A Report to the Patient Safety Committee of Arizona General Hospital

1
A Report to thePatient Safety Committeeof
Arizona General Hospital

• Prepared by Members of the
• University of Missouri-Columbia Interdisciplinary
  Workgroup
• for the CLARION INTERPROFESSIONAL CASE
  COMPETITION
• SPRING 2005

2
INTRODUCTIONS

• Ashley Mahon
• Accelerated Option BSN, RN Program
• UMC School of Nursing
• Russell McCulloh
• 4th Year, MD Program
• UMC School of Medicine
• Kevin Norris
• 3rd Year, PT Program
• UMC School of Health Professions
• Brian Stout
• 3rd Year, MHA/MBA Dual Degree Program
• UMC Schools of Medicine Business

3
She might be trouble -Bus Driver
4
PRESENTATION OVERVIEW

• Case Overview
• Methods of Analysis
• Major Findings
• Specific Findings
• Recommendations/Action Plan
• Tracking Indicators
• Cost Analysis
• Systems Issues
• References/Acknowledgments

5
CASE OVERVIEW

• Arizona General Hospital
• Tertiary care center
• 620 bed-facility
• 97 Behavioral Health Beds
• AGH Values
• Dignity
• Collaboration
• Stewardship
• Excellence

6
CASE OVERVIEW

• Part of Southwest HC System (SWH)
• Flagship for HC delivery in Maricopa Co.
• 10 affiliated clinics
• Clinical Expertise Centers of Excellence
• Behavioral Health
• Womens Health
• Rehabilitation
• Cardiovascular services
• Neuroscience
• Oncology
• Orthopedics
• Spine Care

7
CASE OVERVIEW

• 36 year old female
• 20 year history of schizophrenia
• Admitted for decreased mental status
• Treated for suspected overdose
• Self-administered medication overdose in hospital
• 3-week stay in BHU
• Discharged to home
• Readmitted seven weeks later for relapse of
  psychotic symptoms and alcohol intoxication

8
METHODS

• Investigation
• Identification of Major Events
• Causal Flow Analysis
• Root-Cause Analysis (VA-NCPS)
• Identification of Contributing Factors
• Remediation
• Literature Review
• Development of Recommendations
• Progress Assessment
• Cost Analysis
• Extrapolation

9
MAJOR FINDINGS

• Three adverse events were identified
• Self-Induced Clozaril Overdose
• Job/Coverage Loss Rehospitalization
• Self-Extubation
• Self-Induced Overdose
• Unsuccessful suicide attempt
• Near-miss of a reportable JCAHO sentinel event
• Any suicide of a patient in a setting where the
• patient is housed around-the-clock

10
Self-InducedDrug Overdose
11
Self-Induced Overdose Timeline
12
Self-Induced OverdoseFlow Diagram
13
Self-Induced Overdose RCA

• Root Cause Statement
• Level of patient observation and
• access to potentially toxic medications
• resulted in increased possibility
• of self-induced overdose.
• Three contributing factors domains were identified

14
Care Team Communication
15
Care Team Role Definition
16
Policies Procedures
17
Self-Induced OverdoseIshikawa
18
Self-Induced OverdoseContributing Factors

• Care Team Communication
• Parallel and informal evaluation and
  communication of self-harm risk
• Informal assumption of polysubstance abuse
• Care Team Roles
• Medication identified solely by ER staff
• Primary focus on only physical health aspects of
  admission
• Policies Procedures
• Persistent access to patient of potentially toxic
  medications
• PMH gathered solely from patients medication
  bottle

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Self-Induced OverdoseRecommendations

• Care Team Communication
• AMR tab dedicated to psychosocial issues1
• Care Team Roles
• All pt home meds are to be ID by pharmacist2
• Policies Procedures
• Develop a standard protocol for evaluation
  management of all overdose patients3
• Establish procedures for pts. at possible risk
  for self harm1,4
• Establish security procedures for the intake,
  storage, and disposition of pt home meds2
• Similar policy for potentially harmful pt. items2

