Reducing Readmissions

Cheryl Ruble, MS, RN, CNSMontana Regional Meetings

Glendive Medical CenterGlendive, MT

Your Improvement Opportunity

• Do you know what your readmission rates are? Overall? For specific clinical conditions?

• Compared to other hospitals in your area, state, national? Should you compare to others or just yourself?

• What’s possible?

Aim Statement

• Reduce overall readmissions by 20% from the 2010 baseline by December 31, 2012

• By end of 2013, reduce readmissions for heart failure by 30%.

Outcome Measure

All cause readmissions within 30 days

Process Measure

All cause readmission can include:

• DC phone calls• Risk Assessment completed• Med-Rec completed on DC• Percent of patients with

complete, customized after care plan

• Percent patients with completed DC education

Outcome Measure

Heart failure patients – readmission within 30 days, all cause

Readmission Reduction Drivers

Reduce readmissions by 20% by 12/31/2013

Identify high risk patients

Risk assessment & stratification

Enhanced admission assessment

Multi-disciplinary care team to coordinate care

Self-management skills

Patient/Caregiver knowledge of medications, symptoms, self-care strategies

Identify and address patients’ health literacy and activation levels

Use of teach-back to validate understanding

Coordination of information along the

care continuum

Create a patient-centered record

Timely communication with members of the care team who are not hospital based

Medication reconciliation at admission, change in level of care, and at discharge

Adequate follow-up and community resources

Coordination with physician/other care provider to facilitate resources and follow-up needs

Post-discharge calls and visits

Integrate organizations and Consider medical home capabilities. Coordinate with skilled nursing facilities.

Determine community resources for vulnerable populations

AIM Primary Driver Secondary Driver

Driver: Identify high risk patients

Risk Stratify: Identify High Risk Patients and Communicate to all Providers

High Risk Patients

• Patient has been admitted two or more times in the past year

• Patient is unable to teach-back, or the patient or family caregiver has low degree of confidence to carry out self-care at home

Nielsen GA, Rutherford P, Taylor J. How-to Guide: Creating an Ideal Transition Home. Cambridge, MA: Institute for Healthcare Improvement; 2009. Available at http://www.ihi.org.

Risk Assessment

• Use a validated readmission risk assessment tool

• Select an easy to implement risk assessment

Assessing Patient Risk

Project Red Risk Factors• Depressive symptoms • Limited health literacy • Frequent hospital admissions • Unstable housing • Substance abuse

http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/PDFs/TARGET.pdf

Risk Stratification

• Low risk – normal process

• Moderate risk – enhanced hospital process

• High risk – enhanced hospital process + community intervention

Assessing Patient Risk

Project BOOST 8P Screening Tool– Problem medications– Psychological– Principal diagnosis– Polypharmacy– Poor health literacy– Patient support– Prior hospitalization– Palliative care

http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/PDFs/TARGET_screen_v22.pdf

Driver: Self-Management Skills

Patient self management as goal

Primary Driver: Self Management Skills

• Assess patient / caregiver knowledge: of medications, symptoms, self-care strategies

• Health literacy: Identify and address patient’s health literacy and activation level; use culturally appropriate training materials and clear written instructions using health literacy concepts

• Teach-back: Use teach-back to validate understanding; use patient-centered, culturally sensitive educational tools

Medication Reconciliation

•Medication reconciliation– Perform at a minimum on admission & discharge– List given to patient/care giver clearly identifies– For high risk patients, work with home health or other ambulatory providers

Medication EducationProject RED – After Hospital Care Plan Example

http://www.ahrq.gov/about/annualconf09/jack.htm

Assess Health Literacy

Health literacy measurement tool, available in English and Spanish, from AHRQ

Red Flags for Low Literacy in Patients

• Frequently missed appointments• Incomplete registration forms• Non-compliance with meds• Unable to name meds, explain

purpose or dosing• Identifies pills by looking at

them, not reading label• Unable to give coherent,

sequential history• Ask few questions• Lack of follow through on tests

or referrals

Strategies to Improve Patient Understanding

• Focus on “need to know” & “need to do”

• Use ‘Teach Back’• Demonstrate/draw

pictures• Use clearly written

education materials– 5th grade level or below

8 Tips for Clinicians

1. Use plain language2. Limit info (2 – 4 points)3. Be specific & concrete, not

general4. Demonstrate, draw

pictures, use models5. Repeat, summarize6. Avoid Yes/No questions

• Open ended questions

7. Teach Back8. Be positive

Teach Back is….

