The CNS Role and Outcomes Management Evelyn Taverna, RN, MS, CCRN, CNS Guest Lecturer: N 226 February 19, 2003
Overview  <ul><li>Purpose: to extend the traditional role of  case management  to patient population based  clinical resou...
Population Based Teams <ul><li>Cardiology </li></ul><ul><li>Cardiovascular Surgery </li></ul><ul><li>Medicine </li></ul><u...
Team Members <ul><li>Clinical Nurse Specialists </li></ul><ul><li>RN Case Managers </li></ul><ul><li>Social Workers </li><...
CPMC Quality & Clinical Resource Management Model Clinical Nurse Specialist  Population Based Case Manager Social Worker  ...
Quality & Clinical Resource Management Model CLINICAL NURSE SPECIALISTS Cardiology, Cardiac Surgery, Interventional Endosc...
The CNS as Team Leader <ul><li>Masters prepared expert nurse clinician  </li></ul><ul><li>Manage clinical resources </li><...
Project Selection <ul><li>External Sources/Needs </li></ul><ul><ul><li>Mandatory – JCHAO Core Measures  & Standards </li><...
Project Selection <ul><li>External Regulatory Requirements </li></ul><ul><li>JCAHO CORE Measures - 2002 </li></ul><ul><ul>...
Project Selection <ul><li>JCAHO Standards </li></ul><ul><li>Pain Management – Jackie Phan, CNS </li></ul><ul><li>Patient S...
Project Selection  <ul><li>External Requirements </li></ul><ul><li>California CABG Outcomes Reporting Program (CCORP) – Ji...
Developing Clinical Questions <ul><li>Institutional Sources </li></ul><ul><ul><li>Quality committees </li></ul></ul><ul><u...
Current Projects <ul><li>Medication Error Reduction </li></ul><ul><ul><li>Coumadin dosing project  </li></ul></ul><ul><ul>...
Current Projects <ul><li>Medication Error Reduction </li></ul><ul><ul><li>Coumadin dosing project  </li></ul></ul><ul><ul>...
Benchmarking Resources <ul><li>Agency for Health Care Policy & Research(AHCPR) </li></ul><ul><li>AHA,ACC </li></ul><ul><li...
Influencing Physician Practice   <ul><li>The CNS is the “point person” for providing cost, service, and quality informatio...
Cardiology CNS <ul><li>Acute Coronary Syndrome </li></ul><ul><li>CHF  </li></ul><ul><li>Pacemaker Study  </li></ul><ul><li...
Cardiology:  <ul><li>AMI </li></ul><ul><ul><li>ED chest pain protocol </li></ul></ul><ul><ul><li>STEMI and NSTEMI protocol...
AMI  Outcome Measures <ul><li>Aspirin at arrival </li></ul><ul><li>Beta blocker at arrival </li></ul><ul><li>Median time t...
AMI (cont.) <ul><li>Beta blocker prescribed at discharge </li></ul><ul><li>ACE I at discharge for LVSD </li></ul><ul><li>A...
AMI Strategies <ul><li>ED Chest Pain Risk Assessment </li></ul><ul><li>Acute Coronary Syndrome  Protocols/Order Sets </li>...
 
AMI Case Study <ul><li>Mr. M is a 54 year old man admitted with c/o of chest pain which began while watching the 49’ers pl...
AMI Case Study <ul><li>PMH: </li></ul><ul><li>CAD, S/P angioplasty in 1989 </li></ul><ul><li>Diabetes </li></ul><ul><li>Hy...
AMI Case Study <ul><li>Physical Exam: </li></ul><ul><li>Vital stable with bradycardia of 58 </li></ul><ul><li>Oxygen sat 9...
AMI case study <ul><li>Interventions: </li></ul><ul><li>Plavix </li></ul><ul><li>Nitro </li></ul><ul><li>Morphine </li></u...
AMI case study <ul><li>Discharge planning </li></ul><ul><li>Cardiac rehab (PT, OT, Dietary) </li></ul><ul><li>Smoking cess...
