A Report to the
Patient Safety Committee
of Arizona General Hospital
Prepared by Members of the
University of Missouri-Columbia Interdisciplinary Workgroup
for the CLARION INTERPROFESSIONAL CASE COMPETITION
SPRING 2005
AGH
INTRODUCTIONS
• 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 trouble”
-Bus Driver
AGH
PRESENTATION
OVERVIEW
•
•
•
•
Case Overview
Methods of Analysis
Major Findings
Specific Findings
– Recommendations/Action Plan
– Tracking Indicators
– Cost Analysis
• Systems Issues
• References/Acknowledgments
AGH
CASE OVERVIEW
• Arizona General Hospital:
– Tertiary care center
– 620 bed-facility
– 97 Behavioral Health Beds
• AGH Values:
– Dignity
– Collaboration
– Stewardship
– Excellence
AGH
CASE OVERVIEW
• Part of Southwest HC System (SWH)
 Flagship for HC delivery in Maricopa Co.
 10 affiliated clinics
• Clinical Expertise Centers of Excellence
 Behavioral Health
 Women’s Health
 Rehabilitation
 Cardiovascular services
 Neuroscience
 Oncology
 Orthopedics
 Spine Care
AGH
CASE 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
AGH
METHODS
• 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
AGH
MAJOR 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-Induced
Drug Overdose
AGH
Self-Induced Overdose
Timeline
10 AM TR
2 PM TR
4 PM FRI:
Unidentified Pt is Pt transferred
Pt transferred to
admitted to ER
to ICU
1:30 AM FRI: unmonitored med unit
Pt self-extubates
ER
Pt & Substance/Amt
ID by Rx Bottle
found among
pt’s belongings
ICU
~6:30 PM FRI:
Near Sentinel Event:
Self-Induced Overdose
WARD 10A
7:30 PM FRI
Pt reintub.;
transferred
back to ICU
ICU
Psych team
sees Pt
Clozaril Overdose
Assumed
Security check results in pill bottle
remaining among pt belongings
Rx bottle transferred
w/ Pt belongings;
left unsecured in pt room
RN investigates on
tip from roommate;
contacts intern
(~7PM)
Sr Resident
responds
Intern investigates;
Contacts Sr Resident
AGH
Self-Induced Overdose
Flow Diagram
Security check
results in meds
remaining with pt
belongings
Pt Presents in ER
No ID or
PMH
available
No External Provider
Contacted; No
Pharmacist
Involvement
in ER
Pt, Substance, Amt all
identified by Pill Bottle
Clozaril
Overdose/
Substance Abuse
Assumed
No Psych team
involvement
No formal suicide risk/
behavioral assessment
performed in
ICU/Ward 10A
No formal
communication re:
suicide risk
Clozaril left
unsecured and
attainable in pt
room
Pt consumes
700mg
Clozaril
Self-Induced
Drug Overdose
Pt left unobserved
in step-down ward
Delayed
response to
Overdose
Pt not formally
recognized as
suicide risk
Pt readmitted
to ICU;
Reintubated
No entry into pt
record concerning
suicide risk
AGH
Self-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
AGH
Care Team Communication
Care Team Communication
Informal Communication
of Pt Behavior/
Likely Actions
Parallel/Isolated
Team Communication
Over-reliance
on Chart
Informal Report of
Risk for Self-harm
AGH
Care Team Role Definition
RPh Not Involved in
Collecting Pt PMH
RPh Not Involved
in Medication ID
Care Team
Role Definition
Medical Team Assessment
of Purely Medical Issues
Psych Assessment of
Behavioral Health Issues
Restricted to Med Status
& Schizophrenia
AGH
Policies & Procedures
Policies & Procedures
Availability/Use of
Overdose Protocols
Inadequate
Risk Assessment
for Self-harm
Availability/Use of Home
Med Storage Protocols
AGH
Self-Induced Overdose
Ishikawa
Care Team Communication
Policies & Procedures
Availability/Use of
Overdose Protocols
Inadequate
Risk Assessment
for Self-harm
Informal Communication
of Pt Behavior/
Likely Actions
Parallel/Isolated
Team Communication
Availability/Use of Home
Med Storage Protocols
Informal Report of
Risk for Self-harm
Over-reliance
on Chart
Self-Induced
Clozaril Overdose
RPh Not Involved in
Collecting Pt PMH
RPh Not Involved
in Medication ID
Care Team
Role Definition
Medical Team Assessment
of Purely Medical Issues
Psych Assessment of
Behavioral Health Issues
Restricted to Med Status
& Schizophrenia
AGH
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
AGH
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
AGH
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
AGH
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
AGH
Self-Induced Overdose:
Dollars and Sense
Comparative Costs of Sitter vs ICU Stay
With Intervention:
Room Sitter Wage
# of Hours Surveillance
Observation Costs
$
$
15.00
24
360.00
Est .