20
Self-Induced OverdoseTracking Indicators

• Suspected overdose patients assessed for
  self-harm risk
• Employees scoring 70 or greater on knowledge
  assessment of behavioral health training courses
• Home medications stored securely
• All indicators are percentage-based goals for
  implementation are to be set at 100 compliance

21
Self-Induced OverdoseCost Analysis

• Incurred costs
• Room sitters (personnel-dependent)
• Time/resource demands for training personnel
  re new assessment procedures
• Monitoring/ongoing risk assessment
• Cost-neutral measures
• AMR changes covered by IT contract
• Estimated savings
• Reduced risk of emergent intervention

22
Self-Induced Overdose Dollars and Sense
23
Job/Coverage Loss and Rehospitalization
24
Job/Coverage Loss Rehospitalization Timeline
25
Job/Coverage Loss Rehospitalization Flow Diagram
26
Job/Coverage Loss Rehospitalization RCA

• Root Cause Statement
• Level of social services involvement led to the
  patients job coverage loss and ultimately
  resulted in patients relapse readmission to
  the hospital.
• Three contributing factor domains were identified

27
Care Team Communication
28
Inadequate Social Services
29
AMR Usage
30
Job/Coverage Loss Rehospitalization Ishikawa
31
Job/Coverage Loss Rehosp.Contributing Factors

• Care Team Communication
• Care teams engaged in parallel and informal
  communication
• Coordination of Social Services
• Patient assigned to HCC
• Currently defined roles for HCC and SW
• HCC only involved near end of pts stay
• AMR Usage
• Hospital staff unfamiliar with documenting
  psycho-social information into the AMR
• Incomplete integration of AMR with organizational
  culture

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Job/Coverage Loss Rehosp.Recommendations

• Care Team Communication
• Psych team and SW make daily rounds together for
  all primary diagnoses of mental illness,
  psychosis, and drug overdose5
• Fully integrated multi-disciplinary teams
• Coordination of Social Services
• Redefine the role of the HCC6,7,8
• Automatic referral to SW in cases with primary
  dx. of mental illness, psychosis, or drug
  overdose
• AMR Usage
• AMR Tab for psycho-social information
• Formal mechanism for staff feedback

33
Job/Coverage Loss Rehosp. Tracking Indicators

• Staff satisfaction rate with AMR (20 increase
  from baseline)
• Voluntary exit survey for patients receiving
  Psych/SW team care
• Percent of pts. admitted with diagnosis of mental
  illness, psychosis, or drug overdose, assessed by
  SW (100)
• Percent of pts seen by HCC within
• - 36 hours of admission (gt95)
• - 48 hours of admission (100)
• 5. Number of readmissions due to mental illness,
  psychosis, or drug overdose (10 reduction)

34
Job/Coverage Loss Rehosp. Cost Analysis

• Cost Neutral Recommendations
• AMR changes (provided through IT contract)
• Social Worker/Psych rounds
• Referral policies
• Incurred Costs
• Additional HCCs (case managers)9
• Savings
• Reduce number of psych readmissions6
• Reduced LOS by 10 with multi-disciplinary
  rounds5
• Reduced per-patient cost of stay by up to 16
  with multi-disciplinary rounds5

35
Job/Coverage Loss Rehosp. Dollars and Sense
36
Job/Coverage Loss Rehosp. Dollars and Sense
37
Self-Extubation
38
Self-Extubation Timeline
39
Self-Extubation Flow Diagram
40
Self-Extubation RCA

• Root Cause Statement
• The level of sedation agitation
• management increased the likelihood
• of patient self-extubation
• Three major contributing factor domains were
  identified

41
Care Team Communication
42
Policies Procedures
43
Scheduling
44
Self-Extubation Ishikawa
45
Self-ExtubationContributing Factors

• Care Team Communication
• Time/location of pharmacist involvement
• Communication b/w front-line providers
• Policies Procedures
• Extent of behavioral assessment
• Availability/use of agitation management
  protocols
• Availability/use of sedation and weaning
  protocols
• Scheduling
• Provider staffing-level in ICU

