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Implementing a Rib Fracture Management Pathway and

PIC Scoring Tool to Reduce ICU Readmissions


Susan Mastroianni RN, MSN
University of San Francisco
BACKGROUND METHOD FINANCIAL IMPLICATIONS
 31% of patients requiring an ICU stay account for
The institution is a 413 bed Level I trauma/burn adult SWOT ANALYSIS 70% of the total hospital costs (Fakhry et al., 2013)
and pediatric center in a 4 state region. The Strengths Weaknesses  Patients with an ICU readmission had 4 times the
microsystem encompasses general surgery patients METHODS FOR PROJECT median ICU length of stay (Institutional data,
1. Short implementation time
with rib and or sternal fractures admitted to the 1. Supported by Chief of Trauma & Trauma
Program Manager 2. Staff will need long term education and
reinforcement of project  Approval of the project 2013)
2. Data supports need for change
Trauma ICU, Burn-Pediatric ICU, and acute care units 3. Virtually no cost to institution 3. Minimal cash flow to create PIC score board for
Average ICU costs for rib fractures without
 Data collection 
4. Large enough Trauma population to see the patients
impact of this program one year from now 4. Early identification of decompensation in
5. Twenty years experience with the Trauma patients with blunt chest injury at times is difficult
complications or comorbidities = $10,371.57/day
 Meeting with lead team members-
population to detect.

or $31,114.71/3days (WSHA, 2013)


5. Unable to secure more staff for increased work
load.

gain departmental insight , define

Positives

Negatives
Reducing ICU re-admissions by 20% will save the
SPECIFIC AIM: We aim to improve the care scope of the problem, and identify

institution $124,458.84 over 2 years
of patients with rib fractures and or sternal fractures 1. Current CMS initiatives support methods
to decrease LOS, ICU readmissions and
1. Difficult to employ change concepts
2. Pushback from staff to do more with less processes.
RESULTS
improve patient and family satisfaction
and reduce ICU readmission rates by 20% within 2. Improve Medicaid reimbursements for
3. Respiratory therapy unable to bill for time

 Create protocol, PIC scoring board,


doing IS and initial assessment
the hospital 4. Lack of sustainability once program is finished
one year after implementing the Rib Fracture 3. Physician, Nursing, Respiratory Therapy, 5. Poor compliance by staff and families

Management Pathway.
Patient & Family collaborative effort
4. Discover other opportunities for other
improvements
6. Staff feeling too busy to be consistent with
pathway patient/family handout, timeline Rib Fracture Management Pathway
and educational plan for staff. Inclusion criteria:
Extubated or recently extubated
GCS 13-15
>14 years of age
* Patient & Family Handout
** PIC Scoring Tool
*** Bronchiole Hygiene Protocol
**** APS Guidelines for Systemic
Analgesia and Neuraxial Catheters

Threats
+ Rib & Sternal fracture/s

Opportunities Absence of high spinal cord injury

(> 65 years and 3+ rib fractures)


ICU
ACUTE CARE

EVIDENCE OF THE PROBLEM STEPS FOR IMPLEMENTATION Nursing:



Notify Respiratory of patient
admission
Elevate HOB 30 degrees if
Respiratory
Therapy:
• RT to assess patient
within 6 hrs. of
Provider
On admission order:
• IS, C&DB Q1hr &WA
• Nursing
Provider
On admission order:
• IS, C&DB Q1 hr. & WA
• Nursing
Respiratory
Therapy:
• RT to assess patient
within 1 hr. of
Nursing:


Notify Respiratory of patient
admission
Elevate HOB 30 degrees if not
not contraindicated admission communication -Rib communication- Rib contraindicated
admission
• Instruct patient and family • Measure initial IS Fracture Fracture • Measure initial IS • Instruct patient and family on PIC
on PIC scoring methods and volumes after pain Management Management volumes after pain scoring methods and rationale
rationale control achieved Pathway ordered. Pathway ordered. control achieved o Proper IS method and
o Proper IS method • Set goal and alert Document PIC score, Document PIC score, • Set goal and alert C&DB method

2015 ( 5 months)
pain & IS levels Q4hr pain, &IS levels Q1hr *Give patient and family

2016 (12 months)


and C&DB method levels (800cc) •

FISHBONE DIAGRAM
levels (800cc)
• *Give patient and family • Routine clinical care in ORCA & on PIC in ORCA and on PIC • Routine clinical care educational handout
educational handout o IS score board. score board • Place PIC scoring board in visible
o IS
• Place PIC scoring board in monitoring • ***BHP protocol • Mobilization at least monitoring place in room
visible place in room Q6hr & prn • Mobilization at least TID • Note goal and alert levels (800cc)
Q4hr & prn
• Note goal and alert o Incorporate TID • HOB at least 30 o Incorporate on board
levels(800cc) on board reporting of • HOB at least 30 degrees reporting of • Routine clinical care
• Routine clinical care PIC score degrees if not • Notify provider when PIC score o Chart PIC score, pain &
o Chart PIC score, IS and goals contraindicated total PIC score <4 and goals in IS levels Q1hr in ORCA
• Notify provider when and/or a score of 1 o Incentive Spirometer 1hr

July-2016
levels, & pain Q4hr in daily daily team

January & February March, April, & May June-2015 in ORCA


o Incentive
Spirometer 1hr •
team
rounds
**Notify resident & RN
total PIC score is <4
and/or a score of 1
in any category after
in any category after
intervention(s)
• Pain medication

rounds
**Notify resident & RN
when total PIC score
WA
o Cough and DB 1hr WA
o Mobilize as soon as
PEOPLE/ PROCESSES (WA) intervention(s) plan ****See APS possible
PATIENTS when total PIC score < 4 or a score of 1 in
STAFF o Cough and Deep < 4 or a score of 1 in • Pain medication Guidelines any category after o Incorporate reporting of

