A Report to theA Report to thePatient Safety Patient Safety

CommitteeCommitteeof Arizona General of Arizona General

HospitalHospitalPrepared by Members of the

University of Missouri-Columbia Interdisciplinary Workgroup

for the CLARION INTERPROFESSIONAL CASE COMPETITIONSPRING 2005

AGHAGHINTRODUCTIONS

• Ashley Mahon– Accelerated Option BSN, RN Program– UMC School of Nursing

• Russell McCulloh– 4th Year, MD Program– UMC School of Medicine

• Kevin Norris– 3rd Year, PT Program– UMC School of Health Professions

• Brian Stout– 3rd Year, MHA/MBA Dual Degree Program– UMC Schools of Medicine & Business

She “might be She “might be trouble”trouble”

-Bus Driver-Bus Driver

AGHAGH PRESENTATION OVERVIEW

• Case Overview• Methods of Analysis• Major Findings• Specific Findings

– Recommendations/Action Plan– Tracking Indicators– Cost Analysis

• Systems Issues• References/Acknowledgments

AGHAGHCASE OVERVIEW

• Arizona General Hospital:– Tertiary care center– 620 bed-facility– 97 Behavioral Health Beds

• AGH Values:– Dignity– Collaboration– Stewardship– Excellence

AGHAGHCASE OVERVIEW

• Part of Southwest HC System (SWH) Flagship for HC delivery in Maricopa Co.10 affiliated clinics

• Clinical Expertise Centers of Excellence Behavioral HealthWomen’s HealthRehabilitationCardiovascular servicesNeuroscienceOncologyOrthopedicsSpine Care

AGHAGHCASE OVERVIEW

• 36 year old female• 20 year history of schizophrenia• Admitted for decreased mental status• Treated for suspected overdose• Self-administered medication overdose in

hospital• 3-week stay in BHU• Discharged to home• Readmitted seven weeks later for relapse of

psychotic symptoms and alcohol intoxication

AGHAGHMETHODS

• Investigation:– Identification of Major Events– Causal Flow Analysis– Root-Cause Analysis (VA-NCPS)– Identification of Contributing Factors

• Remediation:– Literature Review– Development of Recommendations– Progress Assessment– Cost Analysis– Extrapolation

AGHAGHMAJOR FINDINGS

• Three adverse events were identified:– Self-Induced Clozaril Overdose– Job/Coverage Loss & Rehospitalization– Self-Extubation*

• Self-Induced Overdose:– Unsuccessful suicide attempt– Near-miss of a reportable JCAHO sentinel event:

“Any suicide of a patient in a setting where the patient is housed around-the-clock”

Self-InducedSelf-InducedDrug OverdoseDrug Overdose

AGHAGH Self-Induced Overdose Timeline

10 AM TRUnidentified Pt isadmitted to ER

ER WARD 10AICU

7:30 PM FRIPt reintub.;transferredback to ICU

2 PM TRPt transferred

to ICU

4 PM FRI:Pt transferred to

unmonitored med unit

ICU

Pt & Substance/AmtID by Rx Bottlefound among

pt’s belongings

Security check results in pill bottleremaining among pt belongings

Clozaril OverdoseAssumed

Rx bottle transferredw/ Pt belongings;

left unsecured in pt room

1:30 AM FRI:Pt self-extubates

Psych teamsees Pt

~6:30 PM FRI:Near Sentinel Event:

Self-Induced Overdose

RN investigates ontip from roommate;

contacts intern(~7PM)

Intern investigates;Contacts Sr Resident

Sr Residentresponds

AGHAGH Self-Induced OverdoseFlow Diagram

Pt Presents in ER

Security checkresults in meds

remaining with ptbelongings

Clozaril leftunsecured andattainable in pt

room

Pt readmittedto ICU;