N/A N/A 1.8 2.0 Days in ICU 4.0 4.0 3.9 3.9 4.8 4.8 4.1 4.4 Length of Stay 2002 1 st  Q 2002 2 nd  Q 9.7% 10.1% 10.0% 8.5%...
N/A N/A 1.8 2.0 Days in ICU 4.0 4.0 3.9 3.9 4.8 4.8 4.1 4.4 Length of Stay 2002 1 st  Q   2002 2 nd  Q 9.7% 10.1% 10.0% 8....
ACUTE MI DEMOGRAPHICS AND RISK FACTORS N/A 1% 1% (2) Cardiogenic Shock N/A 7% 27% (71) Pulmonary edema N/A 16% 15% (39) Ra...
AMI  Opportunities for Improvement <ul><li>Emergency Department: </li></ul><ul><ul><li>Door to EKG time </li></ul></ul><ul...
CARDIOLOGY SEVICE LINE  2001 – 2002 - 0.1 1.52 203 1.53 219 .52/67 143 Chest Pain + .96 2.71 14 1.75 55 .58/74 140 Angina ...
CARDIOLOGY SERVICE LINE COST DATA 2001 – 2002 143 Chest Pain 140 Angina 127 Heart Failure 122 AMI No Comp 121 AMI & Major ...
Congestive Heart Failure <ul><li>System-wide PI Project </li></ul><ul><li>High volume, high resource utilization </li></ul...
Ace Inhibitor on Discharge for EF < 40%
 
Strategies  <ul><li>CNS patient population oversight </li></ul><ul><li>CHF patient education materials </li></ul><ul><li>W...
Strategies for Improvement <ul><li>Staff education </li></ul><ul><li>CNS follows CHF inpatients </li></ul><ul><li>Chart al...
California Pacific Medical Center Permanent Pacemaker Analysis 2002 Ann Edmonson RN, Quality Improvement Jill Ley RN, Card...
Pacemaker Project <ul><li>Indications </li></ul><ul><li>Pacer type </li></ul><ul><li>Vendor </li></ul><ul><li>Anesthesia t...
Data Collection Processes <ul><li>Softmed Report for ICD-9 Code 37.83 </li></ul><ul><ul><li>Dates:  Jan, 2000 – May, 2002 ...
Indications for Pacemaker # of patients
Pacemaker Complications <ul><li>Lead Dislodgement </li></ul><ul><li>Infection </li></ul><ul><li>Pneumothorax </li></ul><ul...
CNS Contributions <ul><li>Ideally positioned to influence  team </li></ul><ul><li>Knowledgeable about evidence based pract...
Achieving Continual Improvement <ul><li>Format meetings and forums to continually review care delivery </li></ul><ul><li>I...
Clinical Nurse Specialist <ul><li>Ability to Blend </li></ul><ul><ul><li>clinical, research & financial aspects of outcome...
 
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California Pacific Medical Center The CNS Role and Outcomes ...