46
Self-ExtubationRecommendations

• Care Team Communication
• Ensure timely urine/serum toxicology screens in
  conjunction with overdose protocols
• Develop AMR flag for pharmacist consult in all
  cases involving drug overdose
• Policies Procedures
• Institute routine use of agitation management
  protocols by ICU staff (Ramsay)10
• Institute use of sedation protocols in ICU11,12
• Institute use of weaning protocols in ICU10,13
• Scheduling
• Evaluate adequacy of ICU staffing/training10,14,15

47
Self-ExtubationTracking Indicators

• Incidence of self-extubation (ICU)
• Length of ventilator support (ICU)
• ICU pt-nurse staffing ratios (1.5-1.7)
• Number of pts (per 100 intubated pts) that score
  below 3 on two consecutive hourly Ramsay
  Assessments (Zero)
• Percent of overdose pts whose records include RPh
  consult notes (100)
• Percent of overdose pts whose urine/serum
  toxicology screens are ordered w/in 1 Hr of admit
  to ER (100)

48
Self-ExtubationCost Analysis

• Incurred Cost
• Increased ICU Staffing?
• Physician/RPh Consult Fees
• Implementation of protocols/training
• Monitoring/ongoing risk assessment
• Estimated Savings
• Decreased LOS in ICU (Decrease of 3.5 days)16,17
• Shorter Duration of Ventilator Support (Decrease
  of 2.5 days17 between 63 and 89 of SEs do not
  require reintubation10)
• Costs of Reintubation (gt40 Decrease)11

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Self-ExtubationDollars and Sense
50
The Big Picture
51
Recommendation Summary

• Communication
• AMR/organizational culture integration
• Policies and Procedures
• Expansion of care team member roles
• Supporting AGH mission and values
• Dignity
• Collaboration
• Stewardship
• Excellence

52
What If

• Psych would have been more actively involved in
  patient care?
• Risk for self-harm would have indicated need for
  11 staffing and/or suicide observation in ICU
  and suicide observation in Ward 10A
• Pharmacy would have been more actively involved
  in patient care?
• Patient and drug ID would have been confirmed
• Patient PMH might have been available
• Concerns over sedative interactions might have
  been dismissed

53
What If

• Social Services would have been more actively
  involved in patient care?
• Patient job/coverage loss might have been avoided
  altogether
• Patient would have had access to local mental
  health resources and safety net coverage
• All three domains had been aligned with delivery
  of acute care?
• No adverse events?
• Patient would have certainly left our institution
  better off than when she arrived (in many ways)

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Targeting Continuity of Mental Health Services

• Within the Institution
• Mental Health Services
• Pharmacy
• Social Services
• Acute/Chronic Care
• Within the Community
• Provider/MCO Collaboration
• Partnerships
• Regional Leadership

55
Future Directions

• Increase pharmacy integration
• Discharge Planning/Consultation18,19,20
• Pharmacy and Therapeutics Committee18,19
• Collaborative Drug Therapy18,19
• Medication Reconciliation21
• Psychiatric Pharmacist22,23
• Integrating social services behavioral health
• Functional Integration Team18 (AGH BHCE)
• Wellness Recovery Action Plans24 (WRAP)
• Ongoing collaboration between
• AGH community pharmacies
• AGH satellite clinics
• SWH ValueOptions25,26

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Concluding Remarks

• Consistent with
• Our institutional mission
• IOM IHI vision of the future
• Our patients needs/rights to access receive
  safe, reliable, and comprehensive care
• It doesnt work to leap a twenty-foot chasm
• in two ten-foot jumps
• -American Proverb

57
A Report to thePatient Safety Committeeof
Arizona General Hospital

• Prepared by Members of the
• University of Missouri-Columbia Interdisciplinary
  Workgroup
• for the CLARION INTERPROFESSIONAL CASE
  COMPETITION
• SPRING 2005