Reintubated

Pt, Substance, Amt allidentified by Pill Bottle

No ID orPMH

available

No entry into ptrecord concerning

suicide risk

No formal suicide risk/behavioral assessment

performed inICU/Ward 10A

No formalcommunication re:

suicide risk

Pt not formallyrecognized as

suicide risk

Pt left unobservedin step-down ward

Pt consumes700mgClozaril

Delayedresponse toOverdose

No External ProviderContacted; No

PharmacistInvolvement

in ER

Self-InducedDrug Overdose

ClozarilOverdose/

Substance AbuseAssumed

No Psych teaminvolvement

AGHAGHSelf-Induced Overdose RCA

• Root Cause Statement:

“Level of patient observation and access to potentially toxic medications

resulted in increased possibility of self-induced overdose.”

• Three contributing factors domains were identified

AGHAGHCare Team Communication

Care Team Communication

Parallel/IsolatedTeam Communication

Over-relianceon Chart

Informal Report ofRisk for Self-harm

Informal Communicationof Pt Behavior/Likely Actions

AGHAGHCare Team Role Definition

Care TeamRole Definition

RPh Not Involved inCollecting Pt PMH

RPh Not Involved in Medication ID

Medical Team Assessmentof Purely Medical Issues

Psych Assessment ofBehavioral Health IssuesRestricted to Med Status

& Schizophrenia

AGHAGHPolicies & Procedures

Policies & Procedures

Availability/Use ofOverdose Protocols

InadequateRisk Assessment

for Self-harm

Availability/Use of HomeMed Storage Protocols

AGHAGH Self-Induced OverdoseIshikawa

Self-InducedClozaril Overdose

Policies & Procedures

Care Team Communication

Care TeamRole Definition

Availability/Use ofOverdose Protocols

InadequateRisk Assessment

for Self-harm

Availability/Use of HomeMed Storage Protocols

Parallel/IsolatedTeam Communication

Over-relianceon Chart

Informal Report ofRisk for Self-harm

Informal Communicationof Pt Behavior/Likely Actions

RPh Not Involved inCollecting Pt PMH

RPh Not Involved in Medication ID

Medical Team Assessmentof Purely Medical Issues

Psych Assessment ofBehavioral Health IssuesRestricted to Med Status

& Schizophrenia

AGHAGH Self-Induced Overdose:Contributing Factors

• Care Team Communication– Parallel and informal evaluation and

communication of self-harm risk– Informal assumption of polysubstance abuse

• Care Team Roles– Medication identified solely by ER staff– Primary focus on only physical health aspects of

admission• Policies & Procedures

– Persistent access to patient of potentially toxic medications

– PMH gathered solely from patient’s medication bottle

AGHAGH Self-Induced Overdose:Recommendations

• Care Team Communication– AMR “tab” dedicated to psychosocial issues1

• Care Team Roles– All pt home meds are to be ID by pharmacist2

• Policies & Procedures– Develop a standard protocol for evaluation &

management of all overdose patients3

– Establish procedures for pts. at possible risk for self harm1,4

– Establish security procedures for the intake, storage, and disposition of pt home meds2

– Similar policy for potentially harmful pt. items2

AGHAGH Self-Induced Overdose:Tracking Indicators

1. Suspected overdose patients assessed for self-harm risk*

2. Employees scoring 70% or greater on knowledge assessment of behavioral health training courses*

3. Home medications stored securely*

*All indicators are percentage-based; goals for implementation are to be set at 100% compliance

AGHAGH Self-Induced Overdose:Cost Analysis

• Incurred costs– Room sitters (personnel-dependent)– Time/resource demands for training personnel

re: new assessment procedures– Monitoring/ongoing risk assessment

• Cost-neutral measures– AMR changes covered by IT contract

• Estimated savings– Reduced risk of emergent intervention

AGHAGH Self-Induced Overdose: Dollars and Sense

Comparative Costs of Sitter vs ICU Stay

With Intervention:Room Sitter Wage 15.00$ Est.