W/O Intervention:
Avg. Cost of Stay (ICU):
Avg. LOS in Days (ICU)
Avg Cost/Day (ICU)
$ 44,845.00 A
6.01 A
$ 7,461.73 A
Est. Savings W/ Intervention:
$
7,101.73
Job/Coverage Loss
and Rehospitalization
AGH
Job/Coverage Loss
& Rehospitalization Timeline
7 AM FRI: 10 AM FRI:
Pt 1st
10 AM TR
Psych Team
becomes
Pt is admitted to ER
Interview
responsive
ER
ICU
Pt Assigned
to HCC
LOS in BHU:
Three Weeks
Behavioral Health Unit
7:30 PM FRI
Pt reintub.;
transferred
back to ICU
~7:30 PM SAT
Monday PM:
Pt extubated; regains Pt transferred
Consciousness
to BHU
WARD 10A
24 Hrs from
Admission
ICU
36 Hrs from
Admission
Behavioral Health Unit
60 Hrs from
Admission
90+ Hrs from
Admission
Time Away from Institution:
60 Days
Post-Discharge
ER
Behavioral Health Unit
HCC sees pt
Adverse Event:
Pt suffers head laceration;
for the 1st time?
Pt Loses Job/
Readmitted to ER
Rx runs out; Pt unable to
HC Coverage Job Loss
not entered
obtain needed medication;
into AMR
Pt relapses
Pt admitted to BHU
AGH
Job/Coverage Loss &
Rehospitalization Flow Diagram
Pt Admitted to ER
Pt assigned to
HCC according
to policy
Social Worker
is not involved
in patient’s care
Pt admitted to
ICU; then Ward
10A; then back
to ICU
HCC does not see
patient within 36
hour window
Employer is not
Contacted
PT transferred
to Behavioral
Health Unit
Patient loses job
(and coverage)
Pt relays job
loss to Nurse
Pt is
Discharged
BHU Nurse unfamiliar
with AMR re: Social
Services
Pt runs out of
Zyprexa; No refill
due to lost
coverage
No record of
Job Loss
entered into
AMR
Pt Relapses;
Readmitted
Pt not connected
w/ social service
resources
HCC unaware of
pt job loss
AGH
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
AGH
Care Team Communication
Care Team Communication
No Psych Team
Communication
of PS Info
Lack of Communication
between Care Teams
AGH
Inadequate Social Services
Inadequate Social Services
Suboptimal Process for
Assigning Patients upon Admit
No Social Worker
Involvement
HCC Involved
Too Late in Stay
Failure to act on PS History
Within 36 Hrs of Admit
AGH
AMR Usage
No Contingency
Backup
AMR Does Not Meet
Staff Needs
AMR Usage
Failure to Enter
Job Loss Info
Insufficient
Training
AGH
Job/Coverage Loss &
Rehospitalization Ishikawa
Inadequate Social Services
Suboptimal Process for
Assigning Patients upon Admit
Care Team Communication
No Social Worker
Involvement
No Psych Team
Communication
HCC Involved
of PS Info
Too Late in Stay
Lack of Communication
between Care Teams
Failure to act on PS History
Within 36 Hrs of Admit
Job/Coverage Loss
& Rehospitalization
No Contingency
Backup
AMR Does Not Meet
Staff Needs
AMR Usage
Failure to Enter
Job Loss Info
Insufficient
Training
AGH
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
AGH
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
AGH 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)
AGH
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
AGH
Job/Coverage Loss & Rehosp.:
Dollars and Sense
Cost of Universal Case Management
