BACKGROUND

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LEND Training and Quality Improvement: Building Leadership Skills While Enhancing Patient and Family-Centered Care. Claire Beers, Katherine DiNicola, Marjorie Dobra, Robin Gardner, Carrie Goodberlet, Jed Nordfelt, Johanna Stump Lisa DeLucia, Michelle Casey, Mark Orlando, Stephen Sulkes. - PowerPoint PPT Presentation

Transcript of BACKGROUND

LEND Training and Quality Improvement:Building Leadership Skills

While Enhancing Patient and Family-Centered Care

Claire Beers, Katherine DiNicola, Marjorie Dobra, Robin Gardner, Carrie Goodberlet, Jed Nordfelt, Johanna Stump

Lisa DeLucia, Michelle Casey, Mark Orlando, Stephen Sulkes

BACKGROUND

LEND FELLOW LEARNING OUTCOMES

Unsafe Behaviors• Elopement: Nearly half of children with an

ASD elope, and more than half of these “go missing.” Elopement is associated with autism severity, and is often goal-directed. (Pediatrics 2012)

• Drowning: Children who wander are often drawn to water sources. Accidental Drowning was identified as one of the leading causes of death among children who have a diagnosis of ASD (AWAARE, 2012)

• Pica: Prevalence: 25-30% of children who have a diagnosis of ASD Pica can lead to: Lead Poisoning, Bowel Problems, Intestinal Obstructions or Perforations, Dental Problems, and Parasitic Infection

• Aggression: Many children who have a diagnosis of an ASD exhibit aggressive behaviors towards those close to them. This can be challenging to emergency providers who come across a person with ASD.

• Self-Injurious Behavior : Children who have a diagnosis of ASD are more likely to engage in SIB (Schroeder, et. al, 2002) This includes Head, face, or body slapping, banging, biting, chewing, pinching, punching, or scratching. These behaviors can increase during times of stress.

• Ability to Communicate During Emergency: Children who have a diagnosis of ASD often are affected in the area of communication and over 1/3 are unable to communicate basic personal information (AWAARE, 2012).

Anderson C, Law JK, Daniels A, Rice C, Mandell DS, Hagopian L, Law P. Occurrence and Family Impact of Elopement in Children With Autism Spectrum Disorders. Pediatrics 11/12; 130(5):1-8, 11/12.

AWAARE Collaboration. (2012). Become Aware. Retrieved from http://www.awaare.org/index.htm

Centers for Disease Control and Prevention. (2012). New Data on Autism Spectrum Disorders (ASDs). Retrieved from http://www.cdc.gov/Features/CountingAutism/ 

Interactive Autism Network (IAN). (2012). Challenging Behaviors. Retrieved from http://www.iancommunity.org/cs/challenging_behavior/

PDSA Cycle Results: Percent Documented

Kirch Center Safety Resource List

OBJECTIVES – This study

Cycle Descriptions:Cycle 1: Baseline

One Randomly selected week in October, 201122 charts reviewed

Cycle 2: Providers Informed of Activity; no specific intervention proposed

After informal presentation to Kirch Practitioners of QI project

One randomly selected week in December, 2011Cycle 3: Small Group Template Implemented

5 Practitioners volunteered to utilize a Template called “Symptoms”

Reviewed from week of January 30, 201219 charts reviewed total

Cycle 4: Template Presented to Full TeamFormal presentation to Kirch Practitioners in

February First week in April, 2012Total of 20 charts reviewed

Cycle 5: New Electronic Medical Record in Place with Adjustable Templates

Five months after new EMR implemented19 Charts reviewed

DESIGN/METHODS RESULTS

PLAN-DO-STUDY-ACT (PDSA) CyclesA Tool for Incremental Improvement

The Problems

• The CDC created a new ICD-9 Code for Wandering and Elopement (V40.31) based on the interest and high rates reported by major autism groups (2012).

• AWAARE and IAN , for example, reported wandering rates from 50% to high as 92% (2012).

• Only 14% of patients said they received information from medical professionals (IAN, 2012).

• The Golisano Children’s Hospital Kirch Center serves a large population with Autism Spectrum Disorders and wants to become proactive in using the CDC Codes and promoting understanding about wandering.

• Other key autism related safety issues associated with wandering were also identified and incorporated into the study to see if they were being reported and discussed.

• Notation in a Medical Center/Community-wide Electronic Medical Record alerts providers in multiple settings of risks

Five Chart Reviews / PDSA Cycles were conducted in the Kirch Clinic

• Four reviews conducted of all practitioners during follow-up visits

• One review conducted of practitioners who volunteered to use behavioral template

Chart Selection Criteria:• First two patients over age three seen during that

week by each practitioner with diagnosis of ASD or PDD-NOS

References

Initial clinical team resistancePractitioners tend to focus on what they feel is

important during patient visits. Their time is very limited and they like to address the immediate concerns of the patient, leaving less time for documentation of other screening

Needed resources to implement changeseRecords was not live during at start of project and

AllScripts did not have an easily accessible template. With implementation of new system, quality markedly increased

Practitioners, recognized the importance of the risk-areas and given the right tools, change how their practice

Produced a safety resource list (paper and electronic)

Spread awareness across the Kirch Developmental Center of Autism Risk Areas

Wandering Safety:www.AWAARE.orgwww.Autism_Risk_Management.comwww.Project_Lifesaver.orgwww.UNYFEAT.org (Autism Risk and Safety section)

Drowning Prevention and Water Safety:www.warnonline.org/english/index.htmlautism.fsu.edu/documents/DrowningBrochureDRAFT.pdf

Pica Prevention:www.healthguideinfo.com/autism-treatment/p114419/

SIB and Aggressionwww.autism.com/ind_self-injurious_behavior_treat.asphttp://Autism-help.org/behavior-intro-autism.htm

Literature Review SkillsUnderstand Quality Improvement Process and Use of PDSA

Cycle Approach to Incremental ChangePresentation and Interdisciplinary Team Engagement SkillsQuantitative SkillsNegotiation and Conflict ResolutionSystems Change to Achieve Family-Centered CareAdvocacy with Medical Center to add codes to electronic

medical record system

Risk Area PDSA #1 %n = 22

PDSA #2 % n = 22

PDSA #3 %n =20

PDSA #4 %n = 19

PDSA #5 %n = 19

Elopement 9 18 32 39 84

Drowning 5 0 0 17 11

Pica 50 23 32 56 36

Aggression 50 50 47 50 63

Self-Injury 18 23 32 17 47

EmergencyCommunication

0 0 0 22 21

Implementing Safety Templates in Electronic Health Records for Children with ASDs

95

50 50

18

0

18

0

23

50

23

0

32

0

32

47

32

0

39

17

5650

1722

84

11

37

63

47

21

0102030405060708090

PDSA 1

PDSA 2

PDSA 3

PDSA 4

PDSA 5

DISCUSSION AND CONCLUSIONS