# of Hours Surveillance 24 Observation Costs 360.00$

W/O Intervention:Avg. Cost of Stay (ICU): 44,845.00$ A

Avg. LOS in Days (ICU) 6.01 A

Avg Cost/Day (ICU) 7,461.73$ A

Est. Savings W/ Intervention: 7,101.73$

Job/Coverage Loss Job/Coverage Loss and Rehospitalizationand Rehospitalization

AGHAGH

10 AM TRPt is admitted to ER

ER ICUWARD 10AICU Behavioral Health Unit

7:30 PM FRIPt reintub.;transferredback to ICU

7 AM FRI:Pt 1st

becomes responsive

Pt Assignedto HCC

~7:30 PM SATPt extubated; regains

Consciousness

24 Hrs fromAdmission

36 Hrs from Admission

Monday PM:Pt transferred

to BHU

60 Hrs fromAdmission

Behavioral Health Unit Post-Discharge ER Behavioral Health Unit

90+ Hrs fromAdmission

HCC sees ptfor the 1st time?

LOS in BHU:Three Weeks

Time Away from Institution:60 Days

Job Lossnot entered into AMR

Adverse Event:Pt Loses Job/HC Coverage Rx runs out; Pt unable to

obtain needed medication;Pt relapses

Pt suffers head laceration;Readmitted to ER

Pt admitted to BHU

10 AM FRI:Psych Team

Interview

Job/Coverage Loss& Rehospitalization Timeline

AGHAGH Job/Coverage Loss & Rehospitalization Flow Diagram

Pt assigned toHCC according

to policy

Social Workeris not involved

in patient’s care

HCC does not seepatient within 36

hour window

Patient loses job(and coverage)

HCC unaware ofpt job loss

BHU Nurse unfamiliarwith AMR re: Social

Services

PT transferredto BehavioralHealth Unit

Pt Admitted to ER

No record ofJob Loss

entered intoAMR

Pt relays jobloss to Nurse

Pt admitted toICU; then Ward10A; then back

to ICU

Pt Relapses;Readmitted

Pt isDischarged

Employer is notContacted

Pt runs out ofZyprexa; No refill

due to lostcoverage

Pt not connectedw/ social service

resources

AGHAGH Job/Coverage Loss & Rehospitalization RCA

• Root Cause Statement :

“Level of social services involvement led to the patient’s job & coverage loss

and ultimately resulted in patient’s relapse & readmission to the hospital.”

• Three contributing factor domains were identified

AGHAGHCare Team Communication

Care Team Communication

No Psych TeamCommunication

of PS Info

Lack of Communicationbetween Care Teams

AGHAGHInadequate Social Services

Inadequate Social Services

No Social WorkerInvolvement

Failure to act on PS HistoryWithin 36 Hrs of Admit

Suboptimal Process forAssigning Patients upon Admit

HCC InvolvedToo Late in Stay

AGHAGHAMR Usage

AMR Usage

No ContingencyBackup

InsufficientTraining

Failure to EnterJob Loss Info

AMR Does Not MeetStaff Needs

AGHAGH Job/Coverage Loss & Rehospitalization Ishikawa

Job/Coverage Loss& Rehospitalization

Inadequate Social ServicesCare Team Communication

AMR Usage

No ContingencyBackup

InsufficientTraining

Failure to EnterJob Loss Info

AMR Does Not MeetStaff Needs

No Psych TeamCommunication

of PS Info

Lack of Communicationbetween Care Teams

No Social WorkerInvolvement

Failure to act on PS HistoryWithin 36 Hrs of Admit

Suboptimal Process forAssigning Patients upon Admit

HCC InvolvedToo Late in Stay

AGHAGH Job/Coverage Loss & Rehosp.:Contributing Factors

• Care Team Communication:– Care teams engaged in parallel and informal

communication

• Coordination of Social Services:– Patient assigned to HCC– Currently defined roles for HCC and SW– HCC only involved near end of pt’s stay

