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Paring the risk of antibiotic resistance
One unintended consequence of the increased attention to early sepsis identification and intervention can be unnecessary or excessive antibiotic use. Overuse of broad-spectrum antibiotics, in turn, can fuel the emergence of life-threatening infections such as antibiotic-resistant Clostridium difficile, a scourge in many hospitals.
For a sepsis quality improvement (QI) initiative at the University of Utah, Salt Lake City, the hospitalist coleaders took several precautions to lessen the risk of antibiotic overuse. Kencee K. Graves, MD, said she and her colleague Devin J. Horton, MD, designed the hospital’s order sets in collaboration with an infectious disease specialist and pharmacist so they could avoid overly broad antibiotics whenever possible. The project also included an educational effort to get pharmacists in the habit of prompting medical providers to initiate antibiotic de-escalation at 48 hours. The hospital had an antibiotic stewardship program that likely helped as well, she said. As a result of their precautions, the team found no significant difference in the amount of broad-spectrum antibiotics doled out before and after their QI pilot project.
Infection control and antimicrobial specialists also can help; they can monitor an area’s resistance profile, create a antibiogram and reevaluate sepsis pathways and order sets to adjust the recommended antibiotics as the resistance profile changes. “I think we still have a long ways to go,” said Andy Odden, MD, SFHM, patient safety officer in the department of medicine at Washington University in St. Louis. “The initial risk of mortality is so much more dramatic than the long-term risks of developing antimicrobial resistors that unless you have the antimicrobial stewardship people with a seat at the table, that voice can get drowned out very easily.”
The antimicrobial stewardship program at University of Pennsylvania, Philadelphia, has received a boost from technology. The program offers initial guidance on which broad-spectrum antibiotics to consider depending on the suspected source of the sepsis-linked infection. Software by Jackson, Wyo.–based biotech company Teqqa also synthesizes the university hospital’s resistance data based on blood, urine, and sputum cultures. “It can predict the antibiotic sensitivity of a given bug growing out of a given culture on a given unit,” said Craig A. Umscheid, MD, MSCE, of the department of epidemiology and vice chair for quality and safety in the department of medicine at the university.
The bigger issue, Dr. Umscheid said, is when and how to de-escalate antibiotic treatment. “If somebody is feeling better in 48 hours or 72 hours and no cultures have grown back, they have no more fever, and their white counts have normalized, do you start pulling off the antibiotics slowly and, if so, how do you do that?” Several trials are examining such questions, including a multicenter collaboration called DETOURS (De-Escalating Empiric Treatment: Opting-Out of Rx for Selected Patients With Suspected Sepsis). One of the trial’s chief aims is to set up a new opt-out protocol for acute care patients in the wards.
One unintended consequence of the increased attention to early sepsis identification and intervention can be unnecessary or excessive antibiotic use. Overuse of broad-spectrum antibiotics, in turn, can fuel the emergence of life-threatening infections such as antibiotic-resistant Clostridium difficile, a scourge in many hospitals.
For a sepsis quality improvement (QI) initiative at the University of Utah, Salt Lake City, the hospitalist coleaders took several precautions to lessen the risk of antibiotic overuse. Kencee K. Graves, MD, said she and her colleague Devin J. Horton, MD, designed the hospital’s order sets in collaboration with an infectious disease specialist and pharmacist so they could avoid overly broad antibiotics whenever possible. The project also included an educational effort to get pharmacists in the habit of prompting medical providers to initiate antibiotic de-escalation at 48 hours. The hospital had an antibiotic stewardship program that likely helped as well, she said. As a result of their precautions, the team found no significant difference in the amount of broad-spectrum antibiotics doled out before and after their QI pilot project.
Infection control and antimicrobial specialists also can help; they can monitor an area’s resistance profile, create a antibiogram and reevaluate sepsis pathways and order sets to adjust the recommended antibiotics as the resistance profile changes. “I think we still have a long ways to go,” said Andy Odden, MD, SFHM, patient safety officer in the department of medicine at Washington University in St. Louis. “The initial risk of mortality is so much more dramatic than the long-term risks of developing antimicrobial resistors that unless you have the antimicrobial stewardship people with a seat at the table, that voice can get drowned out very easily.”
The antimicrobial stewardship program at University of Pennsylvania, Philadelphia, has received a boost from technology. The program offers initial guidance on which broad-spectrum antibiotics to consider depending on the suspected source of the sepsis-linked infection. Software by Jackson, Wyo.–based biotech company Teqqa also synthesizes the university hospital’s resistance data based on blood, urine, and sputum cultures. “It can predict the antibiotic sensitivity of a given bug growing out of a given culture on a given unit,” said Craig A. Umscheid, MD, MSCE, of the department of epidemiology and vice chair for quality and safety in the department of medicine at the university.
The bigger issue, Dr. Umscheid said, is when and how to de-escalate antibiotic treatment. “If somebody is feeling better in 48 hours or 72 hours and no cultures have grown back, they have no more fever, and their white counts have normalized, do you start pulling off the antibiotics slowly and, if so, how do you do that?” Several trials are examining such questions, including a multicenter collaboration called DETOURS (De-Escalating Empiric Treatment: Opting-Out of Rx for Selected Patients With Suspected Sepsis). One of the trial’s chief aims is to set up a new opt-out protocol for acute care patients in the wards.
One unintended consequence of the increased attention to early sepsis identification and intervention can be unnecessary or excessive antibiotic use. Overuse of broad-spectrum antibiotics, in turn, can fuel the emergence of life-threatening infections such as antibiotic-resistant Clostridium difficile, a scourge in many hospitals.
