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					         Parenteral and Enteral Access:                                                                   Disclosure:
     A Coordinated Approach for Improving
        Patient Care and Reducing Costs
                                                                                               I have no commercial
                       Malcolm K. Robinson, MD                                          relationships relevant to the topic
                      Assistant Professor of Surgery
                         Harvard Medical School                                                   being presented.
                     Brigham and Women’s Hospital




                 Learning Objectives                                                         Self Assessment Questions
                                                                                   1.    A coordinated approach for parenteral and enteral
                                                                                         access is beneficial by:
     1. List three benefits to a coordinated approach for                               a.   Achieving access in a timely manner
        parenteral and enteral access                                                   b.   Assuring selection of the optimal route for nutrition support
                                                                                        c.   Inserting the access device in the most cost-effective and safe
     2. List two ways a coordinated approach to                                              location
                                                                                        d.   All of the above
        parenteral and enteral access can improve                                       e.   None of the above
        patient outcomes                                                           2.    Tying PICC approvals to PN approvals is beneficial
     3. List two ways a coordinated approach to                                          because:
                                                                                        a.   It slows down the process for both, allowing the team more time
        parenteral and enteral access can reduce costs                                       to fully develop the nutrition plan
                                                                                        b.   It minimizes inappropriate PICC insertions
                                                                                        c.   It promotes a good working relationship between the house
                                                                                             officers and the nutrition support team




                                                                                             Patient Care Challenges facing
           Self Assessment Questions
3.    The NST can promote the use of enteral nutrition by
                                                                                              Nutrition Support Specialists
     a.   Offering a streamlined approach to enteral access consults
     b.   Developing protocols to promote the use of enteral nutrition for          • Developing a nutrition care plan for
          patients at high nutritional risk
     c.   Providing staff education when parenteral nutrition requests are
                                                                                      individual complex patients needing our
     d.
          denied
          All of the above
                                                                                      expertise.
     e.   None of the above                                                         • Developing a systems plan for delivery of
4.    Which of the following is a way a nutrition support team can
      save costs?                                                                     complex nutrition care within a variety of
     a.   Immediately approving all requests to start PN                              settings (e.g., hospital, rehab, home).
     b.   Clustering all cases to be done in the operating room on one day of
          the week
     c.   Limiting PICC insertions to one day per week to save staffing costs
     d.   Inserting most PICCs at the bedside to limit use of the interventional
          radiology suite
              Unfortunate Ingestion                         Intestinal Obstruction from Furniture Cushion Foam Bezoar
   Ruiz MC, Soler-Gonzalez J. N Engl J Med; 2005;353:2270           Chiu B, Ciaccio C, West MA. Surgery; 2005;138:956-958




                                                                 Delivering Nutrition Care in the
                                                                Hospital Setting: Some Challenges
   Dealing with individual patient                              •Disparate patient populations (e.g., med,
nutrition support challenges is very                            surg, OB/GYN, Cards) each with unique
                                                                requirements for nutritional care.
different from developing a systems
                                                                •Multiple disciplines (MD, RN, PA) who
   plan for delivery of specialized                             may have different expectations.
          nutrition support.                                    •Limited nutrition training for healthcare
                                                                professionals.




  Delivering Nutrition Care in the                                   Delivering Nutrition Care :
 Hospital Setting: Some Challenges                                 Results of an Inadequate Plan to
                                                                       Address the Challenges
•Some healthcare professionals have limited                               Inappropriate                            Disjointed
                                                                          Nutrition Care                          Nutrition Care
appreciation of nutrition support for
improving patient outcome.
•Parenteral and enteral access procedures                                                     Ineffective
                                                                                             Nutrition Care
are done by a variety of disciplines (e.g.,
surgeons, GI, RN, PA, house staff) with
variable expertise and knowledge of                                           Poor Patient
                                                                                                                Increased
appropriate use .                                                              Care and
                                                                               Outcome
                                                                                                              Patients Costs
   Appropriateness of PN Utilization
         by Clinical Service                                                                                      Per Cent of Time TPN Appropriately Utilized,
                                                                                                                       with and without MSS Consultation
               100                                78%(78)*
                90                                                Indicated
                80                                                Preventable
                           48%                                    Not Indicated
                70         (52) 35%
     PERCENT




                60
                                (38)
                50
                                         17%
                40                       (19)             10%       12%
                30                                        (10)*     (12)*
                20
                10
                 0
                            Surgery                 Medicine

*p<0.001 vs Surgery                             Trujillo et al; JPEN 1999;23:109-113

                                                                                                              Trujillo et al; JPEN 1999;23:109-113




         MSS Parenteral and Enteral Access                                                                                             Number of RN, PA, and IR
                Procedures FY 96                                                                                                        PICC Placements FY 00
                                                                                       Number of Placements




                     Total Procedures:
                            171




                                                                                                                     * FY 00 data estimated based on available
                                                                                                                     data from one half of the fiscal year




                Per Cent of PICCs Placed by                                                                          Mean Time to PICC Placement at
                     Discipline FY 00                                                                                  Inception of PICC Service
                                                                                                      Delivering Nutrition Care :
                                  Comprehensive                                                    One Plan to Address the Challenges
                                     MSS

                                                                                                        Inpatient                                             Outpatient
                                                                                                       Consultation                                             Care




                                                                                                     QA                         Comprehensive
                                                                                                                               Metabolic Support                     Nutrition
                                                                                                   Program                                                           Education
                                                                                                                                Service (MSS)
          Decreased
         Patient Care                                                Improved
            Costs                                                   Patient Care
                                                                                                        Short-term                                            Long-term
                                                                                                        Parenteral                                          Parenteral and
                                                                                                         Access                                             Enteral Access




                  Inpatient Nutrition
                  Consultation Service
                                                                                                             MSS PICC Service
                                                                                               • Review and approve/disapprove all PICC
• Make recommendations regarding care of
                                                                                                 requests.
  patients with complex nutrition problems (e.g.,
  TPN, TFs).                                                                                   • Triage order of PICC placements.
• Mandatory approval/disapproval of TPN use                                                    • Assess and treat PICC issues/complications.
  for all inpatients.                                                                          • Review all chest x-rays of PICC patients and
• Metabolic Cart Studies.                                                                        approve PICC for use.
• Mandatory approval/disapproval anabolic                                                      • Place outpatient PICCs.
  agent use (e.g., growth hormone, oxandrolone)
  for all inpatients.