• Asking patients to repeat in their own words what they need to know or do, in a non-shaming way.

• Not a test of the patient, but of how well YOU explained a concept.

• A chance to check for understanding and, if necessary, re-teach.

Teach Back Is…

• Ensuring agreement & understanding– Critical to achieving

adherence• Associated with

improved patient engagement in their own care

“I want to make sure I explained it correctly. Can you tell me in your own words how you understand the plan?”

Teach Back Examples

• “I want to be sure I explained everything clearly. Can you please explain it back to me so I can be sure I did?”

• “What will you tell your husband about the changes we made to your blood pressure medicine?”

• “We’ve gone over a lot of information about getting more exercise in your day. In your own words tell me some of the ways you can get more exercise. How will you make it work at home?”

Teach Back Examples

• “Can you tell me how you take each medicine?”

• “When do you take these medicines?”

• “Home much or how many do you take?”

“Show me how many pills you would take in 1 day.”

Teach-back

• Teach-Back guide from Medicare Quality Improvement Organizations National Coordinating Center for the Integrating Care for Populations and Communities Aim (ICPCA)

• Train clinical staff, use “I” statements

ASTHMA ZONESKnow your zone: Green, Yellow, or Red

Green Zone: All Clear No cough, wheeze, or shortness of breath Sleeping through the night Can do usual activities Don’t need quick-relief (rescue) medicine most

daysor Peak Flow:______________ as instructed

Green Zone Means Your symptoms are under control Continue taking your medications as ordered Continue activity as tolerated Keep all doctor appointments

Yellow Zone: Caution Cough, wheeze, or shortness of breath, chest

tightness Waking at night due to asthma symptoms Can do some but no all usual activities Using more quick-relief (rescue) medicine more

frequently No improvement in your symptoms after

medications were startedor Peak Flow:______________

Yellow Zone Means: Warning Your symptoms may mean that you need a

change in your medications Call your doctor_____________________ number_____________________ Call your Home Care Nurse 24 hour

number___________________________Tell your home care nurse if you call or see your doctor

Red Zone: Medical Alert Very short of breath, ribs show Quick-relief (rescue) medicine has not helped• If you have trouble walking or talking• Your lips or fingernails are blue• You are feeling faintor Peak Flow:______________

Red Zone Means: Emergency This indicates that you need to be seen by a

doctor right away- NOW!

Call 911 or go to the nearest emergency room

COPD ZONESKnow your zone: Green, Yellow, or Red

Green Zone: All Clear Able to do usual activities No new symptoms No chest pain Your usual medications are controlling your symptoms

Green Zone Means Your symptoms are under control Continue taking your mediations as ordered Continue activity as tolerated Use pursed lip breathing as instructed Keep all doctor appointments

Yellow Zone: Caution If you have any of the following signs and symptoms: Increased cough and/or discolored sputum production Increased in shortness of breath with usual activity level Increase in the amount of quick relief medications used Change in usual energy level: increase in either fatigue

or restlessness

Yellow Zone Means: Warning Your symptoms may indicate that you need an adjustment of

your medications Call your doctor_____________________ number_____________________• You should consult or see your doctor within 24-48 hours Call your Home Care Nurse 24 hour

number___________________________Tell your home care nurse if you call or see your doctor

RED ZONE: MEDICAL ALERT Severe or unusual shortness of breath: shortness of

breath at rest Unrelieved chest pain Wheezing or chest tightness at rest Need to sit in chair to sleep if you don’t normally New or increased confusion

RED ZONE Means: Emergency This indicates that you need to be evaluated by a

doctor right away – NOW!