For a sepsis quality improvement (QI) initiative at the University of Utah, Salt Lake City, the hospitalist coleaders took several precautions to lessen the risk of antibiotic overuse. Kencee K. Graves, MD, said she and her colleague Devin J. Horton, MD, designed the hospital’s order sets in collaboration with an infectious disease specialist and pharmacist so they could avoid overly broad antibiotics whenever possible. The project also included an educational effort to get pharmacists in the habit of prompting medical providers to initiate antibiotic de-escalation at 48 hours. The hospital had an antibiotic stewardship program that likely helped as well, she said. As a result of their precautions, the team found no significant difference in the amount of broad-spectrum antibiotics doled out before and after their QI pilot project.
Infection control and antimicrobial specialists also can help; they can monitor an area’s resistance profile, create a antibiogram and reevaluate sepsis pathways and order sets to adjust the recommended antibiotics as the resistance profile changes. “I think we still have a long ways to go,” said Andy Odden, MD, SFHM, patient safety officer in the department of medicine at Washington University in St. Louis. “The initial risk of mortality is so much more dramatic than the long-term risks of developing antimicrobial resistors that unless you have the antimicrobial stewardship people with a seat at the table, that voice can get drowned out very easily.”
The antimicrobial stewardship program at University of Pennsylvania, Philadelphia, has received a boost from technology. The program offers initial guidance on which broad-spectrum antibiotics to consider depending on the suspected source of the sepsis-linked infection. Software by Jackson, Wyo.–based biotech company Teqqa also synthesizes the university hospital’s resistance data based on blood, urine, and sputum cultures. “It can predict the antibiotic sensitivity of a given bug growing out of a given culture on a given unit,” said Craig A. Umscheid, MD, MSCE, of the department of epidemiology and vice chair for quality and safety in the department of medicine at the university.
The bigger issue, Dr. Umscheid said, is when and how to de-escalate antibiotic treatment. “If somebody is feeling better in 48 hours or 72 hours and no cultures have grown back, they have no more fever, and their white counts have normalized, do you start pulling off the antibiotics slowly and, if so, how do you do that?” Several trials are examining such questions, including a multicenter collaboration called DETOURS (De-Escalating Empiric Treatment: Opting-Out of Rx for Selected Patients With Suspected Sepsis). One of the trial’s chief aims is to set up a new opt-out protocol for acute care patients in the wards.
Preventing sepsis alert fatigue
If they’re too infrequent, alerts can delay sepsis identification and treatment. If they’re too abundant, the alerts can overwhelm providers. Finding the sweet spot for sepsis alerts, QI leaders say, can require time, technology, patience – and sometimes trial and error.
University Hospital in Salt Lake City wanted to broaden its sepsis recognition system to ensure that decompensating patients were seen and resuscitated quickly, regardless of the cause. Another hospital offered a lesson in what not to do when a staff member cautioned that a sepsis alert system based on SIRS alone had been a “total disaster” and left providers fuming. One report suggested that nearly half of all ward patients meet SIRS criteria at some point during their hospitalization, and that using the criteria for sepsis screening in hospital wards is both “time consuming and impractical.”1
Instead, University Hospital tweaked its MEWS or Modified Early Warning System, based on consultations with hospitalists, ICU physicians, and other providers about the appropriate thresholds for vital signs. “It’s kind of like asking someone, ‘Well, when are you really scared of the heart rate and when are you sort of scared and when are you not scared at all?’ ” said project coleader Devin J. Horton, MD, an academic hospitalist.
The team also analyzed the number of alerts per week per unit and their sensitivity and specificity in detecting sepsis. As junior faculty members, Dr. Horton and his collaborator, academic hospitalist Kencee K. Graves, MD, were mindful to avoid angering other doctors over being alerted too often. For their MEWS scoring system, they sacrificed a bit of sensitivity to ensure that the number of alerts remained manageable.
Before going live with its own new alert system, Middlesex Hospital in Middletown, Conn., had a subgroup spend several weeks testing the system in silent mode and tweaking different parameters such as respiratory rate and heart rate to reduce the potential for too many alerts. “If you look at each and every alert, then you can identify how to make your adjustment so that it’s not overly sensitive,” said Terri Savino, MSN, RN, CPHQ, the hospital’s manager of patient experience and service excellence.
A sepsis task force also shared data showing the hospital’s significant reductions in sepsis mortality, total hospital mortality, and sepsis length of stay. “Medical staff were willing to accept the frequency and high sensitivity of the alert because the data demonstrated that it was making a difference in the lives of our patients,” said David M. Cosentino, MD, the hospital’s chief medical information officer.
Other alert systems’ mixed performances have yielded important lessons. At the University of Pennsylvania, Philadelphia, one prototype detected clinically deteriorating patients and sent an alert to the nurse, physician, and a rapid response team. Alerted providers converged on the patient’s bedside within 30 minutes and decided whether to elevate the level of care. Craig Umscheid, MD, MSCE, of the department of epidemiology and vice chair for quality and safety in the department of medicine, said the system was associated with a suggestion of reduced mortality.2 But it was noisy and less helpful than it could have been, he said, because it didn’t separate out declining patients already known to the team from those who were still unrecognized.
Tools to predict which patients may develop severe sepsis or septic shock have worked even less well, he said. One triggered an alarm before patients showed signs of clinical deterioration. “The team didn’t know what to do with that prediction,” Dr. Umscheid said. As a result, the alert didn’t improve mortality or discharges to home. “If you’re making this prediction too early and providers don’t know what to do with the information, it’s not going to change care or affect patient outcomes,” he said. “It’s just going to frustrate providers.”
References
1. Churpek MM et al. Incidence and prognostic value of the systemic inflammatory response syndrome and organ dysfunctions in ward patients. Am J Respir Crit Care Med. 2015 Oct 15;192(8):958-64.
