Triage and Clinical pathway - niems.go.th · PDF fileClinical care pathway •...

Triage – Pathway – Fast track

หองฉกเฉนสความเปนมาตรฐาน

นพ.เอกกตต สรการ

แผนกฉกเฉน

ศนยการแพทยโรงพยาบาลกรงเทพ

Triage

• การนาปญหา อาการ และสภาพผ ปวยในเบองตนมา

ประมวลผลตามเกณฑทกาหนด

• จดลาดบความเรงดวนของปญหา

• คดเลอก และจดลาดบการบรการอยางเหมาะสมตาม

ทรพยากรทมในขณะนน

Clinical care pathway

• การนามาตรฐานการรกษามาประกอบเปนกระบวนการ

ทตอเนองกน

• ผ ปวยไดรบการดแลจากสหสาขาวชาชพทเกยวของ

• แนวทางมาตรฐานทกาหนด

• กรอบเวลาทแนนอน

Chest pain

Stroke Heart failure

Trauma TBI Fracture “…………”

EMS

ER

ER Neuro

X-Ray

OR ICU

Stroke unit ICU

งานทมผเกยวของหลายฝาย จาเปนตองมแนวทางให

ผเกยวของในกระบวนการนนกระทาไดถกตองตามลาดบ

มาตรฐานการปฏบตงาน

SOP (Standard operating procedure) • แนวทางมาตรฐานใหผ เกยวของในกระบวนการนนกระทา

ถกตองตามลาดบ

• นามาใชกาหนดบทบาท เพอใหทมสหสาขาวชาชพปฏบตตาม

มาตรฐานการรกษา และประสานงานในการดแลผ ปวยฉกเฉน

อยางมขนตอน ภายในกรอบเวลาทกาหนด

Code STEMI Goal :

Door-to-balloon 90 minutes


การใช SOP ทาใหขนตอนการตรวจรกษาเปนไปในแนวทางเดยวกน ไมเบยงเบนจากมาตรฐาน และเกดมผลด

ทสงเสรมการทางานระหวางทมใหมประสทธภาพดขน ดงน • Logical orders and priority • Improve communication • Increase situation awareness • Improve cross-checking and monitoring

EMS

ER

ER Neuro

X-Ray

OR ICU

Stroke unit ICU


การใช SOP ทาใหขนตอนการตรวจรกษาเปนไปในแนวทางเดยวกน ไมเบยงเบนจากมาตรฐาน และเกดมผลด

ทสงเสรมการทางานระหวางทมใหมประสทธภาพดขน ดงน • Support workload management • Set limit or acceptable tolerance • Support error management • Facilitate conflict resolution

ขอบคณ

• Stroke Pathway Team • Stroke Coordinator

• Acute Myocardial Infarction Pathway Team

• Heart Coordinator

• Emergency Department

• Trauma Team

Primary Stroke Center Tracer

20

Patient knowledge

Calling 1719

EMS System

ED Staff

Stroke Team

Stroke Unit

CHANPONG TANGKANAKUL,MD STROKE PROGRAM DIRECTOR

BANGKOK HOSPITAL MEDICAL CENTER 15 JANUARY 2013

Goal To provide quality of care for well being of our patients.

22

Primary Stroke Center

Mission To enhance the well being of our patients by providing comprehensive and compassionate neurological care in environment of continually improving practice led by a trained health care team and specialized physicians PLM.3

ME#1,2

Goal

Program Management Primary Stroke Committee • Clinical pathway guideline approval • Documentation development • Education and training program • Implementation pathway • Data collection, tracking, analyze variances to improve

performance indicators • Tracer round • Patient perception survey • Monthly report to quality management committee • Corrective action of CCPC findings

23

PLM.1 PLM.2 DFC.4

JEXCO CEC

MEC HEC

GLS, BME Ancillary TQCI

QMC

Program Committee Program Director Program Manager

Program Quality Co.

Operating Group Program Nurse Co.

