Inter-Disciplinary Collaboration Fosters Success in New geriatric...
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Inter-Disciplinary Collaboration Fosters Success in New geriatric Fracture Program at RIH Lynn McNicoll, MD, Nadia Mujahid, MD, Donna Dumouchel, RN, Barbara Rilley, RN Rhode Island Hospital, Lifespan, Providence, Rhode Island Abstract Methods Results Conclusion Hip fractures are becoming increasingly common and traumatic events in the elderly population. Orthopedic and geriatrics co-management programs reduce variability and improve care quality in mortality, length of stay (LOS) and other critical outcomes. The Rhode Island Hospital (RIH) Orthopedics and Geriatrics programs collaborated and convened an inter-disciplinary team that met on a monthly basis for the planning and implementation of the RIH Geriatric Fracture Program (GFP) beginning Spring, 2011. To benchmark, track, and monitor our efforts, we developed a dashboard for the GFP patients. The team streamlined the pre-operative risk stratification and formally addressed geriatric syndromes. Three process improvements accelerated the program’s progress toward measureable outcomes: 1) The implementation of a streamlined process to admit GFP patients from the ED to facilitate early operative intervention; 2) the development of ED, pre-operative and post-operative order sets to address delirium reduction and expedite definitive pain management; 3) Collaborative orthopedic and geriatric care co-management for the GFP patients post- operatively. Input from all healthcare providers in this process included nursing representatives who helped facilitate the smooth implementation of these protocols. Nurse champions were identified from the Geriatric Resource Nurse course. The metrics that improved within the first year included the following: 1) the average LOS decreased from 7.6 to 6.5 days (16% reduction); 2) in-patient mortality decreased from 2.5% to 1.7% (32% reduction) resulting in 2 lives saved annually; and, 3) proportionally, the rates of pneumonia, readmissions, and restraint use have trended downward, while patient satisfaction has improved. Pain satisfaction scores remain a challenge. The RIH GFP is an outstanding example of how collaboration among different specialties and disciplines with specific goals and enthusiasm can improve quality of care, outcomes, and patient satisfaction. Background References Hip fractures are becoming increasingly common and traumatic events in the elderly population. Orthopedic and geriatrics co- management programs reduce variability and improve care quality in mortality, length of stay (LOS) and other critical outcomes. In 2011, Rhode Island Hospital committed to developing a Geriatric Fracture Program (GFP) with co-management among Orthopedics and Geriatrics. The specific goals of the GFP were to: 1.Improve collaboration of care with screening protocols finalized & implemented by August 2011 2.Reduce pain and suffering by improving pain satisfaction scores by 3 points by December 2012 3.Improve patient and family satisfaction by improving patient satisfaction scores by 3 points by December 2012 4.Reduce average LOS by 0.5 day every 6 months for 2 years thus reducing LOS by 2 days by June 2013. 5.Improve coordination/ transition of care by obtaining a PT evaluation within 24 hours of surgery for 100% of patients by October 2011 6.Reduce readmission rates by 20% by December 2012 7.Reduce mortality by 30% by December 2012 An inter-disciplinary team that met monthly beginning Spring 2011. A dashboard of quality measures specific to hip fractures was developed. Input from all healthcare providers in this process included nursing representatives who helped facilitate the smooth implementation of these protocols. Nurse champions were identified from the Geriatric Resource Nurse course. The following were areas for improvement that were identified and addressed over the course of the project: 1- Surgical Risk Stratification Delays: Pre-operative risk stratification was streamlined with one geriatrician responsible for most evaluations. This reduced delays in the pre-operative period and providing consistency in pre-operative risk stratification, avoided unnecessary cardiac testing and provided continuity of care in the post-surgical period. 2- OR Delays: OR scheduling issue was tackled by having at least 1 OR room available midday to facilitate surgery within 24 hours, so that patients admitted overnight would be seen early morning by the geriatrician for possible same day surgery. 