9/1/2017 Si Sickle ckle Cell Nur Cell Nurse Navi e Navigati - - PDF document

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9/1/2017 Si Sickle ckle Cell Nur Cell Nurse Navi e Navigati - - PDF document

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9/1/2017 Si Sickle ckle Cell Nur Cell Nurse Navi e Navigati tion on: : An Innovative Approach So Crisis Doesn't Mean an Emergency Department Visit Kerri Stuart, RN,MSN Natalie Merilus, RN,BSN Debra Burgess, RN,BSN,MHA UC Davis

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9/1/2017 1

Si Sickle ckle Cell Nur Cell Nurse Navi e Navigati tion

  • n:

:

An Innovative Approach So Crisis Doesn't Mean an Emergency Department Visit

Kerri Stuart, RN,MSN │ Natalie Merilus, RN,BSN │ Debra Burgess, RN,BSN,MHA UC Davis Comprehensive Cancer Center/UC Davis Medical Center - Sacramento, California

2017 ANCC National Magnet Conference October 12, 2017  09:30 am  Session C530

Disclosures

  • The presenters for this presentation have disclosed no conflict of interest related

to this topic.

  • Objectiv

jectives es

  • Learn viable solutions to promote excellence in nursing to improve clinical
  • utcomes for a defined patient population.
  • Promote patient centered care and improve the patient experience through

implementation of a nurse navigation for individuals with sickle cell disease

  • T
  • gain a better understanding of how data can motive change and help

focus performance improvement projects

Crea eating ting a a he health althier ier wo world t d throu rough b bold i innova novatio tion

UC Davis Health System

UCDHS Mission

  • Improve lives and transform health care by

providing excellent patient care, conducting groundbreaking research, fostering innovative, inter-professional education, and creating dynamic, productive partnerships with the community.

  • UC Davis School of Medicine
  • Betty Irene Moore School of Nursing
  • Practice Management Group
  • UC Davis Medical Center

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9/1/2017 2

UC Davis Medical Center

  • Comprehensive 619-bed academic teaching hospital
  • Serves 33-counties, covering 65,000-square-mile radius
  • Reach is extended through the telemedicine program, which provides remote,

medically underserved communities throughout California access to specialty and subspecialty care.

  • Centers of Excellence
  • Comprehensive Cancer Center
  • Regional Burn Center
  • Level 1 Trauma Center
  • Vascular & Heart Center
  • Stroke Center
  • Children's Hospital
  • Mind Institute

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Am bulatory Care Division

  • 11 Prim

11 Primar ary y Care Netwo Network rk Sites ites

  • Offering care in 10 cities across the region
  • 26 Hospita

26 Hospital l Based Based Clinics: Clinics:

  • Comprehensive Cancer Center
  • Heart and Vascular Center
  • Health Management and Education
  • Spine Center
  • Women’s Center for Health
  • Transplant Center
  • Hom

Home Health Health & & Hospice, Hospice, ser serving 3 ing 3 counties counties

  • Pr

Provid ide e sp specialty ecialty car care in in 150 field 150 fields.

  • Over

er 1, 1,000 p 000 physici ysicians make up ke up UC UCD D me medic dical gr grou

  • up
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UC Davis Com prehensive Cancer Center

  • NCI designated Comprehensive Cancer Center
  • Medical & Surgical Oncology Clinic
  • Adult and Pediatric Infusion Rooms
  • Pediatric Hematology & Oncology Clinics
  • Radiation Oncology
  • Breast Health Center
  • QOPI certified
  • U.S. News National hospital for Cancer Care

Com prehensive Cancer Center Nursing

  • 53% of nursing staff have specialty certification (OCN, CPHON, BMTCN)
  • Cancer Center Clinics
  • Infusion Rooms
  • Radiation Oncology
  • Multidisciplinary Huddles:
  • Clinical Trials
  • Combined Modality Therapies
  • Unit-Based Practice Council

Professional Practice Model

  • Nursing Professional Practice Model foundation

for relationship based care

  • Va

Values

  • Deliver extraordinary compassion, courage,

integrity, in every situation!

  • Missio

Mission

  • Provide science-based, technologically

precise, compassionately delivered nursing care.

  • Vis

Vision

  • n
  • The highest quality of patient care provided

through the advancement of nursing practice.

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UCD Adult I nfusion Services- Main Cam pus

  • 24,260 patients treated in FY 2015-16
  • 49 chairs, 6 bedrooms
  • 3 Infusion Rooms (2 adult; 1 pediatric)
  • Oncology and Non-Oncology patients treated (70/30)
  • Offer Phase 1 and other traditional and pathwayt therapeutic clinical trials
  • Outpatient blood transfusions

Historical Triage Priority for I nfusion Treatm ents

  • 1. New chemotherapy start
  • 2. Emergent platelet transfusion
  • 3. Emergency IV hydration
  • 4. Scheduled ongoing chemotherapy
  • 5. Emergent blood transfusions
  • 6. Scheduled blood product transfusions
  • 7. Non-Oncology treatments

8.

