clin mngr iii

7/28/2019 Clin Mngr III

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Dr Bambang Suryono S


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HEALING IS AN ART,

MEDICINE IS A SCIENCE,

HEALTHCARE IS A BUSINESS.


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Interaksi antar profesi dan satuan

kerja

Hubungan antar profesi:

Konsultasi/rawat bersama/alih rawat

Tim

Prosedur penelitian

Prosedur pendidikan

Interaksi kelompok SMF & Instalasi Penegakan peraturan


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Care management An organized system or process for delivering

health care to a patient, including assessment,development of a Plan of Care, initiation and

coordination of referrals and services, andevaluation of care.

2008 Home Health Nursing : Scope and Standards ofPractice


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Case manager Case manager is a designation used to define a lead

person for the episode of care.

Shifting of case manager.

Case management is the responsibility of every memberof the team.

*Nurses * Therapists

*etc


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Type of ICU Closed and Open ICU

Type:

Type A, Type B and Type C


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Case management skills Responsible to the patient and to the team

*Clinical decision making *Education

*Advocacy

*Collaboration

*Care coordination

*Communication


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Case management skills Responsible to the patient and to the team

*Privacy

*Supervision

*Managing patient outcomes

*Regulatory compliance

*Managing the financial cost of care

*Documentation


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Essential CommunicationWith patient and family members

Public

Physician Other team members

Supervisor

Schedulers

Insurance companies

Community support services

Medical appointments


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Is Case Management Alive and Well?

Do your clinicians discuss the plan of care withteam during the first week of care?

Do clinicians tell each other when a patient hashad an issue?

* Medication change?

*Admission?

*Deceased? Is the discharge coordinated?


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Care planning Holistic in nature

Invite other disciplines

Decide on specific goals

*Include quality indicator deficits

(deficits in outcome items)

Coordinate visits cost effectively

Balance clinical solutions with visit numbers


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Focus on outcomes Care planning:

the opportunity to improve the outcomes for the

patient intentionally.


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Quality Assurance & PatientSafety


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Improvement Improvement is measured as scoring at a better

level than at the start of the episode.

It does not mean full recovery is always goal.


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QA It encompasses the principles of how an

organization should be run

Kaizen : continuous search for improvement inoneself and in the system


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The key to an organizations success is

to master the art of orchestrating

collective thinking.


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Potential for improvement Considerations:

Prior level of function

Homebound status

Patient goals

Need to expand view beyond being functional inthe home environment for those patients that

want to re-enter the community


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New style of management Removing the causes of problems in the system

improving quality of care

Problem identifications

to be solved The right man in the right place

People motivated to run the job


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People should be authorized and

encouraged to bypass managers and

solved problems themselves Supervisors and managers must be

specialists who will support

their people when problems arise.


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A structured problem-solving process

Resistance of implementationmust be resolved along the way


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.

Follow-up

Action


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Home Health Compare

Improvement in ambulation/ locomotion

Improvement in bathing

Improvement of oral medication Improvement in transferring

Improvement with pain interfering with activity

Any emergent care provided


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Home Health Compare

Acute care hospitalization

Improvement in dyspnea

Improvement in urinary incontinence

Discharge to the community Improvement in the status of surgical wounds

Emergent care wound infections/ deterioratingwound status


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Health Care Improvement in ICU

Early mobilization

Enteral FeedingVentilator- Free Days

Avoid Readmission

Avoid Autoextubation

Minimalization of Nosocomial Infection


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Health Care Improvement in ICU Quality of Life

Bacterial Resistance

Sedaso-analgesics


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Contoh QA Mortality

Complaints

Readmission rate LOS > 30 days

Fire and safety practice

Problem identification workshop Review nursing practices

Unexpected events


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Care Planning Transfers Establish criteria for therapy referrals

Assessment and intervention specific to the transfersin item

Establish a standard of care


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Collaborative Care PlanningWorking together as a team does not happen

automatically

Agency culture and structure need to facilitateinterdisciplinary thinking.

Reporting relationships

Staff meetings

Clinical structure Communication strategies

l l d


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. Consultants Surgical attending medical director nurse manager

Critical care attendings clinical nurse

specialist & acute care nurse practitioners

Critical care critical care nurses

fellows PATIENT & FAM

Critical care nutritionists

residents physical therapists

social workers pharmacists respiratory occupational

therapists therapists

PATIENT &

FAMILY


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Team meetingsWeekly? Bi-weekly? Monthly?

How long?

Who attends? Focus of the meeting?

Do they work?


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Team care planning Can it work?

Reducing readmission to ICU

-Determining risk factors -Visit patterns for those considered at risk

-Establish referral criteria for services


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It is not easy . Concerns : Time

Cost

Competing priorities The focus must be on strategic and intentional

care delivery.