3- Service Management Confusion : The presence of a geriatric medicine consultant on the orthopedic team provided continuity of care both pre- and post-operatively, thereby preventing unsafe patient transitions during the hospital stay. 4- Pain Management: A simplified pain regimen in the order sets and teaching Orthopedic residents and physician assistants resulted in better pre- and post-operative pain management. 5- Early Mobilization : Early mobilization was encouraged in the post- operative period by physical therapist and nursing staff to help facilitate early recovery, and prevention of skin breakdown and delirium. 6- Sleep Management and Delirium Recognition and Management: Delirium and sleep management were addressed by incorporating principles from The Miriam Hospital GENESIS protocols for delirium and sleep. 7- A Coordinated Healthcare Team: Improved communication among all members of the healthcare team, including RNs, case managers, physical therapist and physicians has improved discharge planning. 8- Early Discharge Planning: Discharge planning begins on admission, when the family is given a rough estimate of hospital stay. This facilitates early bed searches in skilled nursing facility (SNF) of interest, thereby preventing unnecessary delays and preventing increased hospital LOS. 9- Prevention of geriatric syndromes : In addition to the co- management model with a geriatrician to prevent geriatric syndromes, The participants brought back evidence-based guidelines and related educational materials that were shared with other members of the GFP team. The average age is 82.3 with 72.5% being female. The metrics that improved within the first year included the following: 1) the average LOS decreased from 7.6 to 6.4 days (16% reduction); 2) in-patient mortality decreased from 2.5% to 1.7% (32% reduction) resulting in 2 lives saved annually; and, 3) proportionally, the rates of pneumonia, readmissions, and restraint use have trended downward, while patient satisfaction has improved. Pain satisfaction scores remain a challenge. LOS was longest if patients were admitted on Thursdays or Saturdays. Ninety percent of patients were discharged to a skilled nursing facility or an acute rehabilitation facility but our rates of discharge home have more than doubled. The RIH GFP is an outstanding example of how collaboration among different specialties and disciplines with specific goals and enthusiasm can improve quality of care, outcomes, and patient satisfaction. Initially the initiative focused mostly on hip fractures but we have expanded the geriatric-orthopedics co-management to other fractures in the elderly including ankle, femur, or spinal fractures. We also have started two other co-management programs with our Joint Center of Excellence at The Miriam Hospital and with the trauma service at Rhode Island Hospital. Measure Baseline Q4/10 to Q3/11 Q4 2011 Q1 2012 Q2 2012 Q3 2012 Q4 2012 2012 Patient Satisfaction 50.5 57.3 57.1 52.5 52.2 55.7 54.3 (+3.8) Communication with RN 68.0 62.5 76.9 72.4 73.1 70.4 73.2 (+5.2) Pain Satisfaction 65.3 60.8 69.3 68.5 68.3 62.6 67.3 (+2) Press Ganey Scores Mortality Length of Stay Measure Baseline 8/10 to 7/11 Re-measurement 8/11 to 12/2012* % Change ED LOS 8.3 8.0 4% decrease Hospital LOS 7.6 6.4 16% decrease Readmission 13% 11% 15% decrease Surgical Complications 14.4% 12% 17% decrease Mortality 6/243 = 2.5% 5/297= 1.7% 32% decrease Discharge Home 4% 9.4% 135% increase Outcomes 1. William W. Hung, et al. Hip Fracture Management Tailoring Care for the Older Patient JAMA. 2012;307(20):2185-21945 2. Kim SH et al; Hip fractures in the United States: 2008 nationwide emergency department sample. Arthritis care & research 2012;64:751-7. 3. Brown CA et al; Analysis of past secular trends of hip fractures and predicted number in the future 2010-2050. Journal of orthopaedic trauma 2012;26:117-22. 4. Fisher AA, et al. Outcomes for Older Patients With Hip Fractures: The Impact of Orthopedic and Geriatric Medicine Cocare. J Orthop 2006;20:172–8 5. Friedman, SM et al. Impact of a Comanaged Geriatric Fracture Center on Short-term Hip Fracture Outcomes .Arch Intern Med. 2009;169(18):1712-1717 6. Deschodt, M et al, Preventing delirium in older adults with recent hip fracture through multidisciplinary geriatric consultation. J Am Geriatr Soc. 2012 Apr;60(4):733-9 *some data not available for up to December 2012 Acknowledgements: We would like to acknowledge the nurses, nurses’ aides, rehabilitation specialists, social workers, and of course, the patients and families of COOP 2 unit at Rhode Island Hospital for their support of this program.