Go to the nearest emergency room or call 911

DIABETES ZONESKnow Your Zones – Green, Yellow, or Red

Green Zone: All ClearAverage blood sugars are typically between 80 and 150.Most fasting blood sugars are between 80 and 120.No decrease in your ability to maintain normal activity levelNo ketones in your urine ( if Type 1)

Green Zone MeansYour symptoms are under controlContinue taking your medications as prescribedContinue to follow your dietKeep you doctor appointmentsContinue to have your A1c measured every 3 to 6 months and monitor your blood sugars

Yellow Zone: CautionAverage blood sugars are between 150 and 250.Most fasting blood sugars are over 150.Two or more blood sugar readings less than 70 in the past week Two or more blood sugar readings above 200 in the past weekTrace to small amounts of ketones in your urine ( if Type 1)Difficulty maintaining normal activity levelNausea, not able to keep food down or eat normally

Yellow Zone Means: CautionYour symptoms mean that you may need an adjustment in your medicationsCall your doctor ____________________ Number:_____________________ Home health 24 hour number:______________Please tell your home care nurse if you call or go see your doctor

RED ZONE: Medical AlertAverage blood sugars are above 250.Most fasting blood sugars are over 200Two or more events in the past week when blood sugar was less than 60.You are unable to stay awake even during the dayIndividual is not responsive, has passed out

RED ZONE MEANS: EmergencyThis indicates that you need to be evaluated by a doctor right away – NOW!Name:_________________________Number:_______________________Call 911: if individual is unresponsive

PNEUMONIA ZONESKnow your zone: Green, Yellow, or Red

Green Zone: All Clear Having slight to no shortness of breath Temperature below 100 Slight cough No chest pain You are able to drink liquids and eat normally

Green Zone Means Your infection is being treated The medications are working that helps fight the infection Increase your activities slowly; it may take several weeks

before you feel normal. Make sure to go to your doctor as directed

Yellow Zone: Caution Fever over 101 Have an increase in shortness of breath Have an increase in coughing Your sputum changes color You are not taking in liquids Feeling more tired than when you were in the hospital

Yellow Zone Means: Warning You may need to adjust your medications Call your doctor to discuss your symptoms

Doctor: ___________________________Phone: _________________________

Call your Home Care Nurse 24 hour number___________________________

RED ZONE: MEDICAL ALERT Very difficult time breathing Your breathing does not get any better if you sit or lay

down Having chest pain Feeling more confused or having trouble thinking Coughing up blood

RED ZONE Means: Emergency You need to be seen by a doctor NOW! Call 911 or go to the nearest Emergency

room.

Resources

• HRET’s Preventable Readmissions http://hret-hen.org/preventable-readmissions

• State Action on Avoidable Rehospitalizations (STAAR) Initiative, http://www.ihi.org/IHI/Programs/StrategicInitiatives/STateActiononAvoidableRehospitalizationsSTAAR.htm

• Project RED (Re-Engineered DC) http://www.bu.edu/fammed/projectred/index.htlm Brian Jack, MD

• Project BOOST (Better Outcomes for Older adults through Safe Transitions) http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/CT_Home.cfm Mark Williams, MD, FHM

Resources

• Transitional Care Model http://www.transitionalcare.info Mary D. Naylor, PhD, RN, FAAN

• Patient Activation Measure http://www.insigniahealth.com/solutions/patient-activation-measure

• INTERACT II http://www.interact2.net/• Hospital 2 Home sponsored by the American College of

Cardiology and the Institute for Healthcare Improvement http://www.h2hquality.org/

Finding and Reducing ADEsCheryl Ruble, MS, RN, CNS

Montana Regional Meetings – Barrett Memorial Hospital

Dillion, MT

What is an ADE?

What is an ADE?

• Any injury resulting from medical care involving medication use.

AHRQ

But be careful…..

• The occurrence of an ADE does not necessarily indicate an error or poor quality of care

AHRQ

What is a Medication Error?

What is a Medication Error?

• Any error occurring in the medication use process

ISMP

So how is an ADE and a Med Error Different?

Well what is An ADR?

WHO:“Any response to a drug which is noxious and unintended, and which occurs at doses normally used in man for prophylaxis, diagnosis, or therapy of disease, or for the modification of physiological function.”