2. Umscheid CA et al. Development, implementation, and impact of an automated early warning and response system for sepsis. J Hosp Med. 2015 Jan;10: 26-31.
If they’re too infrequent, alerts can delay sepsis identification and treatment. If they’re too abundant, the alerts can overwhelm providers. Finding the sweet spot for sepsis alerts, QI leaders say, can require time, technology, patience – and sometimes trial and error.
University Hospital in Salt Lake City wanted to broaden its sepsis recognition system to ensure that decompensating patients were seen and resuscitated quickly, regardless of the cause. Another hospital offered a lesson in what not to do when a staff member cautioned that a sepsis alert system based on SIRS alone had been a “total disaster” and left providers fuming. One report suggested that nearly half of all ward patients meet SIRS criteria at some point during their hospitalization, and that using the criteria for sepsis screening in hospital wards is both “time consuming and impractical.”1
Instead, University Hospital tweaked its MEWS or Modified Early Warning System, based on consultations with hospitalists, ICU physicians, and other providers about the appropriate thresholds for vital signs. “It’s kind of like asking someone, ‘Well, when are you really scared of the heart rate and when are you sort of scared and when are you not scared at all?’ ” said project coleader Devin J. Horton, MD, an academic hospitalist.
The team also analyzed the number of alerts per week per unit and their sensitivity and specificity in detecting sepsis. As junior faculty members, Dr. Horton and his collaborator, academic hospitalist Kencee K. Graves, MD, were mindful to avoid angering other doctors over being alerted too often. For their MEWS scoring system, they sacrificed a bit of sensitivity to ensure that the number of alerts remained manageable.
Before going live with its own new alert system, Middlesex Hospital in Middletown, Conn., had a subgroup spend several weeks testing the system in silent mode and tweaking different parameters such as respiratory rate and heart rate to reduce the potential for too many alerts. “If you look at each and every alert, then you can identify how to make your adjustment so that it’s not overly sensitive,” said Terri Savino, MSN, RN, CPHQ, the hospital’s manager of patient experience and service excellence.
A sepsis task force also shared data showing the hospital’s significant reductions in sepsis mortality, total hospital mortality, and sepsis length of stay. “Medical staff were willing to accept the frequency and high sensitivity of the alert because the data demonstrated that it was making a difference in the lives of our patients,” said David M. Cosentino, MD, the hospital’s chief medical information officer.
Other alert systems’ mixed performances have yielded important lessons. At the University of Pennsylvania, Philadelphia, one prototype detected clinically deteriorating patients and sent an alert to the nurse, physician, and a rapid response team. Alerted providers converged on the patient’s bedside within 30 minutes and decided whether to elevate the level of care. Craig Umscheid, MD, MSCE, of the department of epidemiology and vice chair for quality and safety in the department of medicine, said the system was associated with a suggestion of reduced mortality.2 But it was noisy and less helpful than it could have been, he said, because it didn’t separate out declining patients already known to the team from those who were still unrecognized.
Tools to predict which patients may develop severe sepsis or septic shock have worked even less well, he said. One triggered an alarm before patients showed signs of clinical deterioration. “The team didn’t know what to do with that prediction,” Dr. Umscheid said. As a result, the alert didn’t improve mortality or discharges to home. “If you’re making this prediction too early and providers don’t know what to do with the information, it’s not going to change care or affect patient outcomes,” he said. “It’s just going to frustrate providers.”
References
1. Churpek MM et al. Incidence and prognostic value of the systemic inflammatory response syndrome and organ dysfunctions in ward patients. Am J Respir Crit Care Med. 2015 Oct 15;192(8):958-64.
2. Umscheid CA et al. Development, implementation, and impact of an automated early warning and response system for sepsis. J Hosp Med. 2015 Jan;10: 26-31.
If they’re too infrequent, alerts can delay sepsis identification and treatment. If they’re too abundant, the alerts can overwhelm providers. Finding the sweet spot for sepsis alerts, QI leaders say, can require time, technology, patience – and sometimes trial and error.
University Hospital in Salt Lake City wanted to broaden its sepsis recognition system to ensure that decompensating patients were seen and resuscitated quickly, regardless of the cause. Another hospital offered a lesson in what not to do when a staff member cautioned that a sepsis alert system based on SIRS alone had been a “total disaster” and left providers fuming. One report suggested that nearly half of all ward patients meet SIRS criteria at some point during their hospitalization, and that using the criteria for sepsis screening in hospital wards is both “time consuming and impractical.”1
Instead, University Hospital tweaked its MEWS or Modified Early Warning System, based on consultations with hospitalists, ICU physicians, and other providers about the appropriate thresholds for vital signs. “It’s kind of like asking someone, ‘Well, when are you really scared of the heart rate and when are you sort of scared and when are you not scared at all?’ ” said project coleader Devin J. Horton, MD, an academic hospitalist.
The team also analyzed the number of alerts per week per unit and their sensitivity and specificity in detecting sepsis. As junior faculty members, Dr. Horton and his collaborator, academic hospitalist Kencee K. Graves, MD, were mindful to avoid angering other doctors over being alerted too often. For their MEWS scoring system, they sacrificed a bit of sensitivity to ensure that the number of alerts remained manageable.
Before going live with its own new alert system, Middlesex Hospital in Middletown, Conn., had a subgroup spend several weeks testing the system in silent mode and tweaking different parameters such as respiratory rate and heart rate to reduce the potential for too many alerts. “If you look at each and every alert, then you can identify how to make your adjustment so that it’s not overly sensitive,” said Terri Savino, MSN, RN, CPHQ, the hospital’s manager of patient experience and service excellence.
A sepsis task force also shared data showing the hospital’s significant reductions in sepsis mortality, total hospital mortality, and sepsis length of stay. “Medical staff were willing to accept the frequency and high sensitivity of the alert because the data demonstrated that it was making a difference in the lives of our patients,” said David M. Cosentino, MD, the hospital’s chief medical information officer.
