Use care plan to stabilize anxiety in cardiac patients
Multidisciplinary approach, educational efforts key to OK agency’s success
An Oklahoma agency has improved the stabilization of anxiety in its cardiac patients through a program of early assessment and intervention.
Grove-based TRINITY LifeCare, a business of INTEGRIS Grove General Hospital, launched the program four years ago in response to data gleaned from its participation in the Medicare Quality Assurance and Improvement Demonstration Project, says Betty Reichert, RN, performance improvement coordinator.
Reichert says analysis of the Outcome and Assessment Information Set (OASIS) surveys conducted by the agency as part of the demonstration outcome reports showed worse-than-normal responses on key questions relating to patients’ reports of anxiety.
"[OASIS item] MO580 asks: When is the patient anxious?’ MO600 [discusses] behavioral changes that might come into play, and MO620 [is] about the frequency of the different behaviors," she explains.
"When we got our outcome report, we were lower than the reference group, so we felt it was something we needed to look at."
Charting possible outcomes
Reichert says TRINITY LifeCare put together a multidisciplinary team to examine the issue further. The group did chart reviews, looking at both patients who met the expected outcome for stabilizing anxiety and those who didn’t.
"I think we did 15 or 20 charts of both the ones who had met it and the ones who had not met the outcome," she says.
Those results helped the team focus in on cardiac patients, who appeared to be at higher risk for problems stabilizing anxiety. That’s in keeping with research that shows anxiety to be a significant health risk for patients recovering from heart problems.
After extensive review, TRINITY LifeCare’s team identified the problem it wanted to tackle, Reichert says: Staff were doing incomplete assessment and documentation of the causes of anxiety, and failing to apply interventions and goals that were directly targeted at the anxiety.
The team then formulated an action plan (inserted in this issue) that set up care behaviors expected of staff:
• Evaluating and documenting the cause and level of anxiety being reported by the patient, as well as coping skills being used. This would apply not only to anxiety identified during OASIS but also at any point during the course of care, Reichert says. The existing care plan would be amended to include assessment of mental status.
Developing an anxiety care plan
• Addressing anxiety in the care planning process, whenever it was found to interfere with health.
Reichert says TRINITY LifeCare developed its own standardized anxiety care plan, separate from the basic plan of care (see plan, inserted in this issue). The form is in a checklist format, including a nursing diagnosis of the cause of the anxiety, the assessments performed, teaching conducted, and other interventions tried.
Although the focus of the program was on cardiac patients, the form is used whenever any patient reports a problem with anxiety, she says.
"It’s also used with noncardiac patients — we encourage the staff to do that as well," she says. "Although we were seeing in outcomes that cardiac patients were at greater risk, there could be anxiety with any diagnosis for different reasons. The care plan was generic as far as anxiety, no matter what the diagnosis."
Interventions might include teaching the patient coping mechanisms such as relaxation exercises or positive thinking. Reichert says staff also could refer the patient to a professional such as a social worker, therapist, or clergy.
"We could get an MSW in there to help with counseling if there was depression because of a death in the family or something like that," she says.
• Educating staff to suggest interventions to help patients stabilize or lessen anxiety.
TRINITY LifeCare held an inservice for all staff on the subject, conducted by a mental health professional from a nearby hospital. Reichert says this was an important step to help staff deal with a condition that might be more difficult to interpret than the physical problems they were used to seeing.
"As this team was meeting, we began to see that anxiety is not something as easy to identify and to fix as a physical condition," she says. "It really made our team members and our staff think a little bit differently about things other than physical conditions that can create problems with people’s health status."
The agency’s anxiety stabilization program has shown success every year since it was instituted in 1997, based on OASIS results from patients over time.
Whereas previously, TRINITY LifeCare had shown worse outcomes than the reference group, the agency’s outcomes improved over time so that for the 1999-2000 year, its outcomes were significantly better than that of the reference group. (See chart, above.)
Reichert says that while the agency hasn’t held subsequent inservices, the use of the care plan keeps the issue in the minds of staff members. In addition, when the agency gets a new outcome report, she publishes the information to remind staff of the importance of anxiety stabilization.
Her suggestions for agencies attempting to emulate TRINITY LifeCare’s success:
• Make it multidisciplinary. The original team who researched the issue and formulated the action plan included nurses, aides, and social workers.
"I think having a team with multiple disciplines is important because they bring in different views of the patient than nursing sometimes does," she says.
• Develop a separate care plan for anxiety. TRINITY LifeCare’s checklist format makes it easy for a nurse to ask the necessary questions and find the appropriate interventions.
• Don’t just focus on what isn’t working. The team looked both at patients who did meet the outcome and those who didn’t. That approach makes it easier not only to see what doesn’t work, but also those interventions that do work — and to pinpoint staff who can help.
"This helps you identify a staff member who could help with inservicing, and I think that’s an important thing to do — to draw on the resources you have within your agency. That’s becoming more and more important with the cost factors in home health."
Provide staff with information
• Tap local mental health resources. Reichert says the two-hour inservice by the local mental health professional was a real benefit to staff who were grappling with the elusiveness of an anxiety diagnosis.
"The person we had was very dynamic and easygoing and answered a lot of questions," she says. "That was important because this was a very difficult subject to get our hands around as far as how we were going to improve this."
Reichert also recommended that the inservice be an interactive-type presentation, giving staff lots of opportunity to ask questions and pose problems to the speaker.
• Betty Reichert, Performance Improvement Coordinator, INTEGRIS TRINITY LifeCare, P.O. Box 450458, Grove, OK 74345-0458. Phone: (918) 786-4461, ext. 3803. Fax: (918) 787-3645. E-mail: [email protected].
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