Presented by: Patti DeJuilio, MS, RRT-NPS, RRT-ACCS

Excellence Results When There is Multidisciplinary Communication and Collaboration

Objectives

1. Learner will be able to describe the evidence supporting the importance of multidisciplinary rounds/communication, understand that no discipline in a healthcare system can function independently.

2. Learner will be able to formulate ideas to implement in their institution such as rounding in patient room, care conferences, and respiratory involvement. Understanding the importance of everyone’s commitment to the process.

3. Learner will have knowledge about potential impacts of multidisciplinary collaboration and possible metrics to support the staffing.

Disclosure: Sage Clinical Advisory Council

Excellence Results when there is Multidisciplinary Communication and Collaboration

Far and away the best prize that life has to offer is the chance to work hard at work worth doing.

-Theodore Roosevelt

Healthcare Reform

• Healthcare reform summed up: − Decreased revenues − Penalties

• Redistribution of higher Medicare payments • Fixed pay • Ancillary Departments are now cost centers, not revenue centers

How does it affect you?

The Clinician’s Role

• We need to make ourselves and our peers valuable members of the multidisciplinary team!

• We need to be an integral part of our institution’s solution. • We are responsible for earning/gaining respect from administration,

physicians, entire healthcare team • You are the face of your entire group • As much as you can educate and influence your group, the better the

reflection on you

Future of Healthcare

• Value driven • Important metrics: − Outcomes − Patient experience − Cost

• RCPs are the primary providers along with RNs that cost money • Open your eyes to hospital goals and opportunities: − Be part of multidisciplinary teams set to achieve better:

• Outcomes • Patients satisfaction • Cost savings

Multidisciplinary Opportunities

• Patient safety liaison • Research team • House wide practice council • Code response including: − High risk deliveries − Rapid response team

• Transport teams • ICU protocols, including rapid ventilator weaning • Protocols to reduce HAI • Protocols to reduce LOS • Education to reduce readmissions − Post discharge phone calls

Six Aims of Crossing the Quality Chasm

1. Safe 2. Effective 3. Efficient 4. Timely 5. Patient Centered 6. Equitable

Institute of Medicine

AARC Leadership

• Future will have increased complexity of patients requiring increased communication

• Increased scrutiny for quality − Linking quality to reimbursement initiatives such as pay for performance

• Clinical decisions will be increasingly data driven

• Evidenced-based algorithms will be the most common way to deliver respiratory care4

Three Series Conference; Respiratory Care in 2015

Cookie Cutter Medicine Can be the Best Medicine!

• If the cookie cutter is evidence based and provides value then this is good! − We need more cookie cutters!

Creating a Vision for Respiratory Care in 2015 and Beyond

• Our future depends on improving quality, decreasing costs, biomedical innovation and evidenced based medicine

• Administrators are counting on you: − To be comfortable with patient information − To know what to do with it − To adapt to a rapidly changing environment − Be willing to take on additional responsibilities

Creating a Vision for Respiratory Care in 2015 and Beyond; Barnes, Walton, Kacmarek, Durbin, Kageler, and O’Neil

Creating a Vision for Respiratory Care in 2015 and Beyond

• We recognize that it is more and more essential that respiratory therapists attend rounds and advocate for patient specific, best approach to care

• The therapists are relied upon to be the experts on when and how invasive,

non-invasive and high frequency ventilation and the need for ECMO should be applied4

UMass Memorial Critical Care Operations Team

• Those health-care systems that successfully implement interdisciplinary collaboration will be ahead of the curve in providing high quality care at the lowest cost possible.

• Such institutions may have improved education and more quality research as a result6.

UMass Memorial Management Strategy:

Consensus Building

Communication

Collaboration

Accountability

Celebrations

Consistency

Champions5

The 7C’s

Interdisciplinary Collaboration

• An interpersonal process characterized by healthcare professionals from multiple disciplines with shared objectives, decision making, responsibility, and power working together to solve patient care problems; the process is best attained through an interprofessional education that promotes the atmosphere of mutual trust and respect, effective and open communication, and awareness and acceptance of the roles, skills, and responsibilities of the participating disciplines6

Interdisciplinary Collaboration

• No discipline can function in isolation of others (and certainly not in our ICUs) because it is not possible for any one group of health-care providers to address the myriad and complex spectrum of patient-related problems presented by any individual, family, institution, or community7,5.

Collaborative Culture

Lamantia, Gundry Respectful

Interactions

Genuine Listening

Desire to tap into group

intelligence.

