A Report to the Patient Safety Committee of Arizona General Hospital

1. A Report to thePatient Safety Committeeof Arizona General Hospital Prepared by Members of the University of Missouri-Columbia Interdisciplinary Workgroup for the CLARION INTERPROFESSIONAL CASE COMPETITION SPRING 2005

2. INTRODUCTIONS • Ashley Mahon • Accelerated Option BSN, RN Program • UMC School of Nursing • Russell McCulloh • 4th Year, MD Program • UMC School of Medicine • Kevin Norris • 3rd Year, PT Program • UMC School of Health Professions • Brian Stout • 3rd Year, MHA/MBA Dual Degree Program • UMC Schools of Medicine & Business

3. She “might be trouble”-Bus Driver

4. PRESENTATION OVERVIEW • Case Overview • Methods of Analysis • Major Findings • Specific Findings • Recommendations/Action Plan • Tracking Indicators • Cost Analysis • Systems Issues • References/Acknowledgments

5. CASE OVERVIEW • Arizona General Hospital: • Tertiary care center • 620 bed-facility • 97 Behavioral Health Beds • AGH Values: • Dignity • Collaboration • Stewardship • Excellence

6. CASE OVERVIEW • Part of Southwest HC System (SWH) • Flagship for HC delivery in Maricopa Co. • 10 affiliated clinics • Clinical Expertise Centers of Excellence • Behavioral Health • Women’s Health • Rehabilitation • Cardiovascular services • Neuroscience • Oncology • Orthopedics • Spine Care

7. CASE OVERVIEW • 36 year old female • 20 year history of schizophrenia • Admitted for decreased mental status • Treated for suspected overdose • Self-administered medication overdose in hospital • 3-week stay in BHU • Discharged to home • Readmitted seven weeks later for relapse of psychotic symptoms and alcohol intoxication

8. METHODS • Investigation: • Identification of Major Events • Causal Flow Analysis • Root-Cause Analysis (VA-NCPS) • Identification of Contributing Factors • Remediation: • Literature Review • Development of Recommendations • Progress Assessment • Cost Analysis • Extrapolation

9. MAJOR FINDINGS • Three adverse events were identified: • Self-Induced Clozaril Overdose • Job/Coverage Loss & Rehospitalization • Self-Extubation* • Self-Induced Overdose: • Unsuccessful suicide attempt • Near-miss of a reportable JCAHO sentinel event: “Any suicide of a patient in a setting where the patient is housed around-the-clock”

10. Self-InducedDrug Overdose

11. Self-Induced Overdose Timeline

12. Self-Induced OverdoseFlow Diagram

13. Self-Induced Overdose RCA • Root Cause Statement: “Level of patient observation and access to potentially toxic medications resulted in increased possibility of self-induced overdose.” • Three contributing factors domains were identified

14. Care Team Communication

15. Care Team Role Definition

16. Policies & Procedures

17. Self-Induced OverdoseIshikawa

18. Self-Induced Overdose:Contributing Factors • Care Team Communication • Parallel and informal evaluation and communication of self-harm risk • Informal assumption of polysubstance abuse • Care Team Roles • Medication identified solely by ER staff • Primary focus on only physical health aspects of admission • Policies & Procedures • Persistent access to patient of potentially toxic medications • PMH gathered solely from patient’s medication bottle

19. Self-Induced Overdose:Recommendations • Care Team Communication • AMR “tab” dedicated to psychosocial issues1 • Care Team Roles • All pt home meds are to be ID by pharmacist2 • Policies & Procedures • Develop a standard protocol for evaluation & management of all overdose patients3 • Establish procedures for pts. at possible risk for self harm1,4 • Establish security procedures for the intake, storage, and disposition of pt home meds2 • Similar policy for potentially harmful pt. items2

20. Self-Induced Overdose:Tracking Indicators • Suspected overdose patients assessed for self-harm risk* • Employees scoring 70% or greater on knowledge assessment of behavioral health training courses* • Home medications stored securely* *All indicators are percentage-based; goals for implementation are to be set at 100% compliance

21. Self-Induced Overdose:Cost Analysis • Incurred costs • Room sitters (personnel-dependent) • Time/resource demands for training personnel re: new assessment procedures • Monitoring/ongoing risk assessment • Cost-neutral measures • AMR changes covered by IT contract • Estimated savings • Reduced risk of emergent intervention