PHAR TTC SSG HR Nutrition

PLM.1 PLM.2 PLM.8

DFC SSM CIM PMI

BMC Organization Chart

24

Presenter

Presentation Notes

JEXCO = Joint Executive Committee CEC = Chief Executive Committee MEC = Medical Executive Committee HEC = Hospital Excecutive Commitee QMC = Quality management Committee TQC = Total quality center

25

The Journey of BMC Stroke Pathway

Program Management

Inclusion Criteria of BMC Stroke Pathway

Patient with • An ischemic stroke or TIA • Hemorrhagic stroke age > 18 years • Time onset within 7 days • AVM, SAH, cerebral aneurysm • Patient on ventilator • Post operative brain surgery

26

PLM.3 ME3,4

Action Plan for Stroke pathway

27

List of Activities Schedule 2013 Responsible Person

1 2 3 4 5 6 7 8 9 10 11 12

Attend&Lecture in Thai Sroke Society Program director & Stroke co.

Attend ASA meeting in USA

Program director

Study update edition of ASA Guideline ,CCPC standard

Program manager & Stroke co.

R2R :

Stroke co.

Stroke alert drill every quarter : brain, 6D, ICU2, ER

Stroke co.

Stroke pathway tracer : Open chart review by stroke. co & core team

Stroke co.& core team

Monitor outcome & improvement monthly by program director & core team

Program director & manager

HA re-accreditation

HOD core team


28

List of Activities Schedule 2013 Responsible Person

1 2 3 4 5 6 7 8 9 10 11 12

Stroke Day Training 2013 ( 8 hrs) :brain, 6D, ICU2, ER, Multidisciplinary team

Stroke co.

System tracer : CCPC Stroke Program director , manager, stroke co.

Hospital wide training

TQCI, stroke co.

SQE & Portfolio preparation

HOD core team

Stroke care seminar for stroke patient


.JCI CCPC Triennial Survey

TQCI, Program coordinator

Stroke Training 2013 for BDMS Network


Stroke Camp


รพ. จานวน(คน) BMC 60

BDMS Network 10

รพ.พนธมตร 38

รวม 108

Stroke Drill

Course Title Hrs. Target % Achieved Stroke Training Day - Critical care nursing - Update treatment

16 Hrs. (2 days)

All staff in core team and support

team 100 %

Stroke & Traumatic Brain Retreat - Emergency Neurology

16 Hrs. (3 days)

BDMS stroke care givers, supervisors and Referral team

120 participants

PLM.1 ME.3 PLM.2 DFC.2 DFC.4 DFC.5

31


Stroke Pathway Booklet for Patients Day 1 Day 2 Day 8

32

YTD/08 YTD/09 YTD/10 YTD/11 YTD/12

Total number of Stroke patient

432 398 416 413 382

Case Exclusion criteria

140 (32%)

103 (26%)

52 (13%)

59 (14%)

64 (17%)

Case Inclusion criteria for Stroke pathway

289 (67%)

295 (74%)

364 (87%)

354 (86%)

318 (83%)

Case inclusion criteria but not in Pathway

3 (1%)

0 0 0 0

0 00

1

2

3

Unclear signs and symptom Not consult neurologist

Reasons for case drop out from pathway

Num

ber

Stroke Pathway Compliance

33

281230

2249

78

82

238 245287

73

0

50

100

150

200

250

300

350

400

YTD/0

8

YTD/0

9

YTD/1

0

YTD/1

1

YTD/1

2

Ischemic Stroke&TIA Hemorrhagic Stroke

Stroke Pathway Cases

34

Patient Characteristic Diagnosis 2012

35

Female

35% (81/230)

Male

65%(149/230)

Ischemic Stroke& TIAMale

60%(49/82)

Female

40%(33/82)

Hemorrhagic Stroke

36

Patient Characteristic Gender 2012

Refer

19%(44/230)

Walk in

79%(181/230)

In

Hospital

2%(5/230)

Ischemic Stroke & TIA

Refer

66%(54/82)

Walk in

34%(28/82)Hemorrhagic Stroke

37

Patient Characteristic Type of Arrival 2012

Stroke Alert YTD 2008

YTD 2009

YTD 2010

YTD 2011

YTD 2012

Stroke Pathway Cases

260 295 364 354 318

Stroke Alert Calls 23%

(60/260)