• AMR Usage:– Hospital staff unfamiliar with documenting

psycho-social information into the AMR– Incomplete integration of AMR with

organizational culture

AGHAGH Job/Coverage Loss & Rehosp.:Recommendations

• Care Team Communication– Psych team and SW make daily rounds together for all

primary diagnoses of mental illness, psychosis, and drug overdose5

– Fully integrated multi-disciplinary teams

• Coordination of Social Services– Redefine the role of the HCC6,7,8

– Automatic referral to SW in cases with primary dx. of mental illness, psychosis, or drug overdose

• AMR Usage– AMR “Tab” for psycho-social information

– Formal mechanism for staff feedback

AGHAGH Job/Coverage Loss & Rehosp.: Tracking Indicators

1. Staff satisfaction rate with AMR (20% increase from baseline)

2. Voluntary exit survey for patients receiving Psych/SW team care

3. Percent of pts. admitted with diagnosis of mental illness, psychosis, or drug overdose, assessed by SW (100%)

4. Percent of pts seen by HCC within:- 36 hours of admission (>95%)- 48 hours of admission (100%)

5. Number of readmissions due to mental illness, psychosis, or drug overdose (10% reduction)

AGHAGH Job/Coverage Loss & Rehosp.: Cost Analysis

• Cost Neutral Recommendations:– AMR changes (provided through IT contract)– Social Worker/Psych rounds– Referral policies

• Incurred Costs– Additional HCCs (case managers)9

• Savings– Reduce number of psych readmissions6

– Reduced LOS by 10% with multi-disciplinary rounds5

– Reduced per-patient cost of stay by up to 16% with multi-disciplinary rounds5

AGHAGH Job/Coverage Loss & Rehosp.: Dollars and Sense

Cost of Universal Case Management

Number of Additional HCCs Needed: 10

Annual Salary (Case manager)Acute care $53,000 B

Cost of Providing Case Management to All Pts:

$530,000

AGHAGH Job/Coverage Loss & Rehosp.: Dollars and SenseDecreased LOS (Psych Services)

Avg. LOS in Days (Psych): 9.47 A

Decrease: 10%Post-Intervention LOS in Days (Psych) 8.52 Avg Cost of Stay (Psych): 8,757.00$ A

Avg Cost/Day (Psych): 1,027.46$ A

Per Patient Cost W/O Intervention 9,730.00$ Per Patient Cost W/ Intervention 8,757.00$ Savings Per Psych Admission $973.00Avg. # of Psych Admissions 1,041.00 A

Total Annual Savings 1,012,893.00$

Decreased Cost of Stay (Psych Services)Avg. Cost of Stay (Psych): 8,757.00$ A

Estimated Decrease: 16%Avg Cost of Stay W/ Multi-D Rounding 7,355.88$ Savings Per Psych Admission 1,401.12$ Avg. # of Psych Admissions 1,041.00 A

Total Annual Savings 1,458,565.92$

Self-ExtubationSelf-Extubation

AGHAGH

10 AM TRPt presents at ER

ER ICU

1:30 AM FRIPt Self-Extubates(Adverse Event)

Pt is Intubated

Clozaril Overdose Assumed

2 PM TRPt is transferredto Med/Surg ICU

Serum ToxicologyPanel Performed

ICU PharmacistConsulted

3 PM TRICU Nurse

Shift Change

ICU Nurse Chargedw/ Additional Patient

11 PM TRPt Agitated; Orders for 2mg IV Haldol

Every 2 Hours

Pt is Reintubatedand Sedated

Self-Extubation Timeline

AGHAGH Self-Extubation Flow Diagram

Self-Extubation

Paramedics BringPt to ER

Clozaril Overdose Assumed;Additional Drugs Suspected

Patient Admittedto Med Surg ICU

Toxicology Panel isBelatedly Performed(Delaying Results)

