Management unit 5

PATIENT-CENTERED CARE

CARE •"Providing care that is respectful of & responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions" IOM (2001)(nurses, physicians and other members of care partner with patients family to ensure the healthcare decisions respect the patient's wants, needs and preferences) •Philosophy of care(pt centered care is a philosophy of care.) •Engage patients and families(develop care plans that addresses he individual needs of the pt and their family. Allow pt and family to be involved in the end of shift report, provide education not only to the pt but their family)

CASE MANAGEMENT

Coordinates patient care •Focuses attention on quality, outcomes, and cost of care •Collaborative approach to: •provide and coordinate health care services •identify and facilitate options and services for meeting health needs •decrease fragmentation and duplication of care •enhance quality, cost-effective clinical outcomes (Nurse case manager manages a "case load" of pts from preadmission(onset of illness) to discharge (resolution of illness).

DIFFERENT HEALTH CARE SETTINGS REQUIRE DIFFERENT MODELS

Emergency departments use functional nursing(because emphasis is on efficient assessment and immediate treatment ) Team nursing is frequently used in - •Med-surg units may use team nursing •Critical care units use total patient care •Home health agencies may use primary nursing

NEWER MODELS OF CASE MANAGEMENT

Patient Navigators/Nurse Navigators •Assists with appointments, treatments and procedures, insurance, patient-support services, and educational resources •Transitional Care RN(facilitate effective transitions to chronically ill patients, goal to ensure effective communication across settings and providers, appropriate follow up, clear understanding of prescribed medications,assistance with referrals and encouraging patients and families to take an active role in their health care)

LESSONS LEARNED FROM MCIS

Prepare for care of hospital staff and their families •Prepare for possible violence (especially those at higher risk sucha s woman, children, elderly, and those with disabilites) •Power outages (staff needs to know how to adapt if generators don't work, charting) •Examples of decisions that have to be made(Delivering medications when pumps were not functioning, Deciding what meds would be given when the medication supply was depleted, Providing ventilation and suctioning without electricity, Preparing unit-based scenarios can be helpful in preparing for an MCI)

NURSING CARE DELIVERY MODELS: PRIMARY NURSING

RN "primary" nurse assumes 24-hour responsibility from admission through discharge. Nurse is in charge of planning, directing and evaluating patients care from admission to discharge. Provides total pt care or delegates it to LPN or uap. While off duty an associate nurse takes over care who follow the care plan made by the primary nurse . Rn accountable for all care in that 24 hrs. •Advantages(1-1 Care, nurses practice with a high autonomy) •Disadvantages(need for experienced nurses due to the amount of autonomy needed for this, high level of clinical judgement and critical thinking is needed and RN's must be willing to accept a 24 hour period).

CLINICAL PATHWAYS

(Also known as critical paths, practice protocols, and care maps,) Uses a predetermined written plan of care for a particular health problems •Patient care activities •Interprofessional interventions •Desired outcomes •Uses EBP

PHASES OF DISASTER

(similar to public health preventions, primary, secondary and tertiary, Preparedness (Focus on planning, preparing, prevention, and warning) •Relief response (Respond to the emergency, Initiate emergency management system, Mitigate the effects of the hazard) •Recovery (Usually begins 72 hours after the disaster and may continue for 2 to 3 years) •Enhance rehabilitation and reconstruction

EVALUATION OF NURSING CARE DELIVERY MODELS

Are patient outcomes achieved in a timely, cost-effective manner? •Are patients and families happy with care? •Are physicians and other health team members satisfied with care? •Does the system allow for implementation of the nursing process? •Does the system facilitate communication among all members of the health care team?

THE BASICS OF EMERGENCY PREPAREDNESS AND RESPONSE

Disaster(an event that can cause serious damage, destruction, injuries, and death) •Mass casualty incident (MCI)( a disaster that involves a large number of victims and requieres assistacne from multiple resources) •Nursing fundamentals (assess patients or use triage to assess) •Crisis standards of care (Greatest good for the greatest number of people, Triage priorities change in mass casualties, save those who are able to be saved) care given to those who have greatest chance of survival

ATI

Emergency operating plan (EOP) (every facility needs to have an emergency operating plan, part of the plan needs to include training all personnel. TJC requires facilities have an EOP and need to test the plan twice a year. Nursing should be a part of developing and EOP. •Internal emergencies- occur within a facility and includes loss of power or drinkable water, and severe damage or casualties related to fire, weather, explosion, or terrorist attacks. preparedness includes safety and hazardous materials protocols and infection control policies and practices) •External emergencies (affect facilities indirectly. Includes weather, volcanic eruptions, earthquakes, pandemic flu, chemical plant explosions, industrial accidents, building collapses, major transportation accidents, and terrorist attacks0

MASS CASUALTY DISASTER TRIAGE

Emergent (Class I) (life threatening injuries but also a high priority of survival but also a high priority of survival) •Urgent (Class II)( major injuries that are not life-threatening, treatment can wait 45-60 minutes) •Nonurgent (Class III)( minor injuries that are not life threatening and does not need emediate treatment) •Expectant (Class IV)(individuals who are not expected to survive, comfort measures can be given but not restorative care)