                                  Request for PICC
                                                                                                        Coordinating Nutrition Care with
                                                                                                           Parenteral/Enteral Access
                        IV Team        MSS            IR
                                    P/E Service                                                        Request for                                          Request for
                                                                                                         PICC                                                  TPN
                                   PA Screens
                                    Request

                                                               CVL              No Action                                                          Yes/No
              CVL Indicated                                                                                        Yes/No
                                                           Not Indicated        Required                                                           By RD
                                                                                                                 By MSS PA

Hickman or                          IJ/Subclavian           MSS Enteral       Enteral Access
Port-a-Cath      PICC             Percutaneous Line         Access Team         Achieved                                           Yes/No
                                                                                                                                    MSS
                                                                                                                                  Attending
                                     Primary                Enteral Access
                  IV RN
MSS Surgeon                           Team                 Contraindicated
                                                            or unsuccessful
                   PA
                                                                                                                                              No PICC +
                                                                                                                      PICC +
                                                              No Action                                                                        Enteral
                   IR                                         Required                                                 TPN
                                                                                                                                               Feeding
            MSS Parenteral and                                MSS Parenteral and Enteral Access
           Enteral Access Service                                Procedures FY 96 – FY 97
• Perform phone screen for outpatients receiving
  lines or tubes, obviating need for PATC visit.
• Schedule and assist MSS surgeons with OR line
  and tube surgeries.
• Provide follow-up care for line/tube
  outpatients.
• Provide mandatory CVL education and
  training of all BWH house staff.




    Outpatient Nutrition Care                                     Nutrition Education
 •Multidisciplinary team (ideally MD, RD, RN/PA) to           •Provide fundamentals of nutrition
 see patients in office and provide phone support.            education for students, residents,
 •Outpatient team helps coordinate transition from
 inpatient setting to rehab or home.
                                                              and fellows.
 •Team member coordinates delivery of nutrition               •Educational forums to include
 prescription with homecare company, VNA, and                 didactic lectures, clinical rotations,
 patient.
                                                              weekly conferences.
 •Team monitors patient progress (e.g. labs) and
 transitions patient parenteral to enteral feeding when       •Issues regarding parenteral and
 possible.                                                    enteral access to be addressed.




 MSS in Action: A Case Study                                              Case Study

                                                          •1981: 43 y.o. male admitted to outside hospital
    Enterocutaneous fistula and small bowel
                                                          with pelvic abscess due to either a ruptured
    evisceration of twenty-five years’ duration:
                                                          appendix or perforated bowel.
  successful surgical and nutritional management
  V Patel, KM Mogensen, SO Rogers and MK Robinson
                                                          •Abscess treated with percutaneously placed pelvic
             Dig Dis Sci 2007; 52:3209-13.
                                                          drain.
                                                          •Patient declined further treatment, left hospital
                                                          with drain in place, and was lost to follow-up for
                                                          24 years.
                Case Study                                          Case Study
                                                     •2005: Admitted to BWH with c/o profound
•Patient managed persistent drainage and
progressively enlarging drain site with ostomy bag
                                                     fatigue.
obtained without medical supervision when loops      •Reported rapid transit of undigested
of bowel and stool appeared.                         matter from mouth the ECF with 3L output
•1993: Stool output had ceased per rectum and        per day.
emanated from drain site alone.                      •PE: Cachetic with temporal muscle wasting
                                                          •Height 175cm, estimated dry weight 49.7 kg
                                                          •BMI 15.6; 68% IBW; NRI 79




                                                                    Case Study
                                                       •Labs: Na 118; BUN/Cr 95/3.3
                                                       •Radiology: enterocutaneous and
                                                       colovesicle fistulae.
             Case Study:                                              Case Study
             Treatments                            •Post-op complicated by anastomotic
•Rehydration, correction of electrolytes, and      leak requiring conversion to end
TPN via PICC for pre-operative feeding.            jejunostomy (160 cm).
•After six weeks went to OR for extensive          •2/06: resection of defunctionalized colon
resection of small and large bowel distal to       with jejuno-rectal anastomosis to return
ECF with jejuno-colonic anastomosis, repair        bowel continuity.
or colovesicle fistula, omental patch of           •10/06: Wt: 63.4 kg (100%IBW). Two
bladder, sigmoid colectomy with rectal pouch       nights per week TPN.
and end sigmoid colostomy.