• All ADRs are ADEs• All ADEs are not necessarily ADRs

ADRsAll ADEs

So how is an ADE and a Med Error Different?

Adverse Drug Event

Medication Error

Med ErrorADE BOTH

Why do we care?

• Harm and Death>770,000 patients per year

• CostsUp to $5.6M per hospital annuallyUp to $32,000 per patient

AHRQ

So what is an ADE again?

• Any injury resulting from medical care involving medication use.

AHRQ

What do they look like?

What do they look like?

How do we find them?

How do we find them?

• Voluntary reports• Triggers• RCA’s• Electronic data

mining from EMR’s

Voluntary Reports

• Does it work?• Why?• Why not?

The key…

• Make it SAFE• Make it EASY• Make it MEANINGFUL

Triggers

• Does it work?• Why?• Why not?

CLUES

How Did We Get Started?

• RRT’s & ICU nursing staff tipped us off • All RRT’s reviewed by the Critical Care CNS• Large portion were respiratory in nature and required

transfer to ICU• Causative factor – over use of sedatives & analgesics

in post-op patients

• Of note – these were not found in occurrence reports

What Did We Test?

• Revision of work flow & assessment of patient readiness for discharge from PACU to floor.

• ICU, PACU, and ortho unit nurses involved

What’s Our Data Show?

• We virtually eliminated RRTs due to over sedation/ analgesic use post recovery.

• It became a rare event.

What Did We Learn?

• Communication between departments is crucial

• Not about the who but how – at first there was finger pointing between department staff

• Led us to think what about other rescue meds?

Rescue Meds

Other Triggers

Key Tips

• Always involve staff to identify the problem, design a solution, test and implement.

• Use what you have – – RRT forms/audits, – automated medication dispensing reports – use of rescue

meds– Use other reports such as blood product usage

• Consider unanticipated pulls from your automated medication dispensing

RCA’s

• Does it work?• Why?• Why not?

Mining EMR’s

• Does it work?• Why?• Why not?

Lab & Pharmacy Data

• How do you get it?• Does it work?• Why?• Why not?

What do we do with them when we find them?

• Aggregate• Analyze• Look for system

defects• Fix the system

• We are about what and how not who

Reduce harm from ADEs due to high-alert medications (HAMs)

Awareness, Readiness &

Education

Use the ISMP Assessment tool

to assess capacity

Create awareness of HAMs

Assess clinical knowledge

Standardize Care Processes

Implement quarterly ISMP action agenda

Develop standard order sets

Allow nurses to administer rescue drugs per protocol

Sequence implementation

by drug class

AIM Primary Driver Secondary Drivers

Reduce harm from ADEs due to high-alert medications (HAMs)

Avoid errors during care transitions

Implement effective med rec

processes

Where appropriate, create outpt clinics

for HAM f/up

Use flow sheets that follow pt through care

New insulin orders from parenteral to

enteral

Decision Support

Include pharmacist on rounds

Use alerts for dosage limits

Monitor overlapping meds given to a patient

Use alerts to avoid multiple

narcotics/sedatives

Double checks by pharmacy and

nursing

AIM Primary Driver Secondary Drivers

Reduce harm from ADEs due to high-alert medications

(HAMs)

Prevention of Failure

Minimize nurse distraction during

med administration

Standardize concentrations and

dosing options

Timely lab results

Different locations, labels, packaging for

LASA meds

Perform independent double

checks

Use visual cues for HAMs at bedside

Allow pt mgmt of insulin

Set limits on high dose orders

AIM Primary Driver Secondary Drivers

Reduce harm from ADEs due to high-alert medications

(HAMs)

Prevention of Failure -

Continued

Prepackages Heparin infusion

Reduce the number of heparin

concentrations

Use of LMWH versus

unfractionated heparin

Automatic nutrition consults for pts on

warfarin

Use of table drug-to-drug conversion

doses

Use fall prevention programs

Use dosing limits

Prepackages Heparin infusion

AIM Primary Driver Secondary Drivers

Reduce harm from ADEs due to high-alert medications

(HAMs)

Identification & Mitigations of

Failure

Access Culture of Safety using AHRQ

Safety Survey

Use error reporting system

Use of technology to alert key staff when

rescue drug used

Administer meds on time

Analyze override patterns

Smart Use of Technology

Use “Smart” pumps

Understand PCA device errors

Link order sets to lab values

Use of proper levels of alerts

Educate staff on device use

consequences

AIM Primary Driver Secondary Drivers

Awareness, Readiness, Education, Standard Care Processes

• Getting Started: – Is the organization

ready?– Does the organization

have the capacity?– Is the organization

willing?