Other alert systems’ mixed performances have yielded important lessons. At the University of Pennsylvania, Philadelphia, one prototype detected clinically deteriorating patients and sent an alert to the nurse, physician, and a rapid response team. Alerted providers converged on the patient’s bedside within 30 minutes and decided whether to elevate the level of care. Craig Umscheid, MD, MSCE, of the department of epidemiology and vice chair for quality and safety in the department of medicine, said the system was associated with a suggestion of reduced mortality.2 But it was noisy and less helpful than it could have been, he said, because it didn’t separate out declining patients already known to the team from those who were still unrecognized.
Tools to predict which patients may develop severe sepsis or septic shock have worked even less well, he said. One triggered an alarm before patients showed signs of clinical deterioration. “The team didn’t know what to do with that prediction,” Dr. Umscheid said. As a result, the alert didn’t improve mortality or discharges to home. “If you’re making this prediction too early and providers don’t know what to do with the information, it’s not going to change care or affect patient outcomes,” he said. “It’s just going to frustrate providers.”
References
1. Churpek MM et al. Incidence and prognostic value of the systemic inflammatory response syndrome and organ dysfunctions in ward patients. Am J Respir Crit Care Med. 2015 Oct 15;192(8):958-64.
2. Umscheid CA et al. Development, implementation, and impact of an automated early warning and response system for sepsis. J Hosp Med. 2015 Jan;10: 26-31.
Charting a new course in sepsis management
A drug overdose victim is admitted to a hospital. Providers focus on treating the overdose and blame it for some of the patient’s troubling vital signs, including low blood pressure and increased heart rate. Prior to admission, however, the patient had vomited and aspirated, leading to an infection. In fact, the patient is developing sepsis.
This real-world incident is but one of many ways that sepsis can fool hospitalists and other providers, often with rapidly deteriorating and deadly consequences. A range of quality improvement (QI) projects, however, are demonstrating how earlier identification and treatment may help to set a new course for addressing a condition that has remained stubbornly difficult to manage.
Devin J. Horton, MD, an academic hospitalist at University Hospital in Salt Lake City, sometimes compares sepsis to acute MI to illustrate the difficulty of early detection. A patient complaining of chest pain immediately sets in motion a well-rehearsed chain of events. “But the patient doesn’t look at you and say, ‘You know, I think I’m having SIRS [systemic inflammatory response syndrome] criteria in the setting of infection,’ ” he said. “And yet, the mortality of severe septic shock is at least as bad as acute myocardial infarction.” The trick is generating the same sense of urgency without a clear warning.
The location in a hospital also can present a major obstacle for early identification. Hospitalist Andy Odden, MD, SFHM, patient safety officer in the department of medicine at Washington University in St. Louis, calls hospital wards the “third space” of sepsis care, after the ICU and ED. “A lot of the historical improvement efforts and research has really focused on streamlining care in the ICU and streamlining care in the emergency department,” he said. Often, however, sepsis or septic shock isn’t recognized until a patient is admitted to a medical or surgical ward.
Observational studies by the Surviving Sepsis Campaign suggested that patients diagnosed on the floor had mortality rates comparable to and substantially higher than theoretically sicker patients diagnosed in the ICU and ED, respectively.1 “That was kind of a sea change for a lot of people and really articulated what a lot of us on the wards had been feeling,” Dr. Odden said. “We can’t simply apply the lessons that we’ve learned from the emergency department and the ICU to the wards if we’re going to provide the right care for these patients,” he said.
Dueling definitions
Better sepsis care in hospital wards will require a better understanding of shifting management guidelines. Confusing and contradictory definitions haven’t helped. In October 2015, the Centers for Medicare & Medicaid Services instituted its Sepsis Core Measure (SEP-1) for Medicare, requiring every hospital to audit a percentage of patients treated with best-practice 3- and 6-hour bundles for severe sepsis and septic shock. The SEP-1 measure uses the traditional definition of severe sepsis as two or more SIRS criteria, a suspected or proven infection, and organ dysfunction.
A separate set of guidelines issued by the international Sepsis-3 task force in February 2016, by contrast, concluded that the term “severe sepsis” is redundant.2 The update defines sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection” and asserts that the condition can be represented by an increase in the SOFA (Sequential Organ Failure Assessment) score of 2 or more points.
For hospital wards, the task force recommended a bedside scoring system called qSOFA (quickSOFA) for adult patients with a suspected infection. The risk stratification tool may help rapidly identify those who are likely to have poorer outcomes typical of sepsis if they meet two of the following three clinical criteria: a “respiratory rate of 22 [breaths]/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less.”
CMS doesn’t recognize the Sepsis-3 definition at all and multiple providers have described widespread skepticism and uncertainty over how to reconcile it with the prior definition. Dr. Odden says the dueling definitions have “caused a tremendous amount of confusion” over diagnoses, the necessary sense of urgency, and whether severe sepsis is still a recognized entity. “When people aren’t speaking the same language with the same terminology, there is enormous opportunity for miscommunication to occur,” he said.
Obtaining reliable scores is another matter. The qSOFA blood pressure score generally is measured accurately, he said. On noncritical care units, though, nurses aren’t always trained to consistently and accurately document a patient’s mental status. Likewise, he said, documentation of respiratory rate often is subjective, and an abnormal rate can be easily missed. Changing that dynamic, he stressed, will require coordination with nursing leadership to ensure more consistent and accurate measurements.