  1. 1. The CNS Role and Outcomes Management Evelyn Taverna, RN, MS, CCRN, CNS Guest Lecturer: N 226 February 19, 2003
  2. 2. Overview <ul><li>Purpose: to extend the traditional role of case management to patient population based clinical resource management </li></ul><ul><li>Develop systems to manage patients across the continuum - from inpatient to extended care to home health </li></ul><ul><li>Create teams to effectively manage and integrate departmental activities in a cost effective, outcome driven manner </li></ul>
  3. 3. Population Based Teams <ul><li>Cardiology </li></ul><ul><li>Cardiovascular Surgery </li></ul><ul><li>Medicine </li></ul><ul><li>Neurology/Neurosurgery </li></ul><ul><li>Obstetrics </li></ul><ul><li>Oncology </li></ul><ul><li>Pediatrics </li></ul><ul><li>Pulmonary </li></ul><ul><li>Surgery/Orthopedics </li></ul>
  4. 4. Team Members <ul><li>Clinical Nurse Specialists </li></ul><ul><li>RN Case Managers </li></ul><ul><li>Social Workers </li></ul><ul><li>Administrative Assistants </li></ul><ul><li>Data Analysts </li></ul><ul><li>Quality Coordinators </li></ul><ul><li>Physician Champions </li></ul>
  5. 5. CPMC Quality & Clinical Resource Management Model Clinical Nurse Specialist Population Based Case Manager Social Worker Patient/Family Based Administrative Assistant Support QUALITY MANAGEMENT CLINICAL MANAGEMENT RESOURCE MANAGEMENT OUTCOMES MANAGEMENT DISCHARGE PLANNING SOCIAL SERVICES UTILIZATION MANAGEMENT UR PHYSICIANS HOSPITALISTS STAFF MANAGEMENT DEPARTMENTS
  6. 6. 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 <ul><li>Clinical Management </li></ul><ul><li>Protocols </li></ul><ul><li>Best practice guidelines </li></ul><ul><li>Clinical consultation </li></ul><ul><li>Staff education </li></ul><ul><li>Complex case review </li></ul><ul><li>Resource Management </li></ul><ul><li>Benchmarking </li></ul><ul><li>MD comparisons </li></ul><ul><li>LOS/level of care </li></ul><ul><li>Cost/resource analysis </li></ul><ul><li>Resource utilization </li></ul><ul><li>Outcomes Management </li></ul><ul><li>Quality, cost, service </li></ul><ul><li>Data analysis/research </li></ul><ul><li>Clinical effectiveness </li></ul><ul><li>PI projects </li></ul><ul><li>Sutter initiatives </li></ul>
  7. 7. The CNS as Team Leader <ul><li>Masters prepared expert nurse clinician </li></ul><ul><li>Manage clinical resources </li></ul><ul><ul><li>Define care requirements (best practices) </li></ul></ul><ul><ul><li>Monitor their impact on outcome achievement </li></ul></ul><ul><li>60% of time actively involved with patients </li></ul><ul><ul><li>Daily interaction with patients, families, clinical staff, nurses, and physicians </li></ul></ul><ul><li>Continually evaluate patient care needs </li></ul><ul><ul><li>Individuals and aggregate population </li></ul></ul><ul><ul><li>Seek opportunities for improvement </li></ul></ul>
  8. 8. Project Selection <ul><li>External Sources/Needs </li></ul><ul><ul><li>Mandatory – JCHAO Core Measures & Standards </li></ul></ul><ul><ul><li>State Requirements - OSHPD </li></ul></ul><ul><ul><li>Sutter Initiatives </li></ul></ul><ul><ul><li>Press-Ganey Patient Satisfaction Survey </li></ul></ul><ul><ul><li>VHA Programs </li></ul></ul><ul><li>Internal Sources </li></ul>
