From the NICU to Primary Care: Improving the Quality of the Transition

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From the NICU to Primary Care Improving the
Quality of the Transition

• Virginia A. Moyer, MD, MPH
• Professor of Pediatrics, Baylor College of
  Medicine
• Chief, Section of Academic General Pediatrics
• Chief Quality Officer, Medicine
• Texas Childrens Hospital

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Cartoon
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Overview

• Care transitions
• Patient safety challenge
• Literature
• HFMEA
• Definition
• Description
• AHRQ Planning Grant
• NICU to ambulatory follow-up
• Process
• Results
• HFMEA
• Qualitative
• Next steps

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Background

• Patient Safety literature increasingly
  acknowledges potential risks of care transitions
• Adult literature reveals significant
  vulnerabilities
• Proactive evaluation of error-prone health care
  processes can inform interventions to prevent
  adverse patient outcomes before they occur

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Care Transitions

• Sometimes called handoffs
• Movement of patients between health care
  practitioners and settings
• Shift changes
• ER to hospital
• OR to post-op or ICU
• ICU to floor
• One facility to another

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Hospital to Home

• Prolonged time period during handoff
• Unclear lines of responsibility
• Lack of patient understanding of health care
  problems
• Lack of readiness for self-care responsibilities
• Lack of information for follow-up provider

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Pediatric Care Transitions

• Inpatient to ambulatory setting
• Pediatric literature relatively silent except for
  measuring follow-up appointments
• Focus has been on lack of compliance by
  caregivers rather than on systematic issues
  around discharge
• 28 of children discharged from a pediatric ICU
  (not a NICU) did not receive timely medical
  follow-up

McPherson ML, Lairson DR, Smith EO, Brody BA,
Jefferson LS. Noncompliance with medical
follow-up after pediatric intensive care.
Pediatrics 2002109(6)94.
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Research in Adults

• 19 of patients had identifiable adverse events
  in the first 3 weeks home
• 73 of older patients misused at least one
  medication
• gt1 medical error per discharge summary

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Research in the NICU
What to do?
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FMEA Failure Mode and Effects Analysis
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What is a FMEA?The technique involves
identifying potential mistakes before they happen
to determine whether the consequences of those
mistakes would be tolerable or intolerable

• Potential failures are identified in terms of
  failure modes
• For each mode the effect on the total system is
  studied.

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Why FMEA?

• Powerful approach for proactive risk assessment
• Used in other high risk industries such as
  aerospace, aviation, nuclear industry

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HFMEA Process

• Team generates a flow diagram of main process and
  sub-processes
• Team brainstorms about all potential errors at
  each step (failure modes)
• Each is scored for probability it will occur
  (frequency) and potential severity if it did
  occur (severity)
• Frequency score x severity score hazard score
• High-risk failure modes identified as well as
  related causes or contributory factors

DeRosier J, Stalhandske E, Bagian JP, Nudell T.
Using health care Failure Mode and Effect
Analysis the VA National Center for Patient
Safety's prospective risk analysis system. Jt
Comm J Qual Improv. 2002 May28(5)248-267,
209.
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AHRQ Planning Grant

• Conduct HFMEA on NICU to ambulatory care
  transitions
• Conduct retrospective review to confirm or modify
  HFMEA findings
• Conduct qualitative assessment of the process to
  accomplish the HFMEA

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Setting Texas Childrens Hospital

• NICU
• 78 Level III beds, 62 Level II beds
• gt200 VLBW (lt1500gm) babies per year, many other
  babies with complex congenital abnormalities
• Special Needs Primary Care Clinic
• Housed at main campus
• gt100 children on home ventilators 24-7 coverage
• TCPA
• 42 private practices, including 5 Medical Homes
• Shared electronic record with TCH
• TCHP
• TCH-owned Medicaid Managed Care Plan, 230,000
  kids

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Our Project

• Perform a HFMEA for the transition in care from
  NICU to ambulatory follow up
• Use multiple methods to see if our predictions
  are correct
• Revise the HFMEA
• Develop a mitigation plan to address the
  identified risks