  • 8. Sickle C

Sickle Cell ll Crisi isis

  • 9. Phlebotomies
  • 10. Endocrine tests

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Opportunity Knocks….

  • Improve patient experience
  • Deliver patient centered care & care experience
  • Improve staff satisfaction
  • Better utilization of hospital wide resources
  • Innovative care delivery for Sickle Cell patient population

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9/1/2017 5

QI Project: I nnovative I dea for Change

Could we transfer care from ED to the outpatient setting and improve the patient experience for SCD patients?

YES!

  • Ambulatory Care Model
  • Implemented an outpatient model at the adult infusion center to provide

an alternative, more therapeutic environment for SCD patients needing treatment for VOCs

  • Other services offered: central line care, chelation therapy, IV hydration

and manual exchange transfusions & blood product administration

  • Designated nurse navigator
  • Establish therapeutic relationships with high utilizers of ED/inpatient care
  • Focused on better management of uncomplicated VOCs
  • Hours of operation: Monday - Thursday 8am to 8pm

Friday 8am to 6pm

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Living w ith Sickle Cell

My Life with Sickle Cell Available on YouTube at: https://www.youtube.com/watch?v=CF2uthKdpTg

Sickle Cell Disease

  • Affects nearly 100,000 individuals of

African American, Hispanic, Middle Eastern, Asian and Indian descent in the United States

  • Inherited genetic disorder resulting from

the presence of mutated form of hemoglobin (hemoglobin S)

  • All genotypes contain at least one sickle

gene, where HbS makes up at least half the hemoglobin present.

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SCD: Several Genotypes

  • Major sickle genotypes include the following:
  • HbSS

HbSS disease or sickle cell anemia the mo most commo mmon n form

  • HbS/b-0 t

0 thalasse assemia mia – Double heterozygote for HbS and b-0 thalassemia; clin clinically indistinguis stinguishable f hable from s sickle c le cell a anemia ( (SCA) )

  • HbS/b+ t

thalasse assemia a - Mi Mild-to-mode

  • to-moderate s

rate seve verity rity with variability in diff differen ent ethni ethnicities es

  • HbSC

HbSC disease - Double heterozygote for HbS and HbC characterized by mo modera rate te clin clinical sev severi rity

  • HbS/hereditar

ditary p persiste istence o nce of fetal H l Hb (S/HPHP) - Very m mild or asy ild or asympt ptom

  • matic phenotype
  • HbS/Hb

HbS/HbE syndr drom

  • me - Ve

Very r rare with a phenotype usually similar to HbS/b+ thalassemia

  • Rare combinations of HbS with other abnormal hemoglobins such as HbD Los Angeles,

G-Philadelphia, HbO Arab, and others

Crea eating ting a a he health althier ier wo world t d throu rough b bold i innova novatio tion

SCD: Life Expectancy Over the Decades

  • Manifests as early as infancy
  • 1970s: Early mortality
  • median age of survival 14.3 years of age
  • 1990s: HbSS median life expectancy:
  • females 48
  • males 42
  • 1990s: HbSC median life expectancy:
  • females 68
  • males 60

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SCD: Disease w ith Com plex Health Care Delivery I ssues Barriers to Care

  • Similar issues to care faced by

patients with other chronic illness

  • Fragmented care delivery

system

  • Care is poor for this

population

  • Often lack PCP or

hematologist to manage care

Patient

Complexity

  • Pharmacotherapy
  • Compliance with treatment

regimen

  • Behavioral Issues
  • Coping with chronic illness
  • Stigma associated with
  • pioid use for pain control

Complications

  • Acute Chest Syndrome
  • Stroke
  • Pneumonia
  • Priapism
  • Cardiac problems
  • PE/DVT
  • Dehydration
  • Sickle Cell pain crisis

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Provision of Care for I ndividuals w ith SCD

  • Many children and adults with chronic diseases such as SCD do not receive the

recommended preventive care provided to other children and adults.

  • Frequently, patients with SCD don’t have a PCP
  • Often times their hematologist serves dual role to manage all care needs

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SCD Health I ssues Chronic nic C Complic licatio ations ns

  • CNS involvement
  • Cardiac problems
  • Pulmonary hypertension
  • Hemolytic anemia
  • Renal failure
  • Liver problems and cholelithiasis
  • Ocular conditions
  • Leg sores/ulcers
  • Bone & joint problems

Acute I ute Issue ssues & & Complicat cation

  • ns
  • The most common complication of SCD is an acute

episode of severe pain, referred to as an acute vaso-occlusive crisis (VOC).