19%

(57/295)

15%

(55/364)

12%

(43/354)

12%

(39/318)

Thrombolytic Therapy Administered

10%

(6/60)

4%

(2/57)

7%

(4/55)

14%

(6/43)

18%

(7/39)

38

Stroke Alert : Call for thrombolytic Rx

Stroke Fast Track … Process Topic YTD 2011 Q1/12 Q2/12 Jul 12 Aug 12 Sep 12 Case 6 3 2 0 1 1 Door to 1st Doctor (10 mins)

100% (6/6)

100% (3/3)

100% (2/2)

NA 100% (1/1)

100% (1/1)

Door to Stroke Team (15 mins)

100% (6/6)

100% (3/3)

100% (2/2)

NA 100% (1/1)

100% (1/1)

Door to CT read (45 mins)

100% (6/6)

100% (3/3)

100% (2/2)

NA 100% (1/1)

100% (1/1)

Door to Lab result (45 mins)

83% (5/6)

100% (3/3)

100% (2/2)

NA 100% (1/1)

100% (1/1)

Door to Needle (60 mins)

83% (5/6)

67% (2/3)

115 นาท

ใหนอก ICU

50% (1/2)

80 นาท โดย

Telestroke

NA 0% (0/1)

83 นาท BP สง

0% (0/1)

130 นาท แพทยตดสนใจ

Item Process N = 7 case

Target (time/mins.)

Mean Achieved (Time/mins.)

1 Arrival time to Doctor first see Pt. 10 5

2 To Neurologic expertise available 15 5

3 To CT Completed 25 21

4 To CT Read 45 23

5 To lab report: BS, INR, Plt. Count 45 36

6 To thrombolysis starts 60 78

Process Indicators of IV rtPA

Patient perception

41

PLM DFC SSM

CIM.1 CIM.4 PMI.2

ME#6 PMI.3

low use of tPA

Process People

Facilities Management

Unfamiliar with Stroke Fast Track

Arrival at ER outside window New and young rotated ER staffs

No neurologist

Opportunities and Challenges

Pre-notification by EMS in BMC (2012) • EMS 5 in 39 cases (12.82%) • Pre-notification 4 in 5 cases (80%) • Arrival time (from home to ER) 5, 14, 35, 35, 36 min

43

DVT & PE DVT and PE

• PE accounts for 10% of deaths after stroke • PE were more likely to occur in the first 3 months after stroke

Sign and symptom • Swelling , warm , redness, tenderness

Ix • US Doppler , D-dimer

lowering the risk of DVT

• early mobilization • use of external compression devices. • The use of intermittent external compression devices is

reasonable for treatment of patients who cannot receive anticoagulants (Class IIa; Level of EvidenceB). (Revised from the previous guideline13)

22/08/56 Bangkok Rehabilitation Center

Nunchaya Chayaopas,M.D., Physiatrist 44

Dysphagia



Pressure ulcer



Presenter

Presentation Notes

Pressure sores (bed sores) are an injury to the skin and underlying tissue. They can range from mild reddening of the skin to severe tissue damage-and sometimes infection-that extends into muscle and bone. Pressure sores are described in four stages: Stage 1 sores are not open wounds. The skin may be painful, but it has no breaks or tears. The skin appears reddened and does not blanch (lose color briefly when you press your finger on it then remove your finger). In a dark-skinned person, the area may appear to be a different color than the surrounding skin, but it may not look red. Skin temperature is often warmer. And the stage 1 sore can feel either firmer or softer than the area around it. At stage 2, the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin. It can look like a scrape (abrasion), blister, or a shallow crater in the skin. Sometimes this stage looks like a blister filled with clear fluid. At this stage, some skin may be damaged beyond repair or may die. During stage 3, the sore gets worse and extends into the tissue beneath the skin, forming a small crater. Fat may show in the sore, but not muscle, tendon, or bone. At stage 4, the pressure sore is very deep, reaching into muscle and bone and causing extensive damage. Damage to deeper tissues, tendons, and joints may occur. In stages 3 and 4 there may be little or no pain due to significant tissue damage. Serious complications, such as infection of the bone (osteomyelitis) or blood (sepsis), can occur if pressure sores progress.