ICU Pharmacistis Consulted

(Delayed)

Pt Stabilized,Intubated,

and Sedated

ICU Nurse ShiftChange Occurs

Attending Nurse isgiven an additionalpt; which distractshim from Patient

PatientBecomesAgitated

Cautiousorder given for

addtnl sedation

Sedation is inadequate;Pt again becomes Agitated

No RPh in ER

No BehavioralRisk-Assessment;Despite Overdose

Patient Restsin ICU

AGHAGHSelf-Extubation RCA

• Root Cause Statement :

“The level of sedation & agitation management increased the likelihood

of patient self-extubation”

• Three major contributing factor domains were identified

AGHAGHCare Team Communication

Care TeamCommunication

DelayedInvolvement

of Pharmacist

Level of PharmacyInvolvement

EMT/ER/ICUInformal

Communication

Delayed SerumToxicology

Results

AGHAGHPolicies & Procedures

Policies & Procedures

Extent ofBehavioral

Assessment

Availability/Useof Sedation/Weaning

Protocols

Availability/Use ofAgitation Mgmt

Protocols

AGHAGHScheduling

Scheduling

2:1 ICUStaffing Ratio

Inappropriate Demandson ICU Nurses

AGHAGHSelf-Extubation Ishikawa

Self-Extubation

Care TeamCommunication

Policies & Procedures

Scheduling

2:1 ICUStaffing Ratio

Extent ofBehavioral

Assessment

Inappropriate Demandson ICU Nurses

DelayedInvolvement

of Pharmacist

Level of PharmacyInvolvement

EMT/ER/ICUInformal

Communication

Delayed SerumToxicology

Results

Availability/Useof Sedation/Weaning

Protocols

Availability/Use ofAgitation Mgmt

Protocols

AGHAGH Self-Extubation:Contributing Factors

• Care Team Communication:– Time/location of pharmacist involvement– Communication b/w front-line providers

• Policies & Procedures:– Extent of behavioral assessment– Availability/use of agitation management

protocols– Availability/use of sedation and weaning

protocols

• Scheduling: – Provider staffing-level in ICU

AGHAGH Self-Extubation:Recommendations

• Care Team Communication:– Ensure timely urine/serum toxicology screens in

conjunction with overdose protocols– Develop AMR flag for pharmacist consult in all

cases involving drug overdose

• Policies & Procedures:– Institute routine use of agitation management

protocols by ICU staff (Ramsay)10

– Institute use of sedation protocols in ICU11,12

– Institute use of weaning protocols in ICU10,13

• Scheduling:– Evaluate adequacy of ICU staffing/training10,14,15

AGHAGH Self-Extubation:Tracking Indicators

1. Incidence of self-extubation (ICU)2. Length of ventilator support (ICU)3. ICU pt-nurse staffing ratios (1.5-1.7)4. Number of pts (per 100 intubated pts)

that score below 3 on two consecutive hourly Ramsay Assessments (Zero)

5. Percent of overdose pts whose records include RPh consult notes (100%)

6. Percent of overdose pts whose urine/serum toxicology screens are ordered w/in 1 Hr of admit to ER (100%)

AGHAGH Self-Extubation:Cost Analysis

• Incurred Cost:– Increased ICU Staffing?– Physician/RPh Consult Fees– Implementation of protocols/training– Monitoring/ongoing risk assessment

• Estimated Savings:– Decreased LOS in ICU (Decrease of 3.5 days)16,17 – Shorter Duration of Ventilator Support (Decrease

of 2.5 days17; between 63 and 89% of SEs do not require reintubation10)

– Costs of Reintubation (>40% Decrease)11

AGHAGH Self-Extubation:Dollars and Sense

Decreased LOS in ICU Decrease in Days: 3.5Avg LOS in Days (ICU) 6.01 A

Avg Cost of Stay (ICU): 44,845.00$ A

Avg Cost/Day (ICU): 7,461.73$ Avg. # of ICU Patients/Yr: 4,991 A

Annual Cost W/O Intervention 223,821,395.00$ Annual Cost W/ Intervention 93,476,156.65$

