Dr Bambang Suryono S

HEALING IS AN ART, MEDICINE IS A SCIENCE,

HEALTHCARE IS A BUSINESS.

Interaksi antar profesi dan satuan kerja

Hubungan antar profesi:

Konsultasi/rawat bersama/alih rawat Tim Prosedur penelitian Prosedur pendidikan Interaksi kelompok SMF & Instalasi Penegakan peraturan

Care management
An organized system or process for delivering

health care to a patient, including assessment, development of a Plan of Care, initiation and coordination of referrals and services, and evaluation of care.

2008 Home Health Nursing : Scope and Standards of Practice

Case manager
Case manager is a designation used to define a lead

person for the episode of care. Shifting of case manager.

Case management is the responsibility of every member

of the team.

*Nurses * Therapists *etc

Type of ICU
Closed and Open ICU
Type: Type A, Type B and Type C

Case management skills

Responsible to the patient and to the team
*Clinical decision making *Education *Advocacy *Collaboration *Care coordination *Communication

Case management skills

Responsible to the patient and to the team *Privacy

*Supervision
*Managing patient outcomes *Regulatory compliance

*Managing the financial cost of care

*Documentation

Essential Communication

With patient and family members Public Physician Other team members Supervisor Schedulers Insurance companies Community support services Medical appointments

Is Case Management Alive and Well?

Do your clinicians discuss the plan of care with

team during the first week of care? Do clinicians tell each other when a patient has had an issue? * Medication change? *Admission? *Deceased? Is the discharge coordinated?

Care planning
Holistic in nature Invite other disciplines

Decide on specific goals

*Include quality indicator deficits (deficits in outcome items) Coordinate visits cost effectively Balance clinical solutions with visit numbers

Focus on outcomes
Care planning:

the opportunity to improve the outcomes for the patient intentionally.

Quality Assurance & Patient Safety

Improvement
Improvement is measured as scoring at a better

level than at the start of the episode.

It does not mean full recovery is always goal.

QA
It encompasses the principles of how an

organization should be run

Kaizen : continuous search for improvement in

oneself and in the system

 The key to an organizations success is

to master the art of orchestrating collective thinking.

Potential for improvement

Considerations:

Prior level of function Homebound status Patient goals Need to expand view beyond being functional in the home environment for those patients that want to re-enter the community

New style of management

Removing the causes of problems in the system

improving quality of care Problem identifications to be solved The right man in the right place People motivated to run the job

 People should be authorized and

encouraged to bypass managers and solved problems themselves Supervisors and managers must be specialists who will support their people when problems arise.

 A structured problem-solving process

Resistance of implementation

must be resolved along the way

Follow-up

Action <............ Monitoring

Activities

Assessment

Home Health Compare

Improvement in ambulation/ locomotion Improvement in bathing Improvement of oral medication Improvement in transferring Improvement with pain interfering with activity Any emergent care provided

Home Health Compare

Acute care hospitalization Improvement in dyspnea Improvement in urinary incontinence Discharge to the community Improvement in the status of surgical wounds Emergent care wound infections/ deteriorating wound status

Health Care Improvement in ICU

Early mobilization

Enteral Feeding
Ventilator- Free Days Avoid Readmission

Avoid Autoextubation
Minimalization of Nosocomial Infection

Health Care Improvement in ICU

Quality of Life Bacterial Resistance Sedaso-analgesics

Contoh QA
Mortality Complaints

Readmission rate
LOS > 30 days Fire and safety practice

Problem identification workshop

Review nursing practices Unexpected events

Care Planning Transfers

Establish criteria for therapy referrals

Assessment and intervention specific to the transfers

in item Establish a standard of care

Collaborative Care Planning

Working together as a team does not happen

automatically Agency culture and structure need to facilitate interdisciplinary thinking. Reporting relationships Staff meetings Clinical structure Communication strategies

Consultants Surgical attending medical director nurse manager Critical care attendings clinical nurse specialist & acute care nurse practitioners Critical care critical care nurses PATIENT& & FAM fellows PATIENT FAMILY Critical care nutritionists residents physical therapists pharmacists occupational therapists

social workers respiratory therapists

Team meetings
Weekly? Bi-weekly? Monthly? How long?

Who attends?
Focus of the meeting? Do they work?

Team care planning Can it work?

Reducing readmission to ICU -Determining risk factors

-Visit patterns for those considered at risk

-Establish referral criteria for services

It is not easy .
Concerns : Time

Cost Competing priorities The focus must be on strategic and intentional care delivery.

