nurses blending caring practice with teaching to improve...
TRANSCRIPT
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Nurses Blending Caring Practice with Teaching to Improve Medication Communication 2018 NICHE Conference Date: Thursday, April 12, 2018 Session: 1Time: 1:30-2:45 Track: Health, Wellness and Transitions
Intermediate Cardiac Care UnitCindy Rivet MS, RN, CNL, CVN, NE-BCClinical Manager of CCU/PCU
Disclosures
• The speakers have no relevant financial or non-
financial relationships to disclose
The Miriam Hospital • The Miriam Hospital is a 247 bed, private, not-for-profit,
community, teaching hospital, affiliated with Brown University,
located in Providence, RI
• Founding partner of Lifespan, a comprehensive health care
system
• Has more than 2300 employees
• 870 physicians
• 50 full-time house staff (medical school graduates)
• 700 registered nurses
• Five time recipient of the Magnet Award for Excellence in Nursing
• NICHE member since 2008
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Care Environment The Coronary Care Unit
• 9 bed medical teaching high level intermediate care unit, specializing in the complex needs of cardiovascular patients
Staff
• Clinical Manager
• Clinical Nurse Leader
Master’s Student
for duration of pilot project
• Advanced Practice Manager
• 19 RNs
• 4 Licensed Independent Practitioners
• 6 CNAs
• 4 Secretaries
Quality Improvement/Quality Assurance Data Analysis • CCU HCAHPS scores –Medication Communication &
Quietness of Environment were lowest scores
• Decided to focus on Medication Communication
• Multiple types of medications are prescribed during and after hospitalization
• Cardiac medications are high on the list of those that can cause serious harm
• Patients with cardiovascular disease are at a higher risk for errors and adverse drug events after discharge
Hospital Priorities
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Professional Practice Model
Method/Measure of Success
• Consistently provide medication information to patients in a way that is understandable during their hospital stay
Promote safe medication- taking behaviors after discharge
Earlier recognition of adverse drug events
Improve medication adherence after discharge
Reduced patient re-admissions
Show improvement in HCAHPS scores
Literature
• “Patient reported measures are strongly correlate with better patient outcomes and largely represent nurse and physician communication-based care”
(Bartlett Ellis, Bakoyannis, Haase, Boyer & Carpenter, 2016, p. 1149)
• “Higher hospital-level patient satisfaction is associated with lower 30-day risk-standardized readmission rates”
(Boulding, Glickman, Manary, Schulman & Stalin, 2011, p. 46)
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Baseline Data • 3rd Quarter : April-June 2016
• Top-Box “Always” Percentile Rank by Received Date
• Overall Communication about Medications 26th percentile
o Staff describe medicine side effects = 12th percentile
o Staff tell you what new medication is for = 55th percentile
o Patient understood purpose of medication = 66th percentile
• Goal: 50th percentile in the Overall Medication Communication Domain during pilot project
Med-COMM Project
• CCU’s project was designed to increase patient satisfaction with medication communication
• 5 Components:1. Tailored medication education sheets for CCU patient population
2. Signage in patient rooms
3. Nursing specific intervention
4. Collaboration between RNs, MDs & LIPs, Pharmacy
5. Daily Leadership rounds
• “Tell me and I forget. Teach me and I remember. Involve me and I learn”
~Benjamin Franklin~
Project Approval/Resources
• Approval by:
Pharmacy
Nursing Executive Committee
Patient Experience Committee
CCU Quality Improvement/Assurance Committee
• Utilized:
Lifespan Print Shop
Lifespan Interpreter Services
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Tailored Medication Sheets
• Collaborated with Pharmacy-Omnicell utilization list
• Tailored to CCU patient population/highly administered medications
• Sorted by Drug Class1. Medication name
2. Purpose
3. How often to take medication
4. Side effects
• Patient centered language and graphics
• Handout to patients on admission to CCUo Promotes on-going discussion about medications and patient
involvement in Plan of Care
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Patient Rooms
• Addition of signage above white-board:
As part of our goal to provide you with excellent care and prepare you for a safe discharge, we want to ensure you know your medications
and their possible side effects.
Always Ask if you have questions or concerns.