Collegiality

Integrity

Support Empowerment

Communication7,5

Using Teamwork to Improve Patient Outcomes

• Teamwork can be described in many ways to describe ICU care giver collaboration − Researchers have described this by utilizing the following framework:

Society of Critical Care Medicine, 2015

• Individual attributes •Team composition •The task •Environmental resources •Organizational culture

Input

•Teamwork behaviors •Compliance with protocols

Process

•Patient outcomes •Resource utilization •Staff satisfaction

Output

Using Teamwork to Improve Patient Outcomes

• Implementation of daily multidisciplinary rounds by RN, MD and RT: − Review checklist of ventilator bundle goals:

• Decreased VAP from 1.5/month to 0.5/month in a surgical ICU 10

• Similar findings of reduced VAP incidence were found in a different center’s

open trauma ICU 11

• Conversely, poor team interactions have been associated with ICU adverse

events − Studies have shown 32-37% patient safety errors result of poor

teamwork 12, 13

• Teamwork may improve patient outcomes and avoid adverse events

Multidisciplinary Team Rounds

• Non threatening environment • Educational environment • Respect is given to those in attendance − Good listening skills encouraged

• Family participation and transparency • People held accountable • Good outcomes celebrated • Surveillance of protocol adherence • Communication and collaboration are actively encouraged • Caregivers empowered

Additional Communication Opportunities

Financial Stewardship

Patient Satisfaction

Critical Care Grand Rounds

Daily Safety Huddles

Monthly Multidisciplinary ICU Core Team

Northwestern Medicine Central DuPage Hospital

Central DuPage Hospital

• 2 – 16 bed adult ICUs • 24/7 critical care intensivist program • Talented caregivers empowered at bedside • Medical Director, Dr. Jeffrey Huml − Committed to fostering an environment that allows teams to work

together collaboratively to share and solve problems with results ending in improved patient outcomes

• We give care that we would want our own family members to have

Northwestern Medicine Western Region

Central DuPage Hospital

• Ventilator Wean program implemented in 2009 • Ventilator Weaning order sets were improved and expounded: − Utilizing current evidence and best practice guidelines

• Project expanded to include pharmacology and mobility • RCPs are members of turn teams • Specific order sets for the post operative cardiac patients were developed • Respiratory assessment protocol instituted house-wide in 2006 and

updated as appropriate • RTs actively involved in VAE reduction Protocol; NV-HAP protocol • RT driven obstructive sleep apnea protocol implemented June, 2015.

Northwestern Medicine Western Region

Journey

• RCPs attend all rounds led by critical care Intensivists: • Even included on patients not currently on our service

− Present detailed report on respiratory status of each patient • Shift report has evolved as a result and continues to improve

− Provide evidence based suggestions on appropriate care for each respiratory patient

• RCPs have more visibility and interface with physicians, thereby; eliminating

the need for Intensivist to give respiratory order to RN rather than RCP

• Unusual occurrence reporting has risen and therefore opportunities for improvement are more clear as a result of CUSP and Safety.Always

ICU Score Card Purpose: To review processes, clinical practice and evidence-based quality improvement among critical care leaders in an interdisciplinary forum

APACHE vs. SMR

May No. of Admissions 193 No. of Deaths 9 No. of 24 hour Readmissions 1 SMR (Excludes CABG patients) 0.46 SMR (ALL patients) 0.51 Sept – May 2015 YTD SMR 0.40

Post Op Heart Weaning Protocol

* Prolonged Ventilation Patient had a prolonged v entilator > 24 hours

D N % D N %May 204 12 0 0.0 16 0 0.0Jun 2014 18 1 5.6 27 4 14.8Jul 2014 18 1 5.6 20 1 5.0Aug 2014 12 2 16.7 21 3 14.3Sep 2014 9 0 0.0 15 0 0.0Oct 2014 11 2 18.2 23 2 8.7Nov 2014 14 0 0.0 21 1 4.8Dec 2014 6 2 33.3 14 4 28.6Jan 2015 9 0 0.0 16 2 12.5Feb 2015 15 3 20.0 21 5 23.8Mar 2015 17 1 5.9 24 1 4.2Apr 2015 10 0 0.0 18 0 0.0

Rolling 12 Month 151 12 7.9 236 23 9.7

Month

CAB Only ALL CAB YTD TREND

STS National Mean CAB Only

8.40

5

10

15

20

25

30

35

Achieving Excellence: Outcomes VAP Rate

Ventilator Acquired Pneumonia Initiative

Redefining Excellence: Initiative and Innovation ICU Process Improvement Projects

Safe Airway Initiative:

Redefining Excellence: Initiative and Innovation ICU Process Improvement Projects

