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1、Pneumonia care Controversies and Challenges,Meera Kelley MD Clinical Coordinator, MRNC, Inc. The QIO for the Carolinas,April 14, 2005,Medical Review of NC, Inc.,2,Overview,Issues with the indicators Other broad challenges Discussion,April 14, 2005,Medical Review of NC, Inc.,3,PN-1 Oxygenation assess
2、ment PN-2 Pneumococcal vaccination PN-3b Blood cultures PN-4 Adult smoking cessation advice PN-5 Antibiotic timing PN-5a Initial antibiotic w/in 8 h hospital arrival PN-5b Initial antibiotic w/in 4 h hospital arrival PN-6a Initial antibiotic selection ICU PN-6b Initial antibiotic selection Non ICU P
3、N-7 Influenza vaccination,April 14, 2005,Medical Review of NC, Inc.,4,PN-1 Oxygenation assessment,Inadequate oxygen (hypoxemia) is common in severe pneumonia and is a known mortality risk factor. Giving supplemental oxygen has been shown to decrease mortality among patients with pneumonia.,April 14,
4、 2005,Medical Review of NC, Inc.,5,Controversies & Challenges Oxygenation assessment,No,April 14, 2005,Medical Review of NC, Inc.,6,PN-3b Blood cultures,Published pneumonia treatment guidelines recommend performance of blood cultures for all inpatients to optimize therapy. Improved survival has been
5、 associated with optimal therapy. Yield is greater if the culture is collected before antibiotics are administered.,April 14, 2005,Medical Review of NC, Inc.,7,Controversies & Challenges Blood cultures,Drawn late-after antibiotics Not drawn at all-not routinely done for outpatients,April 14, 2005,Me
6、dical Review of NC, Inc.,8,PN-4 Adult smoking cessation advice/counseling,Smoking accounts for one out of every five deaths in the US and is the most important modifiable cause of premature death. Smoking cessation advice is clinically effective and cost-effective. Hospitalization can be an ideal op
7、portunity for a patient to stop smoking. Patients who receive even brief smoking-cessation advice from their physicians are more likely to quit.,April 14, 2005,Medical Review of NC, Inc.,9,Controversies & Challenges Smoking cessation advice,Documentation Preventive, long term issues not routinely ad
8、dressed by physicians,April 14, 2005,Medical Review of NC, Inc.,10,PN-5 Antibiotic timing,Timely administration of antibiotics = improved outcome among pneumonia patients Improved survival with receipt of antibiotics within 4 h of admission (Khan 1990) Shortening the time-to-first-dose to 4 h was as
9、sociated with improved survival (McGarvey 1993) First dose of antibiotic within 3 hours -less likely to die within 30 days (Meehan 1995) 30-day mortality 10% (P=0.04) lower, length of hospital stay shorter among patients whose first antibiotic administered within 4 h (Bratzler 2001),April 14, 2005,M
10、edical Review of NC, Inc.,11,Controversies & Challenges Antibiotic timing,Time from arrival to diagnosis,April 14, 2005,Medical Review of NC, Inc.,13,Controversies & Challenges Antibiotic selection,Elderly, nursing home patient, other reasons want to give broader therapy,April 14, 2005,Medical Revie
11、w of NC, Inc.,14,April 14, 2005,Medical Review of NC, Inc.,15,PN-2 Pneumococcal vaccination,Indicated for persons 65 years of age Up to 75% effective in preventing pneumococcal bacteremia and meningitis. Also important due to increasing antibiotic resistance among pneumococci Hospitalization is an u
12、nderutilized opportunity,April 14, 2005,Medical Review of NC, Inc.,16,April 14, 2005,Medical Review of NC, Inc.,17,PN-7 Influenza vaccination,Indicated for people 50 years Highly effective in preventing influenza-related pneumonia, hospitalization, and death. Hospitalization is an underutilized oppo
13、rtunity,April 14, 2005,Medical Review of NC, Inc.,18,April 14, 2005,Medical Review of NC, Inc.,19,Controversies & Challenges inpatient immunizations,Too sick Wont work Takes long time to establish history Physician role,April 14, 2005,Medical Review of NC, Inc.,20,Controversies & Challenges pneumoco
14、ccal vaccination,Perception of risk of reimmunization Cochrane Databast Syst Rev 2003; (4) CD000422-”pneumococcal vaccination does not prevent pneumonia or death in adults”,April 14, 2005,Medical Review of NC, Inc.,21,Controversies & Challenges influenza vaccination,Availability It made me sick Docs
15、 prefer to give it in office,April 14, 2005,Medical Review of NC, Inc.,22,Other broad challenge- working with physicians,April 14, 2005,Medical Review of NC, Inc.,23,Communicating with docs-tips,Bear in mind-most are feeling overwhelmed frazzled terrified We need to; tell them only what they need to