                                                         Components of Metabolic Care
                                                               for this Patient

                                                                 •TPN
                                                 Inpatient       •Refeeding Management    Short-term
                                                Consultation                              Parenteral   •PICC
                                                                 •Pre-Op feeding
                                                                                           Access


                                                                       Comprehensive
                                                                      Metabolic Support
                                                                       Service (MSS)          •Manage SBS
                                                                                              •Transition to PO
                                                                                              •Wean TPN

                                                  Long-term                               Outpatient
                                                Parenteral and   Convert to Port            Care
                                                Enteral Access
             Keys to Success                                                     Comprehensive
                                                                                    MSS
                                                                                                         Collect data to
•Multidisciplinary team (MD, RD, RPh, PA) with          Determine if MSS                                 identify issues and
expertise in nutrition support, and parenteral and      modifications needed                             determine MSS effect
                                                        or existence justified                           on patient care
enteral access.                                         based on data
•Coordinated approach to care between multiple                                        QA
services.                                                                           Program
•Mandatory requirement for approval of use of certain
                                                                  Decreased
resources.                                                                                                Improved
                                                                 Patient Care
•MSS policies are approved by MSEC and ICU                          Costs                                Patient Care
                                                                                 Collect cost data and
committees so that they are hospital-wide policies                               determine MSS effect
which can not circumvented.
Improvements in Patient Care as a Result                                                   Disclosures
of the Multidisciplinary Nutrition Support
                   Team                                                          I have no commercial relationships relevant
                                                                                         to the topic being presented.
                     Vihas Patel, MD, FACS, CNSC
                  Director, Metabolic Support Service
                  The Brigham and Women’s Hospital
                               Instructor
                        Harvard Medical School
                            February 1, 2009




                                                                                     Improving Patient Care
                             Comprehensive
                                MSS
                                                      Collect data to
                                                                             •   PN Utilization
 Determine if MSS                                     identify issues and
 modifications needed                                 determine MSS effect   •   PICC Service
 or existence justified                               on patient care
 based on data                                                               •   Parenteral & Enteral Access Service
                                   QA
                                 Program                                     •   Complex Cases
           Decreased
                                                                             •   Options for Non-Academic Medical
          Patient Care                                 Improved                  Centers
             Costs                                    Patient Care
                              Collect cost data and
                              determine MSS effect




                                                                                  2008 PN Utilization Update
                                                                             • Review of all inpatient PN starts
                                                                               between 8/1/08 and 10/31/08 for:
                                                                                  – Ordering service
         Effect on PN Utilization                                                 – Indication for PN
                                                                                    • Indicated—following A.S.P.E.N. guidelines
                                                                                    • Preventable—could have gotten enteral access
                                                                                    • Not Indicated—able to take oral nutrition
                                                                                  – MSS vs. Non-MSS




                                                                                                                                     1
              PN Utilization at BWH                                                                         Appropriateness of PN Use by Clinical Service
 Pre & Post Mandatory MSS PN Approval Process                                                                               2008 Update

        100%                                              90%                                                100%
         90%                82%                                                            79%                                                                                                        85%
                                                                                                              90%
         80%                                                                                                                                                   78%                   78%
                                                                                                              80%
         70%
         60%                                                                 56%                              70%
         50%                                                                                                  60%
                                                                                                                                 48%
         40%                                                                                                  50%
         30%                                                                      26%                         40%                        35%
                                                                                    18%          19%
         20%                        14%                          10%                                          30%
                                                                                                                                                17%                     20%
         10%                          4%                            0%                             2%         20%                                                                                         13%
                                                                                                                                                                                           10% 12%
          0%                                                                                                  10%                                                          2%                                2%
                         MSS 1999                      MSS 2008            Non-MSS         Non-MSS
                                                                                                               0%
                                                                             1999            2008                           Surgery 1999                   Surgery 2008 Medicine 1999 Medicine 2008

                                  Indicated                    Preventable       Not indicated                                              Indicated                  Preventable    Not indicated
Trujillo et al; JPEN 1999;23:109-113 and internal audit data                                            Trujillo et al; JPEN 1999;23:109-113 and internal audit data




       Parenteral Nutrition (PN) Use for Adult Hospitalized Patients: A
                Study of Usage in a Tertiary Medical Center                                                                                         What works?
                                DeLegge MH et al. Nutr Clin Pract 2007;22:246-249



 60%
                                              56%                                                       • Mandatory NST approval for all PN
                                                                                                          starts—requires “buy in” from hospital
 50%
                                                                     40%                                  administration
 40%
                                                                                                        • Intensive education & support for staff
 30%
                                                                                                          RDs
 20%
                                                                                                        • Promotion of enteral access & feeding
 10%                                                                                 4%
                                                                                                          when appropriate
   0%

                               Appropriate                     Not appropriate     Unknown




                                                                                                                                                                 Request for PICC




                                                                                                                                         IV                                                  Interventional
                                                                                                                                         RN                                                    Radiology
                Central Venous Access:
                 The MSS PICC Service
                                                                                                               PICC                                    PICC                            PICC                PICC
                                                                                                             placement                               placement                       placement           placement
                                                                                                             successful                             unsuccessful                     successful         unsuccessful




                                                                                                            PICC placement process prior to April 2000                                      Alternative plan developed




                                                                                                                                                                                                                         2
 Quality Assurance Issues Related to
                                                                                                BWH PICC Placement Team
               PICCs
• Inappropriate requests by physicians                                                      • Formed in April 2000
  not familiar with clinical indication for                                                 • Multidisciplinary Team Includes:
  PICC insertion                                                                                  – Physician Assistants (PAs) working with
• Inefficient placement process leading                                                             Metabolic Support Service (MSS) surgeons
  to delays in patient care and discharge                                                         – Certified intravenous (IV) nurses from the
  from hospital                                                                                     IV Team
• High volume may lead to significant                                                             – Interventional Radiologists
  cost containment issues




                                                                                                                                     Request for PICC
                                      Bedside Ultrasound
                                                                                                            IV Team                   MSS PICC                    IR
                                                                                                                                       Service
• We thought that the use                                                                                              Disapproved
  of ultrasound could                                                                     Alternative plan developed                  PA screens
                                                                                                                                       request
  improve success rate of                                                                                                                      Approved
  bedside PICC insertion                                                                                                             Bedside attempt
                                                                                                                                        by IV RN
• PAs were trained to use
  ultrasound at the bedside                                                                                                 Unsuccessful

                                                                                                                                                                         PICC placement
  starting in November 2000                                                                                              Bedside attempt by PA with US guidance             successful