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But it is worth it! The goal of care is to maintain or improve the

quality of life for patients and their families andother caregivers, or to support patients in theirtransition to the end of life.

This is accomplished through the initiation,coordination, management, and evaluation ofresources needed to promote the patients optimallevel well-being and function 2008. HHN


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Evidence-Based Medicine The conscientious, explicit, and judicious use of

current best evidence in making decisions about thecare of individual patients.

An approach to EBM:

Ask a clinically relevant question

Search for evidence Evaluate the evidence

Apply the evidence


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Clinically relevant questionsA patient or problem

An intervention or diagnostic test (if relevant)

A comparison group (if relevant)An outcome


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Search for the best evidence Medline indexes (www.Pubmed.gov)

The Cochrane Library (www.Cochrane.org)
http://www.pubmed.gov/http://www.cochrane.org/http://www.cochrane.org/http://www.pubmed.gov/


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Evaluate the evidence Is the evidence valid?

What are the results?


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Applying the evidence Diagnostic studies

Prognostic studies

Treatment or prevention studies Systemic reviews, overviews, and meta-analyses

Clinical decisions analyses

Economic analyses

Clinical practice guidelines


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Diagnostic


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Diagnostic


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Is the evidence valid?Was there an independent, blind comparison with a

gold standard?

Did the patient sample include an appropriatespectrum of patients?

Was the gold standard applied to all patients?


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What are the results?Are likelihood ratios presented?


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Will the results help me care for

my patients?Will the test results be reproducible and applicable to

patients in my clinical setting?

Will the test results change my management?


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Penilaian RekomendasiA. Didukung 2 penelitian level I

B. Didukung 1 penelitian level I

C. Didukung penelitian level II D. Didukung minimal 1 penelitian level III

E. Didukung penelitian level IV atau V


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Penilaian Bukti I. RCT luas + hasil jelas, risiko rendah pada alpha dan

atau beta error

II. RCT kecil + hasil tidak jelas

III. Non randomisasi, kontrol secara bersamaan IV.Non randomisasi, kontrol historis dan opini ahli

V.Serial kasus, penelitian tidak terkontrol dan opini ahli.


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EBM in ICUA. Severity-of-illness scoring systems use of

elements of : the history, physical examination, anddiagnostic tests to objectively gauge illness severity

and determine prognosis. Four main applications:

Clinical research

Performance assessment Resource allocation

Guidance in individual patient decisions


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Scoring systems in adult CCMAPACHE (acute physiology and chronic health

evaluation)

SAPS ( simplified acute physiology score)

MPM (mortality probability model)


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.APACHE (I,II and III) is based on the premise that

severity of illness on ICU admission is based on a

patients physiologic reserve (age and the presence ofcomorbidities) and the extent of any acute physiologicabnormalities (worst abnormalities within 24 hours ofadmission)

SAPS (I and II) was initially developed assimplification of the APACHE I classification system.SAPS II uses 17 variables and performs similarly to

APACHE II


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. MPM (I and II) is a statistical modeling system that

uses patient clinical variables to predict the probabilityof hospital mortality rather than to measure severityof illness.

TRISS (trauma and revised injury severity score) is aseverity-of-injury scoring system for trauma patients,but is not specific to ICU trauma admissions.


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. Multiple Organ Dysfunction Score is an organ

dysfunction score that is calculated based on apatients respiratory, renal, hepatic, cardiovascular,hematologic and neurologic function.

SOFA (sequential organ failure assessment) is anorgan dysfunction score that mainly differs from theMODS in that it includes therapeutic interventions inits assessment of a patients cardiovascular function.


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. B. Outcomes of special interest in the intensive care

unit. 1. Inhospital mortality

2. The 28-day mortality

3. Hospital length of stay

4. Ventilator free days


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Case 1 Pasien yang keluar dari ICU dalam bulan Juli ada 7%

mengalami readmissi ke ICU dalam 24 jam.

Problem identification?

Perbaikan?


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Case 2 Pasien tetanus yang dirawat di ICU dengan diazepam

kejang sulit diatasi. Kejang baru hilang dalam 12 hari.

Adakah cara yang lebih baik untuk mengatasi kejang?

EBM?

Implementasi?


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Case 3 Seorang pasien dengan AMI dan hemodinamik tidakstabil. Selain itu pasien menderita DM dan asthmabronchiale. Ada tanda AKI yang terlihat dari kenaikanureum dan creatinin.

Pasien dirawat di ICU dan di kelola oleh tim dokter.

Siapa duduk dalam tim? Siapa ketua tim? Apa rencanakerjanya?

clin mngr iii

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