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HEALTHCARE IS A BUSINESS.
Konsultasi/rawat bersama/alih rawat Tim Prosedur penelitian Prosedur pendidikan Interaksi kelompok SMF & Instalasi Penegakan peraturan
Care management
An organized system or process for delivering
health care to a patient, including assessment, development of a Plan of Care, initiation and coordination of referrals and services, and evaluation of care.
Case manager
Case manager is a designation used to define a lead
of the team.
Type of ICU
Closed and Open ICU
Type: Type A, Type B and Type C
*Supervision
*Managing patient outcomes *Regulatory compliance
Essential Communication
With patient and family members Public Physician Other team members Supervisor Schedulers Insurance companies Community support services Medical appointments
team during the first week of care? Do clinicians tell each other when a patient has had an issue? * Medication change? *Admission? *Deceased? Is the discharge coordinated?
Care planning
Holistic in nature Invite other disciplines
*Include quality indicator deficits (deficits in outcome items) Coordinate visits cost effectively Balance clinical solutions with visit numbers
Focus on outcomes
Care planning:
Improvement
Improvement is measured as scoring at a better
QA
It encompasses the principles of how an
Prior level of function Homebound status Patient goals Need to expand view beyond being functional in the home environment for those patients that want to re-enter the community
improving quality of care Problem identifications to be solved The right man in the right place People motivated to run the job
encouraged to bypass managers and solved problems themselves Supervisors and managers must be specialists who will support their people when problems arise.
Follow-up
Activities
Assessment
Improvement in ambulation/ locomotion Improvement in bathing Improvement of oral medication Improvement in transferring Improvement with pain interfering with activity Any emergent care provided
Acute care hospitalization Improvement in dyspnea Improvement in urinary incontinence Discharge to the community Improvement in the status of surgical wounds Emergent care wound infections/ deteriorating wound status
Enteral Feeding
Ventilator- Free Days Avoid Readmission
Avoid Autoextubation
Minimalization of Nosocomial Infection
Contoh QA
Mortality Complaints
Readmission rate
LOS > 30 days Fire and safety practice
automatically Agency culture and structure need to facilitate interdisciplinary thinking. Reporting relationships Staff meetings Clinical structure Communication strategies
Consultants Surgical attending medical director nurse manager Critical care attendings clinical nurse specialist & acute care nurse practitioners Critical care critical care nurses PATIENT& & FAM fellows PATIENT FAMILY Critical care nutritionists residents physical therapists pharmacists occupational therapists
Team meetings
Weekly? Bi-weekly? Monthly? How long?
Who attends?
Focus of the meeting? Do they work?
It is not easy .
Concerns : Time
Cost Competing priorities The focus must be on strategic and intentional care delivery.
quality of life for patients and their families and other caregivers, or to support patients in their transition to the end of life. This is accomplished through the initiation, coordination, management, and evaluation of resources needed to promote the patients optimal level well-being and function 2008. HHN
Evidence-Based Medicine
The conscientious, explicit, and judicious use of
current best evidence in making decisions about the care of individual patients.
An approach to EBM:
Ask a clinically relevant question Search for evidence Evaluate the evidence Apply the evidence
Diagnostic
Diagnostic
gold standard? Did the patient sample include an appropriate spectrum of patients? Was the gold standard applied to all patients?
Penilaian Rekomendasi
A. Didukung 2 penelitian level I
B. Didukung 1 penelitian level I C. Didukung penelitian level II D. Didukung minimal 1 penelitian level III E. Didukung penelitian level IV atau V
Penilaian Bukti
I. RCT luas + hasil jelas, risiko rendah pada alpha dan
atau beta error II. RCT kecil + hasil tidak jelas III. Non randomisasi, kontrol secara bersamaan IV.Non randomisasi, kontrol historis dan opini ahli V.Serial kasus, penelitian tidak terkontrol dan opini ahli.
EBM in ICU
A. Severity-of-illness scoring systems use of
elements of : the history, physical examination, and diagnostic tests to objectively gauge illness severity and determine prognosis. Four main applications: Clinical research Performance assessment Resource allocation Guidance in individual patient decisions
evaluation) SAPS ( simplified acute physiology score) MPM (mortality probability model)
simplification of the APACHE I classification system. SAPS II uses 17 variables and performs similarly to APACHE II
.
MPM (I and II) is a statistical modeling system that
uses patient clinical variables to predict the probability of hospital mortality rather than to measure severity of illness.
TRISS (trauma and revised injury severity score) is a
severity-of-injury scoring system for trauma patients, but is not specific to ICU trauma admissions.
dysfunction score that is calculated based on a patients respiratory, renal, hepatic, cardiovascular, hematologic and neurologic function.
SOFA (sequential organ failure assessment) is an
organ dysfunction score that mainly differs from the MODS in that it includes therapeutic interventions in its assessment of a patients cardiovascular function.
.
B. Outcomes of special interest in the intensive care
unit. 1. Inhospital mortality 2. The 28-day mortality 3. Hospital length of stay 4. Ventilator free days
Case 1
Pasien yang keluar dari ICU dalam bulan Juli ada 7%
Case 2
Pasien tetanus yang dirawat di ICU dengan diazepam
kejang sulit diatasi. Kejang baru hilang dalam 12 hari. Adakah cara yang lebih baik untuk mengatasi kejang? EBM? Implementasi?
Case 3
Seorang pasien dengan AMI dan hemodinamik tidak
stabil. Selain itu pasien menderita DM dan asthma bronchiale. Ada tanda AKI yang terlihat dari kenaikan ureum dan creatinin. Pasien dirawat di ICU dan di kelola oleh tim dokter. Siapa duduk dalam tim? Siapa ketua tim? Apa rencana kerjanya?