• A new flow for PICC                                                                                                       Unsuccessful

  consults was developed                                                                                                          PICC placed in IR


From: http://www.bardaccess.com/ultra-siterite-6.php accessed 1/5/09                                                        Unsuccessful       PICC placement process after April 2000




  Total PICC Requests by Fiscal Year                                                                           Screening Process
                                                      Increased by 93 %                   • Each PICC consult is first screened for
                               3500
                                                                                            appropriateness of indication and then triaged
                               3000
                                                                                            to IV RN, MSS PA or IR insertion attempt
                                                                                                – PICC may be disapproved by CDC, JCAHO or K/DOQI
          Number of Requests




                               2500
                                                                                                  guidelines
                               2000
                                                                                                      • No need for central venous access (e.g., tied to PN approval)
                               1500
                                                                                                      • Patient already has central venous access
                               1000                                                                   • Patient has fever or suspected/confirmed bloodstream
                                500                                                                     infection
                                  0                                                                   • Patient has stage IV or V chronic kidney disease
                                      FY 00   FY 02   FY 04     FY 06     FY 07   FY 08               • More durable central venous access is indicated
         Requests                     1652    2265    2493      3024      3123    3195




                                                                                                                                                                                          3
                     Percent of PICC Requests                                                Improved Care & Reduced Costs for Patients Requiring
                                                                                               Peripherally Inserted Central Catheters: the Role of
                       Denied by Fiscal Year                                                        Bedside Ultrasound & a Dedicated Team
                                                                                                       Robinson MK, Mogensen KM, Grudinskas GF, Kohler S, Jacobs DO. JPEN 2005;29:374-379

                                     40
                                     35                                                   • Quarterly data from three time periods were
         disapproved for placement




                                     30                                                     assessed:
              % PICC requests




                                     25                                                                     – “Service Inception” (Apr-Jun 2000)
                                     20                                                                     – “Ultrasound Initiation” (Oct-Dec 2000)
                                     15                                                                     – “Current Service” (Oct-Dec 2002)
                                     10
                                                                                          • The following parameters were assessed
                                      5
                                                                                                            –                      Total PICC requests
                                      0
                                          FY   FY   FY   FY   FY   FY   FY   FY   FY                        –                      Total PICC placements
                                          00   01   02   03   04   05   06   07   08                        –                      Location of placement
% Disapproved 32.6 30.7 26.3 26.1 26.6 26.3 26.9 31.2 38.5                                                  –                      Days to placement
                                                                                                            –                      Average cost of PICC placement




Improved Care & Reduced Costs for Patients Requiring                                      RN, PA, and IR PICC/CVC Placements
  Peripherally Inserted Central Catheters: the Role of
       Bedside Ultrasound & a Dedicated Team                                                         by Fiscal Year      Use of IR
 Robinson MK, Mogensen KM, Grudinskas GF, Kohler S, Jacobs DO. JPEN 2005;29:374-379                                                                                                                                  remains
                                                                                                                                                              Up 77% from Inception                                  low!

                                                                                                                                       2500                                                  9% decrease
                                                                                                                                                                            2222      2186
                                                                                                                                                                            107                    1992
                                                                                                                                                                 1829                  75
                                                                                                                                       2000                                                         69
                                                                                                            Number of Placements




                                                                                                                                                      1670        67
                                                                                                                                                      112                   1108      1030                           IR CVCs
                                                                                                                                       1500
                                                                                                                                                                  813                              995               IR
                                                                                                                                              1112*   618
                                                                                                                                                                                                                     PA
                                                                                                                                       1000   346                                                                    RN
                                                                                                                                               14
                                                                                                                                        500           940         949       994       1045         902
                                                                                                                                              752
    There was a significant decrease in the number of patients sent to
   interventional radiology from inception of the service to initiation of                                                                0
ultrasound, from initiation of ultrasound to the current service, and from
                                                                                                                                              FY 00   FY 02     FY 04     FY 06       FY 07      FY 08
                  service inception to the current service                             * FY 00 data estimated based on
                                                                                       available
                                                                                       data from one half of the fiscal year
                                                                                                                                                                                              FY 07 : 36 IR CVCs ; FY 08 : 26 IR CVCs




Improved Care & Reduced Costs for Patients                                                                                          Mean Time to PICC Placement by
   Requiring Peripherally Inserted Central
                                                                                                                                   Quarter, April 2000 to October 2008
Catheters: the Role of Bedside Ultrasound & a
               Dedicated Team
 Robinson MK, Mogensen KM, Grudinskas GF, Kohler S, Jacobs DO. JPEN 2005;29:374-379
                                                                                                                            3.5

                                                                                                                                   3

                                                                                                                            2.5

                                                                                                                                   2                                                                              IR PICCs
                                                                                              Time (days)




                                                                                                                                                                                                                  IR CVCs
                                                                                                                            1.5                                                                                   Service
                                                                                                                                   1

                                                                                                                            0.5

                                                                                                                                   0
                                                                                                                                        Q3/4
                                                                                                                                              FY 02    FY 04        FY 06      FY 07         FY 08
                                                                                                                                        FY 00
We demonstrated a significant decrease (80% ↓) in time to PICC insertion
                                                                                                                                              This improvement continues today.