Hospital-Acquired Pressure Ulcer Reduction Turn Team

Business Case Ventilator Productivity

POINTS PROCEDURE

3 Oral Care/VAP care

4 Ventilator Subsequent

3 Withdrawal Arterial Blood

3 Arterial Blood Analysis

2 In-Line Suction

2 Patient/Ventilator Assessment

7 Early Mobilization Adult or Turn Team every 2 hours

AARC Uniform Reporting Manual 5th Edition

CDH Outcomes

• Administration committed to supporting efforts at improving safety and outcomes efficiently

• Additional FTE’s 5 Years

Later…

•Record low risk adjusted morality rate of 0.48

Patient Satisfaction

Scores •Now 100%

excellent

PRC “Teamwork”

• From 20% excellent in 2011

• To > 75% excellent in most months

Move to Improve: Early Mobilization in the ICUs

Anne Drolet APN/ANP Esperanza Magat RN, ICU Patti DeJuilio MS, RRT-NPS Katie Tucker PT, DPT

Move to Improve: • Purpose: − To introduce an evidence based mobility program designed to maintain

baseline mobility and functional capacity, decrease incidence of delirium, decrease ventilator days and decrease LOS in hospitalized patients 14

A multidisciplinary focus on early mobilization as part of the daily clinical routines

Maintain patients at their baseline mobility and functional levels

Initiate Mobility Protocol when the patient is hemodynamically stable

Patients to have activity at least twice daily: •When the patient tolerates chair activity, he/she is to be up in the

chair for all meals. • If physical therapy is consulted, the PCT will continue to mobilize

the patient 1-2 times/day in addition to PT

Move to Improve- Early Mobilization

Move to Improve Early Mobilization: ICU

Mobility Protocol: Non-ICU

Sedation (RASS)

Delirium (CAMS)

Multidisciplinary Approach

Ventilator Weaning

Multidisciplinary Team is Mobilizing Patients ICU Mobility Data

Incidence and Prevention of Non-Ventilator Hospital Acquired Pneumonia

Victoria Nickola-Arinta, MS-RRT

Charter

40

Exec Sponsor: David Cooke, MD Sponsor(s): Patricia DeJuilio MS, RRT-NPS, Jamie Copp, RN, BSN

Process Owner(s): All bed tower PCTs Improvement Leader: Victoria Nickola MS, RRT Team Members: Bed tower MDs, RNs, RCPs and PCTs

Key Metrics

Outcome Metric(s): Reduction of NV-HAP rates to target or below with a stretch goal being 0% (Current rate calendar year 2014: 2.15 per 1000 pt. days) Process Metric(s): Monitor NV-HAP rate monthly (ICD code 9) over FY15 to see reduction % Monitor compliance with oral care/documentation Monitor oral care product use per patient day Monitor oral care documentation via EPIC flowsheet row data request

Milestones

Description Define – Complete project charter 12/14

Measure – Identify/finalize baseline measures 01/15

Analyze – Identify key drivers 01/15

Improve – Improvements identified/implemented 03/15-05/15

Control – establish and implement control plan 06/15

Date (MM/YY)

Project Overview

Problem Statement: US hospitals are required to monitor ventilated patients who contract pneumonia but are not required to monitor non-ventilated hospital acquired pneumonia (NV-HAP) patients. According to the Centers for Disease Control and Prevention, hospital acquired pneumonia accounts for approximately 15% of all hospital acquired infections. Data regarding NV-HAP is under reported and sparse. A recent retrospective analysis of 2014, identified 145 cases of NV-HAP in the bed tower alone at Central DuPage Hospital (CDH). CDH has a robust mobility program and follows head of bed elevation and incentive spirometry as current routine practice.

Goal/Benefit: Reducing NV-HAP has the potential for improving outcomes, safety, and quality of life as well as fiscal savings.

In-Scope: Includes all patients admitted to the inpatient bed tower (units 2-4 A, B, & C) at CDH.

Our of Scope: Pediatrics, mother baby, labor and delivery, NICU and ICU’s

System Capabilities: Prevention based oral care education to PCTs, RCPs and RNs (Healthstream/clinical tip) and protocol use will reduce incidence of NV-HAP.

Resources Required: Physician, RN, RCP, PCT buy-in and support and current oral-care products provided from bed tower pyxis.

Last Update: 4/14/15

Why NV-HAP?

