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7/28/2019 Clin Mngr III
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Dr Bambang Suryono S
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HEALING IS AN ART,
MEDICINE IS A SCIENCE,
HEALTHCARE IS A BUSINESS.
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Interaksi antar profesi dan satuan
kerja
Hubungan antar profesi:
Konsultasi/rawat bersama/alih rawat
Tim
Prosedur penelitian
Prosedur pendidikan
Interaksi kelompok SMF & Instalasi Penegakan peraturan
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Care management An organized system or process for delivering
health care to a patient, including assessment,development of a Plan of Care, initiation and
coordination of referrals and services, andevaluation of care.
2008 Home Health Nursing : Scope and Standards ofPractice
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Case manager Case manager is a designation used to define a lead
person for the episode of care.
Shifting of case manager.
Case management is the responsibility of every memberof the team.
*Nurses * Therapists
*etc
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Type of ICU Closed and Open ICU
Type:
Type A, Type B and Type C
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Case management skills Responsible to the patient and to the team
*Clinical decision making *Education
*Advocacy
*Collaboration
*Care coordination
*Communication
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Case management skills Responsible to the patient and to the team
*Privacy
*Supervision
*Managing patient outcomes
*Regulatory compliance
*Managing the financial cost of care
*Documentation
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Essential CommunicationWith patient and family members
Public
Physician Other team members
Supervisor
Schedulers
Insurance companies
Community support services
Medical appointments
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Is Case Management Alive and Well?
Do your clinicians discuss the plan of care withteam during the first week of care?
Do clinicians tell each other when a patient hashad an issue?
* Medication change?
*Admission?
*Deceased? Is the discharge coordinated?
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Care planning Holistic in nature
Invite other disciplines
Decide on specific goals
*Include quality indicator deficits
(deficits in outcome items)
Coordinate visits cost effectively
Balance clinical solutions with visit numbers
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Focus on outcomes Care planning:
the opportunity to improve the outcomes for the
patient intentionally.
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Quality Assurance & PatientSafety
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Improvement Improvement is measured as scoring at a better
level than at the start of the episode.
It does not mean full recovery is always goal.
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QA It encompasses the principles of how an
organization should be run
Kaizen : continuous search for improvement inoneself and in the system
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The key to an organizations success is
to master the art of orchestrating
collective thinking.
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Potential for improvement Considerations:
Prior level of function
Homebound status
Patient goals
Need to expand view beyond being functional inthe home environment for those patients that
want to re-enter the community
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New style of management Removing the causes of problems in the system
improving quality of care
Problem identifications
to be solved The right man in the right place
People motivated to run the job
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People should be authorized and
encouraged to bypass managers and
solved problems themselves Supervisors and managers must be
specialists who will support
their people when problems arise.
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A structured problem-solving process
Resistance of implementationmust be resolved along the way
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.
Follow-up
Action
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Home Health Compare
Improvement in ambulation/ locomotion
Improvement in bathing
Improvement of oral medication Improvement in transferring
Improvement with pain interfering with activity
Any emergent care provided
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Home Health Compare
Acute care hospitalization
Improvement in dyspnea
Improvement in urinary incontinence
Discharge to the community Improvement in the status of surgical wounds
Emergent care wound infections/ deterioratingwound status
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Health Care Improvement in ICU
Early mobilization
Enteral FeedingVentilator- Free Days
Avoid Readmission
Avoid Autoextubation
Minimalization of Nosocomial Infection
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Health Care Improvement in ICU Quality of Life
Bacterial Resistance
Sedaso-analgesics
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Contoh QA Mortality
Complaints
Readmission rate LOS > 30 days
Fire and safety practice
Problem identification workshop Review nursing practices
Unexpected events
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Care Planning Transfers Establish criteria for therapy referrals
Assessment and intervention specific to the transfersin item
Establish a standard of care
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Collaborative Care PlanningWorking together as a team does not happen
automatically
Agency culture and structure need to facilitateinterdisciplinary thinking.
Reporting relationships
Staff meetings
Clinical structure Communication strategies
l l d
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. Consultants Surgical attending medical director nurse manager
Critical care attendings clinical nurse
specialist & acute care nurse practitioners
Critical care critical care nurses
fellows PATIENT & FAM
Critical care nutritionists
residents physical therapists
social workers pharmacists respiratory occupational
therapists therapists
PATIENT &
FAMILY
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Team meetingsWeekly? Bi-weekly? Monthly?
How long?
Who attends? Focus of the meeting?
Do they work?
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Team care planning Can it work?
Reducing readmission to ICU
-Determining risk factors -Visit patterns for those considered at risk
-Establish referral criteria for services
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It is not easy . Concerns : Time
Cost
Competing priorities The focus must be on strategic and intentional
care delivery.
