Introduction to 7 south Cardiology Wards Medical Director 7 South Bart Cox MD Unit Director 7 South Melissa Johnson RN MSN Pharmacist Tiffany Montoya PharmD PhC Chief Resident Mark Garcia MD ID: 440656
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Slide1
Cardiology Wards
Introduction to 7 southSlide2
Cardiology Wards
Medical Director 7 South
– Bart Cox, MD
Unit Director 7 South
– Melissa Johnson, RN, MSN
Pharmacist – Tiffany Montoya,
PharmD
,
PhC
Chief Resident – Mark Garcia, MD Slide3
Presentation Goals and Objectives
Interdisciplinary approach
Improve communication between Residents, Nurses, Pharmacists, Social Workers,
Discharge Managers, Techs
Improve
outcome measures, education, and patient care
Identify areas needing improvement and areas of success
Discuss Core Measures and HF Performance Indicators
Increase resident’s knowledge of 7 south
Projects, On going research, New devices
Changes in protocols
Identify and address issues
Medication Reconciliation Tutorial Slide4
Inpatient Cardiology
Goals and Objectives Slide5
Inpatient Cardiology Wards - Orientation
Read the University Cardiology Rotation Handout
in the email packet
Be familiar with email packet material
New Call schedule
Must comply with duty hours (28hr rule)
Clinic schedules
Residents need to be familiar with all patients on service
Recommend creating a master schedule and posting it in the workroom
Slide6
Orientation Packet
University cardiology rotation goals and expectations
Discharge summary
t
emplate
H and P template
Nuts and bolts for orders
Call schedule sample
Common phone numbers
Common medications and
dosage
Orientation PowerPoint Slide7
Performance Measures
Core Measures and why it is this important to you
Heart Failure Performance Indicators Slide8
Core measures and Public Reporting
Centers for Medicare and Medicaid (CMS)
The Joint Commission (TJC)
And several others teamed up to create the:
Hospital Quality Alliance (HQA)
Used
Evidence Based Medicine
and developed “Core Measures”
Public Reporting of Core Measure compliance
Is this hospital providing care proven to improve mortality, morbidity, re-hospitalizations, etc.? Slide9
Core measures and Public Reporting
TJC (hospital accreditation people) and CMS (payment people)
Receives accreditation survey from
United Hospital Center (UHC)
CMS provides payments to hospitals based upon the Annual Payment Update (APU)
Reductions in payment for noncompliance
Other
payer's:
public and third party use info and compare hospitals
The Joint Commission (TJC)
Hospital accreditation based upon core measures, efforts to improve problem areas, and continuous submission of data Slide10
Core measures and Public Reporting
Provide
transparency to the
public
Holds health care organizations accountable for performance
Provides patients with a high standard of care and interventions known to improve outcomes Slide11
UNMH Core Measures
AMI
Aspirin on arrival
Aspirin prescribed at discharge
ACEI or ARB for LV systolic dysfunction
Beta
Blocker prescribed at
discharge
PCI within 90 minutes of arrival
Statin at discharge
Fibronolytic
therapy with 30 minutes of arrival
Smoking Cessation
HF
Discharge Instruction (6 elements)
Evaluation of LVS function
ACEI/ARB for LVSD
Smoking Cessation Slide12
UNMH Core Measures - Below Target
Covers January 2011 to December 2011
Core
Measures
Apr 2011
– March 2012
Observed%
Oct –
Dec 2011 (Q4)
Observed
%
Jan – March 2012 (Q1)
Observed
%
April – June 2012
2012(Q2)
Observed %
Target
%
(Per UHC)
% HF-3 ACEI or ARB for LVSD
96
97
90
100
95
% AMI-3: ACEi or ARB for LVSD
95
90
100
100
95
% HF-1: Discharge Instructions
88
81
87
92
94Slide13
UNMH Core Measures - Below TargetSlide14
Areas needing IMPROVEMENT and areas of success
Medications
Discharge
Documentation
Ward SpecificSlide15
Areas of improvement: Medications
ACEi
/ARB
- Documentation of intolerance/contraindication
ACEi
/ARB for AMI with LV dysfunction and HF patients with LV dysfunction
Document
ACEi
(or ARB) held for:
Worsening renal function, angioedema, hyperkalemia, hypotension, or renal artery stenosis
If
ACEi
allergy, then
must
state ARB contraindication (allergy not a class effect)
Aldosterone Antagonist
Appropriate documentation
Appropriate indications
Medication Reconciliation
Must be done on admissions, transfers, and discharges
