From the NICU to Primary Care: Improving the Quality of the Transition (Text Version)
On September 27, 2010, Virginia Moyer, made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (530 KB).
From the NICU [Newborn Intensive Care Unit] to Primary Care: Improving the Quality of the Transition
Virginia A. Moyer, MD, MPH
Professor of Pediatrics, Baylor College of Medicine
Chief, Section of Academic General Pediatrics
Chief Quality Officer, Medicine
Texas Children's Hospital
Image: A cartoon of Wile E. Coyote hanging off the edge of a cliff in a small rubber raft is shown.
- Care transitions:
- Patient safety challenge
- AHRQ Planning Grant:
- NICU to ambulatory follow-up
- Next steps
- Patient Safety literature increasingly acknowledges potential risks of care transitions.
- Adult literature reveals significant vulnerabilities.
- Proactive evaluation of error-prone health care processes can inform interventions to prevent adverse patient outcomes before they occur.
- Sometimes called "handoffs"
- Movement of patients between health care practitioners and settings
- Shift changes
- ER to hospital
- OR to post-op or ICU
- ICU to floor
- One facility to another
Hospital to Home
- Prolonged time period during "handoff"
- Unclear lines of responsibility
- Lack of patient understanding of health care problems
- Lack of readiness for self-care responsibilities
- Lack of information for follow-up provider
Pediatric Care Transitions
- Inpatient to ambulatory setting:
- Pediatric literature relatively silent except for measuring follow-up appointments.
- Focus has been on "lack of compliance" by caregivers rather than on systematic issues around discharge.
- 28% of children discharged from a pediatric ICU (not a NICU) did not receive timely medical follow-up.
McPherson ML, Lairson DR, Smith EO, Brody BA, Jefferson LS. Noncompliance with medical follow-up after pediatric intensive care. Pediatrics 2002;109(6):94.
Research in Adults
- 19% of patients had identifiable adverse events in the first 3 weeks home.
- 73% of older patients misused at least one medication.
- >1 medical error per discharge summary.
Research in the NICU
What to do?
FMEA: Failure Mode and Effects Analysis
What is a FMEA?
"The technique involves identifying potential mistakes before they happen to determine whether the consequences of those mistakes would be tolerable or intolerable."
- Potential failures are identified in terms of failure "modes."
- For each mode the effect on the total system is studied.
- Powerful approach for proactive risk assessment:
- Used in other high risk industries such as aerospace, aviation, nuclear industry
Image: Cartoon showing two cars in a head-on crash.
- Team generates a flow diagram of main process and sub-processes.
- Team brainstorms about all potential errors at each step (failure modes):
- Each is scored for probability it will occur (frequency) and potential severity if it did occur (severity).
- Frequency score x severity score = hazard score.
- High-risk failure modes identified as well as related causes or contributory factors.
DeRosier J, Stalhandske E, Bagian JP, Nudell T. Using health care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system. Jt Comm J Qual Improv 2002 May;28(5):248-267, 209.
AHRQ Planning Grant
- Conduct HFMEA on NICU to ambulatory care transitions.
- Conduct retrospective review to confirm or modify HFMEA findings.
- Conduct qualitative assessment of the process to accomplish the HFMEA.
Setting: Texas Children's Hospital
- 78 Level III beds, 62 Level II beds
- >200 VLBW (<1500gm) babies per year, many other babies with complex congenital abnormalities
- Special Needs Primary Care Clinic:
- Housed at main campus
- >100 children on home ventilators; 24-7 coverage
- 42 private practices, including 5 Medical Homes
- Shared electronic record with TCH
- TCH-owned Medicaid Managed Care Plan, ~230,000 kids
- Perform a HFMEA for the transition in care from NICU to ambulatory follow up.
- Use multiple methods to see if our predictions are correct.
- Revise the HFMEA.
- Develop a mitigation plan to address the identified risks.
It takes a team...
- Virginia Moyer, MD, MPH—Principal Investigator
- Karen Finkel, RN, BSN—Patient Safety Office
- Hardeep Singh, MD, MPH—Patient Safety Researcher (VAH)
- Lu-Ann Papile, MD—Neonatologist
- Jochen Profit, MD—Neonatologist
- Charleta Guillory, MD—Neonatologist
- Marcia Berretta, MSW—Social Worker
- Teresa Duryea, MD—Pediatrician
- Lori Sielski, MD—Pediatrician
- Jan Mort, RN—Baylor NICU nurse
- Carol Carrier, RN
- Adam Kelly, PhD—Survey researcher (VAH)
- Myrna Khan, PhD—Patient Safety researcher (VAH)
- Eric Thomas, MD, MPH—Patient safety guru (UT-H)
- Joseph DeRosier—creator of HFMEA (VAH)
Image: A diagram depicts the following NICU to Ambulatory Care process:
NICU to Ambulatory Care (HIGH LEVEL FLOW):
1. Patient identified for potential discharge.
2. Discharge needs identified.
3A. Patient discharged from NICU 3 or 2.