22. Self-Induced Overdose: Dollars and Sense

23. Job/Coverage Loss and Rehospitalization

24. Job/Coverage Loss& Rehospitalization Timeline

25. Job/Coverage Loss & Rehospitalization Flow Diagram

26. Job/Coverage Loss & Rehospitalization RCA • Root Cause Statement : “Level of social services involvement led to the patient’s job & coverage loss and ultimately resulted in patient’s relapse & readmission to the hospital.” • Three contributing factor domains were identified

27. Care Team Communication

28. Inadequate Social Services

29. AMR Usage

30. Job/Coverage Loss & Rehospitalization Ishikawa

31. Job/Coverage Loss & Rehosp.:Contributing Factors • Care Team Communication: • Care teams engaged in parallel and informal communication • Coordination of Social Services: • Patient assigned to HCC • Currently defined roles for HCC and SW • HCC only involved near end of pt’s stay • AMR Usage: • Hospital staff unfamiliar with documenting psycho-social information into the AMR • Incomplete integration of AMR with organizational culture

32. Job/Coverage Loss & Rehosp.:Recommendations • Care Team Communication • Psych team and SW make daily rounds together for all primary diagnoses of mental illness, psychosis, and drug overdose5 • Fully integrated multi-disciplinary teams • Coordination of Social Services • Redefine the role of the HCC6,7,8 • Automatic referral to SW in cases with primary dx. of mental illness, psychosis, or drug overdose • AMR Usage • AMR “Tab” for psycho-social information • Formal mechanism for staff feedback

33. Job/Coverage Loss & Rehosp.: Tracking Indicators • Staff satisfaction rate with AMR (20% increase from baseline) • Voluntary exit survey for patients receiving Psych/SW team care • Percent of pts. admitted with diagnosis of mental illness, psychosis, or drug overdose, assessed by SW (100%) • Percent of pts seen by HCC within: - 36 hours of admission (>95%) - 48 hours of admission (100%) 5. Number of readmissions due to mental illness, psychosis, or drug overdose (10% reduction)

34. Job/Coverage Loss & Rehosp.: Cost Analysis • Cost Neutral Recommendations: • AMR changes (provided through IT contract) • Social Worker/Psych rounds • Referral policies • Incurred Costs • Additional HCCs (case managers)9 • Savings • Reduce number of psych readmissions6 • Reduced LOS by 10% with multi-disciplinary rounds5 • Reduced per-patient cost of stay by up to 16% with multi-disciplinary rounds5

35. Job/Coverage Loss & Rehosp.:Dollars and Sense

36. Job/Coverage Loss & Rehosp.:Dollars and Sense

37. Self-Extubation

38. Self-Extubation Timeline

39. Self-Extubation Flow Diagram

40. Self-Extubation RCA • Root Cause Statement : “The level of sedation & agitation management increased the likelihood of patient self-extubation” • Three major contributing factor domains were identified

41. Care Team Communication

42. Policies & Procedures

43. Scheduling

44. Self-Extubation Ishikawa

45. Self-Extubation:Contributing Factors • Care Team Communication: • Time/location of pharmacist involvement • Communication b/w front-line providers • Policies & Procedures: • Extent of behavioral assessment • Availability/use of agitation management protocols • Availability/use of sedation and weaning protocols • Scheduling: • Provider staffing-level in ICU

46. Self-Extubation:Recommendations • Care Team Communication: • Ensure timely urine/serum toxicology screens in conjunction with overdose protocols • Develop AMR flag for pharmacist consult in all cases involving drug overdose • Policies & Procedures: • Institute routine use of agitation management protocols by ICU staff (Ramsay)10 • Institute use of sedation protocols in ICU11,12 • Institute use of weaning protocols in ICU10,13 • Scheduling: • Evaluate adequacy of ICU staffing/training10,14,15

47. Self-Extubation:Tracking Indicators • Incidence of self-extubation (ICU) • Length of ventilator support (ICU) • ICU pt-nurse staffing ratios (1.5-1.7) • Number of pts (per 100 intubated pts) that score below 3 on two consecutive hourly Ramsay Assessments (Zero) • Percent of overdose pts whose records include RPh consult notes (100%) • Percent of overdose pts whose urine/serum toxicology screens are ordered w/in 1 Hr of admit to ER (100%)

48. Self-Extubation:Cost Analysis • Incurred Cost: • Increased ICU Staffing? • Physician/RPh Consult Fees • Implementation of protocols/training • Monitoring/ongoing risk assessment • Estimated Savings: • Decreased LOS in ICU (Decrease of 3.5 days)16,17 • Shorter Duration of Ventilator Support (Decrease of 2.5 days17; between 63 and 89% of SEs do not require reintubation10) • Costs of Reintubation (>40% Decrease)11

49. Self-Extubation:Dollars and Sense

50. “The Big Picture”