Renal
Clinical Program Indicator
Proposal
Working group:
Sandra Davidson
Clinical Applications Support Clerk
ARHCC
Katie Cave
Patient Care Coordinator Peritoneal Dialysis
ARHCC
Kim Norman
Clinical Nurse Educator ARHCC and
ACDU Hemodialysis
Created May 2010
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Contents
Title
Page
Introduction
3
Project Outline Renal Program Clinical Program Indicator
4- 7
References
8
Appendix
9 -17
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Introduction
A well designed Clinical Program Indicator (CPI) is a health informatics system
that screens, flags or draws attention to a specific clinical issue1, through
notification, reporting and communication (Appendix 1). Its function is to
coordinate the development of collaboration through benchmarking and quality
improvements2.
A working group (Sandra Davidson, ARHCC Clinical Applications Clerk, Katie Cave, PCC for
ARHCC Peritoneal Dialysis Unit and Kim Norman, CNE for ARHCC and ACDU Hemodialysis
Unit)
is proposing to have a CPI applied to all renal patients admitted to acute
care facilities within the Fraser Health Authority (FHA). The CPI is currently
available to the FHA South and East regions, and will be available to the North
once Meditech Client Server has been implemented in July 2010.
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Project outline
There is an increasing interest in health informatics and communication
technologies to support collaboration through healthcare delivery and improve
patient outcomes. The costs associated with inefficient communication can result
in not only inadequate clinical time management but also poor or delayed
treatment planning.
The care of patients in the current healthcare environment inevitably involves a
multidisciplinary approach from admission to discharge. Within the delivery of
health care patients pass between physicians, nurse practitioners, and
pharmacists. The patient often becomes the chief source of communication for
complex medical situations, meaning transitions between units will create an
opportunity for healthcare errors3. As a result all health care professionals
involved need to share patient information and discuss their management 5.
4
Within the FHA Renal Program there have been many undocumented difficulties
and gaps in communication when chronic renal failure (CRF) patients are
admitted to acute care facilities. The Renal Program as with any specialized level
of care requires a certain body of knowledge and skills.
Having a health informatics system known as a CPI applied within the Renal
Program will facilitate practice improvement initiatives, allocation of resources,
validate required services, and assist in knowledge transfer by improving the
accessibility and quality of information4. The cost of the CPI planning and
implementation within the FHA Renal Program is estimated at $1100 (see
Appendix 2)
The benefits of applying the above system include timely referrals to
nephrologists and other health care professionals as well as the ability to keep
accurate statistics of renal patients’ visits to acute care centers throughout the
Fraser Health Authority. Its implementation would also ensure that chronic renal
failure (CRF) patients would receive continuity of care whether they require
hemodialysis (HD), peritoneal dialysis (PD), or follow up treatment in the Kidney
Care Clinic (KCC).
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The CPI would be initiated on a patient’s file when he or she is first registered
within the Renal Program and would exist until either the patient died or was
discharged. The Renal Program would have sole responsibility for the criteria,
application and maintenance of the system, including maintenance during record
merges (Appendix 3 and 4)
The working group has identified unit Registration/ Nursing Unit Clerks to apply
the flags to new patients registered within the Renal Program as part of their job
description of administration. The information will be entered by the registration
staff in one of the following meditech modules:-
ADM - Administration
ITS – Information Technician Specialist
O/E – Order Entry
PCS – Patient Care System
All staff within the Renal Program will have access to the reports menu, but
primarily Nephrologists, Patient Care Coordinators and Program Clerks will
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access the reports in order to provide medical consultations and plan delivery of
care.
Any patient in Fraser East registered as ABHD, ABPD or ABKCC will
automatically have the CPI attached to their file, and data is then recalled from
every subsequent admission or registration. The CPI report will be printed in the
patient’s allergy and alert form at the time of registration and has the ability to be
printed on demand from a separate menu.
Currently there is evidence within the FHA that CPI indicators are a valuable tool.
The FHA Palliative Care Program initially piloted the CPI program in Surrey and
has since expanded their program indicator to the entire Fraser South. Palliative
Care also plan to expand into Fraser North when the Meditech Client Server is
introduced in July 2010 (see Appendix 5 for the experiences of the FHA Palliative
Care Team)
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References
1. Campbell, S.M., Braspenning, J., Hutchinson, A., Marshal, M., (2002)
Research methods used in developing and applying quality indicators in
primary care. Qual safe Care; 11:358-364.
