IHI Open School
Advanced Case Study
The Three Investigators:
Tricia Pil1, Danuta Lesnicki2, & Chris Hope3
University of Pittsburgh1, Lewis University2,
University of Mississippi Medical Center3
Carla’s Story (Part 1)
Day 1: Carla has poor
flow thru her dialysis
catheter. Nurse
schedules U/S for next
AM.
Carla loses her
discharge papers.
Her recommended
follow-up with a
nutritionist never
occurs.
Day 2: After taking three
buses, Carla is late for
her U/S appt. She is
resched for Day 4.
Carla is discharged
after receiving written
instructions; a copy is
mailed to her PMD.
Her recommended
outpatient INR checks
are never done.
Day 3: She is unable to
receive dialysis due to
almost completely
blocked catheter.
Day 7: Carla is ready
for discharge.
Day 25: Carla returns
to ED with right arm
pain and swelling.
Labs show
hyperkalemia; U/S
reveals clot in fistula.
Carla is admitted for
thrombolysis,
anticoagulation, and
dialysis.
Workup shows
subtherapeutic INR and
a new DVT. She is
admitted again.
Continued …
Inpatient nutrition
consult reveals dietary
foods that destabilized
anticoagulant activity.
Carla’s Story (Part 2)
Day 36: Carla is
discharged home again,
feeling sick and weary.
The medical student waits
until rounds to report this
finding. Her elevated INR
is then discovered.
An emergency CT is
performed, showing
bleeding into the brain.
She misses her dialysis
appointment the next day.
Day 40: Carla becomes
lethargic.
Aftermath: Carla has had
a stroke.
Her dialysis nurse
attempts to call her, but is
unsuccessful and forgets
to follow up.
Her INR is critically high
but not reported.
At age 30, she now lives
in a long-term care facility.
Day 39: Carla returns to
the ED complaining of
facial tingling.
Her exam is delayed, and
when done is only
cursory.
What Went Wrong?
• Poor, indirect, and/or nonexistent communication between hospital staff and dialysis unit (discharge
instructions to check INR not relayed to dialysis clinic); hospital and PMD (discharge instructions
sent by mail); hospital and nephrologist (no d/c instructions sent); also,
• Poor communication between nephrologist and dialysis unit medical assistant
Inter-professional • ED physician lacked or did not access dialysis unit medical records or recent hospital discharge
communication
summaries
breakdown
• Medical/surgical nurse and Medical student failed to notify attending
Provider-patient
communication
breakdown
Poor access to
health care
facilities
• RN scheduled ultrasound for next morning without confirming with Carla or informing her about
consequences for arriving late
• Jonas enforced late arrival policy for Carla’s ultrasound and rescheduled for next day without
confirming with Carla
• Caseworker mailed nutrition appointment slip
• Hospital’s visitation restriction policy posed restrictions on discharge communication needs with
patient’s family support
• Mercedes failed to follow up when Carla missed dialysis
• Poor communication between ED physician/staff and Carla’s family/friends
•
•
•
•
Jesse ordered ultrasound at local hospital eight miles away
Carla took three buses and arrived late for ultrasound
No inpatient nutrition consult available on Sunday
Limited hours of operation for dialysis clinic
What Went Wrong? (Continued)
Task Factors
Patient
Characteristics
• No protocol for patients discharged on anticoagulation (ideal situation to include available
nutrition consult or nutritionist at dialysis clinic, timely and direct follow-up with primary medical
doctor (PMD)/nephrologist/dialysis unit at discharge)
• Lack of process to handle critical INR value
• Financial barriers (phone disconnected)
• Transportation
• Electronic Medical Record (EMR) systems are incompatible or nonexistent
Technology
Issues
Diagnostic
Errors
• ED physician failed to adequately assess for possibility of stroke
• Medical/surgical nurse failed to assess face tingling/nausea
• Medical student failed to recognize Carla’s deteriorating mental status
Fishbone Diagram
Patient
Characteristics
•Chronic dialysis
•Financial difficulties
•Variable support
Task Factors
Individual Staff
•No anticoagulation discharge
•ED MD performed cursory
protocol
exam
•No critical INR lab protocol
•Med-surg RN failed to
•Restrictive hospital visitation
assess neuro s/sx
policy
•Med student assessed pt
•Rigid radiology scheduling
policy without patient
communication of
consequences
•No coordinated follow-up
discharge planning process
Carla strokes
•Numerous,
independent operating
healthcare facilities
•Internal cost-cutting
•Geographically distant
and scattered facilities
Institutional
Context
•Staff shortages
•Limited weekend
services
Work
Environment
•Casual attitude re:
anticoag therapy
•Prioritizing pt
volume over quality
of care
Organizational &
Management Factors
Team
Factors
•Poor communication between
inpatient and outpatient
caregivers
•Poor communication between
caregivers and pt/family
•Too many caregivers
•Inadequate supervision of
junior caregivers
•Hierarchical issues?