Mobility and transfer with Falling prevention • In bed • Bed to wheelchair • How to protect your self : back ergonomic



HOW TO PROTECT YOURSELF

Routine to Research

Year Protocol Titles Status

2012

1. Prevalence and Risk factors of Carotid Artery Disease in Asymptomatic Thai Population in Health Promotion Center: BGH

- Final Study Report

2. Establishment of the Thai version of MIDAS by a Validation and Reliability Study

- Cognitive Debrief

3. Headache Registry Program - Data collection

2013 4. The effectiveness of Stroke Pathway at Bangkok Hospital during 2008-2012: Compared to Get With The Guidelines (GWTG)

- Drafting protocol

5. Characteristics and Clinical Outcomes in Epilepsy Patients at Bangkok Hospital

- Drafting protocol

6. Efficacy of biofeedback treatment in headache patient - Drafting protocol

Rt hemiparesis by NIHSS -Telestroke

Acute Myocardial Infarction pathway

December2011 to May 2013

AMI Guidelines

• ACC/AHA 2008 Clinical Performance Measures for Adults with ST-Elevation and Non ST-Elevation Myocardial Infarction

• 2012 ACCF/AHA Focused Updated of the Guidelines for the management of patients with Unstable Angina/ Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline and Replacing the 2011 Focused Update)

• 2013 ACCF/AHA Guidelines for the management of ST-Elevation Myocardial Infarction

Program’s design and scope Criteria Detail

Inclusion Criteria •Non traumatic chest pain •Symptom onset less than 24 hours

Exclusion Criteria •Age less than 18 years •Transfer to other facility •AMA

Enrollment criteria •All chest pain patients who present to ED, OPD or IPD •Age more than or equal 18 years

Discharge Criteria •Successful reperfusion therapy •No angina and hemodynamic stability

54

109

70

39

0

20

40

60

80

100

120

Total STEMI NSTEMI

Total

STEMI

NSTEMI

Total number of patients enrolled to date (Dec2011 to May 2013)

Porter

1.Obtain patient history

Take patient to ED immediately if chest pain

2.Administer Oxygen 5 litres/min

3 Send realtive to proceed Medical Record( if any)

Medical Record

1 Quickly obtain patient history

2 Send the obtained information to ED

*(Door to ED < 5 minutes)

ED Nurses (Do not wait for OPD Card )

1.Obtain chest pain history (Tracking tool for chest pain )

2.Provide care according to standard as follows:

STANDING ORDER ( No.1-5)

2.1 Bed rest

2.2 Stat 12-lead EKG and interpret within 10 min

2.3 O2 canula at 5 litres/min (keep O2 Sat .95%)

2.4 Lab: CBC,BUN,Cr,Troponin T, CK-MB

2.5 Close Monitor EKG and O2 Saturation

3 Notify the on-duty ER physician

4. Call Code STEMI , in case of suspected STEMI

In-house Cardiologist

1. Confirm EKG.

2. Evaluate any Risk stratification

3. Consult attending physician or day to day physician on duty

4. Inform relatives/ explain treatment/consent form

5. Activate Acute MI pathway

ICCU/CCU Nurses

1 Provide care to pt following standard of care

2. Follow treatment as physician's order

3. Prepare readily available of equipments, supplies for emergency

4 Prepare patient for CAG+/-PCI / ECHO

/ Cardiac Imaging

Cath lab staff

1 Prepare readily availableCAG/PCI within 30 minutes

2 Prepare GPIIB/IIIA inhibitor,emergency Cart & PCI set.

3 Assist physician during CAG +/-PCI

4 Cross matching blood for OR if any,notify surgical Team

5. Notify surgical team following standby protocol

All departments in BMC with chest pain patient must follow

pathway as done in ED.