  9. 9. Project Selection <ul><li>External Regulatory Requirements </li></ul><ul><li>JCAHO CORE Measures - 2002 </li></ul><ul><ul><ul><li>CHF </li></ul></ul></ul><ul><ul><ul><li>Perinatal Outcomes </li></ul></ul></ul><ul><ul><ul><li>JCAHO CORE Measures – 2003 </li></ul></ul></ul><ul><ul><ul><li>Community Acquired Pneumonia </li></ul></ul></ul>
  10. 10. Project Selection <ul><li>JCAHO Standards </li></ul><ul><li>Pain Management – Jackie Phan, CNS </li></ul><ul><li>Patient Safety- Gail Guthrie, CNS & Phyllis Erickson, CNS </li></ul><ul><li>Medication Error Reduction – Evelyn Taverna, CNS </li></ul>
  11. 11. Project Selection <ul><li>External Requirements </li></ul><ul><li>California CABG Outcomes Reporting Program (CCORP) – Jill Ley, CNS </li></ul><ul><li>Crusade Study & National Registry for Myocardial Infarction (NRMI) – Evelyn Taverna, CNS </li></ul><ul><li>ACOS Accreditation – Alice Mack, CNS </li></ul><ul><li>National Practice Recommendations: </li></ul><ul><ul><li>AHA, AHCPR, etc. </li></ul></ul>
  12. 12. Developing Clinical Questions <ul><li>Institutional Sources </li></ul><ul><ul><li>Quality committees </li></ul></ul><ul><ul><li>Performance Improvement teams </li></ul></ul><ul><ul><li>Product lines </li></ul></ul><ul><li>Clinician Sources </li></ul><ul><ul><li>Clinical observations </li></ul></ul><ul><ul><li>New products/techniques </li></ul></ul><ul><ul><li>Evidence-based practices </li></ul></ul>
  13. 13. Current Projects <ul><li>Medication Error Reduction </li></ul><ul><ul><li>Coumadin dosing project </li></ul></ul><ul><ul><li>Range-dosing protocol </li></ul></ul><ul><ul><li>Patient controlled analgesia protocol </li></ul></ul><ul><li>New Procedures </li></ul><ul><ul><li>Bariatric surgery outcomes </li></ul></ul><ul><ul><li>Continuous renal replacement therapy </li></ul></ul><ul><ul><li>Off-pump CABG outcomes </li></ul></ul><ul><li>Outcomes Management </li></ul><ul><ul><li>Interventional endoscopy database </li></ul></ul><ul><ul><li>Plavix research and practice change </li></ul></ul><ul><ul><li>VBAC – Best practice </li></ul></ul>
  14. 14. Current Projects <ul><li>Medication Error Reduction </li></ul><ul><ul><li>Coumadin dosing project </li></ul></ul><ul><ul><li>Range-dosing protocol </li></ul></ul><ul><ul><li>Patient controlled analgesia protocol </li></ul></ul><ul><li>New Procedures </li></ul><ul><ul><li>Bariatric surgery outcomes </li></ul></ul><ul><ul><li>Continuous renal replacement therapy </li></ul></ul><ul><ul><li>Off-pump CABG outcomes </li></ul></ul><ul><li>Outcomes Management </li></ul><ul><ul><li>Interventional endoscopy database </li></ul></ul><ul><ul><li>Plavix research and practice change </li></ul></ul><ul><ul><li>VBAC – Best practice </li></ul></ul>
  15. 15. Benchmarking Resources <ul><li>Agency for Health Care Policy & Research(AHCPR) </li></ul><ul><li>AHA,ACC </li></ul><ul><li>VHA </li></ul><ul><li>CMRI </li></ul><ul><li>HBSI Fathom </li></ul><ul><li>Midas </li></ul><ul><li>NRMI 4 </li></ul><ul><li>Crusade </li></ul>
  16. 16. Influencing Physician Practice <ul><li>The CNS is the “point person” for providing cost, service, and quality information to the Medical Staff to guide data driven practice changes which: </li></ul><ul><ul><li>reduce cost variations </li></ul></ul><ul><ul><li>decrease overall cost </li></ul></ul><ul><ul><li>maintain quality outcomes </li></ul></ul><ul><ul><li>improve service </li></ul></ul>