                                                                                                                                                                                                                                        4
 PICC-Associated Bacteremia                               PICC-Associated Bacteremia
Obtained catheter-related blood stream infection data   Obtained catheter-related blood stream infection data
  from infection control for April-September 2008         from infection control for April-September 2008


 PICC type    # of infections Total inserted              PICC indication # of infections Total inserted
 Single lumen    1 (0.2%)          405                    Antibiotics        7 (1.2%)          605
 Double lumen        15 (3.5%)            423             Chemotherapy                3 (7.3%)             41
 Triple lumen         4 (5.1%)             79             PN                          9 (4.1%)             219
                                                          Other                       2 (3.3%)             60




                                                                   Long-Term Access Service
                                                        • Three MSS surgeons
                                                        • OR time available 5 days/week
                                                        • Procedures:
         Parenteral & Enteral                                  –   Tunneled catheters
           Access Service                                      –   Ports
                                                               –   Percutaneous endoscopic gastrostomy (PEG)
                                                               –   PEG with jejunal extension
                                                               –   Open gastrostomy tubes
                                                               –   Jejunostomy tubes
                                                               –   Naso-jejunal tubes




 Why have a dedicated Access Service?                          MSS Parenteral and Enteral Access
                                                                   Procedures FY 96 – FY 08

• BWH is aligned with the Dana Farber                   1000
                                                                                                   1065
                                                                                                    156
  Cancer Institute                                       900
                                                                                           845
                                                                            783
• They have a high volume of patients                    800
                                                                            72
                                                                            17
                                                                                            105
                                                                                                    344
                                                         700
  with central venous and enteral access                 600
                                                                                    607     138
                                                                                                            Port Removals
                                                                                    79
  needs                                                  500                436
                                                                                    21
                                                                                            260
                                                                                                            Feeding Tubes
                                                                                                    217     Tunneled catheters
• Close relationships with:                              400                        242                     Ports
                                                         300
   – Breast cancer center                                200
                                                                    179
                                                                     8
                                                                                            342     348
   – Gynecological cancer center                         100
                                                                    105     258     265

                                                                    66
   – Bone marrow transplant service                        0
                                                                   FY 96   FY 97   FY 00   FY 03   FY 08
   – Head & neck cancer center




                                                                                                                                 5
                                                                            Central Venous Access Phone Screen
     The Access Consult Process
• Consults come in to the MSS Parenteral
  and Enteral Access Coordinator
• Preop paperwork organized for the
  MSS PAs
• PAs conduct preoperative phone
  screening
    – Save patients a visit to the Center for
      Preoperative Evaluation




              Enteral Access Phone Screen
                                                                                     Day of Surgery
                                                                           • MSS PAs assist in all aspects of the
                                                                             procedure
                                                                             – Obtain consent & complete other
                                                                               preoperative paperwork
                                                                             – First assist in the case
                                                                             – Complete postoperative paperwork
                                                                           • Standardized patient educational
                                                                             materials written by MSS clinicians are
                                                                             provided to the patient upon discharge
Streamlined forms facilitate phone screening and standardize the process




                     Postop Care
• The MSS Access Coordinator
  schedules patient follow up as needed
    – PEG patients have automatic follow up                                    Complex Access Cases
      scheduled within 4-7 days of the
      procedure
    – Other patients are on a PRN basis
• MSS PAs have clinic time available
  daily for follow up appointments
• MSS surgeons readily available for
  complex issues




                                                                                                                       6
                                                                                                Use of a Continuous-Flow Device in Patients
                                           Complex Cases:                                              Awaiting Heart Transplantation
                                           Enteral Access                                            Miller LW et al. N Engl J Med 2007;357:885-896


• MW is a 41M with viral myocarditis
  10/18/2008 requiring BiVAD
                             – Repeated attempts at bedside enteral access were
                               unsuccessful
                             – TPN considered risky due to tenuous venous
                               access and concern for bacteremia seeding
                               BiVAD
• He was not fed x 21 days
• TPN was initiated on hospital day 21
• He needed enteral access




Complex Access: Enteral Access                                                                          Insertion of NJT
                                                     (continued)
•             One of our MSS surgeons, Dr. Edward Kelly, also rounds in the
              Cardiothoracic Intensive Care Unit
                             – this partnership facilitated a smooth consult
•             A nasojejunal tube was inserted in the OR under endoscopic
              and fluoroscopic guidance




                                 NJT In Place & Response to                                                Complex Cases:
                                     Nutritional Therapy                                                  Parenteral Access
                                                                                            • RC is a 58M with SBS since 1988
    alb (g/dL), prealb (mg/dL)




                                      45                                                      – 40 cm small bowel in continuity with colon
                                      40
                                      35                                                      – Antithrombin III deficiency, significant clotting
                                      30
                                                                               albumin
                                                                                                issues
                                      25
                                      20                                       prealbumin     – All upper extremity and neck access options to
                                      15                                                        the right atrium exhausted due to clot
                                      10
                                       5
                                       0                                                    • Did well on an oral diet from 1997-2007
                                                                                            • June 2007: acute cholangitis & long ICU stay
                                  11 008

                                            8




                                            8
                                            8

                                  11 008




                                            8

                                            8
                                  12 008




                                            8
                                           08
                                 10 200




                                 11 200

                                 11 200

                                 11 200



                                 12 200

                                 12 200
                                        20




                                                                                            • Weight dropped from 137# to 102#
                                       /2
                                        2




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                                 10




                                                                                              – 74% UBW
                                                         Date
                                                                                              – 64% IBW (IBW is 160#)
                                 TPN       EN                                               • Needed to resume PN
                                 started   started




                                                                                                                                                      7
    Complex Cases: Parenteral Access         Complex Cases: Parenteral Access
                   (continued)                                        (continued)
                                            • 2006 Transhepatic approach to right atrium
• Our partnership with interventional
  radiology facilitated a smooth consult
• The inferior vena cava was the only
  central access available
• A tunneled catheter was inserted in the
  IVC (with tip in the RA)                  • 2007 Translumbar approach to right atrium
     – Transhepatic approach
     – Translumber approach
• PN was started—weight 135# on three
  days/week of PN




