The Perioperative Experience

1. The Perioperative Experience Patient & Nursing Education Anemia Management and Intra-operative Data Collection September 21, 2013 For patient centered care. Fight On.

2. Patient Blood Management (PBM) at USCAn Evolving Program with New Directions!

3. Learning Objectives for SABM Define meaningful Patient Blood Management (PBM) data essential to reporting patient outcomes Establish the growing role of nursing practice in optimal PBM in a variety of settings Identify strategies for educating and training healthcare professionals in PBM Define & Communicate meaningful PBM data that is essential to quality reporting in a format that may correlate w patient outcomes Establish the growing role of nursing practice in optimal PBM in a variety of settings

4. Data Tracking Difficulties with PBM Real Time Intra-op data not well collected from paper or even Electronic Medical Records (EMR) computed formats What – No clear definition of what data is important Who – No consistent designee(s) How – No consistent mechanism Where – No clear pathway into which to feed the data

5. Surgical Timeout Prior to commencement of operation A confirming event for patient safety & global intra-op awareness Multi-disciplinary coordinated effort in OR to Identify Correct Patient, Surgeon, Anesthesia Antibiotics Correct Site and Laterality Allergies Procedure Documentation for Quality record keeping

6. “PBM Timeout”Why Not?--New Variation on Old Theme Perform near completion of surgery Allows for a multi-disciplinary coordinated effort in OR to identify input from Nursing/Anesthesia/Surgery in real time data format Goal: Accurately capture important data elements in an operative EMR module – the Intra-op PBM Dashboard – written as a Power Form Intra–operative PBM Dashboard, then uploads dataset into hospital EMR EMR then query–able for all loaded PBM data Allows accurate collection & tabulation of important clinical variables that historically never had a good capture mechanism and usually have to do chart reviews to identify

7. Data Tracking Difficulties with PBMProblems Solved No clear definition of what data is important We define the important variables to track No consistent time, no consistent designee(s) Near Completion of Case Nursing – Anesthesia – Surgery No consistent mechanism PBM Timeout No clear pathway into which to feed the data Intra–op Dashboard (Power Form) to the EMR

8. Intra-Operative Data-Forms

12. PBM DashboardGenerated from EMR Power-Forms

18. Patient Blood Management Timeout Institutional Implementation of a New Process • Circulating Nurse is Captain of both timeouts and responsible for accurate data entry • Functional efficiency of the Power Form and the Intra–op Dashboard • Do a walk through of the process

19. Process Walkthrough PBM Intra-op Dashboard Implementation PBM Committee identifies important clinical variables and develops mock–up of the module Intra-op module presented to OR Committee as well as IT and EMR Committee’s for acceptance of process and creation of the Power Form that integrates with EMR Quality Committee approval for a process that must be monitored and reported OR Charge Nurse is key for OR Committee to approve the role of nursing here and to develop the nursing competencies to direct the process and supply the data entry

20. Establish the Growing Role of Nursing Practice in Optimal PBM in a Variety of SettingsAnemia Management Program – Patient MarketingPACE – Outpatient Clinics – ICU’s – CRNA’s Physician Offices – Interventional Radiology

21. Nurses and NPs have most immediate patient contact (inpatient and outpatient) In addition, Nurses and NP’s are the managers of the services provided at the major Patient–Entry Portals Nursing Council for PBM–New Concept here as well Nursing managers that oversee hospital service service lines to develop Power Form templates specific to their service line Submission to the PBM Cmte for approval and IT for creation Nurses define workflow for Site-Specific power form Nursing as the Driving Force for Cultural Change in Patient Blood Management

22. Council of Nurse Managers of hosp service lines. Develop EMR power forms & define workflow pathways for completion. Educate staff while quality monitors performance Hospital Culture Transformation Continuing Education QA Responses to Fallouts Critical Clinical Pathways ANH-AMP-Tx Guidelines QA Structures Data Tracking & Sorting Universal Credentialing Practices Hospital Based Committee Integration EMR Integration of TFS & PBM Data Metrics Departmental-Service Line & Programmatic Involvement Nursing Advisory Council

23. AnemiaPBM Public Enemy #1 Anemia Leads to Transfusion Often correctible in a short period of time Nevertheless, accompanies many patients to the OR And now we can track that in our Dashboard And it can become a fallout by service line or even by MD And it can become a PI project Nevertheless, Insurance authorization for ESAs for anemia correction can be difficult, so cannot put pressure on service lines or physicians to correct anemia without some type of institutional effort to centralize and soften the problem