Reshaping sepsis pathways
So how can hospitals identify sepsis sooner? Some hospitals have relied more on EMR-based screening methods; others have relied more on nurses to lead the charge. Either way, Dr. Shieh said, the field is trying to encourage the use of set pathways. Almost every medical center that performs well on sepsis measures, she says, has a good screening program, a pathway implemented through an order set or nursing staff, and a highly trained sepsis team that ensures patients get the treatment they need.
At Middlesex Hospital in Middletown, Conn., a major QI project led to significant improvements in sepsis mortality, total mortality, sepsis-related serious safety events and sepsis length of stay. Terri Savino, MSN, RN, CPHQ, the hospital’s manager of patient experience and service excellence, said the project sprang from concerns by the hospital’s Rapid Response Review Committee about some serious safety events involving a delay in sepsis diagnosis and treatment.
In 2013, the hospital documented three serious safety events related to a delay in diagnosis and treatment of sepsis. In 2014, it recorded only one event and has had none since then. From 2014 to 2015, sepsis-related mortality fell by more than 20%, saving an estimated 25 lives. Sepsis length of stay also declined. “We’re identifying them sooner and treating them sooner so they’re not getting as sick or requiring critical care and longer length of stays,” Ms. Savino said.
Dr. Odden has participated in two multicenter QI initiatives on sepsis. One, a partnership led by the Institute for Healthcare Improvement in Cambridge, Mass., and New York’s North Shore-LIJ Health System, focused on how to diagnose sepsis in hospital ward patients as quickly as possible and how to successfully deliver the 3-hour sepsis bundle.3 Beyond getting everyone on the same page regarding definitions, he said, the collaborators discussed and shared strategies for identifying patients. “One hospital would often have a solution for a problem that other hospitals could either take directly or modify based on their own understanding of their own processes,” he said.
Dr. Odden also participated in a national project sponsored by the Surviving Sepsis Campaign that focused on developing protocols for nurse-led screening processes in hospital wards. Within a pilot unit of each participating hospital, bedside nurses screened every patient for sepsis during every shift. For positive screens, the hospitals then developed protocols for order sets, like blood work and fluids.
The initiative suggested that a nurse-based, every-shift screening method might be one feasible way to identify sick patients as early as possible. “Going through the screening process really seemed to empower the nurses to take a much more active role in partnering with the physicians and in recognizing some of the early warning signs,” Dr. Odden said. The project led to other benefits as well, including improved identification of strokes, delirium, and even a gastrointestinal bleed because the “barriers in communication had been broken down,” he said.
To help medical providers recognize sepsis earlier, Dr. Shieh and her colleagues created a free game called Septris as an adjunctive teaching tool. Based on a player’s diagnosis and treatment decisions, patient outcomes either rise or fall – often rapidly. “I’m an educator and what I know is that the best way you learn is by doing,” she said. The interactive and repetitive nature of Septris, she said, helps its take-home messages stick in a player’s mind without the expense of patient simulations. Dr. Shieh said the game has been adapted for German and British medical institutions as well, and that she collects data from players around the world about their experiences and scores.
Winning interdisciplinary buy-in
To maximize the chances for success, several doctors emphasize the importance of forming an interdisciplinary task force that includes every department affected by a QI project. Ms. Savino said executive sponsorship of her hospital’s QI project was key as well. So was meeting frequently with the carefully chosen team members representing key stakeholders throughout the hospital. “It was a lot of work,” she said. “But I really think that was one reason why it was so successful. We had everybody’s buy-in, and we kept our short-term goals on track.”
Based on their success, the QI initiative has spread to two other hospitals in the University of Utah’s network. “Once the culture changes have been made and the project’s up and going, it’s kind of self-sufficient,” Dr. Horton said. “But it was so much work.” He and Dr. Graves are careful to emphasize that there are other options for sepsis-related QI efforts. “I think it is better to start something small than to believe you can’t do anything at all,” Dr. Graves said.
No matter what the size, assembling a motivated and multidisciplinary team is critical, she said. So is empowering nurses to talk to physicians about decompensating patients and other aspects of sepsis care. Being available and willing to listen to other providers also can pay big dividends. “Knowing that we cared about the project’s success was important to people working on it,” Dr. Graves said.
Despite the remaining challenges, Dr. Shieh points out that sepsis mortality rates have improved significantly, thanks in large part to more awareness and ambitious QI projects. “I do want to say that we have come a long way,” she said.
References
1. Levy MM et al. Surviving Sepsis Campaign: Association between performance metrics and outcomes in a 7.5-year study. Intensive Care Med. 2014 Nov;40(11):1623-33.
2. Singer M et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315(8):801-10.
3. Schorr C et al. Implementation of a multicenter performance improvement program for early detection and treatment of severe sepsis in general medical-surgical wards. J Hosp Med. 2016 Nov;11:S32-9.
4. Lee VS et al. Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality. JAMA. 2016 Sep 13;316(10):1061-72.
A drug overdose victim is admitted to a hospital. Providers focus on treating the overdose and blame it for some of the patient’s troubling vital signs, including low blood pressure and increased heart rate. Prior to admission, however, the patient had vomited and aspirated, leading to an infection. In fact, the patient is developing sepsis.
This real-world incident is but one of many ways that sepsis can fool hospitalists and other providers, often with rapidly deteriorating and deadly consequences. A range of quality improvement (QI) projects, however, are demonstrating how earlier identification and treatment may help to set a new course for addressing a condition that has remained stubbornly difficult to manage.
Devin J. Horton, MD, an academic hospitalist at University Hospital in Salt Lake City, sometimes compares sepsis to acute MI to illustrate the difficulty of early detection. A patient complaining of chest pain immediately sets in motion a well-rehearsed chain of events. “But the patient doesn’t look at you and say, ‘You know, I think I’m having SIRS [systemic inflammatory response syndrome] criteria in the setting of infection,’ ” he said. “And yet, the mortality of severe septic shock is at least as bad as acute myocardial infarction.” The trick is generating the same sense of urgency without a clear warning.