4. Interim Support.
5. Follow up appointment occurs.
Image: A diagram depicts the following NICU to Ambulatory Care process:
NICU to Ambulatory Care (HIGH LEVEL FLOW with Sub-Steps: Updated from 12/05/07 meeting):
1. Patient identified for potential discharge.
- Attending physician decides time for discharge
- Attending discusses decision with rest of care team
- Caregiver identified " notified
- Caregiver teaching initiated
- Consulting services contacted for follow up recommendations
- Consulting services document recommendations for follow up in medical record
- Baylor Clinical RN schedules appts.
- Contact primary care pediatrician done by licensed care provider (NNP, resident, fellow)
- Baylor Clinical RN's ensure home care orders are written
- Care Coordinators arrange for home care and equipment needs
- Discharge prescriptions written and given to caregiver
- Caregiver acquires medications
- Discharge formula order (etc) given to caregiver
- Conduct weekly discharge planning rounds (NICU 2 only)
- Discharge orders are written by licensed care provider
- Baylor Clinical RN prepares
- discharge packet
- Discharge packet given to caregiver by Baylor Clinical RN
- TCH discharge instructions completed and given to caregiver by bedside RN
- Newborn state screening performed per state requirements or at discharge
- For all Baylor patients, discharge data summary form faxed to primary care pediatrician on next business day after discharge
- Discharge data summary form mailed to PCP
- Hard copy of discharge summary is mailed to PCP
- Home Health Care
- Primary Care Pediatrician
- TCH Emergency Dept.
- NICU staff
- Neo Attending
- Community Emergency Depts.
- Community Pharmacist
- Patient is seen by primary care pediatrician
- Primary care pediatrician follows through on no show patients
Image: A diagram depicts Step 2: Discharge needs identified (page 1) of the process model:
2A. Caregiver teaching initiated.
- Teaching is not initiated
- No one coordinates the teaching
- Medication teaching not done by pharmacy
- Medication teaching is not done with home meds
- Teaching is not documented
- Inconsistency with teaching
- Discharge facilitators are not know by the care team
- Lack of primary nursing
- Nurse lacks knowledge for teaching of all required elements for discharge
- Person responsible for teaching regarding nutrition is not identified
- Person responsible for teaching regarding equipment is not identified
- Person responsible for teaching regarding CPR is not identified
- Person responsible for teaching regarding car seat is not identified
- Person responsible for teaching regarding routine care is not identified
- Care giver does not understand teaching
- Contact is not initiated
- Wrong person within specialty is contacted
- Consulting service can not be reaching for follow up
- Consulting service does not respond
- Recommendations are missed by attending
- Conflicts between teams as to appropriateness of recommendations
- Recommendations are never documented in medical record
- Consultants never come
- Written recommendations are lost
- Written recommendations are illegible
- Follow up recommendations do not make sense
- Follow up recommendations can not be followed
- BC RN can not find insurance information
- Insurance is refused
- Provider is out-of-network
- Family is not involved in the appointment scheduling process
- Clinic does not allow BC RN to schedule appointment
- Recommended appointment times not available
- Patient is discharge don't the weekend
- Appointment time not available in a timely manner
- Appointments can't be clustered
- Failure to identify need for interpreter
- BC RN not able to schedule appointment and family fails to follow through
- Primary care pediatrician doesn't' follow through
- BC RN not allowed to schedule appointments by central scheduling
- Person responsible for making contact not identified
- Primary care pediatrician not identified
- Can not find a primary care pediatrician to accept patient
- Can not contact primary care pediatrician
- Can not get a timely appointment with the primary car pediatrician
- Patient information provided to primary care pediatrician but is lost
- Primary care pediatrician not provided with patient information
- Information is lost within the internal TCH system
- Licensed car provider does not make call
Our HFMEA™ Results
- Team identified 114 potential failure modes within the discharge process.
- Final model included 40 high-failure modes and 75 high-risk causes.
- Common issues present across most failure modes and causes:
- Clinicians act in isolation resulting in lack of standardized, coordinated, comprehensive plan of care.
- Parents/caregivers inadequately prepared for home care and management of fragile infants.
- Community providers lack required knowledge and skills to manage medically complex infants.
"Multiple Methods" to confirm the HFMEA
- Self-reporting of events (using TCH reporting system)
- Electronic triggers for possible adverse events:
- ER visits within one month of discharge
- Readmissions within one month
- Missed appointments within one month
- Questionnaire for parents/caregivers:
- The "Care Transitions Measure"
- Charts reviewed using a trigger methodology to confirm or add to HFMEA findings (N=88):
- Failures documented for 14 of 35 sub-steps predicted to have errors, in 1-10 cases each.
- Documentation in current medical records system inadequate to systematically collect reliable data:
- Documentation unavailable for majority of patients for 19 of the 35 sub-steps.
- A pediatric-adapted "care transitions measure" developed and validated.
Qualitative Analysis of the HFMEA Process
- The team members felt that the group functioned extremely well, with a high level of involvement and many new insights gained in the process.