But it is worth it!

The goal of care is to maintain or improve the

quality of life for patients and their families and other caregivers, or to support patients in their transition to the end of life. This is accomplished through the initiation, coordination, management, and evaluation of resources needed to promote the patients optimal level well-being and function 2008. HHN

Evidence-Based Medicine
The conscientious, explicit, and judicious use of

current best evidence in making decisions about the care of individual patients.
An approach to EBM:

Ask a clinically relevant question Search for evidence Evaluate the evidence Apply the evidence

Clinically relevant questions

A patient or problem
An intervention or diagnostic test (if relevant) A comparison group (if relevant) An outcome

Search for the best evidence

Medline indexes (www.Pubmed.gov)
The Cochrane Library (www.Cochrane.org)

Evaluate the evidence

Is the evidence valid?
What are the results?

Applying the evidence

Diagnostic studies
Prognostic studies Treatment or prevention studies Systemic reviews, overviews, and meta-analyses Clinical decisions analyses Economic analyses Clinical practice guidelines

Diagnostic

Diagnostic

Is the evidence valid?

Was there an independent, blind comparison with a

gold standard? Did the patient sample include an appropriate spectrum of patients? Was the gold standard applied to all patients?

What are the results?

Are likelihood ratios presented?

Will the results help me care for my patients?

Will the test results be reproducible and applicable to

patients in my clinical setting? Will the test results change my management?

Penilaian Rekomendasi
A. Didukung 2 penelitian level I
B. Didukung 1 penelitian level I C. Didukung penelitian level II D. Didukung minimal 1 penelitian level III E. Didukung penelitian level IV atau V

Penilaian Bukti
I. RCT luas + hasil jelas, risiko rendah pada alpha dan

atau beta error II. RCT kecil + hasil tidak jelas III. Non randomisasi, kontrol secara bersamaan IV.Non randomisasi, kontrol historis dan opini ahli V.Serial kasus, penelitian tidak terkontrol dan opini ahli.

EBM in ICU
A. Severity-of-illness scoring systems use of

elements of : the history, physical examination, and diagnostic tests to objectively gauge illness severity and determine prognosis. Four main applications: Clinical research Performance assessment Resource allocation Guidance in individual patient decisions

Scoring systems in adult CCM

APACHE (acute physiology and chronic health

evaluation) SAPS ( simplified acute physiology score) MPM (mortality probability model)

. APACHE (I,II and III) is based on the premise that

severity of illness on ICU admission is based on a patients physiologic reserve (age and the presence of comorbidities) and the extent of any acute physiologic abnormalities (worst abnormalities within 24 hours of admission)
SAPS (I and II) was initially developed as

simplification of the APACHE I classification system. SAPS II uses 17 variables and performs similarly to APACHE II

.
MPM (I and II) is a statistical modeling system that

uses patient clinical variables to predict the probability of hospital mortality rather than to measure severity of illness.
TRISS (trauma and revised injury severity score) is a

severity-of-injury scoring system for trauma patients, but is not specific to ICU trauma admissions.

Multiple Organ Dysfunction Score is an organ

dysfunction score that is calculated based on a patients respiratory, renal, hepatic, cardiovascular, hematologic and neurologic function.
SOFA (sequential organ failure assessment) is an

organ dysfunction score that mainly differs from the MODS in that it includes therapeutic interventions in its assessment of a patients cardiovascular function.

.
B. Outcomes of special interest in the intensive care

unit. 1. Inhospital mortality 2. The 28-day mortality 3. Hospital length of stay 4. Ventilator free days

Case 1
Pasien yang keluar dari ICU dalam bulan Juli ada 7%

mengalami readmissi ke ICU dalam 24 jam. Problem identification? Perbaikan?

Case 2
Pasien tetanus yang dirawat di ICU dengan diazepam

kejang sulit diatasi. Kejang baru hilang dalam 12 hari. Adakah cara yang lebih baik untuk mengatasi kejang? EBM? Implementasi?

Case 3
Seorang pasien dengan AMI dan hemodinamik tidak

stabil. Selain itu pasien menderita DM dan asthma bronchiale. Ada tanda AKI yang terlihat dari kenaikan ureum dan creatinin. Pasien dirawat di ICU dan di kelola oleh tim dokter. Siapa duduk dalam tim? Siapa ketua tim? Apa rencana kerjanya?