IHI Open School Advanced Case Study

[Pages:12]IHI Open School Advanced Case Study

Clinton Jackson, John Ehrmann, Angela Keon, Michael Curry, Wayne Jensen, Naval Hospital Pensacola, FL

Overall Process Map

The Patient presents to her normal dialysis appointment where poor blood flow results in an extended procedure and consultation for an ultrasound at a local hospital

Due to transportation (Social) issues, the patient presents to appt for ultrasound the following day late. The ultrasound is not performed due to her tardiness.

On day three, the patient presents to her next regular appointment for dialysis and has no blood flow thru catheter. The patient is sent to ED, diagnosed with a blood clot, and is admitted.

On day seven, the patient is discharged home with orders to take warfarin. The patient is consulted for outpt nutrition appt and told that her Nephrologist should run her INR weekly.

2 ? weeks later, patient is brought to ED with right arm pain and swelling. She is diagnosed with a new DVT and low INR. She is admitted. (Day 25)

During this admission, the hospital dietitian meets with patient and a phone call is placed to the pt's dialysis center to discuss INR (Including a Dr. to Dr. turnover)

The following day (Day 26), the patient is discharged home late on a Friday night. The patient feels nauseated and skips her Monday dialysis appt. The dialysis clinic attempts to reach the patient at home. Later on Monday, day 29, the patient is asked by a friend to go to the ED.

The following day (Day 30) the patient presents to the ED with tingling in the face. She is admitted, INR 5.3 and potassium 6.7. The potassium result is relayed to a responsible physician immediately.

The next morning (Day 31) an emergency head CT is ordered based on elevated INR and pt is diagnosed with subdural hematoma. She is placed in ICU and taken to surgery. The pt is then admitted to a long-term care facility as she is unable to live on her own.

What Contributed to this Adverse Event?

1)Ineffective Communication:

? Poor patient handoff (dialysis to radiology) ? Poor communication with patient (necessity of ultrasound) ? Poor patient handoff (hospital to dialysis)

2)Patient Learning Needs not addressed:

? Poor learning needs assessment of patient by dialysis clinic ? Poor patient education of anticoagulation therapy ? Poor customer service (radiology day 2)

3)Standards of Care not met:

? Poor quality of care delivered at dialysis unit ? Delay in acquiring Head CT (rule out stroke)

New Rules for the System

? New Patient Hand-off Procedure: All referrals sent from originating facility require confirmation of receipt and understanding by provider and patient.

? Conduct learning needs assessment on all patients. Accommodate patients with special needs. If unable to accommodate patient's needs, direct patient to appropriate source for additional assistance.

? Establish protocols for meeting standards of care.

Ideal Process Map of Care

The Patient presents to her normal dialysis appointment where poor blood flow results in an extended procedure and consultation for an ultrasound at a local hospital

Using new Patient Hand-off Procedure, the dialysis nurse types and faxes a referral to the Radiology department with a Patient Hand-off receipt checklist that is sent back to dialysis to confirm receipt and understanding.

Patient learning needs reveal a lack of understanding in the urgency of this test which is addressed and patient verbalizes understanding of the need for radiology tests.

Patient arrives for ultrasound appointment; results are relayed to Nephrologist while patient is in Radiology department.

Nephrologist refers patient to the hospital physician on call to admit patient for treatment using new Patient Hand-off procedure.

Following treatment, the patient receives education concerning anticoagulation therapy. Learning assessment conducted to ensure patient understanding of diet restrictions.

Using new Patient Hand-off Procedure, the inpatient ward nurse communicates to the Dialysis center the need for testing INR at the Dialysis Center.

Improving Part of the System

? Establish a process for confirming a complete patient hand-off in every patient transfer between local healthcare facilities. Aim Statement

What we intend to spread: We will ensure patients and their families receive safe, patient centered, and value-added care from a professional,

devoted, and supportive care team dedicated to quality care. In order to achieve our vision, we will broaden our practices beginning with: 1. Conducting a patient needs assessment 2. Ensuring standard of care is being met through implementation of policies and procedures 3. Establishing safe and methodical Patient handoffs between healthcare facilities

Our target population and timeframe: Within the next six months, spread the patient hand-off process to other privately owned facilities in the area. Negotiate

new policies with our healthcare referral partners to reduce adverse events, maintain compliance with established patient hand-off process, and improve patient satisfaction.

Patient Hand-off Confirmation

This form is to be faxed to the originator of the patient consult or referral to acknowledge receipt.

We (name of healthcare facility/department) have received a consult for (Patient's name) and understand that (test, procedure, or treatment) will be performed at our facility because of (patient's condition). The patient has been contacted and will be seen on (date/time).

Measureable Impact

? Adverse events are reduced to five (or less) per 1,000 patient days

? 95 percent or better compliance with Patient Hand-off Procedure

? 95 percent of patients report that they are satisfied with medical care

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