- The team encountered difficulty applying the HFMEA scoring system to the identified failure modes:
- The severity descriptions did not seem to fit the types of failure modes identified.
- Frequency descriptions did not seem sufficiently granular.
- The group modified both descriptions before it proceeded with scoring.
- Some group members were concerned that scoring severity and frequency at the same time allowed for "gaming" of the scores:
- At the end of the process, the group scored one set of failure modes independently to determine whether this would significantly alter the scores (it did not).
- The final step of the HFMEA is the development of a mitigation plan.
- We addressed the three major themes that were identified in the HFMEA:
- Lack of a standardized discharge plan
- Inadequate parent/caregiver preparation
- Lack of knowledge and skills by community-based health care providers
- We based the intervention on the Care Transitions Intervention (Coleman et. al.), adapted for a pediatric population.
- Enhanced Personal Health Record
- Health Coach
- Just In Time Information for community-based health care providers
Enhanced Personal Health Record
- Existing discharge plan is ad hoc
- Existing standard discharge information limited to a single sheet of paper with diagnoses, medications and appointments written in by hand.
- Note that for many of our babies, the paper chart weighs more than the baby.
Enhanced Personal Health Record
- Welcome, Helpful Information about the Newborn Center, and Important Numbers
- Journaling and Care Pages
- Tips for Choosing Insurance and Pediatrician for Your Baby
- Resources and Support:
- Ronald McDonald House
- Key People, Equipment and Medical Terminology Glossary
- Your Baby's Development, Nutrition, and Feeding:
- Premature Babies Immunization Schedule
- Breastfeeding Your Baby
- Newborn Feeding- Bottle Feeding and Formula Preparation
- Safety and Education:
- Medication Safety
- Giving Oral Medicines
- How to Give a Subcutaneous Injection
- Crib Safety
- Signs and Symptoms of Illness
- Preventing Infection
- Planning for Discharge Checklist
- Calendar with Follow-Up Appointments
- A technically expert individual who takes the role of sensitive coach, teacher and facilitator to foster the development of parents into competent caregivers for their fragile infants.
- Master's prepared health educator, available at the hours parents are able to be present in the NICU.
- Available to staff as a resource person.
Just-in-Time information for primary care providers
- Capitalized on new Evidence Based Guidelines program at Texas Children's.
- One page summaries of evidence based guidelines for common problems:
- Transition from premature formula, oxygen weaning, growth of premature infants, management of gastrostomy, management of tracheostomy, chronic lung disease. and much, much more.
- Sent home with infant and also faxed to provider at the time of discharge.
- Concurrent Cohort Study over 1 year.
- NICU is divided into geographically distinct "pods."
- One NICU III pod and its usual step-down Level II pod comprise the intervention group.
- Other pods comprise the control patients.
- IRB did not require patient/parent consent beyond verbal consent at the time of enrollment.
- But did require written consent for the evaluation of PCP compliance with JIT protocols.
Progress to date
- Recruitment of intervention babies is close to on-schedule (n~50 at 6 months).
- Recruitment of control babies is behind (n~40) because 2 control units were closed for low census.
- Very few refusals to participate, very high rate of response to phone surveys.
- Moderate level of difficulty recruiting PCPs to the J-I-T intervention, so numbers are low.
- Primary outcome is adverse events within 31 days of discharge (death, ER visit, readmission, missed appointments).
- Care Transitions Measure—Neo: administered by phone 2-3 days after discharge and again at 31 days.
- Comfort level and satisfaction of PCPs with common post-NICU problems.
- Adherence to guidelines by PCPs.
- Manual for the Health Coach
- Enhanced Discharge Binder (to be converted to electronic format if and when our EMR implementation actually happens)
- JIT information sheets (to be converted.)
- CTM-Neo—validated tool to evaluate the quality of the NICU discharge experience
- The Care Transitions ProgramSM. http://www.caretransitions.org, accessed January 18, 2007.
- Coleman EA, Berneson RA. Lost in transition: Challenges and Opportunities for improving the quality of transitional care. Ann Int Med 2004 Oct 5; 141(7):533-536.
- DeRosier J, Stalhandske E, Bagian JP, Nudell T. Using health care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system. Jt Comm J Qual Improv 2002 May;28(5):248-267, 209.
- Forster AJ, Clark HD, Menard A, et al. Adverse events among medical patients after discharge from hospital.CMAJ 2004; 170:345-349.
- McPherson ML, Lairson DR, Smith EO, Brody BA, Jefferson LS. Noncompliance with medical follow-up after pediatric intensive care. Pediatrics 2002;109(6):94.
- Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med 2003 Aug;18(8):646-51.
- Philibert I. Leach DC. Re-framing continuity of care for this century. Qual Saf Health Care 2005 Dec;14(6):394-396.
- Roy CL, Poon EG, Karson AS, Ladak-Merchant Z, Johnson RE, Maviglia SM, Gandhi TK. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med 2005;143(2):121-8.
Image: A cartoon of Wile E. Coyote holding a sign which reads "Gravity Lessons" as he plummets down off a cliff is shown.