BIOLOGIC CAUSES OF MASS CASUALTY

Endemic (considered baseline or the expected level of disease)/epidemic (increase in numbers of the disease above expected)/pandemic (an occurrence of a disease over several countries or continents) •Pandemic influenza (global outbreak that happens when a new influenza virus emerges in the human population causing serious illness and death as it spreads worldwide. Previous pendemic flu experiences are spanish flu, asian flu,hong kong flu, avian H1N1 influenza millions died in U.S and world wide cuz of these. Tracking and predicting flu outbreaks is important response to the threat. immunizations are going to be the best defense to influenza outbreaks. Antivirals are available but there isn't enough to cover everyone. Controlling the influenza outbreak includes: isolation, quarantine, and restrictions) •Ebola (s/s include fever, severe headache, muscle pain, weakness, diarrhea, vomiting, abdominal pain, and unexplained hemorrhage. the emergency operations center is working to control the transmission of the disease before it becomes a pandemic

THE NATIONAL IMPERATIVE FOR EMERGENCY PREPAREDNESS

Increase in mass casualty incidents (MCI) •Terrorist attacks •Domestic shootings •Natural disasters •Flu pandemics •Lack of proper training •What is bioterrorism? •What do you know about bioterrorism attacks? Notes-9/11 was the biggest mass casualty this and other events showed the need for coordinated efforts, among first responders and health services including local, state and federal agencies, Lack of proper training during Katrina showed poor emergency response. Law enforcement, EMTs have been the first responders but within biological events health care workers in hospitals and clinics are at risk. What w would be an example of a bioterrorism event?

PREPAREDNESS PHASE

Local systems carry the heaviest burden when disaster occurs, state and federal kicks in when its too large for the local system) Community-preparedness •Assess for risks and type of events that may occur •Plan the emergency activities to ensure correct responses •Build capabilities which are necessary to respond •Agreements between surrounding communities •Hospitals, long-term care facilities, clinics, health departments •Medical Reserve Corps (MRC) (started in 2002 to improve the health and safety of communities by organizing local health care workers and other volunteers to serve their communities, volunteers must complete an emergency response curriculum) •Schools and other large buildings may be needed •All agencies need to have: •Emergency Operating Plan (EOP) (each communities EOP should show the plan for interactions with other community agencies)

ACTIVE SHOOTER EVENTS

Mass shootings (definition is 4 or more deaths/injuries.) •Recommendations for response to an active shooter: (Run: Evacuate is the first and best option, Hide: If evacuation is not possible, hide, Fight: As a last resort, and only when your life is in imminent danger, attempt to disrupt and/or incapacitate the active shooter

PREPAREDNESS PHASE (CONT.)

Metropolitan Medical Response System (MMRS) ( includes plans for expanding hospital care, increasing emergency medical transport, and locating specialized pharmaceuticals) •Disaster Medical Assistance Team (DMAT)(regional groups of health care professionals and administrative staff to be rapid-response team until federal resources can be deployed, can be used for mass burn causalities, pediatric care requirements, and chemical injury or contamination) •Commissioned Corps.(run by the office of the surgeon general, used for public health needs when the local or state sin't enough, uses health care professionals) •Strategic National Stockpile (CDC has a stockpile of certain medications and supplies when here isn't enough during a severe emergency, Jointly managed by the department of Homeland security and health and human services, national repository of antibiotics, chemical antidotes, antitoxins, IV administrations, airway supplies and other medical-surgical items, serves to resupply and enhance the supplies of local and state agencies) •Individual Citizen Preparedness ( everyone should have a plan in case of a disaster or an emergency)

NURSING CARE DELIVERY MODELS: TOTAL PATIENT CARE

Oldest method Nurses are responsible for •Planning •Organizing •Performing all cares ( personal hygiene, medications, tx, emotional support, and education) •Advantages (pts recieve holistic care, only one nurse per shift, nurse has high degree of autonomy, clear lines of responsibility and accountability) •Disadvantage ( very expensive, lack of nurses available)

PATIENT CLASSIFICATION SYSTEM

Pt classification systems looks at patients according to a specific criteria and needs, it is meant to try to put a number to the amount of care needed (acuity). The higher the acuity the more complex and intense the patient's care needs. ANA recommends classification systems consider the patients': •Age and functional ability •Complexity of care needs •Communication skills •Cultural and linguistic diversities •Severity and urgency of the admitting condition •Scheduled procedures •Ability to meet health care requisites •Psychosocial support needs •Other specific needs identified by the patient and by the RN (another factor to consider is the skill, knowledge and experience of staff members)