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But it is worth it! The goal of care is to maintain or improve the
quality of life for patients and their families andother caregivers, or to support patients in theirtransition to the end of life.
This is accomplished through the initiation,coordination, management, and evaluation ofresources needed to promote the patients optimallevel well-being and function 2008. HHN
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Evidence-Based Medicine The conscientious, explicit, and judicious use of
current best evidence in making decisions about thecare of individual patients.
An approach to EBM:
Ask a clinically relevant question
Search for evidence Evaluate the evidence
Apply the evidence
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Clinically relevant questionsA patient or problem
An intervention or diagnostic test (if relevant)
A comparison group (if relevant)An outcome
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Search for the best evidence Medline indexes (www.Pubmed.gov)
The Cochrane Library (www.Cochrane.org)
http://www.pubmed.gov/http://www.cochrane.org/http://www.cochrane.org/http://www.pubmed.gov/7/28/2019 Clin Mngr III
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Evaluate the evidence Is the evidence valid?
What are the results?
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Applying the evidence Diagnostic studies
Prognostic studies
Treatment or prevention studies Systemic reviews, overviews, and meta-analyses
Clinical decisions analyses
Economic analyses
Clinical practice guidelines
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Diagnostic
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Diagnostic
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Is the evidence valid?Was there an independent, blind comparison with a
gold standard?
Did the patient sample include an appropriatespectrum of patients?
Was the gold standard applied to all patients?
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What are the results?Are likelihood ratios presented?
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Will the results help me care for
my patients?Will the test results be reproducible and applicable to
patients in my clinical setting?
Will the test results change my management?
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Penilaian RekomendasiA. Didukung 2 penelitian level I
B. Didukung 1 penelitian level I
C. Didukung penelitian level II D. Didukung minimal 1 penelitian level III
E. Didukung penelitian level IV atau V
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Penilaian Bukti I. RCT luas + hasil jelas, risiko rendah pada alpha dan
atau beta error
II. RCT kecil + hasil tidak jelas
III. Non randomisasi, kontrol secara bersamaan IV.Non randomisasi, kontrol historis dan opini ahli
V.Serial kasus, penelitian tidak terkontrol dan opini ahli.
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EBM in ICUA. Severity-of-illness scoring systems use of
elements of : the history, physical examination, anddiagnostic tests to objectively gauge illness severity
and determine prognosis. Four main applications:
Clinical research
Performance assessment Resource allocation
Guidance in individual patient decisions
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Scoring systems in adult CCMAPACHE (acute physiology and chronic health
evaluation)
SAPS ( simplified acute physiology score)
MPM (mortality probability model)
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.APACHE (I,II and III) is based on the premise that
severity of illness on ICU admission is based on a
patients physiologic reserve (age and the presence ofcomorbidities) and the extent of any acute physiologicabnormalities (worst abnormalities within 24 hours ofadmission)
SAPS (I and II) was initially developed assimplification of the APACHE I classification system.SAPS II uses 17 variables and performs similarly to
APACHE II
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. MPM (I and II) is a statistical modeling system that
uses patient clinical variables to predict the probabilityof hospital mortality rather than to measure severityof illness.
TRISS (trauma and revised injury severity score) is aseverity-of-injury scoring system for trauma patients,but is not specific to ICU trauma admissions.
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. Multiple Organ Dysfunction Score is an organ
dysfunction score that is calculated based on apatients respiratory, renal, hepatic, cardiovascular,hematologic and neurologic function.
SOFA (sequential organ failure assessment) is anorgan dysfunction score that mainly differs from theMODS in that it includes therapeutic interventions inits assessment of a patients cardiovascular function.
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. B. Outcomes of special interest in the intensive care
unit. 1. Inhospital mortality
2. The 28-day mortality
3. Hospital length of stay
4. Ventilator free days
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Case 1 Pasien yang keluar dari ICU dalam bulan Juli ada 7%
mengalami readmissi ke ICU dalam 24 jam.
Problem identification?
Perbaikan?
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Case 2 Pasien tetanus yang dirawat di ICU dengan diazepam
kejang sulit diatasi. Kejang baru hilang dalam 12 hari.
Adakah cara yang lebih baik untuk mengatasi kejang?
EBM?
Implementasi?
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Case 3 Seorang pasien dengan AMI dan hemodinamik tidakstabil. Selain itu pasien menderita DM dan asthmabronchiale. Ada tanda AKI yang terlihat dari kenaikanureum dan creatinin.
Pasien dirawat di ICU dan di kelola oleh tim dokter.
Siapa duduk dalam tim? Siapa ketua tim? Apa rencanakerjanya?
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