  17. 17. Cardiology CNS <ul><li>Acute Coronary Syndrome </li></ul><ul><li>CHF </li></ul><ul><li>Pacemaker Study </li></ul><ul><li>Atrial Fibrillation </li></ul><ul><li>Complex patients </li></ul><ul><ul><li>clinical </li></ul></ul><ul><ul><li>education </li></ul></ul><ul><ul><li>discharge planning </li></ul></ul>
  18. 18. Cardiology: <ul><li>AMI </li></ul><ul><ul><li>ED chest pain protocol </li></ul></ul><ul><ul><li>STEMI and NSTEMI protocol </li></ul></ul><ul><li>Crusade & NRMI 4 data – Focus on NSTEMI outcomes </li></ul><ul><ul><li>IIb/IIIa inhibitor use and bleeding </li></ul></ul><ul><ul><li>interventional procedures </li></ul></ul><ul><li>Sutter Cardiovascular Services Initiative </li></ul><ul><ul><li>AMI task force </li></ul></ul><ul><ul><li>CHF committee </li></ul></ul><ul><li>CHF </li></ul><ul><ul><li>ACE inhibitor use and discharge instruction outcomes & readmission </li></ul></ul>
  19. 19. AMI Outcome Measures <ul><li>Aspirin at arrival </li></ul><ul><li>Beta blocker at arrival </li></ul><ul><li>Median time to thrombolytic therapy </li></ul><ul><li>Median time to PTCA </li></ul><ul><li>Aspirin prescribed at discharge </li></ul>
  20. 20. AMI (cont.) <ul><li>Beta blocker prescribed at discharge </li></ul><ul><li>ACE I at discharge for LVSD </li></ul><ul><li>Adult smoking cessation advice </li></ul><ul><li>Inpatient mortality </li></ul><ul><li>Lipid-lowering agent at D/C </li></ul>
  21. 21. AMI Strategies <ul><li>ED Chest Pain Risk Assessment </li></ul><ul><li>Acute Coronary Syndrome Protocols/Order Sets </li></ul><ul><li>AMI Standard of Care </li></ul><ul><li>AMI Guide to Recovery </li></ul>
  22. 23. AMI Case Study <ul><li>Mr. M is a 54 year old man admitted with c/o of chest pain which began while watching the 49’ers playoff game. Patient lives with wife and works in law enforcement. </li></ul><ul><li>Symptoms included: </li></ul><ul><li>Constant, substernal chest pressure (5/10) </li></ul><ul><li>Diaphoresis </li></ul>
  23. 24. AMI Case Study <ul><li>PMH: </li></ul><ul><li>CAD, S/P angioplasty in 1989 </li></ul><ul><li>Diabetes </li></ul><ul><li>Hypertension </li></ul><ul><li>Hypercholesterolemia </li></ul><ul><li>Current smoker </li></ul><ul><li>Medications: </li></ul><ul><li>Atenolol and Glucophage </li></ul><ul><li>Allergic to Aspirin and Motrin </li></ul>
  24. 25. AMI Case Study <ul><li>Physical Exam: </li></ul><ul><li>Vital stable with bradycardia of 58 </li></ul><ul><li>Oxygen sat 96% on 2 liters </li></ul><ul><li>Lungs clear, no JVD </li></ul><ul><li>Labs: </li></ul><ul><li>Elevated cardiac markers </li></ul><ul><li>Glucose – 295 </li></ul><ul><li>EKG: </li></ul><ul><li>ST elevation in inferior leads </li></ul>
  25. 26. AMI case study <ul><li>Interventions: </li></ul><ul><li>Plavix </li></ul><ul><li>Nitro </li></ul><ul><li>Morphine </li></ul><ul><li>Heparin </li></ul><ul><li>Primary PTCA with GP IIb/IIIa inhibitor during/after PTCA </li></ul><ul><ul><li>Door to balloon time = 100 min. </li></ul></ul>
  26. 27. AMI case study <ul><li>Discharge planning </li></ul><ul><li>Cardiac rehab (PT, OT, Dietary) </li></ul><ul><li>Smoking cessation advice </li></ul><ul><li>Stress management </li></ul><ul><li>Aspirin, Plavix, Beta blocker, ACE I inhibitor, statin </li></ul>