  • Other common acute complications of SCD
  • acute chest syndrome, infections, acute anemia,

splenic sequestration, priapism, acute stroke

  • Signs or symptoms of these complications

require immediate evaluation and treatment to reduce or prevent morbidity and mortality.

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General Managem ent of SCD

  • Goals o

Goals of tr treatm eatment ent ar are e focused on focused on sym symptom contr m control l & & manageme nagement nt of com complic licat atio ions ns

  • Management of vaso-occlusive crisis

Primary management of VOC is hydration and analgesic treatment, typically intravenous opiates

  • Management of chronic pain syndromes
  • Management of chronic hemolytic anemia
  • Prevention and treatment of infections
  • Management of the complications and the various organ damage syndromes
  • Prevention of stroke
  • Detection and treatment of pulmonary hypertension

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Vaso-Occlusive Crisis ( VOC)

  • Defined as pain resulting from tissue ischemia, most commonly in the bone(s)

and bone marrow.

  • Caused by blockages in blood vessels lead to disrupted blood flow
  • Often occurs suddenly without warning
  • The crisis may last several hours to several days and terminate as abruptly as it

began

  • No biomarkers or imaging studies that can validate pain or assess its severity
  • Management of acute pain is central to the care of SCD

Crea eating ting a a he health althier ier wo world t d throu rough b bold i innova novatio tion

Factors Leading to VOC Exacerbation

  • Trig

iggers o

  • f VOCs can

can includ include e

  • Dehydration from acidosis causing a shift in oxygen dissociation curve
  • Changes in body temperature (fever or environmental temp changes)
  • Emotional Stress
  • Hypoxemia due to acute chest syndrome or respiratory problems
  • Alcohol intoxication
  • Pregnancy
  • Pain is o

in is often ten poorly poorly or

  • r inadequat

inadequately ly addr addressed essed in all types in all types of health car health care settings settings

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Typical Care Trajectory for SC Patient w ith VOC

  • Chronic Pain

Manage pain at home

  • Acute Pain

Crisis

Go to ED

  • Hydromorphone
  • Morphine

IV Opioids

  • I V Pain

Management

IP Admit

  • Manage on
  • ral therapy

Discharge

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NI H ED Recom m endations for Pain

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Started by Using PI Process

Regularly Monitor Performance Determine processes to be studied Identify relevant performance data Gather data from your organization & from best performers Analyze outcomes Implement changes for improved

  • utcomes
  • Evaluat

Evaluated d curr current state ent state for tr for treatm eatment t of V VOC C at UC at UCDM DMC

  • Collected UCD ED baseline data for SC

management focusing on VOC treatment

  • Reviewed performance
  • Ide

Identifi tified pr d proc

  • cess be

ss benchmark(s)

  • Established quality metrics
  • Clinical outcome measures
  • Im

Implemen emented new ted new model l of car care

  • Monito

nitored p performan

  • rmance m

e monthly nthly

  • Developed

Developed EMR EMR repor port to track SC patients to track SC patients to to contr control gain l gain Em ergency Departm ent Visits

  • VOCs most common reason for acute care and ED utilization
  • Found 8 patients made up >50% of ED utilization during 2015, 16 made up almost 75%

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Sickle Cell ED Visits at UCDMC

  • 2015 averag

2015 average e ED L ED LOS: 11: 11:45 45 ho hour urs

  • 83% visits VOCs (all patients)
  • 64% for adults 20-60 years
  • Averag

erage tim e time to e to IV IV opio ioid id in in ED: ED: 6: 6:10 ho 10 hour urs in s in 2015 2015

  • 3:45 wait time / 2:20 room time to medication
  • Decision

Decision to to adm admit usually m it usually made de af afte ter 3 r 3 doses o doses of opioid

  • pioid adm

adminis nistered ed

  • 73% o

73% of all patients all patients with sickle with sickle cell crisis cell crisis wer were adm admitt itted ed

  • Averag

erage IP e IP ALOS 5 5 days = ys = Total tal 515 515 days fo ys for r 2015 2015

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SCD I npatient Adm issions

  • Sim

Simila ilar r findings findings for IP for IP adm admissions

  • 16 patients were responsible for 75% IP admits

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Nursing Role in Sickle Cell Crisis/ Managem ent

  • Nur

Nurse Navigator e Navigator

  • Advocacy
  • Patient education
  • Staff education
  • Psychosocial support
  • Treatment delivery
  • Collaboration with care team
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Developm ent of Sickle Cell Pain Managem ent Pathw ay