Rules for A Better System
1. A communication task is not “completed” until a direct conversation has occurred
between the two parties.
─ Connection between providers resulted in several critical patient care delays and omissions.
2. Trust the patient of sound mind. Ask questions of family or friends.
─
─
INR follow-up could have been resolved if caregiver at dialysis clinic acknowledged Carla’s important
message.
Knowing the patient was being discharged that same evening in which her family was visiting, those needs
should have been acknowledged.
3. Use automation in a process whenever possible to reduce variation.
─ Critical INR would have been detected much earlier had an automated process for reporting
critical INRs been available.
4. Structure policies with patient safety in mind and employee flexibility to meet variation
and growth.
─ The ultrasound policy had good intentions, however, the employee should be provided with
the ability to seek guidance for exceptions to meet circumstances of patient hardship or if the
ability to provide the service despite being late is possible.
─ The visitation policy prevented Carla’s family and friends from helping her with her discharge
needs. Again the policy should be used as a guideline and allow the nurse to make certain
exceptions.
Carla’s Story: Ideal Process Map
Day 1: Carla has poor flow
thru her dialysis catheter.
Nurse schedules U/S for
next AM.
Nurse schedules U/S at a
time that Carla confirms
works for her.
Day 2: After taking three
buses, Carla is late for her
U/S appt. She is resched
for Day 4.
Carla arrives for her U/S
the next afternoon, which
shows a developing blood
clot. She is admitted to the
hospital that same day.
Day 3: She is unable to
receive dialysis due to
almost completely
blocked catheter.
Labs show hyperkalemia;
U/S reveals clot in fistula.
Carla is admitted for
thrombolysis,
anticoagulation, and
dialysis.
Day 7: Carla is ready for
discharge.
Carla is discharged after
receiving written instructions; a
copy is mailed to her PMD.
Lydia calls the dialysis unit, which
has extended evening and
weekend hours, to review Carla’s
discharge plan and confirms an
outpatient referral to dialysis clinic’s
nutritionist.
Carla loses her discharge
papers.
Lydia notifies the home care nurse of
Carla’s discharge plan, including an
INR check and home visit within 72
hours after discharge. Carla is
discharged.
Discharge orders are also faxed to
Carla’s nephrologist and PMD.
Alternatively, these outpatient
healthcare providers are able to
access her electronic inpatient
records and discharge summary
remotely via a secure Internet Web
site.
Day 10: 72 hours after
discharge, Carla receives a
home care nurse visit for INR
check and exam. The home
care nurse also coordinates
Carla’s dialysis appt and
follows up on her labs with her
nephrologist and PMD.
Her recommended follow-up with
a nutritionist never occurs.
Her recommended outpatient INR
checks are never done.
Day 25: Carla returns to ED
with right arm pain and
swelling.
Workup shows subtherapeutic
INR and a new DVT. She is
admitted again.
Inpatient nutrition consult
reveals dietary foods that
destabilized anticoagulant
activity.
Carla continues
with dialysis,
anticoagulation
is eventually
concluded.
Nutritionist
follows Carla at
dialysis clinic.
Carla’s Story: Ideal Process Map
(continued)
Day 36: Carla is discharged home
again, feeling sick and weary.
The paramedics, in consultation
with Carla’s PMD, recognize her
symptoms as an early sign of
stroke. She is taken to the hospital
immediately.
