IHI Open School

Advanced Case Study

The Three Investigators:

Tricia Pil1, Danuta Lesnicki2, & Chris Hope3

University of Pittsburgh1, Lewis University2,

University of Mississippi Medical Center3

Carla’s Story (Part 1)

Day 1: Carla has poor flow thru her dialysis

catheter. Nurse schedules U/S for next

AM.

Day 2: After taking three buses, Carla is late for her U/S appt. She is resched for Day 4.

Day 3: She is unable to receive dialysis due to

almost completely blocked catheter.

Labs show hyperkalemia; U/S

reveals clot in fistula.

Carla is admitted for thrombolysis,

anticoagulation, and dialysis.

Day 7: Carla is ready for discharge.

Carla is discharged after receiving written instructions; a copy is mailed to her PMD.

Carla loses her discharge papers.

Her recommended follow-up with a nutritionist never

occurs.

Her recommended outpatient INR checks

are never done.

Day 25: Carla returns to ED with right arm pain and swelling.

Workup shows subtherapeutic INR and

a new DVT. She is admitted again.

Inpatient nutrition consult reveals dietary foods that destabilized anticoagulant activity.

Continued …

Carla’s Story (Part 2)

Day 36: Carla is discharged home again, feeling sick and weary.

She misses her dialysis appointment the next day.

Her dialysis nurse attempts to call her, but is unsuccessful and forgets

to follow up.

Day 39: Carla returns to the ED complaining of

facial tingling.

Her exam is delayed, and when done is only

cursory.

Her INR is critically high but not reported.

Day 40: Carla becomes lethargic.

The medical student waits until rounds to report this finding. Her elevated INR

is then discovered.

An emergency CT is performed, showing

bleeding into the brain.

Aftermath: Carla has had a stroke.

At age 30, she now lives in a long-term care facility.

What Went Wrong?

Inter-professional communication

breakdown

• Poor, indirect, and/or nonexistent communication between hospital staff and dialysis unit (discharge instructions to check INR not relayed to dialysis clinic); hospital and PMD (discharge instructions sent by mail); hospital and nephrologist (no d/c instructions sent); also,

• Poor communication between nephrologist and dialysis unit medical assistant

• ED physician lacked or did not access dialysis unit medical records or recent hospital discharge summaries

• Medical/surgical nurse and Medical student failed to notify attending

Provider-patient communication

breakdown

• RN scheduled ultrasound for next morning without confirming with Carla or informing her about consequences for arriving late

• Jonas enforced late arrival policy for Carla’s ultrasound and rescheduled for next day without confirming with Carla

• Caseworker mailed nutrition appointment slip

• Hospital’s visitation restriction policy posed restrictions on discharge communication needs with patient’s family support

• Mercedes failed to follow up when Carla missed dialysis

• Poor communication between ED physician/staff and Carla’s family/friends

Poor access to health care

facilities

• Jesse ordered ultrasound at local hospital eight miles away

• Carla took three buses and arrived late for ultrasound

• No inpatient nutrition consult available on Sunday

• Limited hours of operation for dialysis clinic

What Went Wrong? (Continued)

Task Factors

• No protocol for patients discharged on anticoagulation (ideal situation to include available nutrition consult or nutritionist at dialysis clinic, timely and direct follow-up with primary medical doctor (PMD)/nephrologist/dialysis unit at discharge)

• Lack of process to handle critical INR value

Patient Characteristics

• Financial barriers (phone disconnected)