Entered in EMR Snapshot

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PI Project Scope

  • Included adult patients age 20-60 years
  • Patients managed by UC Davis Hematology Oncology providers
  • Care provided at the UCD Comprehensive Cancer Center adult infusion
  • room. Subsequently extended to include UCD Rocklin Infusion Center
  • Pilot project initiated August 19, 2015 – February 2016

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Data Monitoring & Quality Metric

  • Outcome measur

Outcome measures

  • Administration of opiate within 1

hour of registration/30 minutes of triage

  • Adequate pain control resulting in

90% of patients discharged home

(able to pain control on oral therapy)

  • Reduction in ED visits and hospital

utilization

EVIDENCE-BASED MANAGEMENT OF SICKLE CELL DISEASE: EXPERT PANEL REPORT, 2014

  • Da

Data ta

  • Pain scores (pre/post therapy)
  • Time to first opioid administration
  • Number of opioid doses needed to

control pain

  • Duration of stay (time to pain control)
  • Discharge status from the Infusion

room

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Encounter Volum e by Location

During Pilot Jan 2015-Feb 2016

  • Adult Infusion Room
  • 32 patients/260 encounters
  • Emergency Department
  • 44 patients/186 visits
  • IP Admissions
  • 38 patients/133 admissions

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Encounter Tracking

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10 20 30 40 50

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31

Number of Encounters Patient ID

Sick Sickle C Cell P ll Pilo ilot P Pati tients

ED vs Ambulatory Visits

# of Visits Inf # ED Visits

Encounter Volum e by Location

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ED Volum e Before & During Pilot Project

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Sickle Cell Services Provided

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Project Results:

UC UCD ED: D ED: Jan F n Feb 2016 2016

  • Time to Opioid: 4:51
  • Arrival to room: 3:18
  • Room to narcotic: 1:38
  • 87% patients admitted with SC pain
  • Started using the SC pain management

pathway! Infusion Infusion Room: Room:

  • Time to IV Opioid: 50 minutes
  • 93% of patients discharged home
  • 4% transferred ED
  • 3% direct admit to Hem Onc service
  • DC home after average of 8 doses
  • Average time to control pain was

6.5 hours

  • Average time for other care

appointments 5 hours

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Meeting the Mark I npatient vs. Outpatient Cost

  • Preliminary cost of care comparisons

Source: UCDHS Decision Support

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UC Davis Health System

Sickle Cell Patients by Principal ICD9 or ICD10 Diagnosis Code* Discharge Dates 08/01/15 ‐ 02/29/16

Visit Type Location Cases Total Costs Average Cost/Visit Inpatient ED ‐ Inpatient Admit 101 $ 1,565,785 $ 15,503 Outpatient Infusion ADULT IV INFUSION CENTER 269 $ 497,320 $ 1,516

Additional Findings

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Patient Feedback

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Length of time between requesting and receiving Ease of access Overall Satisfaction

Pati tient Satis Satisfaction

Neutral Satisfied Very Satisfied 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Access improved

  • ver the past

8 months Good option to manage pain beside ED/ hospital Utilize ED/ hospital less frequently Admitted less frequently Able to discuss other health issues Nurses familiar with my needs

Patient A ent Access/U ss/Utiliz ilization ation

Neutral Agree Strongly Agree

Benefits to Model

  • Offer comprehensive care model
  • Greater consistency with pain management improving the quality
  • f pain control
  • Improved continuity of care
  • Improved patient satisfaction and nurse-patient relationship
  • More patients are discharged home
  • Helps reduce overcrowding in the ED
  • Lower average cost
  • Opportunity to open up more inpatient hospital beds

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Sickle Cell Project Team Contacts

Ke Kerri S Stuart, RN, MSN – Nurse Manager of Adult/Peds Infusion Room(s) Phone: 916. 471.8432 Email: kstuart@ucdavis.edu Natali talie M e Merilu ilus, RN, BSN – SCD Nurse Navigator Phone: 916.734.5859 Email: namerilus@ucdavis.edu Debb Debbie Bur Burgess, RN, BSN, MHA - Cancer Center Quality Manager Phone: 916.734.8674 Email: daburgess@ucdavis.edu

Additional Project Team Members

T ed Wun, MD – Chief, Division of Hematology & Oncology Melina Weir, RN, BSN – Hematology Oncology Clinic Christine T eklehaimanote, NP- Hematology & Oncology Alyssa Johnson, RN, BSN - UCDMC Emergency Department Walter Knowles, Director of Oncology Services UCD Cancer Center

Crea eating ting a a he health althier ier wo world t d throu rough b bold i innova novatio tion