Number of Additional HCCs Needed:
Annual Salary (Case manager)
Acute care
10
$53,000
Cost of Providing Case Management to All Pts:
$530,000
B
AGH
Job/Coverage Loss & Rehosp.:
Dollars and Sense
Decreased LOS (Psych Services)
Avg. LOS in Days (Psych):
Decrease:
Post-Intervention LOS in Days (Psych)
Avg Cost of Stay (Psych):
Avg Cost/Day (Psych):
Per Patient Cost W/O Intervention
Per Patient Cost W/ Intervention
Savings Per Psych Admission
Avg. # of Psych Admissions
Total Annual Savings
Decreased Cost of Stay (Psych Services)
Avg. Cost of Stay (Psych):
Estimated Decrease:
Avg Cost of Stay W/ Multi-D Rounding
Savings Per Psych Admission
Avg. # of Psych Admissions
Total Annual Savings
$
$
$
$
$
$
$
$
$
9.47 A
10%
8.52
8,757.00 A
1,027.46 A
9,730.00
8,757.00
$973.00
1,041.00 A
1,012,893.00
8,757.00
16%
7,355.88
1,401.12
1,041.00
1,458,565.92
A
A
Self-Extubation
AGH
Self-Extubation Timeline
3 PM TR
ICU Nurse
Shift Change
2 PM TR
Pt is transferred
to Med/Surg ICU
10 AM TR
Pt presents at ER
ER
Pt is Intubated
11 PM TR
1:30 AM FRI
Pt Agitated; Orders
for 2mg IV Haldol Pt Self-Extubates
(Adverse Event)
Every 2 Hours
ICU
ICU Pharmacist
Consulted
Clozaril Overdose
Assumed
ICU Nurse Charged
w/ Additional Patient
Serum Toxicology
Panel Performed
Pt is Reintubated
and Sedated
AGH
Self-Extubation
Flow Diagram
Paramedics Bring
Pt to ER
Clozaril Overdose Assumed;
Additional Drugs Suspected
Pt Stabilized,
Intubated,
and Sedated
No RPh in ER
No Behavioral
Risk-Assessment;
Despite Overdose
Patient Admitted
to Med Surg ICU
ICU Pharmacist
is Consulted
(Delayed)
ICU Nurse Shift
Change Occurs
Patient Rests
in ICU
Self-Extubation
Toxicology Panel is
Belatedly Performed
(Delaying Results)
Attending Nurse is
given an additional
pt; which distracts
him from Patient
Cautious
order given for
addtnl sedation
Patient
Becomes
Agitated
Sedation is inadequate;
Pt again becomes Agitated
AGH
Self-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
AGH
Care Team Communication
Care Team
Communication
Delayed
Involvement
of Pharmacist
Level of Pharmacy
Involvement
EMT/ER/ICU
Informal
Communication
Delayed Serum
Toxicology
Results
AGH
Policies & Procedures
Availability/Use of
Agitation Mgmt
Protocols
Extent of
Behavioral
Assessment
Availability/Use
of Sedation/Weaning
Protocols
Policies & Procedures
AGH
Scheduling
Scheduling
2:1 ICU
Staffing Ratio
Inappropriate Demands
on ICU Nurses
AGH
Self-Extubation Ishikawa
Scheduling
Care Team
Communication
Delayed
Involvement
of Pharmacist
2:1 ICU
Staffing Ratio
EMT/ER/ICU
Informal
Communication
Inappropriate Demands
on ICU Nurses
Delayed Serum
Toxicology
Results
Level of Pharmacy
Involvement
Self-Extubation
Availability/Use of
Agitation Mgmt
Protocols
Extent of
Behavioral
Assessment
Availability/Use
of Sedation/Weaning
Protocols
Policies & Procedures
AGH
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
AGH
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
AGH
Self-Extubation:
Tracking Indicators
1.
