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Nurses Blending Caring Practice with Teaching to Improve Medication Communication 2018 NICHE Conference Date: Thursday, April 12, 2018 Session: 1Time: 1:30-2:45 Track: Health, Wellness and Transitions

Intermediate Cardiac Care UnitCindy Rivet MS, RN, CNL, CVN, NE-BCClinical Manager of CCU/PCU

Disclosures

• The speakers have no relevant financial or non-

financial relationships to disclose

The Miriam Hospital • The Miriam Hospital is a 247 bed, private, not-for-profit,

community, teaching hospital, affiliated with Brown University,

located in Providence, RI

• Founding partner of Lifespan, a comprehensive health care

system

• Has more than 2300 employees

• 870 physicians

• 50 full-time house staff (medical school graduates)

• 700 registered nurses

• Five time recipient of the Magnet Award for Excellence in Nursing

• NICHE member since 2008

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Care Environment The Coronary Care Unit

• 9 bed medical teaching high level intermediate care unit, specializing in the complex needs of cardiovascular patients

Staff

• Clinical Manager

• Clinical Nurse Leader

Master’s Student

for duration of pilot project

• Advanced Practice Manager

• 19 RNs

• 4 Licensed Independent Practitioners

• 6 CNAs

• 4 Secretaries

Quality Improvement/Quality Assurance Data Analysis • CCU HCAHPS scores –Medication Communication &

Quietness of Environment were lowest scores

• Decided to focus on Medication Communication

• Multiple types of medications are prescribed during and after hospitalization

• Cardiac medications are high on the list of those that can cause serious harm

• Patients with cardiovascular disease are at a higher risk for errors and adverse drug events after discharge

Hospital Priorities

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Professional Practice Model

Method/Measure of Success

• Consistently provide medication information to patients in a way that is understandable during their hospital stay

Promote safe medication- taking behaviors after discharge

Earlier recognition of adverse drug events

Improve medication adherence after discharge

Reduced patient re-admissions

Show improvement in HCAHPS scores

Literature

• “Patient reported measures are strongly correlate with better patient outcomes and largely represent nurse and physician communication-based care”

(Bartlett Ellis, Bakoyannis, Haase, Boyer & Carpenter, 2016, p. 1149)

• “Higher hospital-level patient satisfaction is associated with lower 30-day risk-standardized readmission rates”

(Boulding, Glickman, Manary, Schulman & Stalin, 2011, p. 46)

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Baseline Data • 3rd Quarter : April-June 2016

• Top-Box “Always” Percentile Rank by Received Date

• Overall Communication about Medications 26th percentile

o Staff describe medicine side effects = 12th percentile

o Staff tell you what new medication is for = 55th percentile

o Patient understood purpose of medication = 66th percentile

• Goal: 50th percentile in the Overall Medication Communication Domain during pilot project

Med-COMM Project

• CCU’s project was designed to increase patient satisfaction with medication communication

• 5 Components:1. Tailored medication education sheets for CCU patient population

2. Signage in patient rooms

3. Nursing specific intervention

4. Collaboration between RNs, MDs & LIPs, Pharmacy

5. Daily Leadership rounds

• “Tell me and I forget. Teach me and I remember. Involve me and I learn”

~Benjamin Franklin~

Project Approval/Resources

• Approval by:

Pharmacy

Nursing Executive Committee

Patient Experience Committee

CCU Quality Improvement/Assurance Committee

• Utilized:

Lifespan Print Shop

Lifespan Interpreter Services

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Tailored Medication Sheets

• Collaborated with Pharmacy-Omnicell utilization list

• Tailored to CCU patient population/highly administered medications

• Sorted by Drug Class1. Medication name

2. Purpose

3. How often to take medication

4. Side effects

• Patient centered language and graphics

• Handout to patients on admission to CCUo Promotes on-going discussion about medications and patient

involvement in Plan of Care

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Patient Rooms

• Addition of signage above white-board:

As part of our goal to provide you with excellent care and prepare you for a safe discharge, we want to ensure you know your medications

and their possible side effects.

Always Ask if you have questions or concerns.