58
References

• Dlugacz, Y.D., Restifo, A., Scanion, K., Nerlson,
  K., et al. (2003). Safety Strategies to Prevent
  Suicide in Multiple Health Care Environments.
  Joint Commission Journal on Quality and Safety,
  29(6), 267-278.
• Harry S. Truman Memorial Veterans Hospital-
  Pharmacy operations and drug procedures. December
  30, 2004.
• Harry S. Truman Memorial Veterans Hospital-
  Prevention and management of disturbed behavior.
  April 22, 2004.
• Harry S. Truman Memorial Veterans Hospital-
  Management of suicidal policy. April 26, 2004.
• Curley, C., McEachern, K. E., Speroff, T. (1998).
  A Firm Trial of Interdisciplinary Rounds on
  Impatient Medical Wards An Intervention designed
  using continuous quality improvement. Med Care,
  36(8), AS4-AS12.
• Cox, W.K., Penny, L.C., Statham, R.P., Roper,
  B.L. Admission intervention team medical center
  based intensive case management of the seriously
  mentally ill. Care Management Journals, 4(4),
  178-184.

59
References

• Rubin, A. Is Case Management Effective for
  People With Serious Mental Illness? A research
  review. Health Social Work, 17(2), 138-150.
• Wickizer, T.M., Lessler, D. Do Treatment
  Restrictions Imposed by Utilization Management
  Increase the Likelihood of Readmission for
  Psychiatric Patients? Medical Care, 36(6),
  844-850.
• 2003 Case Management Salary Survey Results. In
  Advance for Providers of Post-Acute Care.
  May/June 2003, 51-54.
• Maccioli GA et al. (2003). Clinical practice
  guidelines for the maintenance of patient
  physical safety in the intensive care unit Use
  of restraining therapies-American College of
  Critical Care Medicine Task Force 2001-2002.
  Critical Care Medicine. 31(11), 2665-2676.
• Wagner IJ. (1998). A sedation protocol to prevent
  self-extubation. Chest. 113(5),1429.
• Powers J. (1999). A sedation protocol for
  preventing patient self-extubation. Dimensions of
  Critical Care Nursing. 18(2), 30-4.

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References

• Razek T et al. (2000). Assessing the need for
  reintubation a prospective evaluation of
  unplanned endotracheal extubation. Journal of
  Trauma-Injury Infection and Critical Care. 48(3),
  466-9.
• Bray K et al. (2004). British Association of
  Critical Care Nurses position statement on the
  use of restraint in adult critical care units.
  BACCN Nursing in Critical Care. 9(5), 1-19.
• Martin B and Mathisen L. (2005). Use of physical
  restraints in adult critical care A bicultural
  study. American Journal of Critical Care. 14,
  133-142.
• Ramsay MAE. (2005). How to use the Ramsay Score
  to address the level of ICU sedation. Referenced
  Wed Document. Available at http//5jsnacc.umin.ac
  .jp/How20to20use20the20Ramsay20Score20to20a
  ssess20the20level20of20ICU20Sedation.htm.
  Accessed on March 23rd, 2005.
• Kress JP, Pohlman AS, and Hall JB. (2002).
  Sedation and analgesia in the intensive care
  unit. American Journal of Respiratory Critical
  Care Medicine. 166, 1024-1028.

61
References

• IHI 100,00 Lives Campaign. (2004). Getting
  Started Kit Prevent Adverse Drug Events
  (Medication Reconciliation). The Institute for
  Health Improvement. Available at www.ihi.org.
• Paone D, Levy R, and Bringewatt R. (1999).
  Integrating pharmaceutical care a vision and a
  framework. The National Chronic Care Consortium
  The National Pharmaceutical Council. Available at
  www.npcnow.org/resources/PDFs/IPCvisionpaper.pdf.
  
• Saunders, S.M., Tierney, J.A., et al. (2003).
  Implementing a pharmacist-provided discharge
  counseling service. AMJHSP, 60, 1101-1103.
• Rosen CE and Holmes S. (1978). Pharmacists
  impact on chronic psychiatric outpatients in
  community mental health. American Journal of
  Hospital Pharmacy. 35(6), 704-8.
• Kaushal R and Bates DW. (2005). Chapter 7 The
  clinical pharmacists role in preventing adverse
  drug events. AHRQ Patient Safety Manual.
  Available at www.ahrq.gov/clinic/ptsafety/chap7.

