Nebs No More After 24!

1. Nebs No More After 24: Improving Use of Appropriate Respiratory Services UCSF DIVISION OF HOSPITAL MEDICINE Christopher Moriates MD, Maria Novelero MA MPA, Matthew Cascino MD, Katie Quinn MPH, Theodore Omachi MD MBA, Sumant Ranji MD, Raman Khanna MD, Michelle Mourad MD Supported by Caring Wisely, a project of the UCSF Center for Healthcare Value – Delivery Systems Initiative  BACKGROUND PILOT STUDY RESULTS: Nebulizer Utilization CONCLUSIONS • The delivery of a nebulized bronchodilator therapy (nebs) to hospitalized patients is a resource-intensive treatment involving direct care by a Respiratory Therapist (RT). • Metered Dose Inhalers (MDIs) have been shown to be equally effective as nebs when used correctly.1,2,3 • A majority of patients misuse their prescribed MDI, but all are able to achieve mastery with teaching.4 • Administering unnecessary nebs is a missed opportunity to educate patients on the proper use of MDIs. • At our 600-bed academic medical center, we spent over $1 million in direct costs for administration of nebs to non-intensive care unit patients on the Medicine Service during FY2012, averaging approximately 5 nebs for every admission to the high-acuity medicine ward. • A multifaceted intervention has been successful in simultaneously: • Decreasing neb treatments by approximately 50% • Enhancing MDI patient education • Improving evidence-based resident physician knowledge • Savingdirect costs for the medical center • Reducing utilization of these unnecessary treatments may provide an ideal target for improving healthcare value (quality / cost). • References: • 1. Turner MO, et al. Arch Intern Med. 1997;157(15):1736–1744. 2. Dolovich MB, et al. Chest. 2005;127(1):335–371. • 3. Mandelberg A, et al. Chest. 1997;112(6):1501–1505. 4. Press VG, et al. JGIM. 2011;26(6):635–642. • Phase 1: Jun – Aug • Removed neb treatments from the “admit order set” • Enlisted RTs and nurses to provide MDI teaching to inpatients • Phase 2: Aug – Dec • Launched educational program, including prepared facilitator guides for attending physicians • Created promotional campaign including posters, flyers, and pens • Provided targeted feedback to physicians • Phase 3: May-Jul • Introduce CPOE intervention to link neb orders with automatic MDI transitions • Expand project medical center-wide GOALS PILOT STUDY RESULTS: Knowledge and Attitudes WHAT CAN YOU DO? • To decrease neb usage in hospitalized patients on a high-acuity medicine wardby at least 15%. • To provide inpatient education on proper MDI self-administration. • To improve resident physician knowledge regarding the use of appropriate respiratory therapies. Pre- and post-intervention survey used to assess changes to resident physician knowledge and attitudes: • Use MDIs at admission unless there is a clinical indication for nebulizer therapy • Transition your patients from nebs to MDIs after 24 hours, if appropriate, and write an order for RT to provide MDI teaching • Help us spread the word: • MDIs are as effective as nebulizer treatments! • MDIs provide high value, high quality patient care! • We can teach and train our patients on correct MDI use while in the hospital! Nebs No More After 24! Help us improve transitions from nebulizers to MDIs and provide patient education about proper MDI use.