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RESEARCH POSTER PRESENTATION DESIGN © 2012
www.PosterPresentations.com
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CAP Perfect Care Score
Materials for project analysis include:
CMS Guidelines & Core Measures Criteria (63 page document)
•PN 3a = Blood cultures within 24 hours of arrival
•PN 3b = Blood cultures before first antibiotic
•PN 6 = Antibiotic selection (all areas combined)
•PN 6a = Antibiotic selection for patients admitted to critical care
•PN 6b = Antibiotic selection for patients not admitted to critical care
CPOE order set for pneumonia & pharmacy support teams
Pneumonia ABX Cheat-Sheet Non-ICU patient options: (Must order a PAIR to meet core measure) ICU Patient options: (ICU Always requires a PAIR to meet core measure)
Electronic Physician Order Entry Order Set in Cerner Exact verbiage on order entry screens follows. Unique Plan Description: Pneumonia Med/Surg Plan Selection Display: Pneumonia Med/Surg Plan Type: Medical. Version: 2 Begin Effective Date: 05/15/13 End Effective Date: Current Available at all facilities Relevant Diagnosis/Problem: PNEUMONIA DUE TO OTHER SPECIFIED BACTERIA,PNEUMONIA DUE TO PARAINFLUENZA VIRUS,PNEUMONIA DUE TO STAPHYLOCOCCUS, UNSPECIFIED,PNEUMONIA IN INFECTIOUS DISEASES CLASSIFIED ELSEWHERE,PNEUMONIA, ORGANISM UNSPECIFIED Pneumonia Med/Surg General Admission Non-ICU Patients WITH NO Pseudomonal Risk:(NOTE) The appropriate options include (choose one): 1) Ceftriaxone PLUS azithromycin, OR 2) Levofloxacin, OR 3) Ceftriaxone PLUS Doxycycline(NOTE) Comments: Consider for patient at risk for more severe infection and/or resistant organisms ( ICU status, age> 65 years, or disseminated infection). Comments: Pharmacist to adjust regimen per patient's renal function AND enter a consult for "Pharmacy to dose" in powerchart. ICU Patients WITH NO Pseudomonal Risk:(NOTE) The appropriate options include (choose one): 1) Ceftriaxone PLUS Azithromycin, OR 2) Ceftriaxone PLUS Levoflaoxcin, OR 3) If SEVERELY allergic to beta-lactam then Levofloxacin PLUS aztreonam,4) If MRSA is a consideration, consider adding either Vancomycin OR Linezolid. ICU and NON-ICU Patients WITH Pseudomonal Risk:(NOTE) The appropriate options include (choose one):1) Piperacillin/Tazobactam PLUS Tobramycin PLUS Azithromycin, OR 2) Cefepime PLUS Tobramycin PLUS Azithromycin, OR 3) If SEVERELY allergic to beta- lactams, use Aztreonam PLUS Tobramycin PLUS Levofloxacin. Patients with or at risk for MRSA: Consider use of one of the following: 1) Vancomycin, or 2) Linezolid
ONE OF THESE + Rocephin Unasyn Claforan Invanz Teflaro
ONE OF THESE Zithromax Doxycycline Erythromycin Biaxin
OK alone: Levofloxacin Tigecycline
ONE OF THESE + Rocephin (Ceftriaxone) Unasyn (Ampicillin/Sulbactam) Claforan (Cefotaxime) Zosyn (Piperacillin/Tazobactam) Doripenem
ONE OF THESE Zithromax Levofloxacin Erythromycin Avelox Cipro
Physicians may add: Tobramycin, Vancomycin, Linezolid, or any clinically
appropriate medication to complete care.
Nash Health Care Systems struggle to identify creative ways for overcoming
challenges of The Joint Commission’s (TJC) Core Measures and mastering
requirements of The Centers for Medicare and Medicaid (CMS) as these regulatory
systems determine gold standard criteria. Like many hospitals and organizations
across the country, Nash’s teams find that opportunities for improvement increase in
parallel with increased data extraction.
The organization implemented an electronic medical record (EMR) and data
extraction from the computerized system revealed that performance of physicians and
nurses in the care of Community Acquired Pneumonia (CAP) rested far below the
organization’s target. Transparent and accurate data collection delivered indisputable
proof that current processes and approaches were profoundly ineffective. This
prompted a different and creative approach.
The first step required collecting accurate data. Paper records limited the ability to
monitor 100% of patient visits. Using an EMR allows tracking data and capturing
information on every patient diagnosed with pneumonia. Almost every patient
admitted with this diagnosis passed through the emergency department. This singular
point of contact provided an excellent target area to focus efforts.
Step two involved learning the rules and regulations of core measure compliance. A
paired effort between two nurses ensued, followed by expanded efforts involving a
multidisciplinary team of nurses, physicians, and pharmacists. The team compared
CMS requirements with the organization’s computerized physician order entry
(CPOE) for patients with pneumonia. Although an elaborate order set prompted
compliance with CMS guidelines, few physicians elected to use this electronic
protocol when admitting pneumonia patients.
Why? The order set and the CMS guidelines for medication selection offer a
dizzying and complex assortment of options. Nurses remained on the periphery of
care, followed orders, and offered little or no input regarding physician-guided care
plans.
Step three required simplifying choices. Each time the physician champion was
approached with a new suggestion, his response was the same – “Dumb it down.”
