The CNS Role and Outcomes Management

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The CNS Role and Outcomes Management
Evelyn Taverna, RN, MS, CCRN, CNS Guest
Lecturer N 226 February 19, 2003
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Overview

• Purpose to extend the traditional role of case
  management to patient population based clinical
  resource management
• Develop systems to manage patients across the
  continuum - from inpatient to extended care to
  home health
• Create teams to effectively manage and integrate
  departmental activities in a cost effective,
  outcome driven manner

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Population Based Teams

• Cardiology
• Cardiovascular Surgery
• Medicine
• Neurology/Neurosurgery
• Obstetrics
• Oncology
• Pediatrics
• Pulmonary
• Surgery/Orthopedics

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Team Members

• Clinical Nurse Specialists
• RN Case Managers
• Social Workers
• Administrative Assistants
• Data Analysts
• Quality Coordinators
• Physician Champions

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CPMC Quality Clinical Resource Management Model
CLINICAL MANAGEMENT
RESOURCE MANAGEMENT
Clinical Nurse Specialist Population Based Case
Manager Social Worker
Patient/Family Based Administrative Assistant
Support
QUALITY MANAGEMENT
OUTCOMES MANAGEMENT
STAFF MANAGEMENT DEPARTMENTS
UR PHYSICIANS HOSPITALISTS
DISCHARGE PLANNING
SOCIAL SERVICES
UTILIZATION MANAGEMENT
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Quality Clinical Resource Management Model
CLINICAL NURSE SPECIALISTS Cardiology, Cardiac
Surgery, Interventional Endoscopy, Medicine,
Neonatal, Neurology/Neurosurgery, Oncology,
Pediatrics, Perinatal, Pulmonary, Surgery/Ortho
Quality Improvement Focus

• Clinical Management
• Protocols
• Best practice guidelines
• Clinical consultation
• Staff education
• Complex case review

• Resource Management
• Benchmarking
• MD comparisons
• LOS/level of care
• Cost/resource analysis
• Resource utilization

• Outcomes Management
• Quality, cost, service
• Data analysis/research
• Clinical effectiveness
• PI projects
• Sutter initiatives

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The CNS as Team Leader

• Masters prepared expert nurse clinician
• Manage clinical resources
• Define care requirements (best practices)
• Monitor their impact on outcome achievement
• 60 of time actively involved with patients
• Daily interaction with patients, families,
  clinical staff, nurses, and physicians
• Continually evaluate patient care needs
• Individuals and aggregate population
• Seek opportunities for improvement

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Project Selection

• External Sources/Needs
• Mandatory JCHAO Core Measures Standards
• State Requirements - OSHPD
• Sutter Initiatives
• Press-Ganey Patient Satisfaction Survey
• VHA Programs
• Internal Sources

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Project Selection

• External Regulatory Requirements
• JCAHO CORE Measures - 2002
• CHF
• Perinatal Outcomes
• JCAHO CORE Measures 2003
• Community Acquired Pneumonia

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Project Selection

• JCAHO Standards
• Pain Management Jackie Phan, CNS
• Patient Safety- Gail Guthrie, CNS Phyllis
  Erickson, CNS
• Medication Error Reduction Evelyn Taverna, CNS

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Project Selection

• External Requirements
• California CABG Outcomes Reporting Program
  (CCORP) Jill Ley, CNS
• Crusade Study National Registry for Myocardial
  Infarction (NRMI) Evelyn Taverna, CNS
• ACOS Accreditation Alice Mack, CNS
• National Practice Recommendations
• AHA, AHCPR, etc.

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Developing Clinical Questions

• Institutional Sources
• Quality committees
• Performance Improvement teams
• Product lines
• Clinician Sources
• Clinical observations
• New products/techniques
• Evidence-based practices

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Current Projects

• Medication Error Reduction
• Coumadin dosing project
• Range-dosing protocol
• Patient controlled analgesia protocol
• New Procedures
• Bariatric surgery outcomes
• Continuous renal replacement therapy
• Off-pump CABG outcomes
• Outcomes Management
• Interventional endoscopy database
• Plavix research and practice change
• VBAC Best practice

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Current Projects

• Medication Error Reduction
• Coumadin dosing project
• Range-dosing protocol
• Patient controlled analgesia protocol
• New Procedures
• Bariatric surgery outcomes
• Continuous renal replacement therapy
• Off-pump CABG outcomes
• Outcomes Management
• Interventional endoscopy database
• Plavix research and practice change
• VBAC Best practice

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Benchmarking Resources

• Agency for Health Care Policy Research(AHCPR)
• AHA,ACC
• VHA
• CMRI

• HBSI Fathom
• Midas
• NRMI 4
• Crusade

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Influencing Physician Practice

• The CNS is the point person for providing cost,
  service, and quality information to the Medical
  Staff to guide data driven practice changes
  which
• reduce cost variations
• decrease overall cost
• maintain quality outcomes
• improve service

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Cardiology CNS

• Acute Coronary Syndrome
• CHF
• Pacemaker Study
• Atrial Fibrillation
• Complex patients
• clinical
• education
• discharge planning

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Cardiology

• AMI
• ED chest pain protocol
• STEMI and NSTEMI protocol
• Crusade NRMI 4 data Focus on NSTEMI outcomes
• IIb/IIIa inhibitor use and bleeding
• interventional procedures
• Sutter Cardiovascular Services Initiative
• AMI task force
• CHF committee
• CHF
• ACE inhibitor use and discharge instruction
  outcomes readmission

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AMI Outcome Measures

• Aspirin at arrival
• Beta blocker at arrival
• Median time to thrombolytic therapy
• Median time to PTCA
• Aspirin prescribed at discharge

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AMI (cont.)