• Transportation

Technology Issues

• Electronic Medical Record (EMR) systems are incompatible or nonexistent

Diagnostic Errors

• ED physician failed to adequately assess for possibility of stroke

• Medical/surgical nurse failed to assess face tingling/nausea

• Medical student failed to recognize Carla’s deteriorating mental status

Fishbone DiagramPatient

Characteristics Task Factors Individual Staff

Institutional

Context

Work

Environment

Organizational &

Management Factors

Team

Factors

•Chronic dialysis

•Financial difficulties

•Variable support

•No anticoagulation discharge

protocol

•No critical INR lab protocol

•Restrictive hospital visitation

policy

•Rigid radiology scheduling

policy without patient

communication of

consequences

•No coordinated follow-up

discharge planning process

•ED MD performed cursory

exam

•Med-surg RN failed to

assess neuro s/sx

•Med student assessed pt

•Numerous,

independent operating

healthcare facilities

•Internal cost-cutting

•Geographically distant

and scattered facilities

•Staff shortages

•Limited weekend

services

•Casual attitude re:

anticoag therapy

•Prioritizing pt

volume over quality

of care

•Poor communication between

inpatient and outpatient

caregivers

•Poor communication between

caregivers and pt/family

•Too many caregivers

•Inadequate supervision of

junior caregivers

•Hierarchical issues?

Carla strokes

Rules for A Better System

1. A communication task is not “completed” until a direct conversation has occurred

between the two parties.

─ Connection between providers resulted in several critical patient care delays and omissions.

2. Trust the patient of sound mind. Ask questions of family or friends.─ INR follow-up could have been resolved if caregiver at dialysis clinic acknowledged Carla’s important

message.

─ Knowing the patient was being discharged that same evening in which her family was visiting, those needs

should have been acknowledged.

3. Use automation in a process whenever possible to reduce variation.

─ Critical INR would have been detected much earlier had an automated process for reporting

critical INRs been available.

4. Structure policies with patient safety in mind and employee flexibility to meet variation

and growth.

─ The ultrasound policy had good intentions, however, the employee should be provided with

the ability to seek guidance for exceptions to meet circumstances of patient hardship or if the

ability to provide the service despite being late is possible.

─ The visitation policy prevented Carla’s family and friends from helping her with her discharge

needs. Again the policy should be used as a guideline and allow the nurse to make certain

exceptions.

Carla’s Story: Ideal Process MapDay 1: Carla has poor flow thru her dialysis catheter. Nurse schedules U/S for

next AM.

Nurse schedules U/S at a time that Carla confirms

works for her.

Day 2: After taking three buses, Carla is late for her U/S appt. She is resched

for Day 4.

Carla arrives for her U/S the next afternoon, which shows a developing blood clot. She is admitted to the

hospital that same day.

Day 3: She is unable to receive dialysis due to

almost completely blocked catheter.

Labs show hyperkalemia; U/S reveals clot in fistula.

Carla is admitted for thrombolysis,

anticoagulation, and dialysis.

Day 7: Carla is ready for discharge.

Lydia calls the dialysis unit, which has extended evening and

weekend hours, to review Carla’s discharge plan and confirms an

outpatient referral to dialysis clinic’s nutritionist.

Lydia notifies the home care nurse of Carla’s discharge plan, including an INR check and home visit within 72

hours after discharge. Carla is discharged.

Discharge orders are also faxed to Carla’s nephrologist and PMD. Alternatively, these outpatient

healthcare providers are able to access her electronic inpatient

records and discharge summary remotely via a secure Internet Web

site.

Carla is discharged after receiving written instructions; a

copy is mailed to her PMD.

Carla loses her discharge papers.

Her recommended follow-up with a nutritionist never occurs.

Her recommended outpatient INR checks are never done.

Day 25: Carla returns to ED with right arm pain and

swelling.

Workup shows subtherapeuticINR and a new DVT. She is

admitted again.

Inpatient nutrition consult reveals dietary foods that destabilized anticoagulant

activity.

Day 10: 72 hours after discharge, Carla receives a

home care nurse visit for INR check and exam. The home care nurse also coordinates

Carla’s dialysis appt and follows up on her labs with her

nephrologist and PMD.

Carla continues

with dialysis,

anticoagulation

is eventually

concluded.

Nutritionist

follows Carla at

dialysis clinic.

Carla’s Story: Ideal Process Map

(continued)Day 36: Carla is discharged home

again, feeling sick and weary.

She misses her dialysis appointment the next day.

Her dialysis nurse attempts to call her, but is unsuccessful and

forgets to follow up.