Transcript of Inter-Disciplinary Collaboration Fosters Success in New geriatric...
Inter-Disciplinary Collaboration Fosters Success in New geriatric Fracture Program at RIH Lynn McNicoll, MD, Nadia Mujahid, MD, Donna Dumouchel, RN, Barbara Rilley, RN
Rhode Island Hospital, Lifespan, Providence, Rhode Island
Abstract Methods Results Conclusion Hip fractures are becoming increasingly common and traumatic events in the elderly population. Orthopedic and geriatrics co-management programs reduce variability and improve care quality in mortality, length of stay (LOS) and other critical outcomes. The Rhode Island Hospital (RIH) Orthopedics and Geriatrics programs collaborated and convened an inter-disciplinary team that met on a monthly basis for the planning and implementation of the RIH Geriatric Fracture Program (GFP) beginning Spring, 2011. To benchmark, track, and monitor our efforts, we developed a dashboard for the GFP patients. The team streamlined the pre-operative risk stratification and formally addressed geriatric syndromes. Three process improvements accelerated the program’s progress toward measureable outcomes: 1) The implementation of a streamlined process to admit GFP patients from the ED to facilitate early operative intervention; 2) the development of ED, pre-operative and post-operative order sets to address delirium reduction and expedite definitive pain management; 3) Collaborative orthopedic and geriatric care co-management for the GFP patients post-operatively. Input from all healthcare providers in this process included nursing representatives who helped facilitate the smooth implementation of these protocols. Nurse champions were identified from the Geriatric Resource Nurse course. The metrics that improved within the first year included the following: 1) the average LOS decreased from 7.6 to 6.5 days (16% reduction); 2) in-patient mortality decreased from 2.5% to 1.7% (32% reduction) resulting in 2 lives saved annually; and, 3) proportionally, the rates of pneumonia, readmissions, and restraint use have trended downward, while patient satisfaction has improved. Pain satisfaction scores remain a challenge. The RIH GFP is an outstanding example of how collaboration among different specialties and disciplines with specific goals and enthusiasm can improve quality of care, outcomes, and patient satisfaction.
Background
References
Hip fractures are becoming increasingly common and traumatic events in the elderly population. Orthopedic and geriatrics co-management programs reduce variability and improve care quality in mortality, length of stay (LOS) and other critical outcomes.
In 2011, Rhode Island Hospital committed to developing a Geriatric Fracture Program (GFP) with co-management among Orthopedics and Geriatrics. The specific goals of the GFP were to: 1.Improve collaboration of care with screening protocols finalized & implemented by August 2011 2.Reduce pain and suffering by improving pain satisfaction scores by 3 points by December 2012 3.Improve patient and family satisfaction by improving patient satisfaction scores by 3 points by December 2012 4.Reduce average LOS by 0.5 day every 6 months for 2 years thus reducing LOS by 2 days by June 2013. 5.Improve coordination/ transition of care by obtaining a PT evaluation within 24 hours of surgery for 100% of patients by October 2011 6.Reduce readmission rates by 20% by December 2012 7.Reduce mortality by 30% by December 2012
An inter-disciplinary team that met monthly beginning Spring 2011. A dashboard of quality measures specific to hip fractures was developed. Input from all healthcare providers in this process included nursing representatives who helped facilitate the smooth implementation of these protocols. Nurse champions were identified from the Geriatric Resource Nurse course.