1. Beta blocker prescribed at discharge
2. ACE I at discharge for LVSD
3. Adult smoking cessation advice
4. Inpatient mortality
5. Lipid-lowering agent at D/C

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AMI Strategies

• ED Chest Pain Risk Assessment
• Acute Coronary Syndrome Protocols/Order Sets
• AMI Standard of Care
• AMI Guide to Recovery

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AMI Case Study

• Mr. M is a 54 year old man admitted with c/o of
  chest pain which began while watching the 49ers
  playoff game. Patient lives with wife and works
  in law enforcement.
• Symptoms included
• Constant, substernal chest pressure (5/10)
• Diaphoresis

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AMI Case Study

• PMH
• CAD, S/P angioplasty in 1989
• Diabetes
• Hypertension
• Hypercholesterolemia
• Current smoker
• Medications
• Atenolol and Glucophage
• Allergic to Aspirin and Motrin

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AMI Case Study

• Physical Exam
• Vital stable with bradycardia of 58
• Oxygen sat 96 on 2 liters
• Lungs clear, no JVD
• Labs
• Elevated cardiac markers
• Glucose 295
• EKG
• ST elevation in inferior leads

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AMI case study

• Interventions
• Plavix
• Nitro
• Morphine
• Heparin
• Primary PTCA with GP IIb/IIIa inhibitor
  during/after PTCA
• Door to balloon time 100 min.

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AMI case study

• Discharge planning
• Cardiac rehab (PT, OT, Dietary)
• Smoking cessation advice
• Stress management
• Aspirin, Plavix, Beta blocker, ACE I inhibitor,
  statin

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ACUTE MYOCARDIAL INFARCTION NRMI 4 DATA SUMMARY September 2002 Report7/1/01 6/30/02 ACUTE MYOCARDIAL INFARCTION NRMI 4 DATA SUMMARY September 2002 Report7/1/01 6/30/02 ACUTE MYOCARDIAL INFARCTION NRMI 4 DATA SUMMARY September 2002 Report7/1/01 6/30/02 ACUTE MYOCARDIAL INFARCTION NRMI 4 DATA SUMMARY September 2002 Report7/1/01 6/30/02 ACUTE MYOCARDIAL INFARCTION NRMI 4 DATA SUMMARY September 2002 Report7/1/01 6/30/02
INDICATOR CPMC LIKE HOSPITALS (173 centers) CALIFORNIA NATION (1228 centers)
Enrollment Yearly Non Transfer-in 303 260 55489 27330 186439
AGE 76 68 70 69
ST ? and/or LBBB on 1st EKG 28 27 25 27
AMI patients Eligible for Reperfusion a Treated Eligible AMI patients Untreated Eligible AMI patients 42 pts. 60 (25/42) 40 (17/42) 71 29 N/A N/A
IV Thrombolysis 2 pt. 7 13 12
Door to Drug median min. door to data data to decision decision to drug 36 13 17 6 33 8 18 7 34 33
Door to Drug (lt30 minutes) 0 38 44 46
Door to Dilation b door to data data to cath lab cath lab to dilation 124 15 68 41 108 9 61 38 116 105
Door to Dilation (lt90 minutes) 11 (4/35) 33 25 36
NSTEMI 62 63 65 63
NSTEMI Eligible AMI Patients Treated with GP 2b/3a Inhibitor 36 39 27 30
Death 8.5 10.0 10.1 9.7
Length of Stay 2002 1st Q 2002 2nd Q 4.1 4.4 4.8 4.8 3.9 3.9 4.0 4.0
Days in ICU 2.0 1.8 N/A N/A
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ACUTE MYOCARDIAL INFARCTION NRMI 4 DATA SUMMARY September 2002 Report 7/1/01 6/30/02 ACUTE MYOCARDIAL INFARCTION NRMI 4 DATA SUMMARY September 2002 Report 7/1/01 6/30/02 ACUTE MYOCARDIAL INFARCTION NRMI 4 DATA SUMMARY September 2002 Report 7/1/01 6/30/02 ACUTE MYOCARDIAL INFARCTION NRMI 4 DATA SUMMARY September 2002 Report 7/1/01 6/30/02 ACUTE MYOCARDIAL INFARCTION NRMI 4 DATA SUMMARY September 2002 Report 7/1/01 6/30/02
INDICATOR CPMC LIKE HOSPITALS (173 centers) CALIFORNIA NATION (1228 centers)
NSTEMI 62 63 65 63
NSTEMI Eligible AMI Patients Treated with GP 2b/3a Inhibitor 36 39 27 30
Death 8.5 10.0 10.1 9.7
Length of Stay 2002 1st Q 2002 2nd Q 4.1 4.4 4.8 4.8 3.9 3.9 4.0 4.0
Days in ICU 2.0 1.8 N/A N/A
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ACUTE MI DEMOGRAPHICS AND RISK FACTORS
CPMC N 260 LIKE HOSPITALS N 34920 CALIFORNIA
AGE gt75 years 76 59 68 36 70 42
Clinical Presentation Clinical Presentation Clinical Presentation Clinical Presentation
Sx onset to door gt 4 hrs 48 77/160 31 N/A
Chronic renal Insufficiency 17 (45) 12 N/A
No CHF 57 (148) 75 N/A
Rales, JVD 15 (39) 16 N/A
Pulmonary edema 27 (71) 7 N/A
Cardiogenic Shock 1 (2) 1 N/A
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AMI Opportunities for Improvement

