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1、April 14,2005,Medical Review of NC,Inc.,1,Pneumonia careControversies and Challenges,Meera Kelley MDClinical Coordinator,MRNC,Inc.The QIO for the Carolinas,April 14,2005,Medical Review of NC,Inc.,2,Overview,Issues with the indicatorsOther broad challengesDiscussion,April 14,2005,Medical Review of NC
2、,Inc.,3,PN-1 Oxygenation assessment PN-2 Pneumococcal vaccination PN-3b Blood cultures PN-4 Adult smoking cessation advicePN-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
3、antibiotic selection Non ICU PN-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
4、with pneumonia.,April 14,2005,Medical Review of NC,Inc.,5,Controversies&ChallengesOxygenation 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
5、survival has been 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&ChallengesBlood cultures,Drawn late-after antibioticsNot drawn at all-not routinely done for outpatients,April 1
6、4,2005,Medical 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 id
7、eal opportunity 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&ChallengesSmoking cessation advice,DocumentationPreventive,long term issues not routinely addr
8、essed by physicians,April 14,2005,Medical Review of NC,Inc.,10,PN-5 Antibiotic timing,Timely administration of antibiotics=improved outcome among pneumonia patientsImproved survival with receipt of antibiotics within 4 h of admission(Khan 1990)Shortening the time-to-first-dose to 4 h was associated
9、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,Medical Review of NC
10、,Inc.,11,Controversies&ChallengesAntibiotic timing,Time from arrival to diagnosis,April 14,2005,Medical Review of NC,Inc.,13,Controversies&ChallengesAntibiotic selection,Elderly,nursing home patient,other reasons want to give broader therapy,April 14,2005,Medical Review of NC,Inc.,14,April 14,2005,M
11、edical 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 pneumococciHospitalization is an underutilized opportunity,April 14,200
12、5,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 opportunity,April 14,2005,Medical Review of NC,I
13、nc.,18,April 14,2005,Medical Review of NC,Inc.,19,Controversies&Challengesinpatient immunizations,Too sickWont workTakes long time to establish historyPhysician role,April 14,2005,Medical Review of NC,Inc.,20,Controversies&Challengespneumococcal vaccination,Perception of risk of reimmunizationCochra
14、ne 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&Challengesinfluenza vaccination,AvailabilityIt made me sickDocs prefer to give it in office,April 14,2005,Medical Review of NC,Inc.,
15、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 frazzledterrifiedWe need to;tell them only what they need to knowshow how we can make their life better,April 14,2005,Medical Review of N
16、C,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 defined,but limited role to play,April 14,2005,Medical Review of NC,Inc.,25,Communicatin
17、g 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 we need your input”Ensure you will be responsive to feedback“We would like to try this f
18、or 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 futureStep#2 convey to audience how taking the action will give THEM the future they wantStep#3 call to action-ask for commi
19、tment of first stepMark Walton,Center for Leadership Communication,Chapel Hill,April 14,2005,Medical Review of NC,Inc.,27,Message to physiciansWe understand that their day-to-day life is overwhelming,April 14,2005,Medical Review of NC,Inc.,28,Patient care,Billing,Accurate coding,Interruptions,Phone
20、calls,Pharmaceutical reps,Formularies,Insurance status,Health care plans,Office administration,Other patients,Prior authorizations,Clinical practice guidelines,Drug interactions/effects,Beepers/Pages,29,Systematically review each drug for potential side effects and interactions during 20 minute visi
21、t(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 2005;1444 summaries)July 2004;1329),30,April 14,2005,Medical Review of NC,Inc.,31,April 14,2005,Medical Review of NC,
22、Inc.,32,We can.But we cannot ensure that,Bypass,balloon,or stent a heart blockagedissolve a clot for a heart attacktransplant a heartprovide ventilator and BP support for pneumoniatreat resistant bacteria such as MRSA,VRE,DRSP,the antibiotic is given 1 hr prior to CABG(47.6%US)the patient gets an as
23、pirin 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 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 chan
24、ging the process.Contrast:FedEx,EBay,Amazon,Starbucks,April 14,2005,Medical Review of NC,Inc.,34,Who is responsible for improving the system?,April 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 j
25、ust do it?,April 14,2005,Medical Review of NC,Inc.,36,Skills of physicians,assess patientsdirect major aspects of therapyperform specific interventionscommunicate with patients,April 14,2005,Medical Review of NC,Inc.,37,To make best,most efficient,most effective use of physicians skills,need to prot
26、ect time and touch of the patient-physician interaction.Alice G.Gosfield,J.D.,Snyder,9/12/03,April 14,2005,Medical Review of NC,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
27、 14,2005,Medical Review of NC,Inc.,39,Physicians take the lead,There is no indication that the practice of medicine is getting less complex.Spend time today to save time tomorrow.,April 14,2005,Medical Review of NC,Inc.,40,Old paradigmMaintain knowledge-rely on memoryIndividualizeEncourage variation
28、Avoid“cookbook”,Avoid crutches,pocket-fillersWork long hours-continuity of careFollow instructions of physician without questioning for fear of responseHealth is provided by the physician,New paradigmAvoid reliance on memoryProvide consistencySimplifyUse protocols,check tools,referencesMinimize long
29、 hours-encourage safetyMirror back orders,ask questions,raise doubt without fear of retributionHealth 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 patientsdirect major aspects of therapyper
30、form specific interventionscommunicate with patientsNo 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 wayWork with administratorsMake use of computers and technology,April 14,2005,Medical Review of NC,Inc.,44,Questions and Discussion,
