After reading the case study below answer the following question in approximately 100-150 words: 1. give your recommendations on how the organization could improve their operations and quality. Case Study CCHS-5 Standardization of Heparin Nomograms Shannon Phillips, MD, MPH, and Robert Patrick, MD, MBA Background Cleveland Clinic identifies priorities in safety and quality through both public reporting expectations and internal monitoring and reporting systems. The internal monitoring and reporting structure for patient safety is an interdisciplinary patient safety committee led by a physician patient safety officer. This committee oversees the operation of an anonymous, voluntary intranet-based safety event reporting system (SERS), which can be easily accessed by anyone in the institution to report actual safety events or potential risks to safety. SERS entries are collated and reviewed by the committee monthly, and consistent patterns warranting further attention are identified. Methods, Resources, and Performance Targets Anticoagulation—thinning the blood to prevent or treat clotting—is a critical part of safe care for many hospitalized patients. The most common medication errors reported by our frontline caregivers were related to anticoagulants, specifically the intravenous anticoagulant heparin. Successful anticoagulation with heparin is measured by a blood test (PTT), which is collected 6 hours after every change in infusion rate and then daily once therapeutic levels are achieved. Heparin infusions are sometimes started with a one-time large dose of medication (bolus) in an attempt to get the patient inside the therapeutic range quickly. A PTT below the therapeutic range places the patient at risk for clotting, and above the range the risk is for spontaneous bleeding with potentially catastrophic consequences. Heparin-related SERS events were believed to be above a tolerable threshold, and consequently the patient safety committee chartered a project to improve the safety and efficacy of intravenous heparin. Although SERS events are a good trigger for further investigation, they are anecdotal by nature and cannot accurately quantify the magnitude of any given risk. The first task of the team was to develop clinically relevant outcome measures and an information infrastructure to monitor them. Time to initial therapeutic PTT is the traditional outcome used to measure the quality of heparin therapy. This was believed to be inadequate as it measured only how fast the therapeutic range was attained and ignored what happened afterward. A new outcome was defined by the team as a percentage of time on therapy spent below/inside/above range, and initial data showed a 40%/40%/20% distribution. Detailed process mapping with key stakeholders was undertaken and showed prescribing, dosing, administration, and monitoring as the critical steps requiring intervention. Process mapping also allowed us to identify the key leads for our improvement initiative: physician staff, nursing, pharmacy, and laboratory. The team was expanded and the plan step of the first PDSA cycle was undertaken using a combination of Microsystems and Lean techniques. The bundle of interventions developed in this stage is detailed below: • Ordering: physicians • Standardizing electronic ordering into three nomograms and limiting heparin ordering to one of the nomograms. • Defaulting choices within the nomogram such that once a nomogram is chosen, the only remaining choice is bolus or no bolus. • Clear visual distinction in order between bolus/no bolus. • Order cannot be exited without choosing bolus/no bolus. • Dosing: nurses • User-friendly dosing calculator similar to a smart-phone application programmed into the EMR. • Maximum dose limits programmed into the calculator. • Clear, documented nursing acknowledgment of bolus/no bolus choice from the physician order. • Administration: nurses • Smart pumps synchronize with maximum dose limits in the EMR, and overdose cannot be accidentally programmed into the pump. • Monitoring: lab and nurses • Decreased variation in turnaround time for PTT. • Visual display of an icon on a large television screen notifies the nurse that PTT is available and it is time for recalculation of dose and infusion change. Results Pilot sites for the intervention were chosen based on both volume of heparin use and an assessment of willingness to change. The pilot was run for 2 months with improvement from 40%/40%/20% below/inside/above range to 21%/57%/22%. Additionally, there were improvements in process measures such as the percentage of PTT lab draws completed within 15 minutes of designated time and reduction in total cycle time. The target percentage inside range defined in the plan stage was a doubling from 40% to 80%, and so the study portion of this PDSA cycle included a detailed review of “failures” from the pilot. It revealed poor nursing documentation and continued mistakes in dosing as contributors, and consequently two additional interventions were added to the bundle: • Dosing: nurses • Two nurses calculate the dose independently and check figures with each other. • Administration: nurses • The same two nurses who calculated the dose together also program the pump together and record an entry in the EMR. Conclusion The main financial driver in previous clinical trials of anticoagulation was a decrease in cases of catastrophic bleeding associated with anticoagulation. This outcome turned out to be extraordinarily difficult to measure in a real-world setting and even more difficult to attribute directly to improved control of heparin, so there was no attempt made to calculate financial return on investment, and the project was justified solely on the merits of improvement in patient safety. This bundle of process changes has recently been rolled out to all units in our 1,200-bed academic hospital. We continue to monitor percentage time in range and look closely for complications of treatment. Anecdotally, members of the nursing staff have increased confidence in the care they give and call out the important teamwork that has developed as a result of this improvement program.
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