2.
3.
4.
Incidence of self-extubation (ICU)
Length of ventilator support (ICU)
ICU pt-nurse staffing ratios (1.5-1.7)
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%)
AGH
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
AGH
Self-Extubation:
Dollars and Sense
Decreased LOS in ICU
Decrease in Days:
Avg LOS in Days (ICU)
Avg Cost of Stay (ICU):
Avg Cost/Day (ICU):
Avg. # of ICU Patients/Yr:
Annual Cost W/O Intervention
Annual Cost W/ Intervention
Annual Savings
Decreased Ventilator Support
Decrease in Days:
Avg Time on Ventilator in Days (ICU)
Cost/Day (Ventilator Support):
Avg. # of Patients on Ventilator Support/Yr:
Annual Cost W/O Intervention
Annual Cost W/ Intervention
Annual Savings
Decreased Self-Extubation Costs
Percent Decrease:
Avg. Rate of Self-Extubation
Avg Number of Self-Extubations/Year
Avg. Rate of Self-Extubation W/ Intervention
Cost of Reintubation
Annual Cost W/O Intervention
Annual Cost W/ Intervention
Annual Savings
$
$
$
$
$
3.5
6.01
44,845.00
7,461.73
4,991
223,821,395.00
93,476,156.65
130,345,238.35
$
$
$
2.5
12.5
200.00
314
784,393.94
627,515.15
156,878.79
$
$
$
40%
17%
102
10.2%
$117
11,934.00
7,160.40
4,773.60
$
A
A
A
C
C
C
C
C
D
“The Big Picture”
AGH
Recommendation Summary
•
•
•
•
•
Communication
AMR/organizational culture integration
Policies and Procedures
Expansion of care team member roles
Supporting AGH mission and values
– Dignity
– Collaboration
– Stewardship
– Excellence
AGH
What 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 confirmed
 Patient PMH might have been available
 Concerns over sedative interactions might have
been dismissed
AGH
What If…
• Social Services would have been more
actively involved in patient care?
 Patient job/coverage loss might have been
avoided altogether
 Patient 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)
AGH
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
AGH
Future 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
AGH
Concluding 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
in two ten-foot jumps”
-American Proverb
A Report to the
Patient Safety Committee
of Arizona General Hospital
Prepared by Members of the
University of Missouri-Columbia Interdisciplinary Workgroup
for the CLARION INTERPROFESSIONAL CASE COMPETITION
SPRING 2005
AGH
References
1.
2.
3.
4.
5.
6.
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Harry S. Truman Memorial Veterans Hospital- Pharmacy
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AGH
References
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AGH
References
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ay%20Score%20to%20assess%20the%20level%20of%20IC
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AGH
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
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www.npcnow.org/resources/PDFs/IPCvisionpaper.pdf.
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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.
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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_ad
ult.pdf.
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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)
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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.
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Acknowledgments
• Laurel Despins, MS, APRN, BC, CCRN. Project Director. Office
of Clinical Effectiveness. Clinical Nurse Specialist, MedicalNeurosurgical 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.
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Contact 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 Quality
Medical Sciences Building, MA128
University of Missouri-Columbia. Columbia, MO 65211
Voice: (573) 882-8905
Fax: [573] 884-0474
Email: haverstickr@missouri.edu.