The location in a hospital also can present a major obstacle for early identification. Hospitalist Andy Odden, MD, SFHM, patient safety officer in the department of medicine at Washington University in St. Louis, calls hospital wards the “third space” of sepsis care, after the ICU and ED. “A lot of the historical improvement efforts and research has really focused on streamlining care in the ICU and streamlining care in the emergency department,” he said. Often, however, sepsis or septic shock isn’t recognized until a patient is admitted to a medical or surgical ward.
Observational studies by the Surviving Sepsis Campaign suggested that patients diagnosed on the floor had mortality rates comparable to and substantially higher than theoretically sicker patients diagnosed in the ICU and ED, respectively.1 “That was kind of a sea change for a lot of people and really articulated what a lot of us on the wards had been feeling,” Dr. Odden said. “We can’t simply apply the lessons that we’ve learned from the emergency department and the ICU to the wards if we’re going to provide the right care for these patients,” he said.
Dueling definitions
Better sepsis care in hospital wards will require a better understanding of shifting management guidelines. Confusing and contradictory definitions haven’t helped. In October 2015, the Centers for Medicare & Medicaid Services instituted its Sepsis Core Measure (SEP-1) for Medicare, requiring every hospital to audit a percentage of patients treated with best-practice 3- and 6-hour bundles for severe sepsis and septic shock. The SEP-1 measure uses the traditional definition of severe sepsis as two or more SIRS criteria, a suspected or proven infection, and organ dysfunction.
A separate set of guidelines issued by the international Sepsis-3 task force in February 2016, by contrast, concluded that the term “severe sepsis” is redundant.2 The update defines sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection” and asserts that the condition can be represented by an increase in the SOFA (Sequential Organ Failure Assessment) score of 2 or more points.
For hospital wards, the task force recommended a bedside scoring system called qSOFA (quickSOFA) for adult patients with a suspected infection. The risk stratification tool may help rapidly identify those who are likely to have poorer outcomes typical of sepsis if they meet two of the following three clinical criteria: a “respiratory rate of 22 [breaths]/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less.”
CMS doesn’t recognize the Sepsis-3 definition at all and multiple providers have described widespread skepticism and uncertainty over how to reconcile it with the prior definition. Dr. Odden says the dueling definitions have “caused a tremendous amount of confusion” over diagnoses, the necessary sense of urgency, and whether severe sepsis is still a recognized entity. “When people aren’t speaking the same language with the same terminology, there is enormous opportunity for miscommunication to occur,” he said.
Obtaining reliable scores is another matter. The qSOFA blood pressure score generally is measured accurately, he said. On noncritical care units, though, nurses aren’t always trained to consistently and accurately document a patient’s mental status. Likewise, he said, documentation of respiratory rate often is subjective, and an abnormal rate can be easily missed. Changing that dynamic, he stressed, will require coordination with nursing leadership to ensure more consistent and accurate measurements.
Reshaping sepsis pathways
So how can hospitals identify sepsis sooner? Some hospitals have relied more on EMR-based screening methods; others have relied more on nurses to lead the charge. Either way, Dr. Shieh said, the field is trying to encourage the use of set pathways. Almost every medical center that performs well on sepsis measures, she says, has a good screening program, a pathway implemented through an order set or nursing staff, and a highly trained sepsis team that ensures patients get the treatment they need.
At Middlesex Hospital in Middletown, Conn., a major QI project led to significant improvements in sepsis mortality, total mortality, sepsis-related serious safety events and sepsis length of stay. Terri Savino, MSN, RN, CPHQ, the hospital’s manager of patient experience and service excellence, said the project sprang from concerns by the hospital’s Rapid Response Review Committee about some serious safety events involving a delay in sepsis diagnosis and treatment.
In 2013, the hospital documented three serious safety events related to a delay in diagnosis and treatment of sepsis. In 2014, it recorded only one event and has had none since then. From 2014 to 2015, sepsis-related mortality fell by more than 20%, saving an estimated 25 lives. Sepsis length of stay also declined. “We’re identifying them sooner and treating them sooner so they’re not getting as sick or requiring critical care and longer length of stays,” Ms. Savino said.
Dr. Odden has participated in two multicenter QI initiatives on sepsis. One, a partnership led by the Institute for Healthcare Improvement in Cambridge, Mass., and New York’s North Shore-LIJ Health System, focused on how to diagnose sepsis in hospital ward patients as quickly as possible and how to successfully deliver the 3-hour sepsis bundle.3 Beyond getting everyone on the same page regarding definitions, he said, the collaborators discussed and shared strategies for identifying patients. “One hospital would often have a solution for a problem that other hospitals could either take directly or modify based on their own understanding of their own processes,” he said.
Dr. Odden also participated in a national project sponsored by the Surviving Sepsis Campaign that focused on developing protocols for nurse-led screening processes in hospital wards. Within a pilot unit of each participating hospital, bedside nurses screened every patient for sepsis during every shift. For positive screens, the hospitals then developed protocols for order sets, like blood work and fluids.
The initiative suggested that a nurse-based, every-shift screening method might be one feasible way to identify sick patients as early as possible. “Going through the screening process really seemed to empower the nurses to take a much more active role in partnering with the physicians and in recognizing some of the early warning signs,” Dr. Odden said. The project led to other benefits as well, including improved identification of strokes, delirium, and even a gastrointestinal bleed because the “barriers in communication had been broken down,” he said.