• HAP second most common heath care acquired infection in US − Increased morbidity

• 50% not discharged home • Increased mortality

• 18-29% • Extended length of stay

• 4-9 day average • 2 x likely for readmission < 30 days

• Understudied • Focus on VAP

Quinn B, et al. J of Nursing Scholarship, 2014, 46(1):11-19

Analyze and Improve

42

Root Cause Solution Process Metric

Inconsistent provider practice in oral care and oral care documentation in EPIC

Educate on best practices and raise awareness: present to Nursing Assembly & Practice Council

Project submission to Research Review Committee

Learning Request submission to Professional Development: Healthstream for PTCs on NV-HAP risks and the importance of oral care and proper documentation

Develop clinical tip to RNs and RTs

Develop education patients/families on importance of oral care

File EPIC data request (Oral care row flowsheet)

Revise practice that PCTs, RNs, RTs document TID oral care in EPIC; share clinical tip with RNs, RCPs;

Re-evaluate next steps, depending on compliance with oral care, consider anti-microbial

*Monthly data collection of product use from bed tower pyxis machines, monthly QSS office ICD-9 code patient discharges & EPIC Crystal Report for auditing?

Completed

Completed

Process metric completed

N/A

N/A

Patients not educated about or engaged in oral care practices while in the hospital

Process Audit

Proposed go live 5/1/15?

Outcome metric

Opportunities to identify and improve care are missed

Planned Completed

Implementation Timeline Mar

On Hold

8

6

1

2

4

3

5

Aug May Apr Jun Jul 4

Sep 3 8

5 6 1 2

7

7

Conclusion

Conclusion

• Clinicians need to be: − Transparent − Open to learning − Always looking for process improvement projects − Not afraid to share knowledge − Active participants in patient care

Conclusion

• Collect Data • Understand the lingo − LOS, HAI, VAP, NV-HAP

• Present yourselves as someone the staff, physicians, administration want on

their team as you journey forward

• We want to do the right work in the right place at the right time with the right people with the right tools!

• We want multidisciplinary teams in healthcare!

“When you change the way you look at things, the things you look at change.”

-Heisenberg Uncertainty Principle

References

1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. The Committee on the Quality of Health Care in America; Released March 1, 2001.

2. Holland, S. Leadership From Behind the Stethoscope. Advance for Respiratory Care and Sleep Medicine. Feb. 20, 2013. 3. Meyers, T. Respiratory Care 2015: What Does the Future Hold?”. AARC Leadership Task Force. 4. Kacmarek R, Durbin C, Barnes T, Kageler W, Walton J, O’Neil E. Creating a Vision for Respiratory Care in 2015 and Beyond; Journal of Respiratory

Care;2009,Vol 54,No 3. 5. Irwin R, Flaherty H, French C, Cody S, Chandler M, Connolly A, Lilly C. Interdisciplinary Collaboration; The Slogan That Must Be Achieved for

Models of Delivering Critical Care to Be Successful. Chest 2012;142(6):1611-1619. 6. Petri L. Concept Analysis of Interdisciplinary Collaboration. Nurs Forum. 2010;45(2):73-82. 7. Bronstein LR. Index of interdisciplinary Collaboration. Soc Work Res. 2002:26(2):113-126. 8. Bauer, Seth. Using Teamwork to Improve Patient Outcomes. Society of Critical Care Medicine, Critical Connections, February/March, 2015 1-7. 9. Dietz AS, Pronovost PJ, Mendez-Tellez PA, et al. A systematic review of teamwork in the intensive care unit: what do we know about teamwork,

team tasks, and improvement strategies? J Crit Care. 2014;29(6):908-914. 10. Stone ME Jr., Snetman D, O'Neill A, et al. Daily multidisciplinary rounds to implement the ventilator bundle decreases ventilator-associated

pneumonia in trauma patients: but does it affect outcome? Surg Infect (Larchmt). 2011;12(5):373-378. 11. Johnson V, Mangram A, Mitchell C, Lorenzo M, Howard D, Dunn E. Is there a benefit to multidisciplinary rounds in an open trauma intensive

care unit regarding ventilator-associated pneumonia? Am Surg. 2009;75(12):1171-1174. 12. Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 1995;23(2):294-

300. 13. Pronovost PJ, Thompson DA, Holzmueller CG, et al. Toward learning from patient safety reporting systems. J Crit Care. 2006;21(4):305-315. 14. Drolet A, DeJuilio P, Henricks S, Leddy, L, et al. Move to Improve: the feasibility of using an early mobility protocol to increase ambulation in the intensive and intermediate care setting; PHYSICAL THERAPY Journal (PTJ). http://ptjournal.apta.org/content/early/recent; publication in PTJ Feb., 2013.

Questions?

Thank You