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It takes a team

• Virginia Moyer, MD, MPH Principal Investigator
• Karen Finkel, RN, BSN Patient Safety Office
• Hardeep Singh, MD, MPH Patient Safety
  Researcher (VAH)
• Lu-Ann Papile, MD Neonatologist
• Jochen Profit, MD Neonatologist
• Charleta Guillory, MD Neonatologist
• Marcia Berretta, MSW Social Worker
• Teresa Duryea, MD Pediatrician
• Lori Sielski, MD Pediatrician
• Jan Mort, RN Baylor NICU nurse
• Carol Carrier, RN
• Adam Kelly, PhD Survey researcher (VAH)
• Myrna Khan, PhD Patient Safety researcher (VAH)
• Eric Thomas, MD, MPH Patient safety guru (UT-H)
• Joseph DeRosier creator of HFMEA (VAH)

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Process Diagram
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NICU to Ambulatory Care Diagram
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Our HFMEA Results

• Team identified 114 potential failure modes
  within the discharge process
• Final model included 40 high-failure modes and 75
  high-risk causes

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HFMEA Results

• Common issues present across most failure modes
  and causes
• Clinicians act in isolation resulting in lack of
  standardized, coordinated, comprehensive plan of
  care
• Parents/caregivers inadequately prepared for home
  care and management of fragile infants
• Community providers lack required knowledge and
  skills to manage medically complex infants

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Multiple Methods to confirm the HFMEA

• Self-reporting of events (using TCH reporting
  system)
• Electronic triggers for possible adverse events
• ER visits within one month of discharge
• Readmissions within one month
• Missed appointments within one month
• Questionnaire for parents/caregivers
• the Care Transitions Measure

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Retrospective Review

• Charts reviewed using a trigger methodology to
  confirm or add to HFMEA findings (N88)
• Failures documented for 14 of 35 sub-steps
  predicted to have errors, in 1-10 cases each
• Documentation in current medical records system
  inadequate to systematically collect reliable
  data
• Documentation unavailable for majority of
  patients for 19 of the 35 sub-steps.
• A pediatric-adapted care transitions measure
  developed and validated.

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Qualitative Analysis of the HFMEA Process

• The team members felt that the group functioned
  extremely well, with a high level of involvement
  and many new insights gained in the process.
• The team encountered difficulty applying the
  HFMEA scoring system to the identified failure
  modes
• The severity descriptions did not seem to fit the
  types of failure modes identified
• Frequency descriptions did not seem sufficiently
  granular
• The group modified both descriptions before it
  proceeded with scoring.
• Some group members were concerned that scoring
  severity and frequency at the same time allowed
  for gaming of the scores
• At the end of the process, the group scored one
  set of failure modes independently to determine
  whether this would significantly alter the scores
  (it did not).

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Safe Passages

• The final step of the HFMEA is the development of
  a mitigation plan
• We addressed the three major themes that were
  identified in the HFMEA
• Lack of a standardized discharge plan
• Inadequate parent/caregiver preparation
• Lack of knowledge and skills by community-based
  health care providers

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Safe Passages

• We based the intervention on the Care Transitions
  Intervention (Coleman et. al.), adapted for a
  pediatric population.
• Enhanced Personal Health Record
• Health Coach
• Just In Time Information for community-based
  health care providers

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Enhanced Personal Health Record

• Existing discharge plan is ad hoc
• Existing standard discharge information limited
  to a single sheet of paper with diagnoses,
  medications and appointments written in by hand.
  
• Note that for many of our babies, the paper chart
  weighs more than the baby.

