma program
development (education
and CPM)
• Develops CPM
documents (tools,
algorithms, scenarios)
and develops staff
education• Resource, consultant,
and mentor to
multidisciplinary staff
• Recommends content
for pt/family education
• Facilitator and Nursing
Leader for PCMC team
• Responsible for asthmaquality improvement
programs, EBP, research
and program
development across the
continuum of care
• Evaluates asthma data
(process and outcome)
for patients and teams
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Step-Up Therapy, MedicationReconciliation, Chronic Control Table
For Hospital Use Only
Review answers and determine the following items for this patient:
Age: __________________
Current step for asthma management: ___________
Takes controller 4 or more times a week? YES NO
Takes controller 3 or less times a week? YES NO
Does not take a controller
Degree of chronic control is:
** well controlled
** not well controlled
** poorly controlled
Recommendation for change in home management plan? ________________________________________________________________________
What Medication (s) do you or your child take to control your asthma?
MEDICATION
NAME
DOSE How many TIMES PER DAY do
you take this medication?
How many puffs/ nebs do you take per
treatment? If you are taking “pills”, how
many pills do you take each time?
On average, how many times per week do you take this
medication?
0 1 2 3 4 5 Other 1 2 3 4 5 Other________ 1 2 3 4 5 6 7 As Needed
Other_______
0 1 2 3 4 5 Other 1 2 3 4 5 Other________ 1 2 3 4 5 6 7 As Needed
Other_______
0 1 2 3 4 5 Other 1 2 3 4 5 Other________ 1 2 3 4 5 6 7 As Needed
Other_______
0 1 2 3 4 5 Other 1 2 3 4 5 Other________ 1 2 3 4 5 6 7 As Needed
Other_______
0 1 2 3 4 5 Other 1 2 3 4 5 Other________ 1 2 3 4 5 6 7 As Needed
Other_______
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How does your asthma influence your life?1. How often do you or your child have one of the following
problems: cough, wheezing, feeling short of breath, chest
tightness
Don’t
KnowTwice a week or less
More than
Twice a weekThroughout the day
2. How often do you or your child wake up from sleep with
breathing difficulties or cough? Don’t
Know
Less than or equal to
once a month
More than once a
monthMore than once a week
3. What is your or your child’s peak flow level usually? (if
recommended by your doctor) Don’t
Know
80% - 100% personal
best (green)
50% - 80% personal
best (yellow)
Less than 50% of
personal best (red)
4. How often does asthma limit you or your child’s daily
activities: playing, running, exercising, or missing school /
work?
Don’t
Know
Never Some limitation Frequent limitation
5. How often do you or your child use a quick relief (rescue)
medication (for example – albuterol)? Don’t
KnowTwice a week or less
More than
Twice a weekSeveral times a day
6. In the last year, how often did you or your child’s asthma get
worse and require oral steroids, a clinic visit, or an ED visit?Don’t
Know0 – 1 time 2 – 3 times Greater than 3 times
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1. Admission Orders (paper)
2. Review Questionnaire-a. Med Rec/b. Chronic Control (paper)
c. Recommend Step-Up Therapy (paper)
3. Needs Assessment/Teaching Outline (paper)/ Tandem (EMR)
Watch Asthma DVD/TV (passive) Review Flipchart (interactive)
Consult Respiratory Therapy for skills/special needs
Return Demonstration of Skills/Medication Teaching
Discharge Teaching-DOADI/Help2 (EMR) copy and sign (paper)
Process of Education/CPM Documentation (EMR vs. Paper)
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Fishbone-Documentation Problems
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Define role of RT/ nurses
in the educational process
Define role of RT/ nurses
in the educational process
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Prioritization of Leverage Points
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Specific Aim StatementFrom January 2011 - March of 2012, sustaining the
board goals and improvement in documentation from
71%-85% (stretch) will occur with medication teaching:
