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Evidence Based MedicineCongestive Heart Failure Initiative
Allen Hospital, New York Presbyterian NYAM review sessionAugust 10th 2011
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Evidence Based Medicine Approach
– Project began September 2009
– Learned the Basic Skills and Principles of EBM How to ask a question How to perform a relevant search Evaluation and Interpreting articles Principles of guideline evaluation and development
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#1 Choose a project that counts!
– Who are your customers? Doctors: Clinical benefit Hospital: Financial benefit Patients: Improved care
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#2 Involve everyone that matters!Multidisiplinary Team
ER: Dr. Leslie Miller, Dr. Peter Wyer
Hospitalist: Dr. Beth Barron, Dr. Zorica Stojanovic, Dr. Eugene Wong
Cardiology: Dr. Gerald Neuberg, Karen Stugensky, PA
Quality: Avi Fishman, Mary Ellen Hickman
Librarian: John Oliver IT: Amalga: Niloo Shobhani
Social Work: Eileen Kornfield
Nutrition: Susan Fulton Care coordination: Donna
Tingling-Solanges, Doug Morton
Nursing: Kelly Maydon, Alan Levine, Mitzy Placencia
Patient Education: Jody Scopa Goldman
Administration: Michael Fosina VP – Executive Director of Allen Hospital
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# 3 Know what your problems is
Internal scan – Who are our patients? (chart review, patient calls, staff survey)
Admitted from? Discharged to? Services? Insurance? Private physician? When and if follow up scheduled? What medications d/c home on? Smoking? Diabetes? Other co-morbidities? What do the patients think about our care?
External scan – What is in the literature? Home care, Health literacy, Medications, Language barriers,
Patient education, Economic, Prediction rules, and Cardiology evaluation
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#4 What will work for Allen?Knowledge Translation
Group reviewed the evidence, reviewed external guidelines and our internal reviews
Agreed that we would focus on education and the transition of care from hospital to outpatient primary care doctor
Spanish language capabilities a must
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Project began 11/15
Mitzy Placencia, CHF RN– Inpatient education (Patient education handbook)– Core measures evaluation– Outpatient phone calls until seen by primary– Trouble shooting (medications, f/u visits)– Scales– Nutrition consults
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CHF Education and Follow Up Pathway
Day 1 Patient is admitted through the ED • Patient admission notes are screened for appropriateness
of education.
• Patient educated on:• What is CHF• Daily weights• Sodium and Fluid Restrictions• When to call the physician
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CHF Pathway Cont.
Day 2• Review sodium and fluid restrictions• Review medications with the patient and family
Day 3• Review discharge teaching:
• What to do if you notice an increase in symptoms• When to call the physician and when to come to ED.
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After Discharge…
The patient is called at home 2-3 times a week for one month• Medications reconciled• Symptoms assessed• Family members and Home Attendants educated also• Troubleshooting:
• Earlier appointments, medications refilled, diuretics doses increased if necessary and more…
• Education continues!
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Collaborations With Other Healthcare Professionals
CHF classes held on a weekly basis with nutrition.
Weekly meetings with VNSNY Phone calls to the field nurse of various
homecare agencies to discuss the patients’ progress and status.
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#5 Measure your successes and be willing to change/evolve
Volume Impact of early follow up Issues identified with readmitted patients Impact of keeping in touch
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CHF RN Coordinator monthly patients volume (11/15/10 -7/31/11 )
0
5
10
15
20
25
30
35
40
45
50
NOVEM JAN MAR MAY JULY
Number of patients
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Impact of early follow up
All 198 patients had follow up appointment scheduled before discharge:
< 7 days: 111 patients (56%)
> 7 days: 87 patient (44%) 5
25
45
65
85
105
f/u<7d f/u>7d
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Impact of early follow up on readmissions
8 patients (9.2%)% with f/u<7 readmitted
23 patients (20.7%) with f/u>7d readmitted
5
25
45
65
85
105
f/u<7d f/u>7d
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Impact of keeping in touch
Post discharge phone call attempted on all patients seen in hospital.
Only 7 of them were unreachable 5 out of 7 were readmitted
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CHF 30 Day Readmission Measures
Allen
Hospital
Q1 2010 2010 Q1 2011 2011
(Jan-May)
Readmissions
27.5% 28.36% 18.31% 20.16%
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Allen Hospital: 30 day CHF Readmission Rate Jan 2009 - May 2011
0%
10%
20%
30%
40%
50%
60%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Rea
dm
issi
on
Rat
e2009 2010 2011
Source: TSI ; Data current, as of 7/20/2011
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Zorica’s lessons learned slides
We offered one size fits all (education and transition of care) approach…
and added Many different interventions were needed
for each individual patients.
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Positive impact
NYP impact Allen impact
– Future projects?