                                                Approach for Non-Academic
                                                     Medical Centers
                                            • BWH’s partnership with the DFCI has
                                              allowed us to expand our Parenteral
Options for Non-Academic                      and Enteral Access Service
                                            • Options for non-AMCs
     Medical Centers                           – Providing PICC insertion service for
                                                 rehab/nursing homes
                                               – Providing an enteral access service for a
                                                 local rehab or nursing home




Improving Patient Care Summary
                                                                      Comprehensive
•   PN Utilization                                                       MSS
                                                                                              Collect data to
                                             Determine if MSS                                 identify issues and
•   PICC Service                             modifications needed                             determine MSS effect
                                             or existence justified                           on patient care
•   Parenteral & Enteral Access Service      based on data
                                                                           QA
•   Complex Cases                                                        Program
•   Options for Non-Academic Medical                   Decreased
    Centers                                           Patient Care                             Improved
                                                         Costs                                Patient Care
                                                                      Collect cost data and
                                                                      determine MSS effect




                                                                                                                     8
    Decreased Costs as a Result of the                                                       Disclosure:
    Multidisciplinary Nutrition Support
                   Team
                                                                                          I have no commercial
                                                                                      relationships relevant to the
                     Kris M. Mogensen, MS, RD, LDN, CNSD                                 topic being presented.
                                Clinical Manager
                         Brigham and Women’s Hospital
                            Metabolic Support Service
                                February 1, 2009
                            kmogensen@partners.org




                                                                                                  Outline
                              Comprehensive
                                 MSS
                                                           Collect data to        • Cost of running the service
Determine if MSS                                           identify issues and
modifications needed
or existence justified
                                                           determine MSS effect   • Cost savings associated with the service
                                                           on patient care
based on data
                                    QA                                            • Developing the quality improvement
                                  Program                                           program
          Decreased                                                               • Innovations to add value to your service
         Patient Care                                       Improved
            Costs                                          Patient Care
                               Collect cost data and
                               determine MSS effect




                                                                                    Costs Associated with the Service

                                                                                         • Staff
      Cost of Running the                                                                • Training
            Service                                                                      • Capital investments
                                                                                           (equipment)




                                                                                                                               1
                                                                              Determining PA Staffing Levels
                  Staffing Patterns
                                                                            Fiscal Year                2000        2003      2008

              •   Physician assistants                                      MSS PA FTE                  1.5          2       3.25
              •   Medical assistants
                                                                            PICC Consult Volume        1652        2291      3195
              •   Registered dietitians
                                                                            PA:PICC ratio             1:1100      1:1146    1:983
              •   Administrative staff
                                                                            OR Volume                   607         845      1065

 Where are the IV RNs? They are part of our PICC Service, but are staffed
                                                                            PA:OR ratio                1:405       1:423    1:355*
                 by the Department of Nursing’s IV Team.

                                                                            *3 FTE cover OR




         MSS Medical Assistant                                                                 RD Staffing
• PICC volume was increasing dramatically                                   • Inpatient RDs: staffed by the Department
• The PAs were doing an excellent job, but                                    of Nutrition
  needed assistance for efficiency                                            – “Team Leader” RDs are the inpatient
• Hired one MA in 2004                                                          nutrition support dietitians
  – Set up for PICC insertion
  – Assist during the procedure                                             • The MSS has 1 FTE of RD time, plus a
  – Clean up while PA enters orders, documents in                             per diem RD
    medical record
                                                                              – The full time RD is the clinical manager
  – Data entry in our PICC database
                                                                                  • Management, QI, education, research, & pt care
  – Order PICC supplies
  – Assist with metabolic cart studies                                        – The per diem RD has a flexible schedule,
• In 2008, added a per diem MA to work Sundays                                  depending on the home PN census




         Administrative Staffing                                                              Training—PAs
• MSS RN transitioned to the DFCI in 2005                                   • PICC training:
  – Responsibilities: taking calls for inpatient/outpatient                    – Takes ~ 6 weeks of PICC insertion to be
                                                                                 independent with basic screening/approval and
    access consults, preop phone screening, booking                              insertion techniques
    OR, entering/managing data into the Access Service
                                                                               – Formalized ultrasound course added to enhance
    database, home PN management                                                 proficiency
  – We split the position into an administrative role and
                                                                            • OR training takes ~ 4-6 weeks
    a clinical role
  – Developed the position of Parenteral and Enteral
                                                                            • Additional PA tasks ~ 4-6 weeks
    Access Coordinator                                                      • For a PA to be fully independent, a minimum
  – PAs assumed preop phone screening                                         of four months training
    responsibilities & RD took on other tasks of MSS RN                     • A structured training schedule, standardized
                                                                              forms, frequent check ins help smooth the
                                                                              process




                                                                                                                                     2
    PICC Screening Form                                   PICC Progress Note        PEG Consult Form                                  Tunneled Catheter Removal Form




         Training—Other Staff
                                                                                    General Staffing Issues
• MA: close work with PAs, Clinical
  Manager, IV RN manager                                                       • A clinical manager is important to
                                                                                 organize the program
• Administrative staff
                                                                                 – Ideal staffing: a nutrition support
   – Detailed training manuals
                                                                                   certified RD, PA, RN, or BCNSP
   – Hospital training for OR and billing
     procedures, various software programs                                     • Control of turnover is essential
• Success for all: organized training                                          • Need to protect your FTEs
  schedule, good written documentation                                         • HR support to recruit & hire
  & training materials, support, & time                                          qualified staff




The Medical and Financial Costs Associated with Termination of a
                    Nutrition Support Nurse                                                      Percent of PICC Requests
            Goldstein M et al. JPEN J Parenter Enteral Nutr 2000; 24; 323
                                                                                                   Denied by Fiscal Year
                                                                                                                 40
                                                                                                                 35
                                                                                     disapproved for placement




                                                                                                                 30
                                                                                          % PICC requests