Awareness, Readiness, Education, Standard Care Processes

• Assess clinical knowledge of staff

• Create awareness of HAM’s most likely to cause ADE

• Access culture of safety

CLUES

Driver: Standardize the Care Process

“If you can’t describe your process, you don’t have one.” W. Edwards Deming

“Every system is perfectly designed to get the results it gets.”Paul Batalden, Dartmouth

“Standardize what is standardizable and no more”Brent James, MD, Intermountain Health

“Quality is the absence of unexplained variation.”David Nash, MD, Editor, American Journal of Medical Quality

Protocols

• Standard order sets for high priority HAMs– Start with the drug class

with greatest opportunity

• Nurse administered rescue drugs

• Allow for “opt out”• Make it easy to use

What does it have to do with readmissions?

• In one study 1 of 8 readmissions was due to an ADE

• Note…if we eliminated those we would be 60% of the way to our goal of a 20% reduction in readmissions

• Causes:– Failure to monitor– Drug- Drug interactions

Guharoy, 2007

Avoid Errors During Care Transitions

How can we prevent discharge related ADE’s that lead to

readmissions?

How?• Get the meds right!• Monitor meds• Minimize drug-drug

interactions• Reconciliation• Did the patient really get

the outpatient rx’s filled:– PA’s approved– affordable

What matters most?

• Checking out the patient 24-28 hours post discharge to see that they are completely reconciled…that all issues related to med rec are resolved

The Pill Mill

Dr. Suess’ You’re Only Old Once! A Book for Obsolete Children

How do we do that?

• Call them• Visit them• Have them visit

you

Driver: Prevention of Failure

• Medication errors are the most frequent cause of ADEs

• It goes beyond the mind numbing recitation of the 5 rights – right med, right patient, right dose, right time, right route

• System design in crucial! Set the clinician up for success!

NOT DISTURB

MED ERROR

REDUCTION ZONE

DO NOT D

ISTURB

DO NOT DISTURB

Driver: Identification & Mitigation of Failure

• Prompt identification and actions to reduce harm

• Understanding failure and taking broad system view is crucial

• Opportunities for learning and system re-dsign

Culture of SafetyDo you have a non-punitive environment?

Aoccdrnig to rschearch at Cmabrigde Uinervtisy, it deosn’t mttaer in what oredr the ltteers in a word are, the olny iprmoetnt tihng is that the frist and lsat ltteer be at the rghit pclae. The rset can be a total mses and you can still raed it wouthit a porbelm. This is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the word as a wlohe.

Amzanig huh?

The Human Mind

Resources

• 2011 Institute for Safe Medication Practices (ISMP) Medication Safety Self Assessment® for Hospitals http://ismp.org/selfassessments/Hospital/2011/pdfs.asp

• Institute for Healthcare Improvement High-Alert Medication Safety (Improvement Map)

• http://app.ihi.org/imap/tool/#Process=b8541097-7456-4aab-a885-38c31950e6bf• http://www.cshp.org/uploads/file/Shared%20Resources/2012/guideline_anticoag

ulants_2.21.12.pdf• Federico, Preventing Harm from High-Alert Medications, The Joint Commission

Journal on Quality and Patient Safety, 33(9), 537-542• Agency for Healthcare Research and Quality Hospital Survey on Patient Safety

Culture http://www.ahrq.gov/qual/patientsafetyculture/hospsurvindex.htm• Miller et al, Bar code Medication Administration Technology: Charcterization of

High-Alert Medication Triggers and Clinician Workarounds, The Annals of Pharmacotherapy 2011 Feb Vol 45, 162-168