2. Hodder . A, (2006), Communication Systems in Healthcare. Clinical
Biochemistry Revisons; 27(2): 89-98.
3. McGaw. J., Conner.D.A., Delate. T.M., Chester.E and Barnes.C.A, (2007).
A multidisciplinary Approach to Transition Care: A Patient Safety
Innovation Study. The Permanente Journal, 17;4, 4-9
4. Sickkids (1999-2009). Clinical Informatics.
Htt://www.sickkids.ca/Nursing/Clinical%20informatics%20and20Technology/CIT-clinicalinformatics/index.
Retrieved April 26th 2010.
5. The Australian Council on Healthcare Standards (ACHS), (2009). Clinical
Indicator Program 2009. Published by ACHS
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Appendix 1
Critical Care Indicators (CCI) and Clinical Program Indicators (CPI) Comparison
Critical Care Indicators (CCI)
Approved
Indicators
South/East
DNA
ARO
AVB
DNA
ARO
AVB
MAT
North
CASE
PMMV
LATX
Clinical Program Indicators (CPI)
South/East
Palliative Care
Program
North
ARO Contact
Note: North CCI’s will be re-assessed
with MedCONNECT4 and CCI’s will be
standardized across FHA at that time.
Criteria for
Creation of a
NEW Indicator
Urgent notification of risks to
staff/patients/visitors on patient arrival
at all or any FHA facility to protect the
safety of patients/staff and visitors.
Necessary for a substantial period of
time and is relevant for all subsequent
registrations during that time.
** Total # of CCI’s is very limited in order to
minimize the risk of staff ignoring an
important alert due to ‘alert fatigue’.
Initiation
Process
1.
FHA policy identifies criteria for
application:
a. AVB – Workplace Health
(reference policy?)
b. ARO – Infection Control
c. DNA – (see policy)
2. Order sent to Registration &
Health Records via Meditech
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Departmental notifications & reporting,
communication of patient’s participation
in a program to other health
professionals. Note: the intent of CPI’s
is that it has FHA wide relevance and
enhances an FHA wide program.
CPI may be of long or short duration
based on departmental standard.
1.
Department/Program defines
criteria for applying the flag.
2. Department/Program defines
process for communicating
Order Entry (preferred) or by
faxing of manual form.
3. CCI entered by Registration staff
in ADM module.
4. Health Records verifies that CCI
has been entered on correct
account to ensure carry forward
to future visits.
5. The CCI/CPI Management
Committee is responsible for
coordinating communication of
information.
Maintenance
request to enter a CPI
3. Department/Program personnel
enter the flag on a custom screen
in one of the following Meditech
modules: ADM, ITS, OE, PCS.
4. Application and maintenance of
the CPI is solely the
responsibility of the department.
No intervention required by
Registration or Health Records.
5. The Department/Program is
responsible for providing
appropriate communication.
Strict procedures established within
Registration Services and Health Records
to ensure data integrity during the
application of CCI to the patient’s
electronic file, account merges &
switches, etc
Application of a CPI to the patient’s file
is the responsibility of the department
and any risks associated with that are
the responsibility of the department.
Data is demo recalled to all subsequent
admissions/registrations.
Data is demo recalled to all subsequent
admissions/registrations.
A CCI is printed on the Allergy & Patient
Alert form which prints on patient
registration in C/S system only. (Note:
the procedures for printing and
distribution of this form may vary by
site.) The report is also attached to
nursing menus and can be printed on
demand.
CCI is maintained during record merges,
etc.
A CPI is printed on the Allergy & Patient
Alert form which prints on patient
registration. The report may also be
printed on demand from a menu. The
business area is financially responsible
for any reports that need to be created
for their own business purposes. The
business area is also financially
responsible for the revisions of any
reports within the system that are
affected by modifications to the CPI eg
The Allergy & Alert form.
CCI’s are removed from the patient’s
CPIs may or may not be maintained during
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electronic file by Health Records
according to established procedures.
record merges. Any risks associated with
that are the responsibility of the
department.
CCI history is maintained within EMR.
CPI removal is the responsibility of the
department.
Communication
of Information
- Reports ie Nursing Worksheet in OE
- Allergy and patient alert form
Approval
Process
The CCI/CPI Management Committee
approves new indicators.
