肺炎護理面臨問題與挑戰(zhàn)英文

1、Pneumonia careControversies and Challenges,Meera Kelley MDClinical Coordinator, MRNC, Inc.The QIO for the Carolinas,April 14, 2005,Medical Review of NC, Inc.,2,Overview,Issues with the indicatorsOther broad challenge

2、sDiscussion,April 14, 2005,Medical Review of NC, Inc.,3,PN-1 Oxygenation assessment PN-2 Pneumococcal vaccination PN-3b Blood cultures PN-4 Adult smoking cessation advicePN-5 Antibiotic timing PN-5a Initia

3、l 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,April 14,

4、2005,Medical Review of NC, Inc.,4,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 morta

5、lity among patients with pneumonia.,April 14, 2005,Medical Review of NC, Inc.,5,Controversies & ChallengesOxygenation assessment,No,April 14, 2005,Medical Review of NC, Inc.,6,PN-3b Blood cultures,Published pneumoni

6、a treatment guidelines recommend performance 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 ant

7、ibiotics are administered.,April 14, 2005,Medical Review of NC, Inc.,7,Controversies & ChallengesBlood cultures,Drawn late-after antibioticsNot drawn at all-not routinely done for outpatients,April 14, 2005,Medical

8、 Review of NC, Inc.,8,PN-4 Adult smoking cessation advice/counseling,Smoking 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

9、 clinically effective and cost-effective. Hospitalization can be an ideal opportunity for a patient to stop smoking.Patients who receive even brief smoking-cessation advice from their physicians are more likely to quit

10、.,April 14, 2005,Medical Review of NC, Inc.,9,Controversies & ChallengesSmoking cessation advice,DocumentationPreventive, long term issues not routinely addressed by physicians,April 14, 2005,Medical Review of NC,

11、Inc.,10,PN-5 Antibiotic timing,Timely administration of antibiotics = improved outcome among pneumonia patientsImproved survival with receipt of antibiotics within 4 h of admission (Khan 1990) Shortening the time-to-fi

12、rst-dose to 4 h was associated with improved survival (McGarvey 1993)First dose of antibiotic within 3 hours -less likely to die within 30 days (Meehan 1995)30-day mortality 10% (P=0.04) lower, length of hospital stay

13、shorter among patients whose first antibiotic administered within 4 h (Bratzler 2001),April 14, 2005,Medical Review of NC, Inc.,11,Controversies & ChallengesAntibiotic timing,Time from arrival to diagnosis,,April 14

14、, 2005,Medical Review of NC, Inc.,13,Controversies & ChallengesAntibiotic selection,Elderly, nursing home patient, other reasons want to give broader therapy,April 14, 2005,Medical Review of NC, Inc.,14,April 14, 20

15、05,Medical Review of NC, Inc.,15,PN-2 Pneumococcal vaccination,Indicated for persons > 65 years of age Up to 75% effective in preventing pneumococcal bacteremia and meningitis. Also important due to increasing antib

16、iotic resistance among pneumococciHospitalization is an underutilized opportunity,April 14, 2005,Medical Review of NC, Inc.,16,April 14, 2005,Medical Review of NC, Inc.,17,PN-7 Influenza vaccination,Indicated for people

17、 > 50 years Highly effective in preventing influenza-related pneumonia, hospitalization, and death. Hospitalization is an underutilized opportunity,April 14, 2005,Medical Review of NC, Inc.,18,April 14, 2005,Medical

18、 Review of NC, Inc.,19,Controversies & Challengesinpatient immunizations,Too sickWon’t workTakes long time to establish historyPhysician role,April 14, 2005,Medical Review of NC, Inc.,20,Controversies & Chall

19、engespneumococcal vaccination,Perception of risk of reimmunizationCochrane Databast Syst Rev 2003; (4) CD000422-”pneumococcal vaccination does not prevent pneumonia or death in adults”,April 14, 2005,Medical Review of

20、NC, Inc.,21,Controversies & Challengesinfluenza vaccination,AvailabilityIt made me sickDocs prefer to give it in office,April 14, 2005,Medical Review of NC, Inc.,22,Other broad challenge-working with physicians,A

21、pril 14, 2005,Medical Review of NC, Inc.,23,Communicating with docs-tips,Bear in mind-most are feeling overwhelmed frazzledterrifiedWe need to;tell them only what they need to knowshow how we can make their life be