Annual Savings 130,345,238.35$

Decreased Ventilator Support Decrease in Days: 2.5Avg Time on Ventilator in Days (ICU) 12.5 C

Cost/Day (Ventilator Support): 200.00$ C

Avg. # of Patients on Ventilator Support/Yr: 314 C

Annual Cost W/O Intervention 784,393.94$ Annual Cost W/ Intervention 627,515.15$

Annual Savings 156,878.79$

Decreased Self-Extubation CostsPercent Decrease: 40%Avg. Rate of Self-Extubation 17% C

Avg Number of Self-Extubations/Year 102 C

Avg. Rate of Self-Extubation W/ Intervention 10.2%Cost of Reintubation $117 D

Annual Cost W/O Intervention 11,934.00$ Annual Cost W/ Intervention 7,160.40$

Annual Savings 4,773.60$

““The Big Picture”The Big Picture”

AGHAGHRecommendation Summary

• Communication• AMR/organizational culture integration • Policies and Procedures• Expansion of care team member roles• Supporting AGH mission and values

– Dignity– Collaboration– Stewardship– Excellence

AGHAGHWhat If…

• Psych would have been more actively involved in patient care?Risk for self-harm would have indicated need for

1:1 staffing and/or suicide observation in ICU and suicide observation in Ward 10A

• Pharmacy would have been more actively involved in patient care?Patient and drug ID would have been confirmedPatient PMH might have been availableConcerns over sedative interactions might have

been dismissed

AGHAGHWhat If…

• Social Services would have been more actively involved in patient care?Patient job/coverage loss might have been

avoided altogetherPatient would have had access to local mental

health resources and “safety net” coverage

• All three domains had been aligned with delivery of acute care?No adverse events?Patient would have certainly left our institution

better off than when she arrived (in many ways)

AGHAGH Targeting Continuity of Mental Health Services

• Within the Institution– Mental Health Services– Pharmacy– Social Services– Acute/Chronic Care

• Within the Community:

– Provider/MCO Collaboration

– Partnerships– Regional Leadership

AGHAGHFuture Directions:

• Increase pharmacy integration: Discharge Planning/Consultation18,19,20

Pharmacy and Therapeutics Committee18,19

Collaborative Drug Therapy18,19

Medication Reconciliation21

Psychiatric Pharmacist22,23

• Integrating social services & behavioral health: Functional Integration Team18 (AGH BHCE) Wellness Recovery Action Plans24 (WRAP)

• Ongoing collaboration between: AGH & community pharmacies AGH & satellite clinics SWH & ValueOptions25,26

AGHAGHConcluding Remarks

• Consistent with:– Our institutional mission– IOM & IHI vision of the future– Our patients’ needs/rights to access & receive

safe, reliable, and comprehensive care

““It doesn’t work to leap a twenty-foot chasm It doesn’t work to leap a twenty-foot chasm

in two ten-foot jumps”in two ten-foot jumps”

-American Proverb

A Report to theA Report to thePatient Safety Patient Safety

CommitteeCommitteeof Arizona General of Arizona General

HospitalHospitalPrepared by Members of the

University of Missouri-Columbia Interdisciplinary Workgroup

for the CLARION INTERPROFESSIONAL CASE COMPETITIONSPRING 2005

AGHAGH References

1. Dlugacz, Y.D., Restifo, A., Scanion, K., Nerlson, K., et al. (2003). Safety Strategies to Prevent Suicide in Multiple Health Care Environments. Joint Commission Journal on Quality and Safety, 29(6), 267-278.

