3/28/2016 1 Use All the Tools in the Box: Julie Tuttle MSN, RN-BC Manager of Nursing Education John Moren BSN, RN Clinical Preceptor Jared Caron RN Clinical Float Nurse; Data Officer, Quality Clinical Team March, 2016 In accordance with NH RSA 151:13-a This Foundation Medical Partners’ Improvement Document shall be confidential and privileged Southern New Hampshire Health Southern New Hampshire Health is comprised of Southern New Hampshire Medical Center and Foundation Medical Partners, and is Massachusetts General Hospital’s only clinical affiliate in the region. Through this affiliation, patients have easy access to advanced clinical expertise in areas including stroke, cancer, trauma and pediatric specialties. Foundation Medical Partners • Ambulatory Care at Southern New Hampshire Health is made up of more than 300 providers in more than 70 practices across southern New Hampshire and northern Massachusetts. We serve thousands of patients in areas including: • Primary Care • Pediatric Care • Internal Medicine • Medical Specialty • Surgical Specialty Tools of the Trade Pneumococcal Toolkit • ACIP/CDC Vaccine Guidelines • Engaged staff and Providers • Clinical Leadership • Practice Champions • Quality Team Pneumococcal Tools • Algorithms • CDC educational handouts • Consent Forms • Screening Questions • Standing Orders • VIS forms
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3/28/2016
1
Use All the Tools in the Box:
Julie Tuttle MSN, RN-BC Manager of Nursing Education
John Moren BSN, RN Clinical Preceptor
Jared Caron RN Clinical Float Nurse; Data Officer, Quality Clinical Team
March, 2016
In accordance with NH RSA 151:13-a This Foundation Medical Partners’ Improvement Document shall be confidential a nd privileged
Southern New Hampshire Health Southern New Hampshire Health is comprised of Southern New
Hampshire Medical Center and Foundation Medical Partners, and
is Massachusetts General Hospital’s only clinical affiliate in the
region. Through this affiliation, patients have easy access to
advanced clinical expertise in areas including stroke, cancer,
trauma and pediatric specialties.
Foundation Medical Partners • Ambulatory Care at Southern New Hampshire Health is made
up of more than 300 providers in more than 70 practices across
southern New Hampshire and northern Massachusetts. We
serve thousands of patients in areas including:
• Primary Care
• Pediatric Care
• Internal Medicine
• Medical Specialty
• Surgical Specialty
Tools of the Trade
Pneumococcal Toolkit
• ACIP/CDC Vaccine Guidelines
• Engaged staff and Providers
• Clinical Leadership
• Practice Champions
• Quality Team
Pneumococcal Tools
• Algorithms
• CDC educational handouts
• Consent Forms
• Screening Questions
• Standing Orders
• VIS forms
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Pneumococcal Disease
Pneumococcal Disease
• Caused by infection with streptococcus pneumoniae
• Transmission respiratory droplets and
autoinoculation
• Most common infection is:
• Pneumonia
• 900,000 cases annually
• ~ 400,000 hospitalizations
• May also cause ear and sinus infections
Bogart, 2004; CDC, 2009 & 2013
Bogeart, Groot & Hermans, 2004
Adult Risk Factors for IPD
• Decreased immune function from disease or drugs
• Functional or anatomic asplenia
• Chronic heart, lung (including asthma), liver, or renal
disease
• Smokers
• Cerebrospinal fluid leak
CDC, 2015
Prevention
Vaccination!
Pneumococcal Vaccines
Pneumovax (PPSV23)
• Protects against 23 types of pneumococcal bacteria
Prevnar13 (PCV13)
• Protects against 13 types of pneumococcal bacteria
• Referring to a reference tool providing specific clinical guidance at decision point
• For use at the Point of Care
Why did we need it?
• Asking staff to make more decisions
• Decisions involved several criteria and were conditional
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Observing the Problem
Quality Clinical Team
• ~12 clinical staff representing various specialties within FMP
• Discussed observations at our monthly meeting
• We Decided staff needed more guidance
Then we Acted: A full-color flow chart was drafted
• Looked a lot like the CDC/ACIP flow chart
Decision Support Tool: Algorithm Attempt #2
February, 2014
The pivotal step – “Orient”
• Orienting is the key to successfully using the OODA
loop
• Without Orientation, observations are meaningless
• The resulting Decisions and Actions are then flawed
• Fortunately, OODA is a continuous feedback process
Second Attempt
• Incidentally, an email reminder to Care Coordinators
about the algorithm revealed widespread confusion
about pneumococcal vaccination (“Observe”)
• A thorough review of the current tool and ACIP
guidelines revealed problems
• The guidelines require many steps in the decision
process, most were skipped on our first design
(“Orient”)
Stakeholders
• “Easier to follow.”
• “I’ll still check with the Provider if I have questions.”
• “This is still too confusing…”
Fixing ProblemsApril, 2014
• A new tool was needed with as guidance for as
many steps as possible (“Decide”)
• A second algorithm was drafted with key differences
(“Act”)
• Step-by-Step Design
• Color Coding
• ACIP table of high-risk conditions included
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Step-By-Step Design
Starts with Identifying High Risk Conditions
Step-By-Step Design
Next, Identify
Pneumococcal
Immunization Status
Step-By-Step Design
Then, just “Follow the finger”
Color Coding
• Enhances Readability
• Enhances
discrimination between
different risk groups
ACIP table of high-risk conditions
included• Alternate visual
representation
• Provides clarifying
resource
• Matching color coding
• Actually 2 tools in one!
Part Deux…
• 2014 recommendations released just months after
above process
• Added one time routine dose of PCV 13 for 65+
population
• Initially tried expanding existing algorithm
• Eventually opted for 2 separate tools
• 19-64 high risk conditions tool
• 65+ tool
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2014 revision
• Same style tool, but key differences:
• Vertical Orientation
• No need for high-risk condition selection
• Start with Immunization status, then follow the column
• Kept 19-64 year algorithm the same, added
directions to consult the new tool for 65+
population
• Second time around went smoother and faster
(Same day turnaround!) • Since then 2 more minor revisions with similar results
65+ tool
Color Coded by Immunization Status
Vertical Orientation
New Tools in the Box
A Couple Questions
• Who discusses vaccine eligibility with
your patients?• How and when is eligibility decided?
• What do you (they) say?
• Who answers the questions?
• What happens if patients are vaccine
hesitant or decline vaccination?• Is the declination documented?
• Is it followed up?
Adopting a New Method
How do we get people to use it?
• Address or discover the area worth improving
• Prove effectiveness
• The new method is equal/more effective
• Prove utility
• Anyone can be trained to use the new tool
Immediate Hesitancy
• “I’m not the doctor, I’m not the Provider…this isn’t my decision.”
• “I know the schedules and the recommendations, but the patients start to ask questions and I don’t have the answers.”
• “We see patients every 15 minutes, my clinical staff don’t have time to review the immunization history and go down that rabbit hole…along with all their other responsibilities”