24. Anemia Management Program (AMP)Centralized Institutional Response to Pre-operative Patient Anemia Anemia Management Program Piggybacks off the OIC cost and personnel center – low $ Authorizations for ESA’s Infusions, injections, oral therapies Hyper–augmentation JW procedures Conventional Hospital Program Structure Medical Director Nurse Manager P&P’s, Pathways, Order Sets Visits registered into EMR for inclusion in PBM Dashboard

25. PBM Business and Operational Impacts Allays administrative concerns: Reduced inpatient stay Blood product utilization Shifts cost of anemia therapeutics to reimbursable outpatient setting Facilitates physician concerns: “One-stop-shop” anemia Rx eliminates operational inefficiencies Increase patient satisfaction: Public increasingly aware of transfusion risks Market program and transfusion alternatives directly to patients

26. Outpatient Marketing to Patients SMART THING! Pharmaceutical companies did market directly to patients – even if the medication required a prescription Once we have directly sparked patient interest and involvement – that will often trump the resistance to old ways of practice which can then drive the agenda towards modern PBM Patient then will mention to anesthesia in PACE clinic that they want conservation practice

31. OBJECTIVE Identify strategies for educating and training healthcare professionals in PBM

32. Applicable to Personnel Types Nurses, CRNAs, NPs, Nurse Managers Physicians Residents Staff – Unit Clerks, Pharmacy, Blood Bank, Pre-operative Assessment & Clinical Education (PACE) Administration – Quality Admitting, ER, Professional Committee’s Education as a Tool for Cultural change Clinical & Non-Clinical Staff as Targets

33. Hospital based service lines where the action is: Focus educational attention here. Many--Nurse Managed Admitting – ER – Outpatient Department – Transfer Center - PACE OR – OR Scheduling – Blood Bank – AMP ICU – Interventional Radiology Pharmacy – Perfusion Services Education as a Tool for Cultural Change Services as Targets

34. Credentialing for TFS and PBM as a condition of employment NPs belong in credentialing piece in same fashion as physicians Nursing competencies as part of healthstream Re-take test in circumstances where there is a fallout (TFS particularly) Staff education falls in with nursing education Nursing Education

35. Competency Module • ANCILLARY Laboratory Pharmacy Perfusion Services

36. All nurses take a general nursing test Nurses who work for particular hospital based svc would have to take test that included dashboard material for that service line Make it a condition of employment or referral Define Fallouts Fallouts trigger administrative response from PBM program- retake the module for both the offending person as well as the service line manager Specialty or Service Line Credentialing or Competency Module

37. Pathway to our nursing credentialing process on website http://transfusionfree.usc.edu/

39. Site Specific Data-Form designed by Nurse Mgrs+ QA + PBM Committee Model for Data Form creation that generates EMR Powerforms To IT for creation of Powerforms into EMR Dashboard supported by EMR Re-educational processes for individual or Service Line fallouts Implementation Workflow Defined Quality & Nurse Mgrs do Oversight + define fallouts Functional Process at Site Specific Location Education for Competencies

40. Multi-Entry points Demonstration of the multiple entry points from Institutional Site Specific Locations into the EMR via Powerforms

41. Interventional Radiology Critical Care Anemia Mgmt Program Operating Room Pharmacy Blood Bank Donation (PAD, Directed, Unpaid) donor Centers Clinical Dataforms Fed into Cerner as Powerforms Other Clinical? Laboratory PBM Dashboard (from EMR) Financial Data Utilization Review Data

42. Model for PBM Derivative from TFS PBM Critical Pathway for Detailed Analysis of Actual Blood (Product) and Blood Product Costs within the Institution Followed by Institutional Response to Interrogated Data

43. Metrics of Performance Physician Service Line Department Hosp-based Svc Fallouts Institutional Pressure PBM & Quality Cmte Driven Queries PBM Dashboard (from EMR)

44. Questions? Thank you! Yolee Casagrande, RN, MSN Nurse Director Evaluation & Treatment Clinic (ETC), Observation Unit, Infusion Center, Women’s Health Services, and Department of Surgery Clinics 323 442 9696