Ownership
The CCI policy and procedures provide
direction to the CCI/CPI Management
Committee which reports to Barb Mildon,
Chief Nurse Executive & VP, Professional
Practice and Integration
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No historical information retained. No
record in EMR
- departmental specific reports
- Allergy and Pt alert form
Business area requesting modification to
the Allergy and Alert form is financially
responsible for the cost of making those
changes by an outside vendor.
The CCI/CPI Management Committee
approves new indicators.
Once approved, the responsibility for the
CPI is assumed by the department.
Appendix 2
Connie Magnusson, RN,BSN,M.Ed
Manager, Health Informatics - Community & Primary Care
Information Management – FHA
November 2, 2009
To Connie:
Thank you for your interest in our services. Below is a quote for the Renal CPI Reports.
Item
1
2
3
4
5
Description
ADM.PAT.zcus.adm.formg.canada (attached to ADM Emerg
Registration routine – prints on patient’s registration)
Report Name: Allergies and Patient Alerts (Client Server)
Enhancement of existing report: (add 4 queries)
ADM.PAT.zcus.adm.formg.canada.allergies.alerts (desktop version of
above form)
Report Name: Allergies and Patient Alerts (Client Server)
Enhancement of existing report
(add 4 queries)
Report to identify renal inpatients at all sites
Current Inpts Registered to Renal Program - ALL Sites
(Client Server) – See specs on worksheet
Report to identify renal inpatients by program at all sites:
Current Inpts Registered to Renal Program by Program & Site
(Client Server)
Report to identify recurring patients to renal sites who are registered to
renal program
Recurring Renal Patients with Renal CPI Flag (Client Server)
Recreate Standard Report: ADM.PAT.rcr.census.nm
TOTAL (Plus any state and/or local sales taxes as applicable) –
Canadian Funds
Hours
0.5
Cost
$55
0.5
$55
3
$330
2
$220
4
$440
10
$1100
Please feel free to call me if you have any questions about this quote. If approved please have a
PO created and sent to 978-805-4100 and please send me the PO #.
Sincerely,
Jim Cotter
NPR Services
Iatric Systems, Inc.
Phone/Fax: (978) 805-3111
Email: jimc@iatric.com
Web: www.iatric.com
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Appendix 3
Requestor Name & Title: Renal Program – hemodialysis (HD), Peritoneal Dialysis (PD), Kidney Care Clinic
(KCC)
Contact #:
Date :
HD 604 851 4771, PD 604 851 4700 ext 6464198, KCC 604 851 4700 ext 646171
May 1st 2009
Business Sponsor (Director Level) Name & Title: Renal Program Director
Contact #:
Date: May 1st 2009
What is the name of the “flag” that is being requested: Renal Program
Reason for request: To ensure patients with Chronic Renal Failure are identified promptly and Nephrologists
notified
Where are the patients that you expect to flag? Are they in one facility, one community, or multiple
facilities/communities? Are they registered within the Meditech ADM system?
Multiple facilities. Yes they are registered within the Meditech ADM system
Are you expecting to have each facility to be able to flag their own patients or would this be handled centrally?
Their own, each department enters the patients so would automatically be flagged when they enter the
location.
How many patients do you expect to flag on a daily/weekly/monthly basis?
PD 4-10 patients per month. HD 20 patients per month, KCC 20 patients per month. So an approximate total of
40 patients for all Renal Program patients
Benefit expected from “flagging”: Timely referral referrals to Nephrologists will save lives and ensure
patient safety.
How are you expecting these timely referrals to occur? Who would be making them? Is this something that the renal
unit at that site would be responsible for or are you expecting other individuals or departments to initiate?
Will investigate process. When flag is seen by Registration Clerk they would advise the RN looking after the patient
who would then contact the Renal Department (RDU) involved or contact the Nephrologist if dept closed, or if patient
admitted and requires immediate assessment or leave a message at the RDU. Also RDU would be running a report to
see if any of their patients were in Emergency or an inpatient under the location in meditech. Perhaps Connie could
shed some light on this program report haven’t seen it yet.
Duration flag will need to be maintained:
Registration with the Renal Program until discharged from the Renal program or deceased.