NURSING CARE DELIVERY MODELS: TEAM NURSING

RN functions as a team leader and coordinates care for a small group of patients (Rn needs to know the condition and needs of all the patients assigned to that team) RN team leader is responsible for •Planning care •Assigning duties •Directing, supervising, and assisting •Giving direct care •Advantages (high quality safe and effective care, each team member participates in decision making and contributes their expert opinion) •Disadvantages (continuity of care can suffer especially if the team assignments vary team leader may not have leadership skills) (each location or module has a RN as a team leader) •Modification of team nursing •Patient unit divided into modules; same team of caregivers assigned consistently to same geographic location •Goal is to increase the involvement of the RN in planning and coordinating care •Designated modules should contain all the supplies needed by the staff to maximize efficiency

RELIEF RESPONSE PHASE

Response activities (begin at the time of an event provides the first emergency response to victims and stabilizes the situation, the first group to respond will setup a command center, there may be another agency that will come in and take the lead depending on the situation) •National Incident Management System (NIMS) (with emergencies there is usually chaos, the NIMS uses a systematic approach to organize departments and agencies to work together during a disaster, uses hierarchy chain of commands) •Personal Protection and Safety (emrgency responders need to be protected, if they are injured than they arnt able to help others, PPE levels: Leval A- totally encapsulated chemical resistant suit, Level B-chemical splash-resistant suit with hood and self-contained breathing apparatus, maximum respiratory protections but less skin protections than level A. Level C- chemical resistant clothing with a hood and an air-purifying respirator, provides protections against airborne biologic agents and radioactive materials, Level D- uniform or scrubs) •Communication within the Health Care Facility •Communication officers (in charge of communicating with the media, need to prevent panic. some patients may be discharged others may be transferred to other facility, family member may not be able to leave so hospitals may need to supply them with medications or other supplies)

NURSING CARE DELIVERY MODELS: FUNCTIONAL NURSING

Staff members are assigned to complete certain tasks for a group of patients rather than care for specific patients •Lines of responsibility and accountability (Rn performs all assessments, care planning, and administering IV meds, LPN gives all oral medications, UAP performs personal hygiene and take vitals) •Advantages (care is economic and efficient minimum number of RNS needed to supervise, tasks are completed quickly) •Disadvantages ( fragmented care, patient confusion with different individuals, caregivers may feel unchallenged or unmotivated)

STAFFING

Staffing involves the correct mix of individuals (RN, LPN, CNA) to provide patient care needs and safe, quality care)- Nurses roles in patient safety and quality of care •Address patient's needs •Incorporate clinical competence to provide care as needed •Reflect the value RNs •Allow nurses to use professional judgement •Primary considerations for staffing a nursing unit •Number of patients •Intensity of care required (acuity) •Geography of the environment •Staff experience and preparation •Quality of nurses' work (patients have a large diverse needs, we cant staff according to number of patients we need to determine how to staff a unit, nurses can use a patient classification system)

STANDARDIZED NOMENCLATURE FOR POTENTIAL AGENTS (KNOWN AS CBRNE):

Terrorism has created the need to prepare against a variety of different agents, standardized numenclature for potential agents (known as CBRNE): Chemical (agents that injure or kill through vesicants, nerve, blood, or respiratory) •Accident/intentional (chemicals can occur as accident or intentional) •ABCs •Remove chemical (remove clothing and then rinsing with water unless a dry agent such as lye) •Biologic ( disease causing organism sucha s bacteria, fungus, virus, or parasite) •Anthrax •Botulism •Plague •Smallpox •Tularemia •Viral hemorrhagic fevers ( ebola or yellow fever need to be alert to indications of possible attack and for the appearance of the disease •Radiologic (radiation exposure is dependent on time, distance, shielding, and quantity of material) •Decontamination ( should be done before the patient enters the facility, use soap and water and contain the water runoff.) •Radiation monitors (use radiaition badges to monitor radiation levels) •Nuclear (nuclear weapons are difficult and expensive for terrorists to make) •Thermal •Nuclear •Radioactive fallout •Explosive (most common for terrorist)(if suspicious device found don't touch it, clear the area, and isolate the device by closing doors. notify authorities and leave elevators available for authorities, if a caller states theres a bomb keep them on the line, listen for background noises, pay attention to the callers voice, ask as many questions as possible about the bomb)

STAFFING AND ORGANIZATIONAL NEEDS

theres three basic organizational needs that are affected by staffing: Financial resources •Efficiencies ( staffing is hospitals largest expense, the use of staff has direct affect on the finances, even though nursing is the most expensive we are the best resource to improve quality outcomes which could reduce costs.) •Licensing regulations and accreditation(TJC doesn't require safe staffing ratios but do look a the training and competency, they look to see safe quality care is given to patients) •Customer satisfaction (patient satisfaction affects financial rewards for hospitals, medicare rewards hospitals for proving quality care through patient satisfaction)

NURSING CARE DELIVERY MODELS

Detail how task assignments, responsibility, and authority are structured to accomplish patient care •Describe which health care worker is going to perform what tasks, who is responsible, and who has the authority to make decisions •Basic premise is that the number and type of caregivers are closely matched to patient care needs in a cost-effective manner