Day 40: Carla becomes lethargic.
Aftermath: Carla has had a stroke.
Day 39: Carla returns to the ED
complaining of facial tingling.
The medical student waits until
rounds to report this finding. Her
elevated INR is then discovered.
At age 30, she now lives in a longterm care facility
Her dialysis nurse attempts to call
her, but is unsuccessful and
forgets to follow up.
Her exam is delayed, and when
done is only cursory.
An emergency CT is performed,
showing bleeding into the brain.
All missed appts are entered into
the clinic follow-up book. Entries
are checked and reconciled by a
nurse at the end of each shift.
Her INR is critically high but not
reported.
She misses her dialysis
appointment the next day.
The nurse calls Carla. There is no
answer because her phone is
disconnected.
An ambulance is sent to her
house, and her home care nurse,
PMD, and nephrologist are all
notified.
Carla’s critical INR is automatically
flagged for action by the computer.
The attending is notified
immediately.
Carla receives a stat head CT and
is taken to the OR for a developing
but small subdural hematoma that
is successfully drained and
managed.
Carla continues
with dialysis,
anticoagulation
is eventually
concluded.
Nutritionist
follows Carla at
dialysis clinic.
Improving Part of the System
Improvement Statement:
Within 6 months, all patients discharged
on anticoagulant therapy will have
home care nursing follow up within
three days and at one week after
discharge.
Measures of Success
Process Measures
• Number of patients discharged on anticoagulants who are enrolled in QI test
• Total number of patients discharged on anticoagulants
• Number of home nurse visits made
• Number of home INR values reported
Outcome Measures
• Number of critical INR values
• Number of hospital readmissions within 30 days
• Number of adverse vascular events (e.g. hemorrhage, stroke, DVT)
Balancing Measures
• Cost to train, employ home care nurses
• Cost to preserve, transport home INR blood specimens to lab
• Costs of documentation, time spent communicating lab results to outpatient caregivers
• Cost of readmission for coagulopathy complication
• Cost of lost productivity related to rehospitalization
Small Scale Change
Home care RN
visits begin
Hospital nurse
provides patient
information to
home care nurse
Patient on
anticoagulation
therapy is
ready for
discharge
Hospital Nurse explains
to patient and primary
medical doctor (PMD)
hospital’s
anticoagulation
discharge policy
(including home care
RN visits); also provides
home care nurse
contact information with
home visit schedule
Patient is
discharged only
after understanding
of above
acknowledged by
patient and family
Q: Can the frequency of readmissions and adverse vascular events be
reduced with implementation of a home care discharge plan?
What changes will be tested?
•Home care RN visits and INR checks
Who will implement the small tests of change?
•Quality officer, medical-surgical unit nurse manager, inpatient nurse, home care nurse
Where/when will the change take place?
•On inpatient unit and patient’s home; from discharge until 1 week after discharge
What information will be collected?
•The process, outcome, and balancing measures previously outlined
Why is it important?
•The INR level has a narrow therapeutic window and the anticoagulant dose thus needs frequent adjustment
•The high frequency of adverse vascular events associated with either under or over-anticoagulation
•The high risk of morbidity/mortality for patients who suffer a vascular event (hemorrhage or clot), particularly
those with concurrent or underlying medical conditions.
Who, How, and Where will data be collected and analyzed?
•Who: Quality officer, home care nurse
•How: Chart review, INR lab reports
•Where: Quality office
When will data collection take place:
•Within 3 days and at one week after discharge; during the period 6 months before and after test implementation
Obstacles
Argument
Too expensive to hire a
dedicated home care nurse
Argument
Home care nurse is just one more
handoff that increases the likelihood
of a communication error occurring
Less expensive than a
readmission for an adverse
vascular event, which is usually
several days/few weeks long
CounterArgument
Done properly, handoffs can facilitate
and reduce patient morbidity and
mortality during transition of care from
hospital to home—much like the stepdown unit from ICU to floor.
CounterArgument
The End—Thank You!
Chris Hope
University of Mississippi
Jackson, MS
Danuta Lesnicki
Lewis University
Romeoville, IL
Tricia Pil
University of Pittsburgh
Pittsburgh, PA