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1、Pneumonia careControversies and ChallengesMeera Kelley MDClinical Coordinator, MRNC, Inc.The QIO for the CarolinasOverviewIssues with the indicatorsOther broad challengesDiscussionApril 14, 20052Medical Review of NC, Inc.PN-1 Oxygenation assessment PN-2 Pneumococcal vaccination PN-3b Blood cultures
2、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 antibiotic selection Non ICU PN-7 Influenza vaccination April 14, 20053Medical Review o
3、f NC, Inc.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, 20054Medical Review of NC, Inc.Controversies & ChallengesOxy
4、genation assessment NoApril 14, 20055Medical Review of NC, Inc.PN-3b Blood culturesPublished pneumonia treatment guidelines recommend performance of blood cultures for all inpatients to optimize therapy. Improved survival has been associated with optimal therapy. Yield is greater if the culture is c
5、ollected before antibiotics are administered.April 14, 20056Medical Review of NC, Inc.Controversies & ChallengesBlood culturesDrawn late-after antibioticsNot drawn at all-not routinely done for outpatientsApril 14, 20057Medical Review of NC, Inc.PN-4 Adult smoking cessation advice/counselingSmoking
6、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 opportunity for a patient to stop smoking.Patients who receive even brief smoking-ce
7、ssation advice from their physicians are more likely to quit.April 14, 20058Medical Review of NC, Inc.Controversies & ChallengesSmoking cessation adviceDocumentationPreventive, long term issues not routinely addressed by physiciansApril 14, 20059Medical Review of NC, Inc.PN-5 Antibiotic timingTimely
8、 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 with improved survival (McGarvey 1993)First dose of antibiotic within 3 hours -less like
9、ly 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, 200510Medical Review of NC, Inc.Controversies & ChallengesAntibiotic timingTime from arrival to diagnosisA
10、pril 14, 200511Medical Review of NC, Inc. Controversies & ChallengesAntibiotic selectionElderly, nursing home patient, other reasons want to give broader therapyApril 14, 200513Medical Review of NC, Inc.April 14, 200514Medical Review of NC, Inc.PN-2 Pneumococcal vaccinationIndicated for persons 65 y
11、ears 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, 200515Medical Review of NC, Inc.April 14, 200516Medical Review of NC, Inc.PN-7 Influ
12、enza vaccinationIndicated for people 50 years Highly effective in preventing influenza-related pneumonia, hospitalization, and death. Hospitalization is an underutilized opportunityApril 14, 200517Medical Review of NC, Inc.April 14, 200518Medical Review of NC, Inc.Controversies & Challengesinpatient
13、 immunizationsToo sickWont workTakes long time to establish historyPhysician roleApril 14, 200519Medical Review of NC, Inc.Controversies & Challengespneumococcal vaccinationPerception of risk of reimmunizationCochrane Databast Syst Rev 2003; (4) CD000422-”pneumococcal vaccination does not prevent pn
14、eumonia or death in adults”April 14, 200520Medical Review of NC, Inc.Controversies & Challengesinfluenza vaccinationAvailabilityIt made me sickDocs prefer to give it in officeApril 14, 200521Medical Review of NC, Inc.Other broad challenge-working with physiciansApril 14, 200522Medical Review of NC,
15、Inc.Communicating with docs-tipsBear in mind-most are feeling overwhelmed frazzledterrifiedWe need to;tell them only what they need to knowshow how we can make their life betterApril 14, 200523Medical Review of NC, Inc.Communicating your message effectively-tipsStart planning your presentation by de
16、termining 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 playApril 14, 200524Medical Review of NC, Inc.Communicating your message effectively-tipsAcknowledge their challenges“We recognize how busy you are as
17、 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 for 3 months and want you to let us know what you think”April 14, 200525Medical Review of N
18、C, Inc.Communicating your message effectivelyStep #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 commitment of first stepMark Walton, Center for Leadership Communication, Chapel HillApril 14,
19、 200526Medical Review of NC, Inc.Message to physiciansWe understand that their day-to-day life is overwhelmingApril 14, 200527Medical Review of NC, Inc.Patient careBillingAccurate codingInterruptionsPhone callsPharmaceutical repsFormulariesInsurance statusHealth care plansOffice administrationOther
20、patientsPrior authorizationsClinical practice guidelinesDrug interactions/effectsBeepers/PagesApril 14, 200528Medical Review of NC, Inc.Systematically review each drug for potential side effects and interactions during 20 minute visit(new drug approvals FDA 2003; 42, 2002; 92 ) Systematically recall
21、 each step of the best practice for each clinical syndrome may encounter (National Guidelines Clearinghouse summaries Feb 2005; 1444 summaries) July 2004; 1329)2930April 14, 200531Medical Review of NC, Inc.We can. But we cannot ensure thatBypass, balloon, or stent a heart blockagedissolve a clot for
22、 a heart attacktransplant a heartprovide ventilator and BP support for pneumoniatreat resistant bacteria such as MRSA, VRE, DRSPthe 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, gi
23、ven (14% US)penicillin allergic patient doesnt get penicillinApril 14, 200532Medical Review of NC, Inc.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, StarbucksApril 14, 200533Medical Review of
24、NC, Inc.Who is responsible for improving the system?April 14, 200534Medical Review of NC, Inc.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, 200535Medical Review of NC, Inc.Skills of physiciansassess patientsdir
25、ect major aspects of therapyperform specific interventionscommunicate with patientsApril 14, 200536Medical Review of NC, Inc.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, 9/1
26、2/03April 14, 200537Medical Review of NC, Inc.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, 200538Medical Review of NC, Inc.Physicians take the leadThere is no indication that
27、the practice of medicine is getting less complex.Spend time today to save time tomorrow.April 14, 200539Medical Review of NC, Inc.Old paradigmMaintain knowledge-rely on memoryIndividualizeEncourage variationAvoid “cookbook”, Avoid crutches, pocket-fillersWork long hours-continuity of careFollow inst
28、ructions of physician without questioning for fear of responseHealth is provided by the physician New paradigmAvoid reliance on memoryProvide consistencySimplifyUse protocols, check tools, referencesMinimize long hours- encourage safetyMirror back orders, ask questions, raise doubt without fear of r
29、etributionHealth is achieved by the teamApril 14, 200540Medical Review of NC, Inc.Cookbook concernsApril 14, 200541Medical Review of NC, Inc.Skills of physiciansassess patientsdirect major aspects of therapyperform specific interventionscommunicate with patientsNo checklist, cookbook, or computer will ever replace this!April 14, 200542Medical Review of NC, Inc.Bringing healthcare into the 21st centuryPhysicians lead the wayWork with administratorsMake use of computers and technologyApril 14, 200543Medical Review of NC, Inc.Questions and DiscussionApril 14, 200544Medical Review of NC, Inc.
