Patient Education

Interactive Patient Care
Integration Activates Patients,
Reduces Readmissions, Lowers Costs
Monday, February 24
Kimberly Reiners, RN, BSN,CPN, AE-C
& Dallas Parent, RN, BSN, CPN, AE-C
Pediatric Asthma Educator
DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.
Conflict of Interest Disclosure
Kimberly Reiners, RN, BSN, CPN, AE-C
&
Dallas Parent, RN, BSN, CPN, AE-C
Have no real or apparent conflicts of interest to report.
© 2014 HIMSS
Learning Objectives
• Illustrate how bedside patient engagement can
reduce readmissions, ALOS, and cost per patient
• Determine how to successfully select a patient
population for an Interactive Patient Care pilot and
implementation
• Identify the role of IT in network, infrastructure,
configuration and integration decision-making
Value Steps
Satisfaction
Patient Education
• Patient Satisfaction: Patient
engagement increases overall
satisfaction
• Improves patient engagement
• Staff Satisfaction: Improves staff
efficiency in patient care/education
Treatment/Clinical
• Quality of Care: Decrease in asthma
patient Length of Stay
• Provides consistency and standardization
in service and education
• Improves patient compliance tracking and
documentation
• Helps to meet requirements for Children’s
Asthma Care Core Measure
Savings
• Decrease Direct Variable Cost/Patient Day
• Decrease asthma patient Length of Stay
http://www.himss.org/ValueSuite
Cardon Children’s Medical Center
• Pediatric Tower Opened November 2009
• Increased capacity to total of 248 beds
• Functions as a hospital within a hospital
• Designed with a “Through the Eyes of a Child” theme
• Non-profit mission is to make a difference in people’s
lives through excellent patient care
Pediatric Asthma Background
Statistics of Asthma
Incidence in AZ/USA
The Joint Commission
Core Measures
• An estimated 20 million Americans • Use of relievers for inpatient
suffer from asthma (1 in 15
asthma patients
Americans).
• Use of systemic corticosteroids
• Nearly 5 million asthma sufferers
for inpatient asthma patients
are under age 18. It is the most
• Home Management Plan of Care
common chronic childhood
complete and given to patient/
disease, affecting more than one
family
child in 20.
• Arizona has the second highest
rate of asthma in the nation.
• The annual cost of asthma is
estimated to be nearly $18 billion.
Asthma Education Prior to
GetWellNetwork
• Workbook given to
patients upon physician
order to initiate asthma
teaching
• Videos were shown to
patients by portable DVD/
VCR to the room
• Children and Family
performed return
demonstrations for peak
flow, inhaler, SVN
Why Did We Create an Asthma
Care Plan?
• Ability to streamline education - the resources are
all housed in GetWellNetwork
• Engage the child and the family members in the
plan of care through the interactive approach
• Consistency of teaching
• Tracking mechanism to ensure the plan is
completed before discharge
How the Plan Was Developed
Content Development
• Asthma Health Videos and
Questions asked of
Patients were reviewed by
interdisciplinary team
• Adjusted questions to be
appropriate for school age
children & key pieces of
asthma education needed
by family/patient developed
the content
Interdisciplinary Approach
• Asthma RN Educator
• Pulmonologist
• Hospitalist
• Respiratory Therapy
• Nursing Leadership
• Child Life Specialists
• Staff RN educator
Key Elements of the Care Plan
• 4 phases
• Content questions after
viewing video
• Correct answers are
given to family
• Medical staff can view
responses & scores
received
Implementation of the Care Plan
Staff Training
• Multiple training classes
offered to all staff
• PowerPoint of each phase
presented to all RNs & RTs
• After implementation
training revised – staff to
view entire asthma care
plan & experience what the
patient learns
Badge Card Tool
Impact of the Asthma Care Plan
Child and Family
Response
• “I like that I can take breaks
after each phase if I want to.”
Staff Response
• Nurse staff likes that
reinforcement of bedside
teaching can be completed
• Children ask staff- What score
when it is best time for the
did I get?
patient.
• Parents with known
asthmatics stated they
• RT assisted with asking
learned something they had
where patient is on care plan
not known previously.
while giving treatment to
encourage completion of plan.