• Emergency Department
• Door to EKG time
• Chest pain Risk Assessment Protocol
• CPK Troponin utilization
• Cath Lab
• Door to Balloon time
• Critical Care Telemetry
• Analysis of bleeding requiring intervention
• Patient Education material
• Cardiac Rehab

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CARDIOLOGY SEVICE LINE 2001 2002
DRG PMI/ AGE CASES 2001 LOS 2001 CASES 2002 (Jan-June) LOS 2002 LOS CHANGE 2001- 2002 DIRECT COST 2001 DIRECT COST 2002 CHANGE 2001- 2002 YTD CHANGE
121 AMI Major Comp 1.55/80 106 5.45 118 6.29 .84
122 AMI No Comp 1.24/66 63 3.51 27 4.04 .53
123 AMI Expired 1.56/87 20 3.50 20 3.50 .25
127 Heart Failure .98/75 471 4.17 387 4.89 .72
140 Angina .58/74 55 1.75 14 2.71 .96
143 Chest Pain .52/67 219 1.53 203 1.52 - 0.1
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CARDIOLOGY SERVICE LINE COST DATA 2001 2002
DRG Critical Care Med/Surg RT /Pul Supplies Pharmacy PT Radiology Lab Other
121 AMI Major Comp
122 AMI No Comp
127 Heart Failure
140 Angina
143 Chest Pain
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Congestive Heart Failure

• System-wide PI Project
• High volume, high resource utilization
• Opportunities for Improvement
• ACE Inhibitors on discharge for patients with
  Ejection Fraction lt 40
• Decreasing LOS and readmission rate
• Standardizing patient education materials
• Medical and Nursing Staff Education

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Ace Inhibitor on Discharge for EF lt 40
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Strategies

• CNS patient population oversight
• CHF patient education materials
• Weight chart
• One page - Tips for managing at home
• CHF discharge sheet

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Strategies for Improvement

• Staff education
• CNS follows CHF inpatients
• Chart alert to MD - document reason no ACE
  prescribed
• Data posted in MD newsletter, MD lounge,
  cardiology unit.
• Data reported to Cardiology Medicine Nursing
  QA Committees.

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California Pacific Medical CenterPermanent
Pacemaker Analysis 2002

• Ann Edmonson RN, Quality Improvement
• Jill Ley RN, Cardiac Surgery
• Evelyn Taverna RN, Cardiology
• James Mailhot MD, Cardiology QI Chair

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Pacemaker Project

• Indications
• Pacer type
• Vendor
• Anesthesia type
• Duration of procedure
• Complications

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Data Collection Processes

• Softmed Report for ICD-9 Code 37.83
• Dates Jan, 2000 May, 2002
• Data collection methods by LOS
• If LOS gt 1 day medical record review
• If LOS 1 day PCIS review
• OP note, d/c summary, blood orders
• Anesthesia type and OR time not recorded
• Readmission screen for all patients

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Indications for Pacemaker
of patients
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Pacemaker Complications

• Lead Dislodgement
• Infection
• Pneumothorax
• PM Tachycardia
• Hypotension
• Reprogramming
• Bleeding
• RV Perforation
• CVA
• Death

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CNS Contributions

• Ideally positioned to influence team
• Knowledgeable about evidence based practices
• Impact both processes and outcomes of care
• Improved outcomes documented
• Reduced LOS, complication rates
• Appropriate use of resources
• Documented cost savings
• Links to quality improvement credentialing

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Achieving Continual Improvement

• Format meetings and forums to continually review
  care delivery
• Implement systems to obtain data retrospective,
  concurrent, prospective
• Continually monitor defined indicators
• Multidisciplinary reviews - close the loop
• Determine when to move on to the next project

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Clinical Nurse Specialist

• Ability to Blend
• clinical, research financial aspects of
  outcomes management
• with a focus on quality, compassion caring.

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