  27. 28. N/A N/A 1.8 2.0 Days in ICU 4.0 4.0 3.9 3.9 4.8 4.8 4.1 4.4 Length of Stay 2002 1 st Q 2002 2 nd Q 9.7% 10.1% 10.0% 8.5% Death 30% 27% 39% 36% NSTEMI Eligible AMI Patients Treated with GP 2b/3a Inhibitor 63% 65% 63% 62% NSTEMI 36% 25% 33% 11% (4/35) Door to Dilation (<90 minutes) 105 116 108 9 61 38 124 15 68 41 Door to Dilation b door to data data to cath lab cath lab to dilation 46% 44% 38% 0% Door to Drug (<30 minutes) 33 34 33 8 18 7 36 13 17 6 Door to Drug median min. door to data data to decision decision to drug 12% 13% 7% 2 pt. IV Thrombolysis N/A N/A 71% 29% 42 pts. 60% (25/42) 40% (17/42) AMI patients Eligible for Reperfusion a Treated Eligible AMI patients Untreated Eligible AMI patients 27% 25% 27% 28% ST  and/or LBBB on 1 st EKG 69 70 68 76 AGE 186439 27330 55489 303 260 Enrollment Yearly Non Transfer-in NATION (1228 centers) CALIFORNIA LIKE HOSPITALS (173 centers) CPMC INDICATOR ACUTE MYOCARDIAL INFARCTION NRMI 4 DATA SUMMARY September 2002 Report7/1/01 – 6/30/02
  28. 29. N/A N/A 1.8 2.0 Days in ICU 4.0 4.0 3.9 3.9 4.8 4.8 4.1 4.4 Length of Stay 2002 1 st Q 2002 2 nd Q 9.7% 10.1% 10.0% 8.5% Death 30% 27% 39% 36% NSTEMI Eligible AMI Patients Treated with GP 2b/3a Inhibitor 63% 65% 63% 62% NSTEMI NATION (1228 centers) CALIFORNIA LIKE HOSPITALS (173 centers) CPMC INDICATOR ACUTE MYOCARDIAL INFARCTION NRMI 4 DATA SUMMARY September 2002 Report 7/1/01 – 6/30/02
  29. 30. ACUTE MI DEMOGRAPHICS AND RISK FACTORS N/A 1% 1% (2) Cardiogenic Shock N/A 7% 27% (71) Pulmonary edema N/A 16% 15% (39) Rales, JVD N/A 75% 57% (148) No CHF N/A 12% 17% (45) Chronic renal Insufficiency N/A 31% 48% 77/160 Sx onset to door > 4 hrs Clinical Presentation 70 42% 68 36% 76 59% AGE >75 years CALIFORNIA LIKE HOSPITALS N= 34920 CPMC N =260
  30. 31. AMI Opportunities for Improvement <ul><li>Emergency Department: </li></ul><ul><ul><li>Door to EKG time </li></ul></ul><ul><ul><li>Chest pain Risk Assessment Protocol </li></ul></ul><ul><ul><li>CPK & Troponin utilization </li></ul></ul><ul><li>Cath Lab: </li></ul><ul><ul><li>Door to Balloon time </li></ul></ul><ul><li>Critical Care & Telemetry </li></ul><ul><ul><li>Analysis of bleeding requiring intervention </li></ul></ul><ul><ul><li>Patient Education material </li></ul></ul><ul><ul><li>Cardiac Rehab </li></ul></ul>
  31. 32. CARDIOLOGY SEVICE LINE 2001 – 2002 - 0.1 1.52 203 1.53 219 .52/67 143 Chest Pain + .96 2.71 14 1.75 55 .58/74 140 Angina + .72 4.89 387 4.17 471 .98/75 127 Heart Failure + .25 3.50 20 3.50 20 1.56/87 123 AMI Expired + .53 4.04 27 3.51 63 1.24/66 122 AMI No Comp + .84 6.29 118 5.45 106 1.55/80 121 AMI & Major Comp YTD % CHANGE CHANGE 2001- 2002 DIRECT COST 2002 DIRECT COST 2001 LOS CHANGE 2001- 2002 LOS 2002 CASES 2002 (Jan-June) LOS 2001 CASES 2001 PMI/ AGE DRG
  32. 33. CARDIOLOGY SERVICE LINE COST DATA 2001 – 2002 143 Chest Pain 140 Angina 127 Heart Failure 122 AMI No Comp 121 AMI & Major Comp Other Lab Radiology PT Pharmacy Supplies RT /Pul Med/Surg Critical Care DRG
  33. 34. Congestive Heart Failure <ul><li>System-wide PI Project </li></ul><ul><li>High volume, high resource utilization </li></ul><ul><li>Opportunities for Improvement: </li></ul><ul><ul><li>ACE Inhibitors on discharge for patients with Ejection Fraction < 40% </li></ul></ul><ul><ul><li>Decreasing LOS and readmission rate </li></ul></ul><ul><ul><li>Standardizing patient education materials </li></ul></ul><ul><ul><li>Medical and Nursing Staff Education </li></ul></ul>
