肺炎护理面临问题与挑战-英文ppt课件

1、Pneumonia careControversies and ChallengesMeera Kelley MDClinical Coordinator, MRNC, Inc.The QIO for the Carolinas1;.OverviewIssues with the indicatorsOther broad challengesDiscussion2;.PN-1 Oxygenation assessment PN-2 Pneumococcal vaccination PN-3b Blood cultures PN-4 Adult smoking cessation advice

2、PN-5 Antibiotic timing PN-5a Initial antibiotic w/in 8 h hospital arrival PN-5b Initial antibiotic w/in 4 h hospital arrival PN-6a Initial antibiotic selection ICU PN-6b Initial antibiotic selection Non ICU PN-7 Influenza vaccination 3;.PN-1 Oxygenation assessment Inadequate oxygen (hypoxemia) is co

3、mmon in severe pneumonia and is a known mortality risk factor. Giving supplemental oxygen has been shown to decrease mortality among patients with pneumonia.4;.Controversies & ChallengesOxygenation assessment No5;.PN-3b Blood culturesPublished pneumonia treatment guidelines recommend performance

4、 of blood cultures for all inpatients to optimize therapy. Improved survival has been associated with optimal therapy. Yield is greater if the culture is collected before antibiotics are administered.6;.Controversies & ChallengesBlood culturesDrawn late-after antibioticsNot drawn at all-not rout

5、inely done for outpatients7;.PN-4 Adult smoking cessation advice/counselingSmoking accounts for one out of every five deaths in the US and is the most important modifiable cause of premature death. Smoking cessation advice is clinically effective and cost-effective. Hospitalization can be an ideal o

6、pportunity for a patient to stop smoking.Patients who receive even brief smoking-cessation advice from their physicians are more likely to quit.8;.Controversies & ChallengesSmoking cessation adviceDocumentationPreventive, long term issues not routinely addressed by physicians9;.PN-5 Antibiotic t

7、imingTimely administration of antibiotics = improved outcome among pneumonia patientsImproved survival with receipt of antibiotics within 4 h of admission (Khan 1990) Shortening the time-to-first-dose to 4 h was associated with improved survival (McGarvey 1993)First dose of antibiotic within 3 hours

8、 -less likely to die within 30 days (Meehan 1995)30-day mortality 10% (P=0.04) lower, length of hospital stay shorter among patients whose first antibiotic administered within 4 h (Bratzler 2001)10;.Controversies & ChallengesAntibiotic timingTime from arrival to diagnosis11;.12;.Controversies &a

9、mp; ChallengesAntibiotic selectionElderly, nursing home patient, other reasons want to give broader therapy13;.14;.PN-2 Pneumococcal vaccinationIndicated for persons 65 years of age Up to 75% effective in preventing pneumococcal bacteremia and meningitis. Also important due to increasing antibiotic

10、resistance among pneumococciHospitalization is an underutilized opportunity 15;.16;.PN-7 Influenza vaccinationIndicated for people 50 years Highly effective in preventing influenza-related pneumonia, hospitalization, and death. Hospitalization is an underutilized opportunity17;.18;.Controversies &am

11、p; Challengesinpatient immunizationsToo sickWont workTakes long time to establish historyPhysician role19;.Controversies & Challengespneumococcal vaccinationPerception of risk of reimmunizationCochrane Databast Syst Rev 2003; (4) CD000422-”pneumococcal vaccination does not prevent pneumonia or d

12、eath in adults”20;.Controversies & Challengesinfluenza vaccinationAvailabilityIt made me sickDocs prefer to give it in office21;.Other broad challenge-working with physicians22;.Communicating with docs-tipsBear in mind-most are feeling overwhelmed frazzledterrifiedWe need to;tell them only what

13、they need to knowshow how we can make their life better23;.Communicating your message effectively-tipsStart planning your presentation by determining your goal-what do you want them to do when the leave?They will be more enthusiastic if they have a clear, well defined, but limited role to play24;.Co

14、mmunicating your message effectively-tipsAcknowledge their challenges“We recognize how busy you are as it is and want this to ultimately make your life better.”Offer to help “We will do as much of the work as possible, but we need your input”Ensure you will be responsive to feedback “We would like t

15、o try this for 3 months and want you to let us know what you think”25;.Communicating your message effectivelyStep #1 tell the story of the positive futureStep #2 convey to audience how taking the action will give THEM the future they wantStep # 3 call to action-ask for commitment of first stepMark W

16、alton, Center for Leadership Communication, Chapel Hill26;.Message to physiciansWe understand that their day-to-day life is overwhelming27;.Patient careBillingAccurate codingInterruptionsInterruptionsPhone callsPharmaceutical repsFormulariesInsurance statusHealth care plansOffice administrationOther

17、 patientsPrior authorizationsClinical practice guidelinesDrug interactions/effectsBeepers/Pages28;.Systematically review each drug for potential side effects and interactions during 20 minute visit(new drug approvals FDA 2003; 42, 2002; 92 ) Systematically recall each step of the best practice for e

18、ach clinical syndrome may encounter (National Guidelines Clearinghouse summaries Feb 2005; 1444 summaries) July 2004; 1329)29;.30;.31;.We can. But we cannot ensure thatBypass, balloon, or stent a heart blockagedissolve a clot for a heart attacktransplant a heartprovide ventilator and BP support for

19、pneumoniatreat resistant bacteria such as MRSA, VRE, DRSPthe antibiotic is given 1 hr prior to CABG (47.6% US)the patient gets an aspirin on discharge (84% US)heart failure patient assess LVF (70% US)flu shot history assessed, given (14% US)penicillin allergic patient doesnt get penicillin32;.We hav

20、e revolutionized what we do, without changing how we do it.We have advanced the product without changing the process.Contrast: FedEx, EBay, Amazon, Starbucks33;.Who is responsible for improving the system?34;.How do we ensure the right treatment for the right patient at the right time, no more, no l

21、ess?Tell the doctors to just do it?35;.Skills of physiciansassess patientsdirect major aspects of therapyperform specific interventionscommunicate with patients36;.To make best, most efficient, most effective use of physicians skills, need to protect time and touch of the patient-physician interacti

22、on.Alice G. Gosfield, J.D., Snyder, 9/12/0337;.Clinical information patients history, and key aspects of care for their conditions-must be present and readily utilized during the patient-physician encounter 38;.Physicians take the leadThere is no indication that the practice of medicine is getting less complex.Spend time today to save time tomorrow.39;.Old paradigmMaintain knowledge-rely on memoryIndividualizeEncourage variationAvoid “cookbook”, Avoid crutches, pocket-fill