1. Door to EKG time < 10 minutes

2. Pt should not stay in ED longer than 40 minutes

3. In Case of STEMI please see in Code STEMI protocol

Team Responsibilities for Acute Myocardial Infarction

Remark:

Code STEMI Flow

Patient present with chest pain

12 Leads EKG

bed rest+O2 5 LPM

Suspected EKG: STEMI

Other area in BMC

Call ERT ( Tel.3458 )

Press 6 Code STEMIContact center*SMS to STEMI Team*Call Important person( 1st call interventionist,Cathlab)

Team on site* 1st Call Interventionist* Heart coordinator/Supervisor* Porter* Cath lab stand by

STEMI

Cardiac Cath Lab

Non STEMINotify attending Cardiologistfor other treatment 128

ER

AMI performance measures

• Aspirin at arrival • Dual antiplatelet prescribed at discharge • Statin prescribed at discharge • Time to PCI < 90 minutes • Smoking cessation counseling • ACEI/ ARB for LVSD at discharge • Patient perception score >4.5

100%

83%

100%

100%

100%

89% 10

0%

100%

80%

100%

97%

100%

100%

100%

100%

100%

100%

100%

100%

0%

20%

40%

60%

80%

100%

120%

Dec

11(7

/7)

Jan1

2(7/

7)

Feb1

2(7/

7)

Mar

12(5

/5)

Aprl

12(6

/6)

May

12(7

/7)

Jun1

2(7/

7)

Jul1

2(2/

2)

Aug1

2(6/

6)

Sep1

2(5/

6)

Oct

12(9

/9)

Nov

12(8

/8)

Dec

12(8

/8)

Jan1

3(8/

9)

Feb1

3(1/

1)

Mar

13(3

/3)

Aprl

13(4

/5)

May

13(3

/3)

YTD

(103

/106

)

Aspirin at arrival JC-US Benchmark

ASA at arrival

JC-US benchmarking 98.4%

Dual Antiplatelets prescribed at discharge

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

0%

20%

40%

60%

80%

100%

120%D

ec11

(7/7

)

Jan1

2(7/

7)

Feb1

2(7/

7)

Mar

12(6

/6)

Aprl

12(7

/7)

May

12(7

/7)

Jun1

2(7/

7)

Jul1

2(2/

2)

Aug1

2(7/

7)

Sep1

2(6/

6)

Oct

12(9

/9)

Nov

12(8

/8)

Dec

12(8

/8)

Jan1

3(9/

9)

Feb1

3(1/

1)

Mar

13(3

/3)

Aprl

13(5

/5)

May

13(3

/3)

YTD

(109

/109

)

Dual Antiplatelets prescribed at dischargeJC-US Benchmark


Statin prescribed at discharge

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

0%

20%

40%

60%

80%

100%

120%D

ec11

(7/7

)

Jan1

2(7/

7)

Feb1

2(6/

6)

Mar

12(6

/6)

Aprl

12(6

/6)

May

12(7

/7)

Jun1

2(7/

7)

Jul1

2(2/

2)

Aug1

2(5/

5)

Sep1

2(6/

6)

Oct

12(9

/9)

Nov

12(8

/8)

Dec

12(8

/8)

Jan1

3(9/

9)

Feb1

3(1/

1)

Mar

13(3

/3)

Aprl

13(5

/5)

May

13(3

/3)

YTD

(105

/105

)

Statin prescribed at dischargeJC-US Benchmark

JC-US benchmarking 97%

Time to PCI ≤ 90 min

100%

100%

100%

73%

50%

100%

50%

50%

100%

0%

20%

40%

60%

80%

100%

120%D

ec11

(1/2

)

Jan1

2(1/

2)

Feb1

2(1/

1)

Mar

12(0

/0)

Aprl

12(0

/0)

May

12(1

/1)

Jun1

2(2/

4)

Jul1

2(0/

0)

Aug1

2(0/

0)

Sep1

2(1/

1)

Oct

12(0

/0)

Nov

12(3

/3)

Dec

12(0

/0)

Jan1

3(0/

0)

Feb1

3(0/

0)