• Confirmation of • Develop prototype of PIC • Educate RN, physician, & • Meet with the clinical Data Breath (DB)1hr WA
o Mobilize as soon as
any category after plan ****See APS
Guidelines
Other:
• Incorporate
intervention(s) PIC score and goals in
daily team rounds
intervention(s)
Stakeholder support score board (Sue) Respiratory staff on 4 units Analyst to request same possible
o Incorporate
Other:
• Incorporate
reporting of PIC
score and goals in
o Record PIC score Q1hr
on PIC score board
Delay in transfer to
• Create graphs and tables. over 4 weeks, 5/17th- data variables of general reporting of PIC reporting of PIC daily team rounds • **Notify resident & RT when total
acute care Difficult to detect early • Meet with Trauma score and goals in score and goals in • ***Order BHP PIC score <4 or a score of 1 in any
deterioration in blunt chest Present to staff (Sue) 6/15th (CNE, CNS, & Sue) surgery patients admitted daily team rounds daily team rounds protocol on all category after intervention(s)
Higher patient/nurse Program Manager to o Record PIC score patients transferring
ratio on acute care injury from June 2015-May 2016 to acute care.
Lack of consistency with
• Conduct meetings with formulize a timeline for • Begin implementation of Q4hr on PIC score
pulmonary toilet efforts with rib fractures or sternal board

Only 1 Respiratory Therapist Increasing complexity nurse managers and staff education and rollout pathway-June 15, 2015 • **Notify resident & RT when

Inconsistency among resident staff & co-morbidities fractures, rapid response total PIC score <4 or a score
for 6 acute care floors respiratory therapists to of project ( TPM & Sue) (Everyone) of 1 in any category after
when ordering BHP protocol for calls, ICU readmission intervention(s) ****APS GUIGELINES
Consider Multimodal Systemic Analgesia per
Fewer allocated dollars
towards FTEs
patients upon discharge to Acute Aging population with ^ HIGH NUMBER OF gain departmental insight • Prepare PPT of process • Meet with Managers to rates, & length of stay
• PIC score < 4 total or < 1 in any category?
• Is it pain that limits the patient’s recovery? APS recommendations- >SEE PAGE 2
Care fall rates/accidents. RAPID RESPONSE
(Sue) improvement for staff gather feedback after staff
CALLS & ICU RE- (Data Analyst)
ADMISSIONS AMONG • Create draft of Rib Fracture • Meet with critical care & education. (NMs, ANMs,
PATIENTS WITH RIB • Analyze data one year
Absence of specific respiratory
FRACTURES Management Pathway &
Patient and family teaching
acute care CNS/CNE to
review final educational
staff, & Sue)
• Daily rounding of all
after implementation of  Staff education has been delayed 2 weeks due to last
management guidelines for pathway & debrief lead
minute changes in the protocol (see timeline)
Consistently high inpatient
blunt chest injury handout (TPM & Sue) plan (Sue) patients admitted with rib
census team and microsystem
Limited bed capacity- Current ICU discharge criteria fail • Meet with CNS and CNE • Educate RN, physician, & fractures: provide support members on results (Sue)
contributes to delay in to capture early recognition of to review pathway & gain Respiratory staff on 4 units to staff, answer questions
patient transfer to another
unit.
patient’s deterioration

APS-Pain management
insight for staff education over 4 weeks, 5/17th- regarding pathway to
• Determine whether or not
pathway should be
 Actions in the timeline are up to date and are on track
(CNS,CNE & Sue) 6/15th (CNE, CNS, & Sue) assure compliance and
modified (Lead improvement
The pathway, neuraxial guidelines, and PIC scoring
guidelines unclear
• Meet with Data Analyst • Present Rib Fracture understanding, listen to 
team)
and Clinical Nurse Management Pathway at staff feedback (Sue)
ENVIRONMENT POLICIES/
PROCEDURES Specialist (Data Analyst) the ICU M&M, 4/22/2015 tool will be electronically placed on an internal
• Analyze data-rapid & Trauma Council mtgs.-
response rates, ICU April 22 & May 19th, 2015 decision support site to allow quick access and
readmissions & LOS (Sue) (Sue)
• Microsystem assessment of • Hold a huddle with lead reference to protocol
rapid responses and ICU improvement team to
DATA ANALYSIS: readmission process (Sue) solidify roles, functions, &

CNL RECOMMENDATIONS
• Formulate an outline & processes (Lead
improvement)
 559 general surgery patients objectives for project (TPM
& Sue) • Finalize pathway (Chief of
Trauma, Acute Pain Service,
 124 rapid response calls on 85 patients NMs, Respiratory Care,
TPM, & Sue)  Round frequently on all new patients admitted
 36 patients readmitted to the ICU with rib and or sternal fractures to sustain the
 55% of ICU readmissions were due to respiratory project and maintain adherence to the pathway
distress  Incorporate reporting of PIC score and team goals
CONTRIBUTING FACTORS: into daily bedside rounds
 Unclear acute pain management guidelines  Provide additional “time out” educational
PLAN & DO moments to support staff as well as solicit
 Unclear respiratory management guidelines STUDY & ACT
feedback on implementation process and protocol.
 Difficult to detect subtle changes in blunt chest
 Second analysis of data one year after
injury This figure highlights a two phase, one and a half yearlong plan to institute a protocol to reduce implementation to determine efficacy of pathway
 Aging population associated with the number one length of stay, costs, and ICU readmission rates among patients with blunt chest injury. Black
unintentional injury: Falls denotes the action taken and red denotes the team member responsible (Institutional data & REFERENCES
Microsystem assessment, 2015).
 Available upon request

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