肺炎护理面临问题与挑战-英文课件

1、Pneumonia careControversies and ChallengesMeera Kelley MDClinical Coordinator, MRNC, Inc.The QIO for the CarolinasApril 14, 20051Medical Review of NC, Inc.OverviewIssues with the indicatorsOther broad challengesDiscussionApril 14, 20052Medical Review of NC, Inc.PN-1 Oxygenation assessment PN-2 Pneum

2、ococcal vaccination PN-3b Blood cultures PN-4 Adult smoking cessation advicePN-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 va

3、ccination April 14, 20053Medical Review of NC, Inc.PN-1 Oxygenation assessment Inadequate oxygen (hypoxemia) is common in severe pneumonia and is a known mortality risk factor. Giving supplemental oxygen has been shown to decrease mortality among patients with pneumonia.April 14, 20054Medical Review

4、 of NC, Inc.Controversies & ChallengesOxygenation assessment NoApril 14, 20055Medical Review of NC, Inc.PN-3b Blood culturesPublished pneumonia treatment guidelines recommend performance of blood cultures for all inpatients to optimize therapy. Improved survival has been associated with optimal ther

5、apy. Yield is greater if the culture is collected before antibiotics are administered.April 14, 20056Medical Review of NC, Inc.Controversies & ChallengesBlood culturesDrawn late-after antibioticsNot drawn at all-not routinely done for outpatientsApril 14, 20057Medical Review of NC, Inc.PN-5 Antibiot

6、ic timingTimely 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 h

7、ours -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)April 14, 200510Medical Review of NC, Inc.Controversies & ChallengesAntibiotic timingTime from arriva

8、l to diagnosisApril 14, 200511Medical Review of NC, Inc.April 14, 200516Medical Review of NC, Inc.PN-7 Influenza vaccinationIndicated for people 50 years Highly effective in preventing influenza-related pneumonia, hospitalization, and death. Hospitalization is an underutilized opportunityApril 14, 2

9、00517Medical Review of NC, Inc.April 14, 200518Medical Review of NC, Inc.Controversies & Challengesinpatient immunizationsToo sickWont workTakes long time to establish historyPhysician roleApril 14, 200519Medical Review of NC, Inc.Controversies & Challengesinfluenza vaccinationAvailabilityIt made me

10、 sickDocs prefer to give it in officeApril 14, 200521Medical Review of NC, Inc.Other broad challenge-working with physiciansApril 14, 200522Medical Review of NC, Inc.Communicating with docs-tipsBear in mind-most are feeling overwhelmed frazzledterrifiedWe need to;tell them only what they need to kno

11、wshow how we can make their life betterApril 14, 200523Medical Review of NC, Inc.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 limi

12、ted role to playApril 14, 200524Medical Review of NC, Inc.Communicating 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 inpu

13、t”Ensure you will be responsive to feedback “We would like to try this for 3 months and want you to let us know what you think”April 14, 200525Medical Review of NC, Inc.Communicating your message effectivelyStep #1 tell the story of the positive futureStep #2 convey to audience how taking the action

14、 will give THEM the future they wantStep # 3 call to action-ask for commitment of first stepMark Walton, Center for Leadership Communication, Chapel HillApril 14, 200526Medical Review of NC, Inc.Message to physiciansWe understand that their day-to-day life is overwhelmingApril 14, 200527Medical Revi

15、ew of NC, Inc.Patient careBillingAccurate codingInterruptionsPhone callsPharmaceutical repsFormulariesInsurance statusHealth care plansOffice administrationOther patientsPrior authorizationsClinical practice guidelinesDrug interactions/effectsBeepers/PagesApril 14, 200528Medical Review of NC, Inc.Sy

16、stematically 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 each clinical syndrome may encounter (National Guidelines Clearinghouse summaries Feb 2005; 1444 summa

17、ries) July 2004; 1329)2930April 14, 200531Medical Review of NC, Inc.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 pneumoniatreat resistant bacteria such as MRSA, VRE, DRSPthe antibi

18、otic 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 penicillinApril 14, 200532Medical Review of NC, Inc.We have revolutionized what we do,

19、without changing how we do it.We have advanced the product without changing the process.Contrast: FedEx, EBay, Amazon, StarbucksApril 14, 200533Medical Review of NC, Inc.Who is responsible for improving the system?April 14, 200534Medical Review of NC, Inc.How do we ensure the right treatment for the

20、 right patient at the right time, no more, no less?Tell the doctors to just do it?April 14, 200535Medical Review of NC, Inc.Skills of physiciansassess patientsdirect major aspects of therapyperform specific interventionscommunicate with patientsApril 14, 200536Medical Review of NC, Inc.To make best,

21、 most efficient, most effective use of physicians skills, need to protect time and touch of the patient-physician interaction.Alice G. Gosfield, J.D., Snyder, 9/12/03April 14, 200537Medical Review of NC, Inc.Clinical information patients history, and key aspects of care for their conditions-must be

22、present and readily utilized during the patient-physician encounter April 14, 200538Medical Review of NC, Inc.Physicians take the leadThere is no indication that the practice of medicine is getting less complex.Spend time today to save time tomorrow.April 14, 200539Medical Review of NC, Inc.Old paradigmMaintain knowledge-rely on memoryIndividualizeEncourage variationAvoid “cookbook”, Avoid crutches, pocket-fillersWork long hours-continuity of careFollow instructions of physician without questioning for fear of responseHealth is provided by the physician New paradigmAvoid reliance on me