To help medical providers recognize sepsis earlier, Dr. Shieh and her colleagues created a free game called Septris as an adjunctive teaching tool. Based on a player’s diagnosis and treatment decisions, patient outcomes either rise or fall – often rapidly. “I’m an educator and what I know is that the best way you learn is by doing,” she said. The interactive and repetitive nature of Septris, she said, helps its take-home messages stick in a player’s mind without the expense of patient simulations. Dr. Shieh said the game has been adapted for German and British medical institutions as well, and that she collects data from players around the world about their experiences and scores.
Winning interdisciplinary buy-in
To maximize the chances for success, several doctors emphasize the importance of forming an interdisciplinary task force that includes every department affected by a QI project. Ms. Savino said executive sponsorship of her hospital’s QI project was key as well. So was meeting frequently with the carefully chosen team members representing key stakeholders throughout the hospital. “It was a lot of work,” she said. “But I really think that was one reason why it was so successful. We had everybody’s buy-in, and we kept our short-term goals on track.”
Based on their success, the QI initiative has spread to two other hospitals in the University of Utah’s network. “Once the culture changes have been made and the project’s up and going, it’s kind of self-sufficient,” Dr. Horton said. “But it was so much work.” He and Dr. Graves are careful to emphasize that there are other options for sepsis-related QI efforts. “I think it is better to start something small than to believe you can’t do anything at all,” Dr. Graves said.
No matter what the size, assembling a motivated and multidisciplinary team is critical, she said. So is empowering nurses to talk to physicians about decompensating patients and other aspects of sepsis care. Being available and willing to listen to other providers also can pay big dividends. “Knowing that we cared about the project’s success was important to people working on it,” Dr. Graves said.
Despite the remaining challenges, Dr. Shieh points out that sepsis mortality rates have improved significantly, thanks in large part to more awareness and ambitious QI projects. “I do want to say that we have come a long way,” she said.
References
1. Levy MM et al. Surviving Sepsis Campaign: Association between performance metrics and outcomes in a 7.5-year study. Intensive Care Med. 2014 Nov;40(11):1623-33.
2. Singer M et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315(8):801-10.
3. Schorr C et al. Implementation of a multicenter performance improvement program for early detection and treatment of severe sepsis in general medical-surgical wards. J Hosp Med. 2016 Nov;11:S32-9.
4. Lee VS et al. Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality. JAMA. 2016 Sep 13;316(10):1061-72.
A drug overdose victim is admitted to a hospital. Providers focus on treating the overdose and blame it for some of the patient’s troubling vital signs, including low blood pressure and increased heart rate. Prior to admission, however, the patient had vomited and aspirated, leading to an infection. In fact, the patient is developing sepsis.
This real-world incident is but one of many ways that sepsis can fool hospitalists and other providers, often with rapidly deteriorating and deadly consequences. A range of quality improvement (QI) projects, however, are demonstrating how earlier identification and treatment may help to set a new course for addressing a condition that has remained stubbornly difficult to manage.
Devin J. Horton, MD, an academic hospitalist at University Hospital in Salt Lake City, sometimes compares sepsis to acute MI to illustrate the difficulty of early detection. A patient complaining of chest pain immediately sets in motion a well-rehearsed chain of events. “But the patient doesn’t look at you and say, ‘You know, I think I’m having SIRS [systemic inflammatory response syndrome] criteria in the setting of infection,’ ” he said. “And yet, the mortality of severe septic shock is at least as bad as acute myocardial infarction.” The trick is generating the same sense of urgency without a clear warning.
The location in a hospital also can present a major obstacle for early identification. Hospitalist Andy Odden, MD, SFHM, patient safety officer in the department of medicine at Washington University in St. Louis, calls hospital wards the “third space” of sepsis care, after the ICU and ED. “A lot of the historical improvement efforts and research has really focused on streamlining care in the ICU and streamlining care in the emergency department,” he said. Often, however, sepsis or septic shock isn’t recognized until a patient is admitted to a medical or surgical ward.
Observational studies by the Surviving Sepsis Campaign suggested that patients diagnosed on the floor had mortality rates comparable to and substantially higher than theoretically sicker patients diagnosed in the ICU and ED, respectively.1 “That was kind of a sea change for a lot of people and really articulated what a lot of us on the wards had been feeling,” Dr. Odden said. “We can’t simply apply the lessons that we’ve learned from the emergency department and the ICU to the wards if we’re going to provide the right care for these patients,” he said.
Dueling definitions
Better sepsis care in hospital wards will require a better understanding of shifting management guidelines. Confusing and contradictory definitions haven’t helped. In October 2015, the Centers for Medicare & Medicaid Services instituted its Sepsis Core Measure (SEP-1) for Medicare, requiring every hospital to audit a percentage of patients treated with best-practice 3- and 6-hour bundles for severe sepsis and septic shock. The SEP-1 measure uses the traditional definition of severe sepsis as two or more SIRS criteria, a suspected or proven infection, and organ dysfunction.
A separate set of guidelines issued by the international Sepsis-3 task force in February 2016, by contrast, concluded that the term “severe sepsis” is redundant.2 The update defines sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection” and asserts that the condition can be represented by an increase in the SOFA (Sequential Organ Failure Assessment) score of 2 or more points.
For hospital wards, the task force recommended a bedside scoring system called qSOFA (quickSOFA) for adult patients with a suspected infection. The risk stratification tool may help rapidly identify those who are likely to have poorer outcomes typical of sepsis if they meet two of the following three clinical criteria: a “respiratory rate of 22 [breaths]/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less.”
CMS doesn’t recognize the Sepsis-3 definition at all and multiple providers have described widespread skepticism and uncertainty over how to reconcile it with the prior definition. Dr. Odden says the dueling definitions have “caused a tremendous amount of confusion” over diagnoses, the necessary sense of urgency, and whether severe sepsis is still a recognized entity. “When people aren’t speaking the same language with the same terminology, there is enormous opportunity for miscommunication to occur,” he said.