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Nurse’s Role

1. Med-COMM Intervention**

• Establish dedicated uninterrupted time spent with patient/caregiver to discuss medications and answer questions for at least 5 minutes every shift

• Talk about medication, its purpose and at least 1 side effect

• Document in care plan under Discharge Planning “Med-COMM intervention performed” and include any pertinent information

**Intervention is in compliance with Lifespan RN Standard Care Protocol for Patient Education

Nurse’s Role-Teach-Back

• Discharge process

• Ask clarifying questions to validate the patient’s understanding of health information

• “Patients who clearly understand their post-discharge plan-including how to take their medications-are 30% less likely to be readmitted or visit the emergency department than patients who lack this information.” Peter et al, 2015, p.36

Staff Reminders

• Reminder cards placed on each computer workstation

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Collaboration• Collaborate with MDs & LIPs during patient care rounds for

medication dosing revisions or additions

• CCU does not have a dedicated Pharmacist- shared with Specialty Care Unit & Medical Intensive Care Unit

• Nursing places a Pharmacy consult if education, more in-depth than nursing can provide, is necessary

CCU/Pharmacy Collaboration• Early identification by RNs of patients who may benefits

from PharmD consult: • Complicated cases• Non-compliance/Cost Issues• History of frequent readmissions• Starting new therapy• Hours available: M-F 730a-3p

Leadership Role

• Implement daily rounds to assess compliance

• New admissions to CCU

1. Do you have any medication questions?

2. Did your nurse teach you about your medications?

• Provide feedback to staff

• Monitor effectiveness of project through Press-Ganey HCAHPs data

RN Compliance

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Results- Project Implemented Oct 1, 2016

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20

30

40

50

60

70

80

90

100

Domain:Med Comm

Side Effects UnderstandPurpose

NewMedications

Baseline:April-June 2016

October-December 2016

Follow-Up: April-June2017

October-December 2017

HCAHPS Top-BoxPercentile Rank

by Received Date

Overall Domain Goal: Raised to 75th percentile

after pilot project

Overall Hospital Readmissions

Implications

• Chair of Patient Experience Med Comm sub-committee-report out twice a year, monthly to Management Team

• Expanded use of cardiac teaching sheets throughout facility

• Translation of cardiac sheets into Spanish & Portuguese

• Development of Respiratory medication teaching sheets

• Respiratory sheets currently being translated into Spanish & Portuguese

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Challenges/Limitations

• Overflow of medical patients into CCU

• Short length of stay

• Original pilot project only in English

• Increase in hospital acuity/census and change in patient demographic r/t closure of another local hospital which has impacted all Patient Experience Domains- Pharmacy focus on patients getting prescriptions filled

• Nurses struggle with educating patients on side effects and many patients get fixated on this information---potential for less adherence if scared of side effects

• Many hospital practitioners tell patients to call their PCP if they have questions about meds

Next Steps

• Revising current cardiac sheets for Stroke/TIA patients

• Revising current Chemotherapy teaching sheets

• Analyzing overall hospital Omnicell medication utilization to develop tailored medication sheets for other drug classes/patient populations & service lines

• Modifying sheets for inclusion in Epic to be used at all Lifespan affiliates

Summary

• A patient-centered approach to redesigning patient educational materials by reinforcing key concepts enhanced medication communication for our cardiovascular patients.

• This simple intervention which enhanced nurse-patient communication about medications will positively impact medication adherence and patient outcomes.

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ReferencesBartlett Ellis, R., Bakoyannis, G., Haase, J., Boyer, K., & Carpenter, J. (2016). Patient perceptions of provider and hospital factors associated with new medication communication. Western Journal of Nursing Research, 38(9), 1139-1154.

Boulding, W., Glickman, S., Manary, M., Schulman, K., & Staelin, R. (2011). Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. The American Journal of Managed Care, 17(1), 41-48.

Duffy, J., Baldwin, J., Mastorovich, MJ. (2007). Using the Quality-Caring Model to organize patient care delivery. JONA, 37(12), 546-551.

Nelson, E.C., Batalden, P.B., & Godfrey, M.M. (2007). Quality by design: A clinical microsystems approach. San Francisco, CA: Jossey-Bass.

Peter, D., Robinson, P., Jordan, M., Lawrence, S., Casey, K., & Salas-Lopez, D. (2015). Reducing readmissions using teach-back: Enhancing patient and family education. JONA, 45(1), 35-42.

Special Thanks

• Nicole Hebert, MSN, RN, CNL,CEN

• Clinical Nurse Leader Master’s Student at the time of Pilot Project Implementation-Capstone project

Questions/Contact Information

• Cindy Rivet MS, RN, CNL, CVN, NE-BC

• Clinical Manager- Coronary Care Unit/Procedural Care Unit

• Crivet@lifespan.org

• 401-793-3673

• 164 Summit Avenue

Providence, RI 02906