The following were areas for improvement that were identified and addressed over the course of the project: 1- Surgical Risk Stratification Delays: Pre-operative risk stratification was streamlined with one geriatrician responsible for most evaluations. This reduced delays in the pre-operative period and providing consistency in pre-operative risk stratification, avoided unnecessary cardiac testing and provided continuity of care in the post-surgical period. 2- OR Delays: OR scheduling issue was tackled by having at least 1 OR room available midday to facilitate surgery within 24 hours, so that patients admitted overnight would be seen early morning by the geriatrician for possible same day surgery. 3- Service Management Confusion: The presence of a geriatric medicine consultant on the orthopedic team provided continuity of care both pre- and post-operatively, thereby preventing unsafe patient transitions during the hospital stay. 4- Pain Management: A simplified pain regimen in the order sets and teaching Orthopedic residents and physician assistants resulted in better pre- and post-operative pain management. 5- Early Mobilization: Early mobilization was encouraged in the post-operative period by physical therapist and nursing staff to help facilitate early recovery, and prevention of skin breakdown and delirium. 6- Sleep Management and Delirium Recognition and Management: Delirium and sleep management were addressed by incorporating principles from The Miriam Hospital GENESIS protocols for delirium and sleep. 7- A Coordinated Healthcare Team: Improved communication among all members of the healthcare team, including RNs, case managers, physical therapist and physicians has improved discharge planning. 8- Early Discharge Planning: Discharge planning begins on admission, when the family is given a rough estimate of hospital stay. This facilitates early bed searches in skilled nursing facility (SNF) of interest, thereby preventing unnecessary delays and preventing increased hospital LOS. 9- Prevention of geriatric syndromes: In addition to the co-management model with a geriatrician to prevent geriatric syndromes, The participants brought back evidence-based guidelines and related educational materials that were shared with other members of the GFP team.
The average age is 82.3 with 72.5% being female. The metrics that improved within the first year included the following: 1) the average LOS decreased from 7.6 to 6.4 days (16% reduction); 2) in-patient mortality decreased from 2.5% to 1.7% (32% reduction) resulting in 2 lives saved annually; and, 3) proportionally, the rates of pneumonia, readmissions, and restraint use have trended downward, while patient satisfaction has improved. Pain satisfaction scores remain a challenge. LOS was longest if patients were admitted on Thursdays or Saturdays. Ninety percent of patients were discharged to a skilled nursing facility or an acute rehabilitation facility but our rates of discharge home have more than doubled.
The RIH GFP is an outstanding example of how collaboration among different specialties and disciplines with specific goals and enthusiasm can improve quality of care, outcomes, and patient satisfaction. Initially the initiative focused mostly on hip fractures but we have expanded the geriatric-orthopedics co-management to other fractures in the elderly including ankle, femur, or spinal fractures. We also have started two other co-management programs with our Joint Center of Excellence at The Miriam Hospital and with the trauma service at Rhode Island Hospital.
Measure Baseline Q4/10 to
Q3/11
Q4 2011
Q1 2012
Q2 2012
Q3 2012
Q4 2012
2012
Patient Satisfaction
50.5 57.3 57.1 52.5 52.2 55.7 54.3 (+3.8)
Communication with RN
68.0 62.5 76.9 72.4 73.1 70.4 73.2 (+5.2)
Pain Satisfaction
65.3 60.8 69.3 68.5 68.3 62.6 67.3 (+2)
Press Ganey Scores
Mortality Length of Stay
Measure Baseline 8/10 to 7/11
Re-measurement 8/11 to 12/2012*
% Change
ED LOS 8.3 8.0 4% decrease Hospital LOS 7.6 6.4 16% decrease Readmission 13% 11% 15% decrease Surgical Complications
14.4% 12% 17% decrease
Mortality 6/243 = 2.5% 5/297= 1.7% 32% decrease Discharge Home 4% 9.4% 135% increase
Outcomes
1. William W. Hung, et al. Hip Fracture Management Tailoring Care for the Older Patient JAMA. 2012;307(20):2185-21945 2. Kim SH et al; Hip fractures in the United States: 2008 nationwide emergency department sample. Arthritis care & research 2012;64:751-7. 3. Brown CA et al; Analysis of past secular trends of hip fractures and predicted number in the future 2010-2050. Journal of orthopaedic trauma 2012;26:117-22. 4. Fisher AA, et al. Outcomes for Older Patients With Hip Fractures: The Impact of Orthopedic and Geriatric Medicine Cocare. J Orthop 2006;20:172–8
5. Friedman, SM et al. Impact of a Comanaged Geriatric Fracture Center on Short-term Hip Fracture Outcomes .Arch Intern Med. 2009;169(18):1712-1717 6. Deschodt, M et al, Preventing delirium in older adults with recent hip fracture through multidisciplinary geriatric consultation. J Am Geriatr Soc. 2012 Apr;60(4):733-9
*some data not available for up to December 2012
Acknowledgements: We would like to acknowledge the nurses, nurses’ aides, rehabilitation specialists, social workers, and of course, the patients and families of COOP 2 unit at Rhode Island Hospital for their support of this program.