22、tter,April 14, 2005,Medical Review of NC, Inc.,24,Communicating your message effectively-tips,Start planning your presentation by determining your goal-what do you want them to do when the leave?They will be more enthus

23、iastic if they have a clear, well defined, but limited role to play,April 14, 2005,Medical Review of NC, Inc.,25,Communicating your message effectively-tips,Acknowledge their challenges“We recognize how busy you are as

24、it is and want this to ultimately make your life better.”O(jiān)ffer 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 to try this for 3 mo

25、nths and want you to let us know what you think”,April 14, 2005,Medical Review of NC, Inc.,26,Communicating your message effectively,Step #1 tell the story of the positive futureStep #2 convey to audience how taking the

26、 action will give THEM the future they wantStep # 3 call to action-ask for commitment of first stepMark Walton, Center for Leadership Communication, Chapel Hill,April 14, 2005,Medical Review of NC, Inc.,27,Message to

27、physiciansWe understand that their day-to-day life is overwhelming,April 14, 2005,Medical Review of NC, Inc.,28,Patient care,Billing,Accurate coding,Interruptions,Phone calls,Pharmaceutical reps,Formularies,Insurance st

28、atus,Health care plans,Office administration,Other patients,Prior authorizations,Clinical practice guidelines,Drug interactions/effects,Beepers/Pages,29,,Systematically review each drug for potential side effects and int

29、eractions 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 summa

30、ries Feb 2005; 1444 summaries) July 2004; 1329),30,April 14, 2005,Medical Review of NC, Inc.,31,April 14, 2005,Medical Review of NC, Inc.,32,We can…. But we cannot ensure that…,Bypass, balloon, or stent a heart block

31、agedissolve a clot for a heart attacktransplant a heartprovide ventilator and BP support for pneumoniatreat resistant bacteria such as MRSA, VRE, DRSP,the antibiotic is given 1 hr prior to CABG (47.6% US)the p

32、atient gets an aspirin on discharge (84% US)heart failure patient assess LVF (70% US)flu shot history assessed, given (14% US)penicillin allergic patient doesn’t get penicillin,April 14, 2005,Medical Review of NC,

33、 Inc.,33,We have revolutionized what we do, without changing how we do it.We have advanced the product without changing the process.Contrast: FedEx, EBay, Amazon, Starbuck’s,April 14, 2005,Medical Review of NC, Inc

34、.,34,Who is responsible for improving the system?,April 14, 2005,Medical Review of NC, Inc.,35,How do we ensure the right treatment for the right patient at the right time, no more, no less?,Tell the doctors to just do i

35、t?,April 14, 2005,Medical Review of NC, Inc.,36,Skills of physicians,assess patientsdirect major aspects of therapyperform specific interventionscommunicate with patients,April 14, 2005,Medical Review of NC, Inc.,37,T

36、o make best, 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, 9/12/03,April 14, 2005,Medical Review of NC, I

37、nc.,38,Clinical information –patient’s history, and key aspects of care for their conditions-must be present and readily utilized during the patient-physician encounter,April 14, 2005,Medical Review of NC, Inc.,39,Physic

38、ians take the lead,There is no indication that the practice of medicine is getting less complex.Spend time today to save time tomorrow.,April 14, 2005,Medical Review of NC, Inc.,40,Old paradigmMaintain knowledge-rely o

39、n memoryIndividualizeEncourage variationAvoid “cookbook”, Avoid crutches, pocket-fillersWork long hours-continuity of careFollow instructions of physician without questioning for fear of responseHealth is pro

40、vided by the physician,New paradigmAvoid reliance on memoryProvide consistencySimplifyUse protocols, check tools, referencesMinimize long hours- encourage safetyMirror back orders, ask questions, raise doubt

41、without fear of retributionHealth is achieved by the team,April 14, 2005,Medical Review of NC, Inc.,41,Cookbook concerns,April 14, 2005,Medical Review of NC, Inc.,42,Skills of physicians,assess patientsdirect major a

42、spects of therapyperform specific interventionscommunicate with patientsNo checklist, cookbook, or computer will ever replace this!,April 14, 2005,Medical Review of NC, Inc.,43,Bringing healthcare into the 21st cent