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Nurse’s Role
1. Med-COMM Intervention**
• Establish dedicated uninterrupted time spent with patient/caregiver to discuss medications and answer questions for at least 5 minutes every shift
• Talk about medication, its purpose and at least 1 side effect
• Document in care plan under Discharge Planning “Med-COMM intervention performed” and include any pertinent information
**Intervention is in compliance with Lifespan RN Standard Care Protocol for Patient Education
Nurse’s Role-Teach-Back
• Discharge process
• Ask clarifying questions to validate the patient’s understanding of health information
• “Patients who clearly understand their post-discharge plan-including how to take their medications-are 30% less likely to be readmitted or visit the emergency department than patients who lack this information.” Peter et al, 2015, p.36
Staff Reminders
• Reminder cards placed on each computer workstation
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Collaboration• Collaborate with MDs & LIPs during patient care rounds for
medication dosing revisions or additions
• CCU does not have a dedicated Pharmacist- shared with Specialty Care Unit & Medical Intensive Care Unit
• Nursing places a Pharmacy consult if education, more in-depth than nursing can provide, is necessary
CCU/Pharmacy Collaboration• Early identification by RNs of patients who may benefits
from PharmD consult: • Complicated cases• Non-compliance/Cost Issues• History of frequent readmissions• Starting new therapy• Hours available: M-F 730a-3p
Leadership Role
• Implement daily rounds to assess compliance
• New admissions to CCU
1. Do you have any medication questions?
2. Did your nurse teach you about your medications?
• Provide feedback to staff
• Monitor effectiveness of project through Press-Ganey HCAHPs data
RN Compliance
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Results- Project Implemented Oct 1, 2016
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10
20
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50
60
70
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90
100
Domain:Med Comm
Side Effects UnderstandPurpose
NewMedications
Baseline:April-June 2016
October-December 2016
Follow-Up: April-June2017
October-December 2017
HCAHPS Top-BoxPercentile Rank
by Received Date
Overall Domain Goal: Raised to 75th percentile
after pilot project
Overall Hospital Readmissions
Implications
• Chair of Patient Experience Med Comm sub-committee-report out twice a year, monthly to Management Team
• Expanded use of cardiac teaching sheets throughout facility
• Translation of cardiac sheets into Spanish & Portuguese
• Development of Respiratory medication teaching sheets
• Respiratory sheets currently being translated into Spanish & Portuguese
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Challenges/Limitations
• Overflow of medical patients into CCU
• Short length of stay
• Original pilot project only in English
• Increase in hospital acuity/census and change in patient demographic r/t closure of another local hospital which has impacted all Patient Experience Domains- Pharmacy focus on patients getting prescriptions filled
• Nurses struggle with educating patients on side effects and many patients get fixated on this information---potential for less adherence if scared of side effects
• Many hospital practitioners tell patients to call their PCP if they have questions about meds
Next Steps
• Revising current cardiac sheets for Stroke/TIA patients
• Revising current Chemotherapy teaching sheets
• Analyzing overall hospital Omnicell medication utilization to develop tailored medication sheets for other drug classes/patient populations & service lines
• Modifying sheets for inclusion in Epic to be used at all Lifespan affiliates
Summary
• A patient-centered approach to redesigning patient educational materials by reinforcing key concepts enhanced medication communication for our cardiovascular patients.
• This simple intervention which enhanced nurse-patient communication about medications will positively impact medication adherence and patient outcomes.
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ReferencesBartlett Ellis, R., Bakoyannis, G., Haase, J., Boyer, K., & Carpenter, J. (2016). Patient perceptions of provider and hospital factors associated with new medication communication. Western Journal of Nursing Research, 38(9), 1139-1154.
Boulding, W., Glickman, S., Manary, M., Schulman, K., & Staelin, R. (2011). Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. The American Journal of Managed Care, 17(1), 41-48.
Duffy, J., Baldwin, J., Mastorovich, MJ. (2007). Using the Quality-Caring Model to organize patient care delivery. JONA, 37(12), 546-551.
Nelson, E.C., Batalden, P.B., & Godfrey, M.M. (2007). Quality by design: A clinical microsystems approach. San Francisco, CA: Jossey-Bass.
Peter, D., Robinson, P., Jordan, M., Lawrence, S., Casey, K., & Salas-Lopez, D. (2015). Reducing readmissions using teach-back: Enhancing patient and family education. JONA, 45(1), 35-42.
Special Thanks
• Nicole Hebert, MSN, RN, CNL,CEN
• Clinical Nurse Leader Master’s Student at the time of Pilot Project Implementation-Capstone project
Questions/Contact Information
• Cindy Rivet MS, RN, CNL, CVN, NE-BC
• Clinical Manager- Coronary Care Unit/Procedural Care Unit
• 401-793-3673
• 164 Summit Avenue
Providence, RI 02906