How U of U Health Burn Outpatient Clinic Implemented Patient Reported Outcomes
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Including patients in treatment planning improves their experience, and patient reported outcomes (PROs) offer new ways to do just that — talking with patients about how treatment impacts their daily life. Clinical nurse coordinator Lisa McMurtrey shares the Burn Clinic team’s award-winning work implementing PROs during patient visits without disrupting flow.
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How U of U Health Burn Outpatient Clinic Implemented Patient Reported Outcomes
- 1. © U N I V E R S I T Y O F U T A H H E A L T H , IMPLEMENTATION OF PATIENT REPORTED OUTCOMES IN A BURN OUTPATIENT CLINIC L. MCMURTREY, BSN, RN; D. KNITZ, ACNP-C; C. WEBB, PA-C; K. BARGER, MSW; H. WEEKS, MD; A. COCHRAN, MD, FACS
- 2. © U N I V E R S I T Y O F U T A H H E A L T H BURN CLINIC GENERAL INFORMATION • 4,373 patient visits during FY 2017 • Monday-Friday 8 AM – 5 PM; 4 exam rooms • Pediatric and Adult patients • Interdisciplinary Care Team – Advanced Practice Clinicians (APC) – Child Life Specialist (CLS) and Social Work (SW) – Nursing Staff – Physicians – Physical and Occupational Therapists
- 3. © U N I V E R S I T Y O F U T A H H E A L T H , PROJECT INTRODUCTION • Patient Reported Outcomes (PRO) quantify symptoms, function and quality of life • Burn patients have unique needs related to – Pain – Itching – Physical function – Social activity – Depression – Post-traumatic stress disorder
- 4. © U N I V E R S I T Y O F U T A H H E A L T H , PRO QUESTIONS FOR BURN PATIENTS • General PRO: Patient Reported Measurement Information System (PROMIS) instruments for general health, pain, physical function, social activity, and depression • Burn-specific PRO: 5D Itch and Post-Traumatic Stress Disorder (PTSD-CL) tools
- 5. © U N I V E R S I T Y O F U T A H H E A L T H , • Utilized mEVAL system • Education & training to staff and patients IMPLEMENTATION
- 6. © U N I V E R S I T Y O F U T A H H E A L T H , IMPLEMENTATION Email pts > 16 yo assessment Assessment Complete? Check-in staff prompt pt to complete PRO score integrates into EMR with dot phrase ‘.proburn’ Assessment Complete? Refusal logged Interdisciplinary care team discuss PRO score with patient during visit YES NO NO YES
- 7. © U N I V E R S I T Y O F U T A H H E A L T H , P R O T I P S H E E T Symptom Domain Screen Used Score Interpretation Action Interval Pain PROMIS Pain (v1.1) See PROMIS Interpretation Score > 65 APC addresses Every Visit Itching 5D Itch Scale Score out of 35 (Likert scale 1-5) APC to monitor trend & & intervene Every visit Social Activity PROMIS with Social Roles (v2.0) See PROMIS interpretation* Score ≤ 40 APC addresses 2 months Depression PROMIS (v1.0) See PROMIS interpretation* Score ≥ 65 referral to social work 3 months Physical Function PROMIS Physical Function (v2.0) See PROMIS interpretation* Score ≤ 40 referral to physical therapy 3 months PTSD PTSD-CL Scored out of 85 (Likert scale 1-5) Score ≥ 30 referral to social work 4 months INTERDISCIPLINARY PROVIDER TIP SHEET
- 8. © U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 8 PRO ELIGIBLE* ASSESSMENT COMPLETIONS Reasons for Incomplete / Refusal36% Complete n=704 64% Incomplete n=1,242 9% 12% 13% 27% 39% Missed / Unknown Late Too Sick Language Barrier No Change *Patients ≤ 16 yo are not eligible and excluded from this report
- 9. © U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 8 RESULTS PER INSTRUMENT Instrument Used Mean Score PROMIS Pain 63.20 (S.D. ± 07.04) 5D Itch 15.52 (S.D. ± 05.52) PROMIS Satisfaction with Social Roles 46.62 (S.D. ± 10.10) PROMIS Depression 52.04 (S.D. ± 09.72) PROMIS Physical Function 41.57 (S.D. ± 09.94) PTSD-CL 28.79 (S.D. ± 12.92)
- 10. © U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 8 UTILIZING THE RESULTS WITH PATIENTS Results tracked over time Instrument Social Work Referrals* Depression ≥ 65 34 PTSD ≥ 30 172 Actions taken *Unique patients treated
- 11. © U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 8 LIMITATIONS • Completion and refusal reports are diluted with ineligible patients (<16 years old) • Automated EMR integration is limited with burn-specific 5D Itch & PTSD-CL results • Ongoing collaboration with mEVAL data team to resolve identified issues
- 12. © U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 8 FUTURE DIRECTION • Ongoing education with patients & staff to improve completion results • Implement with our pediatric patient population • Continue implementation with our burn telemedicine patients
- 13. © U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 8 FUTURE DIRECTION
- 14. © U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 8 Thank You Lisa.McMurtrey@hsc.utah.edu
Editor's Notes
- I appreciate the opportunity to present the information from this poster to you today. I would also like to express appreciation to the co-authors and the staff of the Burn Outpatient Clinic for their support of this project.
