Download Care Transitions–Easy as Child`s Play–Right?

Care TransitionsEasy as Child’s Play –Right?
Bronwyn Bartle DNP, CPNP-AC/PC
Duke Children’s Heart Center
Disclosure Statement
I do not have any relevant
financial relationships with any
commercial interests to disclose.
A few questions to get us started
 Do you have a script that drives your
care transition from ICU  floor
A. Yes
B. No
Question #2
 Do you have a script that drives your
care transition from floor to home?
A. Yes
B. No
Question #3
 Do you have a “transition of care
meeting” with the care team and the
family prior to transferring?
A. Yes
B. No
Question #4
 Who calls the pediatrician prior to
discharge?
A. No one does
B. Attending
C. Fellow
D. Nurse practitioner
Question #5
 Is the family aware of “milestones” to
be met prior to transitioning?
A. Yes
B.
No
Do you ever feel Stuck in this game?
 Every time we make strides forward we find
ourselves sliding backwards.
 How can we make it more predictable than a
roll of the dice?
How can we feel less like this? We know we cannot
read into the future –
but we have to
prepare for it.
We try so hard to “get it
right”, always feeling under
pressure, hoping at the final
hour it does not all blow up
And more like this?
Shift our thinking:
Strategic, collaborative,
shared goals,
multidisciplinary
Great idea – but how do we get
there?
 What do you use to coordinate care
transitions?
A.
B.
C.
D.
E.
Journey board
Scripted handoffs
We rely on one person to take care of this
No one does this
I’m not sure how it happens
It’s charted – why the extra step?
 Its like story cubes – we
all use each of the 6 sided
dice to tell the patient’s
story.
 No one tells the story in
quite the same way.
 The end user is the reader
of the story.
Critical to shift your thinking
 Partner with entire care team Multidisciplinary
 Engage all of your resources (social work, discharge
planner, community resources, nursing staff)
 Parent/family engagement
 Critical to success
 Secondary caregiver identified and trained
 Teach back method
 Transparency of goals
What needs to be communicated?




Problem list – active and resolved
Medications
Patient’s current status and most recent changes
Procedures (and results)
 Read the op note/cath report/echo yourself
 Consulted services
 Family update
 Understanding, availability, concerns
Where do I start??
Pediatric Cardiology Infant Discharge Checklist
Things for family to complete:
Date
Ordered
Checklist Item
Checklist Description
Parent CPR teaching
Parent SVT teaching (if
applicable)
Single Ventricle Teaching
(if applicable)
Pulse ox/oxygen Teaching
(if applicable)
G tube teaching (if
applicable)
G tube care (if applicable)
Medication
Administration
Formula Mixing
Feeding Pump
Management (if
applicable)
NG teaching (if
applicable)
Lovenox teaching (if
applicable)
24 Hours of Care
Completed by RN. Caregivers must watch CPR video and complete demonstration
Completed by RN for infants with a history of SVT or at increased risk due to cardiac disease. Please verify that the family
knows the signs and symptoms, how to check for pulse, how to listen for apical pulse, and when to call for help.
Date Completed by
Caregiver #1
Date Completed by
Caregiver #2
Completed by Cardiology NP. Please verify that family understands “Red Flag Checklist” and when to call for help. Family
should have baby scale and notebook at bedside.
Completed by home health care representative and RN. Family should understand alarms, normal ranges for their child,
and when to call for help. Please have patient on home equipment for at least 24 hours prior to discharge.
Completed by Pediatric Surgery NP. Family should receive G tube notebook and understand what to do in emergencies
(tube falls out, malfunction, etc).
Completed by RN. This includes cleaning the site, venting the G tube, and administering medications.
Completed by RN. Please provide medication schedule. Family must demonstrate pulling up medications and proper
medication administration.
Completed by Nutritionist. Please provide handout on proper mixing instructions for higher caloric density formulas.
Completed by home health care representative and RN. Please ensure family knows how to program and use pump for
both bolus feeds and continuous feeds. No more than 4 hours of feeds in bag at one time.
Completed by RN. Each caregiver must place 3 NG tubes each. Please date and initial for all 3.
Completed by RN. Each caregiver must administer 3 injections each. Please date and initial for all 3.
To be completed once ALL TEACHING HAS BEEN DONE. This must be a full 24 hours with at least one caregiver ALWAYS in
the room. Please take patient off hospital equipment (continue vital signs q 4h), and use all home equipment. Caregivers
must complete ALL ASPECTS OF CARE.
Things for the team to complete:
Date
Ordered
Checklist Item
Checklist Description
Car seat fitting
Completed by PT (Deb). Have family bring car seat prior to discharge. Patients born after 36 weeks ONLY require a fitting. Premature infants must
complete car seat test (monitor for apneas and bradys).
Repeat any vaccines given within 1-2 weeks of bypass run. Please list vaccines on discharge instructions (not entered into state database).
Offered during RSV season. Alert pediatrician if patient will be requiring synagis so that future doses are not postponed.
For any patients > 6 mos who have not received that vaccine previously.
Initial newborn screen sent between 24-48 hours. Please send 2nd newborn screen on full feeds (most cardiac babies are NPO prior to cardiac repair).
Completed prior to discharge.
Generally completed within the week prior to discharge.
Must have documented EKG after OR. Usually done in PCICU. Ensure that EKG is in chart/Ebrowser.
Call PCP and give verbal sign out for complex patients. Appointment should be within first week of discharge.
Fellow/Attending will give verbal sign out to cardiologist. Appointment should be within the first 1-2 weeks after discharge.
Please ensure that all specialties know about discharge plans. Arrange appointments as necessary.
Vaccines
Synagis Vaccine
Flu Vaccine
Newborn Screen
BAER Hearing Screen
Discharge ECHO
EKG
PCP Appointment
Cardiology Appointment
Consulting Services
Follow up
**Please return all completed checklists to Michelle Taylor, CPNP-AC/PC. They may be left in the 5300 workroom on weekends and holidays.**
Date
Completed
How will I do this at
home??
How do we get out
of the ICU?!
Strategic
Communication
is Essential
Who will take care of us
when we leave?
Overwhelming? I think not…
 Engages parents even before admission
 Teach back method builds confidence
 Listen to how they explain their child to other family
members – a window into their understanding
 Satisfies list-makers and slackers alike!
 Ensures everyone receives the same teaching.
 Visual reminders
 Always, always state – AT LEAST 24 hours of care
For Parents
 Reassure them that bumps in the road are to
be expected - at EVERY transition point
 Hands on practice, practice, practice is
essential
 Encourage them to ask questions
 Knowledge is power – be clear in your
communication
For team members







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Don’t be afraid to ask for clarity
Don’t accept “I’ve only taken care of them today”
Know what you want to know
Ask where the parents are on their journey
Face to face bedside hand off is best
Transition of care meetings are essential
Minimize free text options in charting
Know the integral part you play
Take Home Points




Give careful thought to care transitions
Be transparent
Be sure the story you are writing is not a cliffhanger!
Supply the next caregiver with tools to succeed –
whether that is the next provider or the parent or the
pediatrician
 The “system” you implement should run without you
For questions:
 [email protected]
 919-681-2343