62
References

• Arizona State Hospital. Wellness Recovery Action
  Plans (WRAP). http//www.azdhs.gov/azsh/patient_pr
  ograms.htm.
• ACP-ASIM. (2000). Pharmacist Scope of Practice.
  Position Paper. American College of Physicians
  American Society of Internal Medicine.
  www.acponline.org/hpp/pospaper/pharm_scope.pdf.
• ValueOptions of Arizona. Assertive Community
  Treatment (ACT). http//www.valueoptions.com/arizo
  na/en/programs/act.htm
• ValueOptions of Arizona. Contract implementation
  fact sheet Recovery for adults with serious
  mental illnesses. Available at http//
  www.valueoptions.com/arizona/en/publications/fact_
  sheet_adult.pdf.

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Data Sources for Cost Analyses

• A - University Health System Consortium Clinical
  Database January through December 2004 (Drawn
  from 9 geographically dispersed academic medical
  centers, bed size from 616 to 692, average of
  beds 660 when applicable, adjusted for 620 bed
  institution)
• B - Annual Salary from 2003 Case Management
  Salary Survey Results. Published in Advance for
  Providers of Post-Acute Care May/June 2003,
  51-54.
• C - University of Missouri Health Care,
  University Hospital January through December
  2004. (Identified at group request by the UMHC
  Office of Clinical Effectiveness when
  applicable, adjusted for 620 bed institution)
• D - Medicare Fee Schedule 2004 (Intubation
  Endotracheal Emergency Code 31500)

64
Acknowledgments

• Kristofer Hagglund, PhD. Dean of Health Policy.
  School of Health Professions. University of
  Missouri-Columbia.
• Kathryn Nelson, MHA. Patient Safety Officer.
  Office of Clinical Effectiveness. University of
  Missouri-Columbia Hospital.
• Betty Nikodim. Senior Analyst. Office of Clinical
  Effectiveness. University of Missouri-Columbia
  Hospital.
• Tim Anderson, RN. Patient Safety Manager. Harry
  S. Truman Memorial Veterans Hospital. Columbia,
  MO.
• Barb Aston, MSW. Social Worker (Retired).
  Mid-Missouri Mental Health Center.
• Kathryn Burks, RN, PhD. Faculty Advisor.
  University of Missouri-Columbia Sinclair School
  of Nursing.
• Charles Brooks, MD, FACP. Residency Director.
  Department of Internal Medicine. UMC School of
  Medicine.
• Rachel Haverstick, MA. Executive Staff Assistant.
  Center for Health Care Quality. University of
  Missouri-Columbia.

65
Acknowledgments

• Laurel Despins, MS, APRN, BC, CCRN. Project
  Director. Office of Clinical Effectiveness.
  Clinical Nurse Specialist, Medical-Neurosurgical
  ICU. University of Missouri-Columbia.
• Mark Kruse. Medical Records. Harry S. Truman
  Memorial Veterans Hospital. Columbia, MO.
• Rebecca Wirth, MSW. Social Worker. Harry S.
  Truman Memorial Veterans Hospital. Columbia, MO.
• Deborah Hurley. Human Resource Associate.
  Department of Health Management and Informatics.
  UMC School of Medicine.
• Jane Bostick, RN, PhD. Faculty Advisor. UMC
  Sinclair School of Nursing.
• Linda Headrick, MD. Sr. Associate Dean for
  Education. University of Missouri-Columbia School
  of Medicine.

66
Contact Information

• Presenter Contact information
• Ashley Mahon aem7ee_at_mizzou.edu
• Russell McCulloh rjm42b_at_mizzou.edu
• Kevin Norris kdn337_at_mizzou.edu
• Brian Stout bjs13e_at_mizzou.edu
• UMC CLARION group was coordinated through the
  University of Missouri-Columbia Center for Health
  Care Quality (CHCQ)
• For more information, please contact
• Rachel Haverstick, Executive Staff Assistant.
• UMC Center for Health Care Quality
• Medical Sciences Building, MA128
• University of Missouri-Columbia. Columbia, MO
  65211
• Voice [phone]
• Fax [phone]
• Email haverstickr_at_missouri.edu.