Mar

13(0

/0)

Aprl

13(1

/1)

May

13(0

/0)

YTD

(11/

15)

Time to PCI ≤ 90 min JC-US Benchmark


NA

NA

NA

NA

NA

NA NA

NA

NA NA

ACEI or ARB of LVSD at Discharge

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

0%

20%

40%

60%

80%

100%

120%D

ec11

(0/0

)

Jan1

2(0/

0)

Feb1

2(0/

0)

Mar

12(1

/1)

Aprl

12(0

/0)

May

12(3

/3)

Jun1

2(1/

1)

Jul1

2(2/

2)

Aug1

2(0/

0)

Sep1

2(1/

1)

Oct

12(1

/1)

Nov

12(2

/2)

Dec

12(1

/1)

Jan1

3(0/

0)

Feb1

3(0/

0)

Mar

13(0

/0)

Aprl

13(1

/1)

May

13(1

/1)

YTD

(14/

14)

AEI or ARB of LVSD at DischargeJC-US Benchmark

JC-US benchmarking 95.5% N

A

NA

NA

NA NA

NA

NA NA

Adult smoking cessation Advise/counseling

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

0%

20%

40%

60%

80%

100%

120%D

ec11

(7/7

)

Jan1

2(2/

2)

Feb1

2(2/

2)

Mar

12(2

/2)

Aprl

12(2

/2)

May

12(1

/1)

Jun1

2(4/

4)

Jul1

2(2/

2)

Aug1

2(1/

1)

Sep1

2(2/

2)

Oct

12(4

/4)

Nov

12(1

/1)

Dec

12(2

/2)

Jan1

3(4/

4)

Feb1

3(0/

0)

Mar

13(0

/0)

Aprl

13(1

/1)

May

13(1

/1)

YTD

(38/

38)

Adult smoking cessation Advise/counselingJC-US Benchmark


Patient perception survey Score

5.00

4.50

5.004.83

5.004.71 4.80

5.00 5.004.86

4.89

4.834.50

4.795.00

5.005.00

1

1.5

2

2.5

3

3.5

4

4.5

5

Dec

-11

Jan-

12

Feb-

12

Mar

-12

Aprl

-12

May

-12

Jun-

12

Jul-

12

Aug-

12

Sep-

12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb-

13

Mar

-13

YTD

Overall experience of this program Target

Bangkok Trauma Center “Trauma Alert” 24/7 Timely access to Trauma team Trauma imaging Operating theatre & ICU Angiographic intervention

68

Severe Trauma Patient

ER Doctor

ER RN1

ER RN2

ER RN3

Trauma Surgeon

U/S X-Ray

Clerk

TRAUMA Alert

OR ICU

Anesth Lab

Blood

CT

Consult

ER

Trauma Team Activation

Bangkok Trauma Center Team

Emergency Medicine

Trauma Nurse

ER Nurs

e

ICU Nurs

e

Trauma Progra

m

Medical Transpo

rt

Ortho Surger

y

Neuro Surger

y

Pediatric

Surgery

Trauma

Surgery

EMT- B

Flight Surge

on

Emergency Room

Computerized Tomography

& Operating

Room

Operating Room

& ICU

Multiple rib fractures Lung injury Ruptured spleen

Fracture of hip joint

Initial care at local hospital

Transferred by Mobile ICU

From scene to bed, back to work

Mortality rate of trauma patients referred to Bangkok Trauma Center in 2011 by severity

Injury Severity Score (ISS) • Mild = 1- 8 • Moderate = 9-15 • Major = 16-24 • Severe > 24

0.00

5.00

10.00

15.00

20.00

25.00

30.00

1-8 9-15 16-24 > 24BMC 0.00 0.27 1.56 20.58USA 0.70 1.94 4.80 27.61

Perc

ent

Mild Moderate Major Severe

* Compare with US National Trauma Data Bank 2011

0

5

10

15

20

25

30

Mild Moderate Major SevereBMC 0 0 3.4 11.76USA 0.8 1.96 4.64 28.05

Perc

ent

Trauma Mortality Rate 2012

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