2. Harry S. Truman Memorial Veterans Hospital- Pharmacy operations and drug procedures. December 30, 2004.

3. Harry S. Truman Memorial Veterans Hospital- Prevention and management of disturbed behavior. April 22, 2004.

4. Harry S. Truman Memorial Veterans Hospital- Management of suicidal policy. April 26, 2004.

5. Curley, C., McEachern, K. E., Speroff, T. (1998). A Firm Trial of Interdisciplinary Rounds on Impatient Medical Wards: An Intervention designed using continuous quality improvement. Med Care, 36(8), AS4-AS12.

6. Cox, W.K., Penny, L.C., Statham, R.P., Roper, B.L. Admission intervention team: medical center based intensive case management of the seriously mentally ill. Care Management Journals, 4(4), 178-184.

AGHAGH References

7. Rubin, A. Is Case Management Effective for People With Serious Mental Illness? A research review. Health & Social Work, 17(2), 138-150.

8. Wickizer, T.M., Lessler, D. Do Treatment Restrictions Imposed by Utilization Management Increase the Likelihood of Readmission for Psychiatric Patients? Medical Care, 36(6), 844-850.

9. 2003 Case Management Salary Survey Results. In: Advance for Providers of Post-Acute Care. May/June 2003, 51-54.

10. Maccioli GA et al. (2003). Clinical practice guidelines for the maintenance of patient physical safety in the intensive care unit: Use of restraining therapies-American College of Critical Care Medicine Task Force 2001-2002. Critical Care Medicine. 31(11), 2665-2676.

11. Wagner IJ. (1998). A sedation protocol to prevent self-extubation. Chest. 113(5),1429.

12. Powers J. (1999). A sedation protocol for preventing patient self-extubation. Dimensions of Critical Care Nursing. 18(2), 30-4.

AGHAGH References

13. Razek T et al. (2000). Assessing the need for reintubation: a prospective evaluation of unplanned endotracheal extubation. Journal of Trauma-Injury Infection and Critical Care. 48(3), 466-9.

14. Bray K et al. (2004). British Association of Critical Care Nurses position statement on the use of restraint in adult critical care units. BACCN Nursing in Critical Care. 9(5), 1-19.

15. Martin B and Mathisen L. (2005). Use of physical restraints in adult critical care: A bicultural study. American Journal of Critical Care. 14, 133-142.

16. Ramsay MAE. (2005). How to use the Ramsay Score to address the level of ICU sedation. Referenced Wed Document. Available at: http://5jsnacc.umin.ac.jp/How%20to%20use%20the%20Ramsay%20Score%20to%20assess%20the%20level%20of%20ICU%20Sedation.htm. Accessed on March 23rd, 2005.

17. Kress JP, Pohlman AS, and Hall JB. (2002). Sedation and analgesia in the intensive care unit. American Journal of Respiratory Critical Care Medicine. 166, 1024-1028.

AGHAGH References

18. IHI 100,00 Lives Campaign. (2004). Getting Started Kit: Prevent Adverse Drug Events (Medication Reconciliation). The Institute for Health Improvement. Available at www.ihi.org.

19. Paone D, Levy R, and Bringewatt R. (1999). Integrating pharmaceutical care: a vision and a framework. The National Chronic Care Consortium & The National Pharmaceutical Council. Available at www.npcnow.org/resources/PDFs/IPCvisionpaper.pdf.

20. Saunders, S.M., Tierney, J.A., et al. (2003). Implementing a pharmacist-provided discharge counseling service. AMJHSP, 60, 1101-1103.

21. Rosen CE and Holmes S. (1978). Pharmacist’s impact on chronic psychiatric outpatients in community mental health. American Journal of Hospital Pharmacy. 35(6), 704-8.

22. Kaushal R and Bates DW. (2005). Chapter 7: The clinical pharmacist’s role in preventing adverse drug events. AHRQ Patient Safety Manual. Available at www.ahrq.gov/clinic/ptsafety/chap7.