Discharge instructions must match discharge summary Slide16
Areas of improvement: Discharge
Written discharge instructions and/or educational material must be given to patient or care giver at discharge and address the following
Activity
Level
Diet
Discharge Medications (med rec)
Follow-up
Appointments
Weight
Monitoring
What
to do if symptoms
worsenSlide17
Areas of improvement: Discharge
Discharge
instructions
Recent decline in HF dc instructions (mostly due to med rec)
Don’t delete instruction sections
Matching lists in dc summary and discharge
instructions
Sign depart process then discharge order (last two things)
Discharge follow-up in 7 days
by any provider
Weekend scheduling
Medication Errors
Medication reconciliation
at admission, transfer, and discharge
decreases
error
ratesSlide18
Areas of improvement:
Depression Screenin
g
PHQ9
and documentation of results
Starting
to screen depression in AMI and HF patients
Residents
need to document scores in dc summary
If
>
10 then discuss treatment options with patient
Treat – sertraline, defer to PCP must have f/u call to PCP, or inpatient psych consultation
If patient has SI/HI or + on question #9 –
needs physician assessment and possible psychiatry consultation if provider feels necessary
Patients will need outpatient
follow up
instructions in dc summary Slide19
Areas of improvement: Documentation
H & P Documentation
Recent decline in complete documentation on H and Ps:
Family History:
Not
okay to state “non-contributory”
It is okay to use that phrase during oral presentations
Review of Systems:
Must document 10 systems – 2 items each
Cannot say “otherwise negative” or “12 point ROS completed and negative” Slide20
Areas of improvement: Ward Specific
Potential hour violations with new call schedule
Be aware of clinic and post call days
Create a master schedule and post in work
room
Let fellow know >1 hour prior to suspected hour violation to handoff duties
Hand
washing:
Physicians
on 7 south 33% (poor
)
Residents need to be familiar with
all
Cardiology patientsSlide21
Areas of success
Aspirin on arrival
Aspirin on discharge
Smoking Cessation
Statin on discharge
LV function evaluation in heart failure
Communication – Showing Patients Respect
Cardiac Rehab referral Slide22
Upcoming Events and Ongoing Research
Ultrafiltration
(
Aquapheresis™) started August 2012
Educational DVDs
Pulmonary
h
ypertension continuous infusionSlide23
Cardiology admissions
Residents will be given a handout on “high risk features”
Will need to call fellow if meeting this criteria
Residents will need to use
powerplans
for all:
Heart Failure admissions (Adult Heart Failure)
Do not uncheck Cardiac Rehab
Acute Myocardial Infarcts (Adult Acute Coronary Syndrome)
All admissions from 7 am – 8:30 pm will be discussed with cardiology fellow
All heart failure admitted to cardiology, unless multiple diagnosis,
heme
/
onc
receiving therapy
All transfers are attending to attendingSlide24
Cardiology admissions
All blocking, refusals, “
turfing
” to other services will require:
Discussion with fellow or attending prior to refusal
Documentation that fellow/attending was in agreement
Consult note will have name of fellow/attending
Consult note on
all
refusalsSlide25
Cardiology admissions
Family Medicine
Give Family Medicine service first option of admission
All STEMIs go to cardiology
PCP and primary cardiologist
Please forward H and P and DC summaries to PCP
and CardiologistSlide26
Cardiology discharges
Use the standardized
DC
summary
template:
Cath
reports, PHQ9 score and discussion, medication contraindications, discharge weight, follow up, reason for medication
changes, etc.
EMR (=
cardiacdischargesummary
)
if typing
Resident not responsible for scheduling PCP appointment
All CAD and HF patients will be referred to cardiac rehab
Make sure it is ordered prior to discharge (on HF
powerplan
)
Do not “uncheck” the cardiac rehab order
Assure appropriate medications and matching dc instructions to dc summary upon discharge
When in doubt ask.Slide27
Medication Reconciliation
Tiffany Montoya, PHARMD, PHC
Medication Reconciliation made easy (and correct)
Evaluations
will be based on compliance
Will be tracking residents performance of med rec
If unable to be at orientation:
Will need to schedule meeting within one week with Tiffany
Mid-point evaluation