16、 know show how we can make their life better,April 14, 2005,Medical Review of NC, Inc.,24,Communicating your message effectively-tips,Start planning your presentation by determining your goal-what do you want them to do when the leave? They will be more enthusiastic if they have a clear, well define
17、d, but limited role to play,April 14, 2005,Medical Review of NC, Inc.,25,Communicating your message effectively-tips,Acknowledge their challenges “We recognize how busy you are as it is and want this to ultimately make your life better.” Offer to help “We will do as much of the work as possible, but
18、 we need your input” Ensure you will be responsive to feedback “We would like to try this for 3 months and want you to let us know what you think”,April 14, 2005,Medical Review of NC, Inc.,26,Communicating your message effectively,Step #1 tell the story of the positive future Step #2 convey to audie
19、nce how taking the action will give THEM the future they want Step # 3 call to action-ask for commitment of first step Mark Walton, Center for Leadership Communication, Chapel Hill,April 14, 2005,Medical Review of NC, Inc.,27,Message to physicians We understand that their day-to-day life is overwhel
20、ming,April 14, 2005,Medical Review of NC, Inc.,28,Patient care,Billing,Accurate coding,Interruptions,Phone calls,Pharmaceutical reps,Formularies,Insurance status,Health care plans,Office administration,Other patients,Prior authorizations,Clinical practice guidelines,Drug interactions/effects,Beepers
21、/Pages,29,Systematically review each drug for potential side effects and interactions during 20 minute visit (new drug approvals FDA 2003; 42, 2002; 92 ) Systematically recall each step of the best practice for each clinical syndrome may encounter (National Guidelines Clearinghouse summaries Feb 200
22、5; 1444 summaries) July 2004; 1329),30,April 14, 2005,Medical Review of NC, Inc.,31,April 14, 2005,Medical Review of NC, Inc.,32,We can. But we cannot ensure that,Bypass, balloon, or stent a heart blockage dissolve a clot for a heart attack transplant a heart provide ventilator and BP support for pn
23、eumonia treat resistant bacteria such as MRSA, VRE, DRSP,the antibiotic is given 1 hr prior to CABG (47.6% US) the patient gets an aspirin on discharge (84% US) heart failure patient assess LVF (70% US) flu shot history assessed, given (14% US) penicillin allergic patient doesnt get penicillin,April
24、 14, 2005,Medical Review of NC, Inc.,33,We have revolutionized what we do, without changing how we do it. We have advanced the product without changing the process. Contrast: FedEx, EBay, Amazon, Starbucks,April 14, 2005,Medical Review of NC, Inc.,34,Who is responsible for improving the system?,Apri
25、l 14, 2005,Medical Review of NC, Inc.,35,How do we ensure the right treatment for the right patient at the right time, no more, no less?,Tell the doctors to just do it?,April 14, 2005,Medical Review of NC, Inc.,36,Skills of physicians,assess patients direct major aspects of therapy perform specific
26、interventions communicate with patients,April 14, 2005,Medical Review of NC, Inc.,37,To make best, most efficient, most effective use of physicians skills, need to protect time and touch of the patient-physician interaction. Alice G. Gosfield, J.D., Snyder, 9/12/03,April 14, 2005,Medical Review of N
27、C, Inc.,38,Clinical information patients history, and key aspects of care for their conditions-must be present and readily utilized during the patient-physician encounter,April 14, 2005,Medical Review of NC, Inc.,39,Physicians take the lead,There is no indication that the practice of medicine is get
28、ting less complex. Spend time today to save time tomorrow.,April 14, 2005,Medical Review of NC, Inc.,40,Old paradigm Maintain knowledge-rely on memory Individualize Encourage variation Avoid “cookbook”, Avoid crutches, pocket- fillers Work long hours- continuity of care Follow instructions of physic
29、ian without questioning for fear of response Health is provided by the physician,New paradigm Avoid reliance on memory Provide consistency Simplify Use protocols, check tools, references Minimize long hours- encourage safety Mirror back orders, ask questions, raise doubt without fear of retribution
30、Health is achieved by the team,April 14, 2005,Medical Review of NC, Inc.,41,Cookbook concerns,April 14, 2005,Medical Review of NC, Inc.,42,Skills of physicians,assess patients direct major aspects of therapy perform specific interventions communicate with patients No checklist, cookbook, or computer will ever replace this!,April 14, 2005,Medical Review of NC, Inc.,43,Bringing healthcare into the 21st century,Physicians lead the way Work with administrators Make use of computers and technology,April 14, 2005,Medical Review of NC, Inc.,44,Questions and Discussion,