AGHAGH References

23. Arizona State Hospital. Wellness Recovery Action Plans (WRAP). http://www.azdhs.gov/azsh/patient_programs.htm.

24. ACP-ASIM. (2000). Pharmacist Scope of Practice. Position Paper. American College of Physicians – American Society of Internal Medicine. www.acponline.org/hpp/pospaper/pharm_scope.pdf.

25. ValueOptions of Arizona. Assertive Community Treatment (ACT). http://www.valueoptions.com/arizona/en/programs/act.htm

26. ValueOptions of Arizona. Contract implementation fact sheet: Recovery for adults with serious mental illnesses. Available at: http:// www.valueoptions.com/arizona/en/publications/fact_sheet_adult.pdf.

AGHAGH Data Sources for Cost Analyses

• A - University Health System Consortium Clinical Database; January through December 2004 (Drawn from 9 geographically dispersed academic medical centers, bed size from 616 to 692, average # of beds = 660; when applicable, adjusted for 620 bed institution)

• B - Annual Salary from: 2003 Case Management Salary Survey Results. Published in: Advance for Providers of Post-Acute Care; May/June 2003, 51-54.

• C - University of Missouri Health Care, University Hospital; January through December 2004. (Identified at group request by the UMHC Office of Clinical Effectiveness; when applicable, adjusted for 620 bed institution)

• D - Medicare Fee Schedule – 2004 (Intubation – Endotracheal Emergency – Code 31500)

AGHAGH Acknowledgments

• Kristofer Hagglund, PhD. Dean of Health Policy. School of Health Professions. University of Missouri-Columbia.

• Kathryn Nelson, MHA. Patient Safety Officer. Office of Clinical Effectiveness. University of Missouri-Columbia Hospital.

• Betty Nikodim. Senior Analyst. Office of Clinical Effectiveness. University of Missouri-Columbia Hospital.

• Tim Anderson, RN. Patient Safety Manager. Harry S. Truman Memorial Veterans Hospital. Columbia, MO.

• Barb Aston, MSW. Social Worker (Retired). Mid-Missouri Mental Health Center.

• Kathryn Burks, RN, PhD. Faculty Advisor. University of Missouri-Columbia Sinclair School of Nursing.

• Charles Brooks, MD, FACP. Residency Director. Department of Internal Medicine. UMC School of Medicine.

• Rachel Haverstick, MA. Executive Staff Assistant. Center for Health Care Quality. University of Missouri-Columbia.

AGHAGH Acknowledgments

• Laurel Despins, MS, APRN, BC, CCRN. Project Director. Office of Clinical Effectiveness. Clinical Nurse Specialist, Medical-Neurosurgical ICU. University of Missouri-Columbia.

• Mark Kruse. Medical Records. Harry S. Truman Memorial Veterans Hospital. Columbia, MO.

• Rebecca Wirth, MSW. Social Worker. Harry S. Truman Memorial Veterans Hospital. Columbia, MO.

• Deborah Hurley. Human Resource Associate. Department of Health Management and Informatics. UMC School of Medicine.

• Jane Bostick, RN, PhD. Faculty Advisor. UMC Sinclair School of Nursing.

• Linda Headrick, MD. Sr. Associate Dean for Education. University of Missouri-Columbia School of Medicine.

AGHAGHContact Information

• Presenter Contact information:– Ashley Mahon: aem7ee@mizzou.edu– Russell McCulloh: rjm42b@mizzou.edu– Kevin Norris: kdn337@mizzou.edu– Brian Stout: bjs13e@mizzou.edu

• UMC CLARION group was coordinated through the University of Missouri-Columbia Center for Health Care Quality (CHCQ)– For more information, please contact:

Rachel Haverstick, Executive Staff Assistant.UMC Center for Health Care QualityMedical Sciences Building, MA128

University of Missouri-Columbia. Columbia, MO 65211Voice: (573) 882-8905Fax: [573] 884-0474

Email: haverstickr@missouri.edu.