All missed appts are entered into the clinic follow-up book. Entries are checked and reconciled by a

nurse at the end of each shift.

The nurse calls Carla. There is no answer because her phone is

disconnected.

An ambulance is sent to her house, and her home care nurse,

PMD, and nephrologist are all notified.

The paramedics, in consultation with Carla’s PMD, recognize her

symptoms as an early sign of stroke. She is taken to the hospital

immediately.

Day 39: Carla returns to the ED complaining of facial tingling.

Her exam is delayed, and when done is only cursory.

Her INR is critically high but not reported.

Carla’s critical INR is automatically flagged for action by the computer.

The attending is notified immediately.

Carla receives a stat head CT and is taken to the OR for a developing but small subdural hematoma that

is successfully drained and managed.

Day 40: Carla becomes lethargic.

The medical student waits until rounds to report this finding. Her elevated INR is then discovered.

An emergency CT is performed, showing bleeding into the brain.

Aftermath: Carla has had a stroke.

At age 30, she now lives in a long-term care facility

Carla continues

with dialysis,

anticoagulation

is eventually

concluded.

Nutritionist

follows Carla at

dialysis clinic.

Improving Part of the System

Improvement Statement:

Within 6 months, all patients discharged

on anticoagulant therapy will have

home care nursing follow up within

three days and at one week after

discharge.

Measures of Success

• Number of patients discharged on anticoagulants who are enrolled in QI test

• Total number of patients discharged on anticoagulants

• Number of home nurse visits made

• Number of home INR values reported

Process Measures

• Number of critical INR values

• Number of hospital readmissions within 30 days

• Number of adverse vascular events (e.g. hemorrhage, stroke, DVT)

Outcome Measures

• Cost to train, employ home care nurses

• Cost to preserve, transport home INR blood specimens to lab

• Costs of documentation, time spent communicating lab results to outpatient caregivers

• Cost of readmission for coagulopathy complication

• Cost of lost productivity related to rehospitalization

Balancing Measures

Small Scale Change

Patient on anticoagulation therapy is ready for discharge

Hospital nurse provides patient information to home care nurse

Hospital Nurse explains to patient and primary medical doctor (PMD) hospital’s anticoagulation discharge policy (including home care RN visits); also provides home care nurse contact information with home visit schedule

Patient is discharged only after understanding of above acknowledged by patient and family

Home care RN visits begin

Q: Can the frequency of readmissions and adverse vascular events be

reduced with implementation of a home care discharge plan?

•Home care RN visits and INR checks

What changes will be tested?

•Quality officer, medical-surgical unit nurse manager, inpatient nurse, home care nurse

Who will implement the small tests of change?

•On inpatient unit and patient’s home; from discharge until 1 week after discharge

Where/when will the change take place?

•The process, outcome, and balancing measures previously outlined

What information will be collected?

•The INR level has a narrow therapeutic window and the anticoagulant dose thus needs frequent adjustment

•The high frequency of adverse vascular events associated with either under or over-anticoagulation

•The high risk of morbidity/mortality for patients who suffer a vascular event (hemorrhage or clot), particularly those with concurrent or underlying medical conditions.

Why is it important?

•Who: Quality officer, home care nurse

•How: Chart review, INR lab reports

•Where: Quality office

Who, How, and Where will data be collected and analyzed?

•Within 3 days and at one week after discharge; during the period 6 months before and after test implementation

When will data collection take place:

ObstaclesLess expensive than a

readmission for an adverse vascular event, which is usually

several days/few weeks long

Too expensive to hire a dedicated home care nurse

Done properly, handoffs can facilitate and reduce patient morbidity and

mortality during transition of care from hospital to home—much like the step-

down unit from ICU to floor.

Home care nurse is just one more handoff that increases the likelihood of a communication error occurring

Argument

Argument

Counter-

Argument

Counter-

Argument

The End—Thank You!

Tricia Pil

University of Pittsburgh

Pittsburgh, PA

Chris Hope

University of Mississippi

Jackson, MS

Danuta Lesnicki

Lewis University

Romeoville, IL