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Enhanced Personal Health Record

• Welcome, Helpful Information about the Newborn
  Center, and Important Numbers
• Journaling and Care Pages
• Tips for Choosing Insurance and Pediatrician for
  Your Baby
• Resources and Support
• Ronald McDonald House
• Key People, Equipment and Medical Terminology
  Glossary
• Your Babys Development, Nutrition, and Feeding
• Premature Babies Immunization Schedule
• Breastfeeding Your Baby
• Newborn Feeding- Bottle Feeding and Formula
  Preparation
• Safety and Education
• Medication Safety
• Giving Oral Medicines
• How to Give a Subcutaneous Injection
• Crib Safety
• Signs and Symptoms of Illness
• Crying
• Colic
• Preventing Infection

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Health Coach

• A technically expert individual who takes the
  role of sensitive coach, teacher and facilitator
  to foster the development of parents into
  competent caregivers for their fragile infants.
• Masters prepared health educator, available at
  the hours parents are able to be present in the
  NICU.
• Available to staff as a resource person

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Just-in-Time information for primary care
providers

• Capitalized on new Evidence Based Guidelines
  program at Texas Childrens
• One page summaries of evidence based guidelines
  for common problems
• Transition from premature formula, oxygen
  weaning, growth of premature infants, management
  of gastrostomy, management of tracheostomy,
  chronic lung disease and much, much more.
• Sent home with infant and also faxed to provider
  at the time of discharge

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Research Design

• Concurrent Cohort Study over 1 year
• NICU is divided into geographically distinct
  pods
• One NICU III pod and its usual step-down Level II
  pod comprise the intervention group
• Other pods comprise the control patients
• IRB did not require patient/parent consent beyond
  verbal consent at the time of enrollment
• But did require written consent for the
  evaluation of PCP compliance with JIT protocols

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Progress to date

• Recruitment of intervention babies is close to
  on-schedule (n50 at 6 months)
• Recruitment of control babies is behind (n40)
  because 2 control units were closed for low
  census
• Very few refusals to participate, very high rate
  of response to phone surveys
• Moderate level of difficulty recruiting PCPs to
  the J-I-T intervention, so numbers are low.

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Outcome Evaluation

• Primary outcome is adverse events within 31 days
  of discharge (death, ER visit, readmission,
  missed appointments)
• Care Transitions Measure Neo administered by
  phone 2-3 days after discharge and again at 31
  days
• Comfort level and satisfaction of PCPs with
  common post-NICU problems
• Adherence to guidelines by PCPs

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Deliverables

• Toolkit
• Manual for the Health Coach
• Enhanced Discharge Binder (to be converted to
  electronic format if and when our EMR
  implementation actually happens)
• JIT information sheets (to be converted)
• CTM-Neo - validated tool to evaluate the quality
  of the NICU discharge experience

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References

• The Care Transitions ProgramSM http//www.caretran
  sitions.org accessed January 18, 2007.
• Coleman EA, Berneson RA. Lost in transition
  Challenges and Opportunities for improving the
  quality of transitional care. Ann Int Med. 2004
  Oct 5 141(7)533-536.
• DeRosier J, Stalhandske E, Bagian JP, Nudell T.
  Using health care Failure Mode and Effect
  Analysis the VA National Center for Patient
  Safety's prospective risk analysis system. Jt
  Comm J Qual Improv. 2002 May28(5)248-267, 209.
• Forster AJ, Clark HD, Menard A, et al. Adverse
  events among medical patients after discharge
  from hospital.  CMAJ. 2004 170345-349.   
• McPherson ML, Lairson DR, Smith EO, Brody BA,
  Jefferson LS. Noncompliance with medical
  follow-up after pediatric intensive care.
  Pediatrics 2002109(6)94.
• Moore C, Wisnivesky J, Williams S, McGinn T.
  Medical errors related to discontinuity of care
  from an inpatient to an outpatient setting. J Gen
  Intern Med. 2003 Aug18(8)646-51.
• Philibert I. Leach DC. Re-framing continuity of
  care for this century. Qual Saf Health Care. 2005
  Dec14(6)394-396.
• Roy CL, Poon EG, Karson AS, Ladak-Merchant Z,
  Johnson RE, Maviglia SM, Gandhi TK. Patient
  safety concerns arising from test results that
  return after hospital discharge. Ann Intern Med.
  2005143(2)121-8.

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Questions?