Need Clinical Input

[hoolahan, ASN, RN]

I work in Home Health, and my agency has demonstrated lower than average outcomes in the care of ct's with pulmonary conditions, this is measured by the OASIS before data, and at discharge, looking at dyspnea. Granted there may be some subjectivity in the answering of questions, but I am taking on the project to improve our outcomes. We also have a very high rate of re-hospitalization for CHF. I will add that we have a very high population of inner-city, and medicaid ct's, with a fairly large rate of non-compliance. And subjectivity can be corrected if we are assessing pt's in a similar way.

I need input from you guys on several issues.

1) Research is the start, I need to know, esp you HH nurses, if anyone out there has found a good pathway, caremap, or disease management program, that you feel has been effective for you. I know there is a great clinical guideline for asthma from NIH/AHCPR, but is there another place I can find this kind of evidence-based for a COPD management guideline? Anyone out there doing disease management for COPD? I have a very solid cardiac background so I am good with the CHF, there is a ton of info available on CHF, but not a lot of "standards" published, that I know of, for COPD. I did asthma disease management, so I am very well-versed in monitoring peak flows, preparing action plans, the meds, etc... Can this be applied to COPD? It seems that much of it is easily adaptable. What about smoking cessation? Is anyone out there incorporating that? Where do you refer ct's for that?

2) I know the nurses are busy. I will probably have only 1 hour to present the plan for COPD and one hour for CHF, in the form of mandatory (groan) inservices. Rather than focusing on getting the OASIS filled out correctly, I think my time is best spent sharing and education what the evidence-based info is, like a mini-hemodynamics for CHF, some of our nurses have no ICU/CCU background and very little hospital experience, and I think they may not truly understand the difference between a beta-blocker and an ace-i, etc... I would like to spend time teaching them a little advanced physiology and assessment techniques, then apply it to their assessments & questions we need to answer. The education is needed so that we are all doing a consistent assessment. My question is, do you think this is the right approach given the time constraint? Or should I just review the care maps I will develop? I was thinking I could supplement the program by having a poster-a-week display with something eye-catching, and interesting to reinforce what we have done, or a case presentation a week, Hey! That's an idea, what about a few case studies? But, how they can particpate effectively w/o the education? Maybe I can hand out the case studies and give individual feedback after they turn them in? And base the posters on items that multiple people got incorrect???? I don't want to insult the nurses in any way, God knows they have enough on their plates, and I want them to feel I am giving them best bang for their buck (or hour.)

Thanks for your input!!

[NRSKarenRN, BSN, RN]

Margaret H:

My agency has COPD program care map. Willing to send to you. WE also have CHF program and diabetc. Send me via e-mail your snail mail and will send off (It has helped keep our asessments accurate and readmits down to some degree.)

Filling out the OASIS questions correctly and consistently however, is the only way your documenttion will help your scores!!!

Our QA nurse (glad it's not part of our intake dept now that we mangage three agency's intakes) voice -mails an oasis tip of the week each friday, as she knows everyone check it on monday. She includes

outcomes agency is being warned about and documentation standards in about 2-3 minute spiel.

Working in Philly we have similar problems with noncompliance and have large population of elderly nuns in convents that we care for. No one thought to check off the nuns as endstage,less than six months, so we've been sited for higher than average "events" re deaths! Filling out the form properly,is making our nurses reexamine what,how and why we do somthing and rexamining our practices, not a bad thing afterall.

This year's safety inservice was a focus on ergonomic,body mechanics and eveeryone needed to demonstrate bed or WC transfers. The committee members were shocked by the number of nurses that admitted they never got patients OOB/chair because they didn't know how to do it by themselves, or were using poor technique! We chose this topic because of ergonomic legislation, increased number of car accidents and back strain staff reported and will redo preseentaion using lift devices and howyer lift in about 3-4 months. So you never know about a topic what your staff actually does know until you inservice them!

Try having fun with topic like millionare of game show in beginning, Throw out kids grap bag candy or Hersey bars to the "Winners" helped at our last CHF program last year!

[hoolahan, ASN, RN]

Thanks Karen,

WE are having the same problem with the high adverse event, at a meeting of some kind of HH QA group, it seems that all agencies in NJ had the same issue. Methinks there is a problem with that question!!

Good ideas, and I am open to more.

I think I'll start with a pre-quiz, cna be millionaire-style, then inservice, then a case study. I am also going to make up a self-learning packet for the nurses. As for the transfers, I'd be in the same boat! I have always felt the nurses should be oriented for a day or two at least with PT, when they are first hired, but God forbid, that's too much $$.