                                                                                                                 25
                                                                                                                 20
                                                                                                                 15
                                                                                                                 10
                                                                                                                  5
                                                                                                                  0
                                                                                                                      FY   FY   FY   FY   FY   FY   FY   FY   FY
                                                                                                                      00   01   02   03   04   05   06   07   08
                                                                               % Disapproved 32.6 30.7 26.3 26.1 26.6 26.3 26.9 31.2 38.5




                                                                                                                                                                       3
                                                                                          Capital Investments
      Justifying More Staff
• Staff must track productivity!
  – Simple spreadsheets to track hours spent
  – Internal databases
• Monitor hospital trends                                                                         From :
                                                                                                  http://www.bardaccess.com/discoversh
                                                                                                  erlock//pdfs/MC-0175-
                                                                                                  01_Sherlock_II_Spec_Sheet_web.pdf

• Remain innovative—can you add a                                                                 accessed 1/29/09




  needed service?



                                                              From: http://www.bardaccess.com/ultra-siterite-6.php                       From: http://www.dotmed.com/listing/229171, accessed
                                                              accessed 1/5/09                                                            10/27/08




                                                                    Cost Savings with Our Team
                                                                       • Decrease catheter-related blood
        MSS Intervention:                                                stream infections (CR-BSIs)
   Prevention of Complications                                         • Decrease inappropriate PN use
        Decreases Costs                                                • Streamlined approach to enteral &
                                                                         parenteral access procedures
                                                                       • Dedicated PICC service




       Delivering Nutrition Care :                                                             Reducing CR-BSIs
   One Plan to Address the Challenges
                                                                • Wide range reported for cost related to
         Inpatient
                                             Short-term
                                             Parenteral
                                                                  CR-BSI
        Consultation
                                              Access
                                                                • Recent review: $3,700-$29,000/episode*
                          Comprehensive
                                                                • Others have quoted $34,508 to $56,167
      QA                                          Nutrition
    Program              Metabolic Support
                          Service (MSS)           Education       per infection survivor.**

          Long-term
                                             Outpatient
        Parenteral and
                                               Care
        Enteral Access
                                                                  *Infect Control Hosp Epidemiol 2008;29:S22-S30
                                                                  ***References: Am J Respir Crit Care Med 1999;160:976-981 and Arch Surg 2001; 136:229-234




                                                                                                                                                                                                4
 Medicare Will Not Pay for Medical
 Errors and Preventable Conditions
                                                                  Reducing CR-BSIs
                                                 • PN-Related
                                                   – PN increases risk of CR-BSIs
                                                   – Strict controls on PN utilization can help reduce
                                                     incidence
                                                 • Catheter-Related
                                                   – Each lumen on a central catheter can be a source
                                                     of infection
                                                   – The PICC Service bases the type of catheter on the
                                                     indication
                                                   – For long-term central venous access, we may
                                                     suggest alternate catheters based on the indication

            Published September 30, 2008




                                                     Cost Associated with PN
             Cost Savings
                                                  • Approximate cost of BWH PN solutions
• By working to reduce CR-BSI, the cost           • Labor not included—drives up cost further
  saved could offset a significant portion          – Pharmacist time + RD time
  of the funds needed to run the NST
                                                                           1 liter              1.5                2               2.5
                                                                                              liters            liters           liters
                                                   Cost                   $19.00             $25.00 $33.00 $40.00




                                                 Improved Care & Reduced Costs for Patients Requiring
        MSS PICC Service                           Peripherally Inserted Central Catheters: the Role of
                                                        Bedside Ultrasound & a Dedicated Team
                                                      Robinson MK, Mogensen KM, Grudinskas GF, Kohler S, Jacobs DO. JPEN 2005;29:374-379

• Quality improvement issues:
                                                                        ey !!
  – Inappropriate requests by physicians not                     m on
                                                          e is
    familiar with clinical indication for PICC      Tim
    insertion
  – Inefficient placement process leading to
    delays in patient care and discharge from
    hospital
  – High volume may lead to significant cost
    containment issues

                                                                     We decreased waiting time by 80%




                                                                                                                                           5
                                                                                                                                                  Improved Care & Reduced Costs for Patients Requiring
                  Improved Care & Reduced Costs for Patients Requiring
                                                                                                                                                    Peripherally Inserted Central Catheters: the Role of
                    Peripherally Inserted Central Catheters: the Role of
                                                                                                                                                         Bedside Ultrasound & a Dedicated Team
                         Bedside Ultrasound & a Dedicated Team                                                                                        Robinson MK, Mogensen KM, Grudinskas GF, Kohler S, Jacobs DO. JPEN 2005;29:374-379
                                      Robinson MK, Mogensen KM, Grudinskas GF, Kohler S, Jacobs DO. JPEN 2005;29:374-379




                                                                                                                                                                         We decreased costs by 25%




                                        Overall Cost Savings Related to
                                                the PICC Service                                                                                         Delivering Nutrition Care :
                                                 FY 01 to FY 03                                                                                      One Plan to Address the Challenges
                                                                                                  $962,260
                                      $1,000,000
                                                                                                                                                                                                                          Short-term
                                                                                                  $127,339                                                     Inpatient
                                                                                                                                                                                                                          Parenteral
                                                                            $774,940                                                                          Consultation
                                                                                                                                                                                                                           Access
                                       $750,000                             $118,696
                     Annual Savings




                                                         $509,519
                                                                                                                        Place ment Cost Savings
                                       $500,000                                                                                                          QA                             Comprehensive
                                                         $82,957                                                        Length of Stay Savings                                                                                  Nutrition
                                                                                                  $834,921                                             Program                         Metabolic Support
                                                                                                                                                                                        Service (MSS)                           Education
                                                                            $656,244
                                       $250,000          $426,562


