innovations in process management/optimizing patient management leslie s. zun, md, mba, faaem...
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Innovations in Process Management/Optimizing
Patient Management
Leslie S. Zun, MD, MBA, FAAEM
Chairman & ProfessorDepartment of Emergency Medicine
Chicago Medical School and Mount Sinai Hospital Chicago, Illinois
Leslie Zun, MD, FAAEM
ObjectivesObjectives• Primary Objective: Enhance pain
treatment in the emergency department• Secondary Objectives:
• Systematic pain assessment and pain treatment
• Rapid determination of the appropriate dose for the complaint
• Proper documentation and QI review of the process
• Proper patient education
Leslie Zun, MD, FAAEM
Why Optimize Patient Why Optimize Patient Management?Management?
• Ensure that patients who need pain medications get them• Minority patients• Pediatric patients
• Reduce errors in administration of pain medications
• Prevent inadequate dosing• Improve proper medication selection• Increase pain dosing schedules• Reduce variability in patient care
Leslie Zun, MD, FAAEM
What can be undertaken to improve What can be undertaken to improve patient pain treatment?patient pain treatment?
• Charting systems• Treatment guidelines for complaint• Establish criteria for administration
of pain medications based on pain scales
• Matching complaint, medication and frequency and dose
• Input into a quality improvement process
Leslie Zun, MD, FAAEM
How to automate the process?How to automate the process?
• Need for sophisticated electronic medical record • Artificial Intelligence
• Interface with physician order entry
• Pop up after certain time intervals
• Interface with pharmacy
Innovations in Process Management/Optimizing Patient Management Electronic Medical Record with Artificail Intelligence
Triage
Evaluation andTreatment
Disposition
Discharge Admit
Triage screen forpain assessment
and treatment
Order screen formedication and
dose
Disposition screenfor on-going pain
medication
Automationpoint #1
Automationpoint #2
Automationpoint #3
QI audits fortriage, treatmentand disposition
Pop-ups
Floor ordersscreen include
pain assessmentand medication
Outpatient charts withpain assessment and
medications
QI audits forinpatient care
QI audits foroutpatient care
Innovations in Process Management/Optimizing Patient Management Electronic Medical Record with Artificail Intelligence
Yes
QI audits
Pain
Scale
Doesthe
patienthavepain?
What isthe
patient'slevel ofpain?
What is thepatient's
complaint?
DataElements
ProcessTriage, Evaluate
and Treat,Discharge
Does thecomplaintmatch the
medication?
Dete
rm
ine
proper
dosage
Is the dose andadministrationappropriate?
Audit forpain
assessment
Audit forpain level
Audit for doseand
administration
Audit forconsistancy
Pain assessment
Pain medication
Pain dosing andadministration
Points for patienteducation
Compaint needspain assessment
Is the pain beingre-assessedperiodically?
Audit forpain re-
assessment
What is the patient's level of pain?Did you order pain medication for the
patient's condition?
Innovations in Process Management/Optimizing Patient Management Electronic Medical Record with Artificail Intelligence
Leslie Zun, MD, FAAEM
What is needed?What is needed?• Standardize pain assessment
• Numerical rating scale measures pain from 0–10 or 0–100 with endpoints of “no pain” and “worst pain ever”
• Agree on treatment guidelines
• Concurrent patient education
Leslie Zun, MD, FAAEM
What is needed?What is needed?Treatment GuidelinesTreatment Guidelines
• Guidelines for common pain conditions such as sickle cell, trauma, fractures, chest pain• Include complaint, pain medication, dose,
frequency and route
• Guidelines begin in triage and follow patient through the ED visit• Standing orders for nurses to give the pain
medication beginning in triage• OTC meds or narcotic agents
Leslie Zun, MD, FAAEM
What is needed? What is needed? Patient Education Patient Education
• Use computerized discharge instructions
• Let the patient control or modulate his\her own pain
• Prescribed standardized dosing
• Add adjuncts to the treatment plan
• Establish a set of follow-up times depending on the discharge diagnosis
Leslie Zun, MD, FAAEM
Establish criteria to start pain Establish criteria to start pain meds early in patient caremeds early in patient care
• Use pain assessments frequently to determine patient’s pain level
• Agreement to treat patients prior to the arrival of consultants or test results
• Need buy-in from the surgical services
• Dispel the myths concerning early pain treatment
Leslie Zun, MD, FAAEM
Dispel MythsDispel Myths
• Administration of analgesic in acute abdomen does not change physical exam.
• LoVeechio, F, Oster, N, Sturman, K, et al: the use of analgesics in patients with acute abdominal pain. J Emerge Med 1997; 15: 775-779.
• 53% of the surveyed surgeons stated pain meds precluded a patient from signing a valid informed consent.
• Graber, MA, Ely, JW, Clarke, S, Kurtz, AS, Weir, R: Informed consent and general surgeons’ attitudes toward the use of pain medication in acute abdomen. Am J Emerge Med 1999;17:113-116.
• Problems with this view_ Pain treatment does not necessarily cloud sensorium.
_ Withholding pain medication could be considered coercion.
_ Pain may in itself cloud a patient’s judgment.
Quality Improvement ProcessQuality Improvement ProcessQI audits
Doesthe
patienthavepain?
What isthe
patient'slevel ofpain?
DataElements
Does thecomplaintmatch the
medication?
Is the dose andadministrationappropriate?
Audit for painassessment
Audit forpain level
Audit for doseand
administration
Audit forconsistancy
Is the pain beingre-assessedperiodically?
Audit forpain re-
assessment
Leslie Zun, MD, FAAEM
Quality Improvement ProcessQuality Improvement Process• Set monitor criteria• Pain is assessed in triage• Pain treatment initiated in triage• Pain treatment must be continued
periodically in the treatment area• If no treatment, reason for non-compliance
with established protocol needs to be documented.
• Discharge instructions and medications must also be documented
Leslie Zun, MD, FAAEM
What does it take to make it work?What does it take to make it work?
• Computer systems with artificial intelligence
• Dedication to good patient care • Commitment to excellent customer
service• Involve all stakeholders in the
improvement process• Determine what can be automated• Implement systems that are user friendly
Questions?Questions?