Lessons Learned
• Developing the content requires interdisciplinary
commitment
• The “wins” for staff in utilizing the care plan
• Work with management to ensure staff attend the
training
• Accountability in the use of the care plan
Total Participation
Number of Patients Requested to complete Asthma Care Plan
Year
Assigned Care Plan
2010
342
2011
550
2012
789
2013
555
Total
2236
Percent Completion by Phase
4 Year Average
100%
96%
95%
90%
90%
85%
82%
81%
80%
75%
70%
Phase 1
Phase 2
Phase 3
Phase 4
Asthma Care Plan
Percent (All Phase) Complete by Year
90%
85%
79%
80%
70%
75%
65%
60%
50%
40%
30%
20%
10%
0%
2010
2011
2012
2013
Children’s Asthma Care (CAC)
Population Ages 2 –17 Core
Measure
• Inpatient principal diagnosis of asthma anywhere in
the facility
• Three inpatient indicators are measured:
 Use of relievers
 Use of systemic corticosteroids
 Completion of Home Management Plan of Care
(HMPC) for patient/family
√HMPC is initiated in hospital or at discharge –
designed for use at home/school to guide care,
maintain control of asthma, and managing
exacerbations.
Children’s Asthma Care
Reminder on
GetWellNetwork for family
regarding Asthma Home
Management Care
Measure Plan
Children’s Asthma Care
CAC- 3 Results
For 3 consecutive months - we
were able to obtain up to 100%
for CAC-3 in 2012.
Our facility received recognition
by The Joint Commission as
"Top Performer on Key Quality
Measures for 2012" relative to
asthma.
2012
•
•
•
•
CAC-1 100 %
CAC-2 100 %
CAC- 3 96.2 %
Composite Score-
98.7 %
2013 (not
final – need
th
to add 4 quarter data)
CAC-1 100 %
CAC-2 100 %
CAC- 3 95.2%
Composite Score-
98.4 %
Pediatric Asthma Patient
Why standardize care:
 Most common chronic disease in children
 Major cause of morbidity and increased health
care cost nationally
 Asthma is one of the most common reasons for
inpatient admission.
 Morbidity and mortality are directly related to
under-treatment and/or inappropriate treatment.
Who was Included in Our New Pediatric
Asthma Pathway?
Children with the diagnosis of Asthma or Reactive Airway Disease…
How do you determine who has RAD?
High-risk children (under age three) who have had four or more wheezing
episodes in the past year that lasted more than one day, and affected
sleep, are much more likely to have persistent asthma after the age of five,
if they have either of the following:
One major criterion:
– Parent with asthma
– Physician diagnosis of atopic dermatitis
– Evidence of sensitization to allergens in the air
OR
Two minor criteria:
– Evidence of food allergies or wheezing apart from colds
The Pediatric Asthma Care
Pathway 6 Steps to Success…
1.
2.
3.
4.
5.
Utilize Respiratory Severity Score (RSS)
Administer Steroids in the ED within 60 min
Order Asthma Protocol
Implement Oxygen Protocol
Implement MDI with spacer delivery method (vs.
Nebulizer) for Mild/Moderate Asthma
6. Evaluate need for Chest X-Rays
Step #1 -
Use Respiratory Severity Score
• RSS is a nationally standardized tool (Qureshi,Pestian, &
Davis, 1998).
• Current literature supports utilizing a
comprehensive tool recognized across multiple facilities
within surrounding healthcare community.
Asthma Respiratory Severity Score
Respiratory
Rate
1 Point
2 Points
3 Points
1 year = < 40
2-3 yrs = < 34
4-5 yrs = < 30
6-12 yrs = < 26
> 12 yrs = < 23
1 year = 41-44
2-3 yrs = 35 -39
4-5 yrs = 31-35
6-12 yrs = 27-30
> 12 yrs = 24-27
1 year = > 45
2-3 yrs = > 40
4-5 yrs = > 36
6-12 yrs = > 31
> 12 yrs = > 28
SpO2
(room air)
Retractions
> 95%
90- 95%
< 90%
None, or Intercostal
Intercostal and
Substernal
Intercostal, Substernal, and
Supraclavicular
Auscultation
Scattered wheeze or endexpiratory wheezes only
Wheezes through complete
expiratory phase
Insp and Exp wheezing or
little to no audible air
movement
Dyspnea
(< 5 yrs)
(> 5 yrs)
Speaks in sentences, or
coos and babbles
Counts to 7-9 in one breath
Speaks in partial sentences,
or utters short cries
Counts to 4-6 in one breath
Speaks in single words or
short phrases, or grunts
Counts to < 3 in one breath
Severity Assessment
Mild
Moderate
Severe
Asthma Score
5-7
8-11
12-15
% Predicted
Peak Flow
> 70%
40-70%
< 40%
Step # 2 -
Administer Steroids in ED in 60 min.