This Eggs and Toast approach was the final precipitate from a long distillation
process. The Eggs and Toast tool supplements the CPOE order set by providing a
visual tool to prompt correct antibiotic selection. Nurses can validate appropriate
therapies for their patients, providing an additional tier to reinforce core measure
compliance.
(For brevity and clarity, all references to pneumonia in this project imply community acquired pneumonia.)
INTRODUCTION TO EGGS & TOAST
OBJECTIVES
MATERIALS RESULTS
CONCLUSIONS
Great care does not require complex systems or fancy vocabulary.
A combination of chart review, ongoing education, and development of
functional tools contributed to the success of this project.
Ongoing efforts target the appropriate treatment for patients with
medication allergies, pseudomonal risk, or admission in critical care areas.
Changing practice patterns requires the support of organizational leaders,
particularly when seeking compliance from professionals and multiple
skill levels. This team learned that creative teaching tools can create a
lasting impression. This project supplemented ongoing efforts including
computerized physician order entry, protocol implementation by triage
nurses, and ongoing educational efforts.
REFERENCES
•CMS Compliance: Tracking Performance with Core Measures. (2009). H&HN: Hospitals & Health
Networks, 83(11), 36. Retrieved from EBSCOhost database.
•Friedberg, M., Mehrotra, A., & Linder, J. (2009). Reporting hospitals' antibiotic timing in pneumonia:
Adverse consequences for patients? American Journal of Managed Care, 15(2), 137-144. Retrieved
from EBSCOhost database.
•Giovanni, F., David, N., Jeph, H., Janine, E., Percy, G., Mari, T., & David J., B. (2009). A hospital-
randomized controlled trial of a formal quality improvement educational program in rural and small
community Texas hospitals: One year results. International Journal for Quality in Health Care, 21(4),
225. Retrieved from EBSCOhost database.
•Lindsay, M., & DeMarco, F. (2008). Use of technology in improving pneumonia core measures.
Critical Care Nurse, 28(2), e18-e19. Retrieved from EBSCOhost database.
•Neuman, M., Ting, S., Meydani, A., Mansbach, J., & Camargo, C. (2012). National study of antibiotic
use in emergency department visits for pneumonia, 1993 through 2008. Academic Emergency Medicine:
Official Journal of The Society for Academic Emergency Medicine, 19(5), 562-568. doi:10.1111/j.1553-
2712.2012.01342.x
•Ostrowsky, B., Sharma, S., DeFino, M., Guo, Y., Shah, P., McAllen, S., & Bhalla, R. (2013).
Antimicrobial stewardship and automated pharmacy technology improve antibiotic appropriateness for
community-acquired pneumonia. Infection Control & Hospital Epidemiology, 34(6), 566-572.
doi:10.1086/670623
Acknowledgements Special thanks to: Kathy Barnhill, RN – data extraction, concurrent performance review. Gail
Gregory, RN – chart review, member of Process Improvement Team. Dr. Daniel Minior –
Physician champion during development of this tool. Luke Heuts, PharmD. – Hospital
pharmacist and tireless supporter of the CAP team. Ryan Griffin, RN – Nurse manager of
Critical Care at NHCS. And all other members of the CAP PI Team who offered support,
encouragement, feedback, and input during this creative process.
In our ongoing process, the team continues to monitor medication
selection, team performance, and patient outcomes. This system continues
to work for Nash Health Care Systems and support optimal patient care.
Our strategies have turned toward the few remaining outliers that keep us
from our ultimate goal – perfect care for every patient, every time.
■ Monitor concurrent performance
■ Identify antibiotic selection discrepancies early
■ Suggest changes within 24 hours of arrival
■ Provide real-time feedback
■ Promote education
■ Deliver perfect care, for every patient, every time
Nash Health Care Systems: Nash General Hospital, Rocky Mount, NC Author: Caroline Cusick Vierheller, MSN, MHA-I, BA, RN, CEN, COHN-S
An EGGS and TOAST approach to Pneumonia
Contact Information
Caroline Cusick Vierheller, MSN, MHA-I, RN, CEN, COHN-S
Operations Improvement Process Coordinator
Chair for Pneumonia Process Improvement Team
2460 Curtis Ellis Drive, Rocky Mount, NC 27804
252-962-6484 E-mail: [email protected]
METHODS
•Daily review of EMTALA Log. Progressed to weekly reviews.
•Introduced “Eggs and Toast” cheat-sheet at MD work stations.
•Converted data to spreadsheet.
•Identify exclusions and integrate exclusion criteria.
•100% chart review.
•Provide electronic and paper feedback to physicians, nurses, & managers.
•All paper communication includes copy of “Eggs and Toast” tool.
•Include positive feedback.
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Compliance with Antibiotic Selection
PN-6 Initial antibiotic selection (all) PN-6a Initial antibiotic selection (ICU-patient)
PN-6b Initial antibiotic selection (non-ICU patient)
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100% Charts reviewed by diagnosis
Admitted Discharged
Results for core measure compliance rest on the combined efforts of the
entire team. Focus shifts from pieces of care delivery to direct attention on
patient outcomes. When all elements of care are delivered according to
CMS guidelines, the case is considered to be an example of Perfect Care.
Team introduced 100% chart reviews and the Eggs and Toast
approach in Sept. 2012.
From complicated… to cured.