- Our Burn Outpatient Clinic completed nearly 4,400 patient visits during fiscal year 2017. We are open Monday through Friday, 8 AM to 5 PM. We have four exam rooms. We care for pediatrics as well as adult patients. We primarily care for patients with burn related wounds, however we also care for patients who have wounds from skin infections, chronic or non-healing wounds as well as wounds sustained from frostbite, Necrotizing Soft Tissue Infection (NSTI) and Toxic Epidermal Necrolysis (TEN). Our patients are primarily seen by a Nurse Practitioner or Physician Assistant. Physicians are available for surgical consultation and other patient needs. Our interdisciplinary team also includes a Child Life Specialist, Social Worker, nursing staff, and Therapy staff.
- Patient Reported Outcomes quantify symptoms, function and quality of life from a patient’s perspective. Burn patients have unique needs related to pain, itching, physical function, social activity, depression and PTSD. Our clinic implemented a patient reported outcomes assessment that would provide burn related information for real-time intervention.
- Our methods began with collaboration between our organization’s mEval team and our interdisciplinary care team to identify which PROMIS instruments we wanted to use. In addition to the standard assessments of general health, pain, physical function, social activity and depression, we were also interested in assessing itching and PTSD. Initially we included sleep and anxiety instruments. We received patient feedback that the assessment was too long. We realized that questions about sleep and anxiety are included in the PTSD tool and the instruments for sleep and anxiety were removed from the assessment.
- We implemented mEval by providing patient education and staff training through the use of “scripts” to help the staff and the patients understand why we were implementing patient reported outcomes and how it would benefit them.
- We designed a workflow that would minimize the impact on our day to day clinic workflow. The assessment is emailed to the patient prior to their clinic visit. The assessment can also be given in the clinic at check in (through the use of a tablet). We are able to administer the assessment to patients with next day or same day scheduled visits. The results are available in the EMR with the use of a .dotphrase. The results are available in real-time to be discussed with the patient during their visit and serve to guide the patient’s plan of care.
- Each instrument has a reporting threshold. We created a provider tip sheet, which serves as a guide to interpret the results of the assessment. Our interdisciplinary team collaborated to decide what intervals would be used for each instrument. A patient in optimal health will have a high physical function score, high social activity score, and low scores for both depression and PTSD.
- Our results: Since implementation in October 2016, 704 assessments have been completed, this is a 36% completion rate. There is a need for us to identify what contributes to a missed opportunity. We want to encourage our patients to complete the assessment. These missed opportunities include issues with the mEval portal not showing our next day and same day appointments. An assessment needs to be generated manually for these patients and check in can be a really busy time to add additional steps. Ongoing conversations with our staff about the importance and value of obtaining the assessment helps them to see that the additional steps are indeed worth the effort. We continue to dialogue and collaborate how to problem solve this situation. We are committed to working to improve our completion rates and look forward to reviewing the results over time. Total n=1,946
- The results of the instruments are listed here. Pain scores—we are close to the reporting threshold and yet given the circumstances of our patients we are pleased that our patients’ pain is being managed as well as it is. We trend the individual 5D itch scores and look for ways to help control this difficult issue. From a social perspective, our patients seem to be doing fairly well. The physical function scores are about where we expect them to be given their physical situation. The mean depression results, are below the reporting threshold for a SW referral. Although PTSD is a concern, the mean PTSD results are also below the reporting threshold for a SW referral.
- We have the ability to trend patient scores over time and we are able to adjust the patient’s plan of care based on these results. Our social worker and therapy staff receive daily reports with the scores for depression, PTSD and physical function. Since implementation, we have made 34 SW referrals for depression and 172 SW referrals for PTSD.
- We acknowledge that there are limitations. The integration of the results into our EMR is limited, particularly with 5D Itch and the PTSD tool. In order to view the specific results for each instrument, you need to leave the EMR and log in to the mEVAL portal. The mEVAL reporting system can be difficult to navigate. It has been challenging to obtain ongoing results for each instrument. The reports (both completion and refusal) include patients who are not eligible (< 16 yrs age) and accurate results need to be calculated separately from the automated report. Ongoing conversations are occurring with the mEVAL data team to work through these issues. We are beginning to see some signs of improvement.
- We continue to provide ongoing education to staff and patients to improve completion rates. While repeated education can seem monotonous, it is necessary to sustain compliance and obtain results. Our hope in the future is to have PRO assessments available to our pediatric patients. We have begun to use PRO’s with our burn telemedicine patients as well. This is a nice addition to the care that we provide these patients remotely.
- This poster was presented earlier this month at the American Burn Association Annual Meeting. There is a computer adaptive test being trialed to assess community participation with burn survivors. It is the Life Impact Burn Recovery Evaluation or LIBRE assessment. This is a tool that is specific to people with burn injuries, and focuses on the social impact of the burn injury. One of the future directions I would like to investigate is how to incorporate LIBRE into mEval. Since implementation, PRO have been an effective way to assess and treat the individual needs of burn patients. The results guide interdisciplinary care and promote early intervention. As we continue to improve our completion rates, we will reach additional patients and be able to support them in more effective and efficient ways as they transition from being a patient with an injury to being a true survivor.