• The ACP triggers the ordering of Steroids for anybody who
receives >1 dose of Albuterol in the ED -0- and ideally
within 60 minutes of arrival.
• BEFORE a pt discharges a patient – a Steroid should
already have been given
• BEFORE an ED Physician writes “Admit to…”… a Steroid
should already have been given to the patient
• Corticosteroids within 1 hour of presentation to an ED
significantly reduces the need for hospital admission.
• Oral steroids are as effective as IV steroids…
Step #3 - Ordering
For Inpatient “Pediatric
Asthma Order”
RSS 5-7: Mild
• Albuterol MDI 4 puffs q4h
• RSS q4h and PRN
• Notify MD when patient
meets D/c criteria
RSS 8-9 Moderate
• Albuterol MDI 8 puffs q2h
• RSS scoring q2h
RSS 10-11 Moderate
• Albuterol MDI 8 puffs q1h
• RSS scoring q1h
For ED “Asthma Protocol”
RSS 12-15 Severe
• Albuterol MDI 10 puffs q 20
minutes until RSS <12 if no
improvement after 3
treatments- notify MD
• Albuterol SVN 0.15 mg/kg
• Continuous Albuterol (SVN)
+ ipatropium 1 mg 1x: If no
improvement after 2 hoursNotify MD RSS q1h
Includes guidelines for admission
criteria
Step #4 –
Implement Oxygen Protocol
• Follow the Oxygen Protocol:
– Oxygen will not be started unless pulse oximetry
values are less than 90%.
• The Expert Panel at the NHLBI:
– Administer supplemental oxygen to maintain SaO2
>90%.
Step #5-
Implement MDI with spacer delivery
* 1st option for all patients with mild to moderate asthma
Spacer vs. Nebulizer:
• More efficient
– lower total dose is required for broncho-dilation
– shorter delivery time
• Side effects
– not as much of a heart rate response
– reduced systemic absorption
• Patient and parent preference
• Lower costs
• Lower hospital admission rates
Step # 6 –
Evaluate need for Chest X-Rays
• The ACP recommend AGAINST the routine ordering of
Chest X-Rays for Asthmatics……
• According to the NHLBI Expert Panel
– Chest radiography is not recommended for routine
assessment but should be obtained for patients
suspected of a complicating cardiopulmonary process,
such as congestive heart failure, or another pulmonary
process such as pneumo-thorax, pneumomediastinum, pneumonia, or lobar atelectasis.
Average Length of Stay
Variable Direct Cost
Looking Forward…
• Integrating Asthma Patient Education with EMR
Value Steps
Satisfaction
Patient Education
• Patient Satisfaction: Patient
engagement increases overall
satisfaction
• Improves patient engagement
• Staff Satisfaction: Improves staff
efficiency in patient care/education
Treatment/Clinical
• Quality of Care: Decrease in asthma
patient Length of Stay
• Provides consistency and standardization in
service and education
• Improves patient compliance tracking and
documentation
• Helps to meet requirements for Children’s
Asthma Care Core Measure
Savings
• Decrease Direct Variable Cost/Patient Day
• Decrease asthma patient Length of Stay
http://www.himss.org/ValueSuite
Questions?
Thank You!
Kimberly Reiners, RN, BSN,CPN,AE-C
Pediatric Asthma Educator
[email protected]
480-412-7902
Dallas Parent, RN, BSN, CPN, AE-C
Team Leader & Asthma Core Team RN
Cardon Children’s Medical Center
[email protected]
References
Cates, C. J. , & Rowe, B.H.(2002). Holding chambers versus nebulizers for betaagonist treatment of acute asthma. Cochrane Review. The Cochrane Library; Issue
1.
Delgado, A. , Chou, K.J., Silver, E.J., & Crain, E.F.(2003.) Nebulizers vs. metereddose inhalers with spacers for bronchodilator therapy to treat wheezing in children
aged 2 to 24 months in a pediatric emergency department. Archive Pediatric
Adolescent Medicine; 157:76-80.
Leversha, A. M., Campanella, S. G., Aickin, R. P., & Asher, M .I.(2000). Costs and
effectiveness of spacer versus nebulizer in young children with moderate and severe
acute asthma. Journal of Pediatrics; 136:497-502.
MacIntyre. N. R. , Anderson, P. .J, Camargo, C. A., Chew, N.,& Fink, J. B.(2000).
Consensus statement: Aerosols and delivery devices. Journal of Aerosolized
Medicine; 13:291-300.

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