  34. 35. Ace Inhibitor on Discharge for EF < 40%
  35. 37. Strategies <ul><li>CNS patient population oversight </li></ul><ul><li>CHF patient education materials </li></ul><ul><li>Weight chart </li></ul><ul><li>One page - Tips for managing at home </li></ul><ul><li>CHF discharge sheet </li></ul>
  36. 38. Strategies for Improvement <ul><li>Staff education </li></ul><ul><li>CNS follows CHF inpatients </li></ul><ul><li>Chart alert to MD - document reason no ACE prescribed </li></ul><ul><li>Data posted in MD newsletter, MD lounge, cardiology unit. </li></ul><ul><li>Data reported to Cardiology & Medicine & Nursing QA Committees. </li></ul>
  37. 39. California Pacific Medical Center Permanent Pacemaker Analysis 2002 Ann Edmonson RN, Quality Improvement Jill Ley RN, Cardiac Surgery Evelyn Taverna RN, Cardiology James Mailhot MD, Cardiology QI Chair
  38. 40. Pacemaker Project <ul><li>Indications </li></ul><ul><li>Pacer type </li></ul><ul><li>Vendor </li></ul><ul><li>Anesthesia type </li></ul><ul><li>Duration of procedure </li></ul><ul><li>Complications </li></ul>
  39. 41. Data Collection Processes <ul><li>Softmed Report for ICD-9 Code 37.83 </li></ul><ul><ul><li>Dates: Jan, 2000 – May, 2002 </li></ul></ul><ul><li>Data collection methods by LOS </li></ul><ul><ul><li>If LOS > 1 day – medical record review </li></ul></ul><ul><ul><li>If LOS = 1 day – PCIS review </li></ul></ul><ul><ul><ul><li>OP note, d/c summary, blood orders </li></ul></ul></ul><ul><ul><ul><li>Anesthesia type and OR time not recorded </li></ul></ul></ul><ul><ul><li>Readmission screen for all patients </li></ul></ul>
  40. 42. Indications for Pacemaker # of patients
  41. 43. Pacemaker Complications <ul><li>Lead Dislodgement </li></ul><ul><li>Infection </li></ul><ul><li>Pneumothorax </li></ul><ul><li>PM Tachycardia </li></ul><ul><li>Hypotension </li></ul><ul><li>Reprogramming </li></ul><ul><li>Bleeding </li></ul><ul><li>RV Perforation </li></ul><ul><li>CVA </li></ul><ul><li>Death </li></ul>
  42. 44. CNS Contributions <ul><li>Ideally positioned to influence team </li></ul><ul><li>Knowledgeable about evidence based practices </li></ul><ul><li>Impact both processes and outcomes of care </li></ul><ul><li>Improved outcomes documented: </li></ul><ul><ul><li>Reduced LOS, complication rates </li></ul></ul><ul><ul><li>Appropriate use of resources </li></ul></ul><ul><ul><li>Documented cost savings </li></ul></ul><ul><li>Links to quality improvement & credentialing </li></ul>
  43. 45. Achieving Continual Improvement <ul><li>Format meetings and forums to continually review care delivery </li></ul><ul><li>Implement systems to obtain data: retrospective, concurrent, prospective </li></ul><ul><li>Continually monitor defined indicators </li></ul><ul><li>Multidisciplinary reviews - close the loop </li></ul><ul><li>Determine when to move on to the next project </li></ul>
  44. 46. Clinical Nurse Specialist <ul><li>Ability to Blend </li></ul><ul><ul><li>clinical, research & financial aspects of outcomes management </li></ul></ul><ul><ul><li>with a focus on quality, compassion & caring. </li></ul></ul>

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