What criteria will you use to determine if a patient requires a “flag”:
Person must be registered with the Renal Program
Which staff have the information/knowledge required to apply the flag:
KCC, HD, PD – Through the registration process, Unit Clerk’s, Patient Care coordinators, Clinical Nurse
Educators
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Would suggest that this be limited to only certain people i.e. probably unit clerks due to process issues that
need in place to prevent “losing the flag”.
Agreed, only Renal registration Clerk’s (UC) would be doing this.
Which staff will be using the flag:
Renal Program staff.
How will this flag influence the care that they provide:
Speak for the patient if they are unable to speak for themselves. Managing resources and allocation. Timely
notification of Nephrologists
What are your expectations of staff who will see the flag…how will you convey those expectations to
them?
We expect notification when a flag is identified to the appropriate renal area. In-service of other units by the
Clinical Nurse Educator, staff meetings and memo’s.
This is probably an unrealistic expectation depending on who you are expecting to notify you.
We believe this is a realistic expectation; some of the RN’s are already notifying us. With this procedure we
feel sure these expectations will be met because there will be a written process to follow, without a lot of grey
areas.
Will staff who are expected to act in some way upon seeing the “flag” require additional reference
information or documentation? Where will they find that information?
Policy and procedure manual kept at a central location or via the FHA intranet site under renal Program.
Additional information would the contact details of HD, PD and KCC.
There are 2 separate Meditech databases in FHA: Fraser North uses Meditech Magic, Fraser East and
South use Meditech Client Server. The two data bases are not linked and it is expected that FN will
move onto the Client Server platform in 2010.
If your request for a flag spans more than one FHA region, what manual or other processes will you
need to put into place to ensure that the application of a flag will meet your needs?
The process will be recognizable by the location identified in the program. Each area specifies printer
name/location and to notify IT if printer changes.
Do some of your patients exist in both the Magic and Client Server Systems?
Yes, however we are only dealing with Meditech Clientele just now. The Magic People will be coming onto Meditech
Client Server eventually and will glean the benefit of our weeding the problems by then.
What process will you put into place to review annually if the flags applied are still relevant? What will
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the criteria be, who will do the review, who will remove the flag?
Annually by the Unit Clerk.
What reports will be required and who will need to print them?
A report that shows visits to outpatient areas (including ER), admits/discharges. Renal program staff will have
the ability to print the reports.
Additional Comments:
Stat blood work such as CP7, CBC, Albumin, PO4, Ca, IPTH. If suspected peritonitis see peritonitis protocol.
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Appendix 4
CPI
Clinical Program Indicators and Ownership
Owner
Palliative Care Program
(Fraser South)
ARO Contact
(MSA, CGH, LMH, DH,
PAH)
Ruth Topolnicky
Clinical Nurse Specialist, Hospice Palliative Care
Fraser Health Authority, Fraser South,
Phone: 604 953-4995, local 3642
Pager: 604 450-2799
Ruth.Topolnicky@fraserhealth.ca
Terry Dickson
Infection Control Nurse, MSA
Phone: 604-557-2997
Terry.Dickson@fraserhealth.ca
Kathleen McWhinney
Manager, Infection Control
Phone: 604-807-0405
Kathleen.McWhinney@fraserhealth.ca
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Appendix 5
Hi Kim,
We call this our Palliative Flagging System and we initially did a pilot in Surrey to
see how it would work. After using it in Surrey for a couple of years we have now
expanded it to the rest of the South and the Valley. Our plan is to expand it to the
North once they come on board with the Client Server version of Meditech in
July.
The reason we created this system is that our hospice palliative care teams and
home nursing care offices were often unaware if one of our known clients was in
an acute care site. We had cases of our clients being in hospital for days before
anyone was notified.
The benefit of this system is that we now know if a client known to our HPC
Program is in any acute site in the South and Valley and we also know where in
the acute site they are whether it is in emergency or on an inpatient unit. We are
able to run reports each day either by acute site or by the community location
that the client is registered to in order to find out where our clients are.
The only down side to this system is that each client has to be registered as a
recurring outpatient in the Client Server system so this has caused a bit of
increased workload for our community HPC clerical staff.
I hope this helps.
Lauren Pye
Program Assistant
Home Health/End of Life
Fraser Health Corporate Office
300 - 10334 - 152A Street
Surrey, BC V3R 7P8
Phone: 604-587-4448
Fax: 604-587-4644
email: lauren.pye@fraserhealth.ca
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