Sustaining the 2011 Board Goal- 81%• Teaching of Triggers- 89% (paper)
• Medications difference between controllers/ relievers,equipment return demonstration-71% (paper)• Asthma Action Plan- 91% (electronic –DOADI)
2012 Board Goal- 50%
Asthma controlmedication reconciliation process-66% (paper)chronic control symptoms-67% (paper)order appropriate controllers-0% (electronic-DOADI)
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Baseline Data 1/1-12/2011
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0%
20%
40%
60%
80%
100%% Asthma Patients-Action Plan
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Teaching Meds-2011/2012 YTD13
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2011.012011.022011.032011.042011.052011.062011.072011.082011.092011.102011.112011.122012.012012.022012.03
% of Patients Med Teaching
Average % with Teaching Medications LCL UCL
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Solutions to Problems
• Role/Responsibility delineation document created (slide 6)
• Education channel, back-up DVDs in toolboxes
• Staff education on the CPM (slide 7), created patient
scenarios for chronic control and step up-therapy usingtools such as the Quick-Guide and Primary Care CPM
• DOADI revised to include new components and reduceformat from 9 to 2 pages
• Team completed a survey to prioritize problems (slide 10)• Reinforced use of the Teaching Outline
• Assisted units with the transition of documentation onpaper forms to electronic medical records
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Specific Aim StatementFrom January 2011 - March of 2012, sustaining the
board goals and improvement in documentation from
71%-85% (stretch) will occur with medication teaching:
Sustaining the 2011 Board Goal- 81%• Teaching of Triggers-89%
• Medications difference between controllers/ relievers,equipment return demonstration-71% (paper)• Asthma Action Plan- 91% (electronic –DOADI)
2012 Board Goal- 50%
Asthma controlmedication reconciliation process-66% (paper)chronic control symptoms-67% (paper)order appropriate controllers-0% (electronic-DOADI)
87% Overall
69% Overall
96%
96%
73%
98%36%
85%
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2012 Goal -YTD
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Stretch ≥90% (RV) , ≥80% (System, MK, PC, UV), ≥75% (LG, AF, DX)
Target ≥85% (RV), ≥75% (System, MK, PC, UV) , ≥70% (LG, AF, DX)
Yellow Not Red, and Not Target or Stretch
Red <80% (RV), <71% (PC), <70% (System, MK, UV), <60% (LG, AF, DX
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2003-2011 6 Month Readmission RateChanges
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Q 1
2 0 0 3
Q 2
Q 3
Q 4
Q 1
2 0 0 4
Q 2
Q 3
Q 4
Q 1
2 0 0 5
Q 2
Q 3
Q 4
Q 1
2 0 0 6
Q 2
Q 3
Q 4
Q 1
2 0 0 7
Q 2
Q 3
Q 4
Q 1
2 0 0 8
Q 2
Q 3
Q 4
Q 1
2 0 0 9
Q 2
Q 3
Q 4
Q 1
2 0 1 0
Q 2
Q 3
Q 4
Q 1
2 0 1 1
Q 2
Q 3
Q 4
Q 1
2 0 1 2
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.45
0.50
0.55
0.60
A v e r a g e
Summary
Apr 16, 2012 10:57:48
Quarterly Readmissions w/in 6 months of Discharge: PCMC
77 67 41 55 60 45 48 53 73 60 46 77 60 49 63 80 80 62 39 75 102 83 68 62 124128113 82 127 87 72 68 119100 79 73 119n
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Asthma Readmission Rate Reduction at PrimaryChildren’s and Nationally
0%
5%
10%
15%
20%
25%
30%
35%
40%
P e r c e n t a g e o f I n p a t i e n t s w h o R e
t u r n e d W i t h i n 1 8 0
D a y s
2010 Asthma Inpatient Encounter (APR-DRG 141)Returns to Hospital within 180 Days – Same APR-
DRG
% Inpatient Returns % ED Returns
Source: Child Health Corporation of
America’s Pediatric Health Information System database
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Future Plans• Audit electronic
documentation
• Make PCMC DVD
• Develop continuousalbuterol protocol
• Develop an asthma
scorecard
• Implement web-based
self-monitoring tool andCare Process Modelacross the system (ED,Insta/Primary Care)
• Partnerships with UDOHand EPA (NAEPP #4) toimpact triggers/homeenvironment
• Business Plan for Returnon Investment (ROI)-direct and indirectmeasures
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Thank-you!20