                                                                                                                                                                Long-term
                                               $0                                                                                                                                                                          Outpatient
                                                                                                                                                              Parenteral and
                                                                                                                                                                                                                             Care
                                                          FY 01              FY 02                 FY 03                                                      Enteral Access

                 Placement Cost Savings = reduction in average cost/PICC x # PICCs/fiscal year
                 LOS Savings = reduction in PICC waiting time (days) x average cost for one day in hospital x # PICCs/fiscal year x 0.5




                  Outpatient Preop Evaluation Savings Related to
                              MSS Phone Screening

                                                                     85 % increase FY 00 to FY 08
                   $120,000
                                                                                                                            $99,800
                   $100,000

                     $80,000
                                                                                    $67,300            $66,900
Annual Savings




                                                               $62,300                                                                                                          Preop phone screening:
                     $60,000                  $54,000
                                                                                                                                                                                         •Efficient

                     $40,000                                                                                                                                                     •Allows the Center for
                                                                                                                                                                               Preoperative Evaluation to
                     $20,000                                                                                                                                                    focus on more complex
                                                                                                                                                                                       patients
                                      $0                                                                                                                                       •Saves our patients a trip
                                                FY 00            FY 01              FY 02               FY 03                FY 08                                                  to the hospital
                   Savings = cost/preop visit x # outpatient access procedures/yr
                   Cost/preop visit: $200 Source: Angela Bader, MD




                                                                                                                                                                                                                                            6
                              Boston Traffic



                                                                                                                Monitoring Quality




        Fr om : http://www.boston.com/news/local/breaking_news/2007/12/storm_could_bri.html accessed 1/26/09




                                                                                                                 Database Software
                                            Comprehensive
                                               MSS
                                                                                         Collect data to
 Determine if MSS                                                                        identify issues and
 modifications needed                                                                    determine MSS effect
 or existence justified                                                                  on patient care
 based on data
                                                    QA
                                                  Program                                                       Spreadsheet Software
           Decreased
          Patient Care                                                                    Improved
             Costs                                                                       Patient Care
                                              Collect cost data and
                                              determine MSS effect




                                                                                                                   MSS PICC Database—Data Entry Form

                     Manager Training
• Does your institution offer employee
  training for spreadsheet software and
  database software?
• If not, seek it out elsewhere
• These are powerful tools that allow you
  to generate tremendous amounts of
  data




                                                                                                                                                       7
         MSS PICC Database—Selected Queries


                                                  Developing Data Collection Tools

                                              •   What are your high-volume procedures?
                                              •   What are your high-cost procedures?
                                              •   What is important to your service?
                                              •   What is important to administration?




                                                           MSS Innovations
 What have you done for me lately?
                                              • Expanded our PICC service to include
                                                Sunday to facilitate Monday discharges
                                              • PICC education reference cards
                                              • Work with Infection Control
                                                  – Monitoring of CR-BSI rates
                                                  – Develop & implement guidelines for use of
                                                    antimicrobial catheters
                                                  – Track outcomes jointly
                                              • MSS Rotation for ICU and GI fellows
                                              • Medical student education




                                                      Billing for PA Services
      Generating Revenue
                                              • Initially, PAs did all tasks without billing
• NSTs are great at saving money, but         • Now generate revenue for:
  that’s often not enough
                                                  – Bedside tunneled catheter removals
• It’s important to find ways to become           – Inpatient PEG consults
  self-sufficient and generate revenue for        – Inpatient PICC insertions
  program development




                                                                                                8
MSS Charges—FY 08 + Q1 FY 09                                                               MSS PA Billing Form
                               612% increase!!

     $180,000
     $160,000
     $140,000
     $120,000
     $100,000
      $80,000
      $60,000
      $40,000
      $20,000
           $0
                        y




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      Opportunities with Increased
               Revenue                                                                                Comprehensive
                                                                                                         MSS
                                                                                                                              Collect data to
• The MSS becomes more self-sufficient with                                  Determine if MSS                                 identify issues and
                                                                             modifications needed                             determine MSS effect
  our physician extenders billing for their                                  or existence justified                           on patient care
  services                                                                   based on data
                                                                                                           QA
• Opportunity for programmatic development                                                               Program
     – Home PN services
     – Increased education for health-care professionals                               Decreased
       and trainees                                                                   Patient Care                             Improved
     – Funding for research                                                              Costs                                Patient Care
                                                                                                      Collect cost data and
                                                                                                      determine MSS effect




     Self Assessment Questions                                                Self Assessment Questions
1.     A coordinated approach for parenteral and enteral
       access is beneficial by:                                         3.    The NST can promote the use of enteral nutrition by
      a.   Achieving access in a timely manner                               a.   Offering a streamlined approach to enteral access consults
      b.   Assuring selection of the optimal route for nutrition             b.   Developing protocols to promote the use of enteral nutrition
           support                                                                for patients at high nutritional risk
      c.   Inserting the access device in the most cost-effective and        c.   Providing staff education when parenteral nutrition requests
           safe location                                                          are denied
      d.   All of the above                                                  d.   All of the above
      e.   None of the above                                                 e.   None of the above
2.     Tying PICC approvals to PN approvals is beneficial               4.    Which of the following is a way a nutrition support
       because:                                                               team can save costs?
      a.   It slows down the process for both, allowing the team             a.   Immediately approving all requests to start PN
           more time to fully develop the nutrition plan                     b.   Clustering all cases to be done in the operating room on one
      b.   It minimizes inappropriate PICC insertions                             day of the week
      c.   It promotes a good working relationship between the               c.   Limiting PICC insertions to one day per week to save staffing
           house officers and the nutrition support team                          costs
                                                                             d.   Inserting most PICCs at the bedside to limit use of the
                                                                                  interventional radiology suite




                                                                                                                                                     9
We thank you for your time!

     Any questions?




                              10

				
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