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State Name: Ohio Practice: Toledo Children Primary Care Team Members:. Chapter Quality Network (CQN) Asthma Pilot Project Team Progress Presentation. Toledo Children Primary Care. Progress Summary Since Learning Session 1.
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State Name: Ohio Practice: Toledo Children Primary Care Team Members: Chapter Quality Network (CQN) Asthma Pilot Project Team Progress Presentation
Progress Summary Since Learning Session 1 • Improved engagement of QI team – providers are meeting monthly to discuss use of NHLB guidelines for care of asthma patients in our office. Staff are meeting frequently to discuss best processes for improving efficiency of providing asthma care. QI data turned in monthly. Team attending all required meetings and phone conferences. • Improving Follow up - Developing system to identify asthma patients by color labeling charts. Reviewing ideas for use of registry for Asthma patients. Scheduling follow up appointments at asthma visits, calling for follow up appointments after ER visits. • Increasing use of Planned care approach – developing and implementing improved workflow to support use of protocols with all providers, developed new asthma visit note to use at Asthma visits. Trained staff on correct use of Spirometry testing. Completing spirometry testing on patients per provider order. • Approach to Employing Protocols – Standardizing processes for each provider and staff to best implement use of evidence-based protocols with all patients. Providing Asthma Action Plan to all patients at asthma visit. • Self management support – Evaluating educational materials that help patients and family learn self management of disease process. IE: written material, asthma education per individual patient or group. Phone education vs. in-person education.
Spirometry ? • Low FEV1 is associated with increase risk for severe exacerbations. • Regular monitoring of pulmonary function is particularly important for asthma patients who do not perceive their symptoms until airflow obstruction is severe. There is no readily available method of detecting the “poor perceivers.” The literature reports that patients who had a near-fatal asthma exacerbation, as well as older patients, are more likely to have poor perception of airflow obstruction. • Two large, retrospective cohort studies have shown that a reduction in FEV1 at an annual visit is associated with increases in the risk of an attack of wheezing and shortness of breath over the next 12 mo.
PDSA Title: Plan: Perform Spirometry testing in office Do: Train nurses to accurately complete testing on appropriate asthmatic patients Study: Validate results of Spirometry testing for accurate results on appropriate asthmatic patients Act: Increase number of accurate tests on appropriate asthmatic patients PDSA Cycles
P P P P P P P P P P P D D D D D D D D D D D S S S S S S S S S S S A A A A A A A A A A A PDSA Ramps TEST 4 What: Perform Spirometry test Who (population): 5 pt. per week Who (executes): All trained nurses Where: Office When:Dec. 2009 TEST 4 What: Spirometry testing Who (population): All patients Who (executes): All trained nurses Where:Office When: June 2010 TEST 3 What: Validate results between trained nurses Who (population): 3 pateints Who All Providers Where: Ofice When: June 2010 TEST 3 What: Perform Spirometry test Who (population): 2-3 pts. Per week Who (executes): 1 trained nurse Where: Office When:Nov. 2009 TEST 3 What: Spirometry testing Who (population10 patients/week Who (executes): all trained nurses Where: Office When: May 2010 TEST 2 What Validate results Spirometry vs Formal PFT Who (population): 1-2 pts. Who (executes): All trained nurses Where: Office When:Feb 2010 TEST 2 What: Perform Spirometry test Who (population): 1 patient/week Who (executes):1 trained nurse Where: Office When:Oct. 2009 TEST 2 What: Spirometry testing Who (population): 2-5 pts/week Who (executes): All participating providers Where: office When: April 2010 TEST 1 What: Validate accurate results Who (population): 5 – 10 pts Who (executes): All trained nurses Where: Office When: Jan 2010 TEST 1 What: Perform Spirometry test Who (population): Train nursing staff Who (executes):Resp therapist: John Where: Office When: October 2009 TEST 1 What: Spirometry testing Who (population): 1 patient Who (executes): Participating providers Where:Office When:March 2010 Monitering results Spirometry Expand Use of Spirometry testing Spirometry testing
Toledo Children's Primary Care: Clinical Assessment Process Map – Paper Chart System Office Visit - Prework Scheduler identifies patient with asthma when setting up chart. CQN data collection form is put in these charts. Asthma education material put in these charts including Asthma Action Plan (Each provider work flow different, requiring different method for each of them) CQN encounter forms readily accessible in each POD when asthma pt. indentified after chart set up Physician/CPNP orders spirometry if appropriate During the visit the Physician/CPNP reviews pt. questionnaire and completes provider questionnaire (difficult to devote time to complete these forms) DR. or CPNP gives patient encounter form to complete if they feel appropriate for that days visit. During Office Visit Patient is ready to be seen by provider Nurse completes spirometery testing Nurse/CRA who rooms patient gives parent patient encounter form and helps them complete form if needed. Physician/CPN/ discusses asthma control If in active flu season and vaccine is due, administer flu shot. If between seasons, annual flu shot is recommended Physician/CPNP/RN/LPN gives/reviews asthma action plan. Gives and reviews asthma educational materials. Offers in home asthma education. Reviews patient encounter form for completeness ( Evaluating multiple methods of providing education to lead to best self management) Working on Creating Asthma recall registry system Physician/CPNP Completes all forms and gives to administrative team member to enter data into equipp. (difficult to devote time to complete these forms) Nurse/CRA sends referral to Caring Service Home Health Care if accepted by family or available group asthma education at hospital Administrative team member returns incomplete forms to provider/CPNP Post Visit Activities
Change is difficult. It is easier to implement small changes. Obtaining data helps measure outcome. Education, education, education. Collaboration with community health care resource is very important. Key Learning
Barriers and Successes 1. Time. 2. Absence of EMR. 3. Variations in care. 1.Quality of care. 2. Increased Asthma education to staff ( protocols for medications refills, f/u visits) 3- Improved teaching to future health care providers. 4- Guidelines and protocols improves efficiency and staff satisfaction, and reduces unnecessary variations of care. 5- Spirometry
Future Plans • EMR/Registry • Continue PDSA’s for efficient use of asthma encounter forms • Continue Team meetings providers and staff • Continue to evaluate methods of patient and family education to help families improve self management of Asthma.