Obtaining reliable scores is another matter. The qSOFA blood pressure score generally is measured accurately, he said. On noncritical care units, though, nurses aren’t always trained to consistently and accurately document a patient’s mental status. Likewise, he said, documentation of respiratory rate often is subjective, and an abnormal rate can be easily missed. Changing that dynamic, he stressed, will require coordination with nursing leadership to ensure more consistent and accurate measurements.
Reshaping sepsis pathways
So how can hospitals identify sepsis sooner? Some hospitals have relied more on EMR-based screening methods; others have relied more on nurses to lead the charge. Either way, Dr. Shieh said, the field is trying to encourage the use of set pathways. Almost every medical center that performs well on sepsis measures, she says, has a good screening program, a pathway implemented through an order set or nursing staff, and a highly trained sepsis team that ensures patients get the treatment they need.
At Middlesex Hospital in Middletown, Conn., a major QI project led to significant improvements in sepsis mortality, total mortality, sepsis-related serious safety events and sepsis length of stay. Terri Savino, MSN, RN, CPHQ, the hospital’s manager of patient experience and service excellence, said the project sprang from concerns by the hospital’s Rapid Response Review Committee about some serious safety events involving a delay in sepsis diagnosis and treatment.
In 2013, the hospital documented three serious safety events related to a delay in diagnosis and treatment of sepsis. In 2014, it recorded only one event and has had none since then. From 2014 to 2015, sepsis-related mortality fell by more than 20%, saving an estimated 25 lives. Sepsis length of stay also declined. “We’re identifying them sooner and treating them sooner so they’re not getting as sick or requiring critical care and longer length of stays,” Ms. Savino said.
Dr. Odden has participated in two multicenter QI initiatives on sepsis. One, a partnership led by the Institute for Healthcare Improvement in Cambridge, Mass., and New York’s North Shore-LIJ Health System, focused on how to diagnose sepsis in hospital ward patients as quickly as possible and how to successfully deliver the 3-hour sepsis bundle.3 Beyond getting everyone on the same page regarding definitions, he said, the collaborators discussed and shared strategies for identifying patients. “One hospital would often have a solution for a problem that other hospitals could either take directly or modify based on their own understanding of their own processes,” he said.
Dr. Odden also participated in a national project sponsored by the Surviving Sepsis Campaign that focused on developing protocols for nurse-led screening processes in hospital wards. Within a pilot unit of each participating hospital, bedside nurses screened every patient for sepsis during every shift. For positive screens, the hospitals then developed protocols for order sets, like blood work and fluids.
The initiative suggested that a nurse-based, every-shift screening method might be one feasible way to identify sick patients as early as possible. “Going through the screening process really seemed to empower the nurses to take a much more active role in partnering with the physicians and in recognizing some of the early warning signs,” Dr. Odden said. The project led to other benefits as well, including improved identification of strokes, delirium, and even a gastrointestinal bleed because the “barriers in communication had been broken down,” he said.
To help medical providers recognize sepsis earlier, Dr. Shieh and her colleagues created a free game called Septris as an adjunctive teaching tool. Based on a player’s diagnosis and treatment decisions, patient outcomes either rise or fall – often rapidly. “I’m an educator and what I know is that the best way you learn is by doing,” she said. The interactive and repetitive nature of Septris, she said, helps its take-home messages stick in a player’s mind without the expense of patient simulations. Dr. Shieh said the game has been adapted for German and British medical institutions as well, and that she collects data from players around the world about their experiences and scores.
Winning interdisciplinary buy-in
To maximize the chances for success, several doctors emphasize the importance of forming an interdisciplinary task force that includes every department affected by a QI project. Ms. Savino said executive sponsorship of her hospital’s QI project was key as well. So was meeting frequently with the carefully chosen team members representing key stakeholders throughout the hospital. “It was a lot of work,” she said. “But I really think that was one reason why it was so successful. We had everybody’s buy-in, and we kept our short-term goals on track.”
Based on their success, the QI initiative has spread to two other hospitals in the University of Utah’s network. “Once the culture changes have been made and the project’s up and going, it’s kind of self-sufficient,” Dr. Horton said. “But it was so much work.” He and Dr. Graves are careful to emphasize that there are other options for sepsis-related QI efforts. “I think it is better to start something small than to believe you can’t do anything at all,” Dr. Graves said.
No matter what the size, assembling a motivated and multidisciplinary team is critical, she said. So is empowering nurses to talk to physicians about decompensating patients and other aspects of sepsis care. Being available and willing to listen to other providers also can pay big dividends. “Knowing that we cared about the project’s success was important to people working on it,” Dr. Graves said.
Despite the remaining challenges, Dr. Shieh points out that sepsis mortality rates have improved significantly, thanks in large part to more awareness and ambitious QI projects. “I do want to say that we have come a long way,” she said.
References
1. Levy MM et al. Surviving Sepsis Campaign: Association between performance metrics and outcomes in a 7.5-year study. Intensive Care Med. 2014 Nov;40(11):1623-33.
2. Singer M et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315(8):801-10.
3. Schorr C et al. Implementation of a multicenter performance improvement program for early detection and treatment of severe sepsis in general medical-surgical wards. J Hosp Med. 2016 Nov;11:S32-9.
4. Lee VS et al. Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality. JAMA. 2016 Sep 13;316(10):1061-72.
Phoenix Children’s Hospital integrates care from ground up
About 4 years ago, officials at Phoenix Children’s Hospital stopped and took a look around. The adult health care landscape was zooming toward value-based models and integrating care so that previously separate components were now working together. The health of whole populations mattered more than ever.
But their hospital, they found, accounted for just 9% of the “care touches” – interactions between a patient and a doctor – of their half-million pediatric population. They were not working closely with primary care doctors and independent specialists. Patients would come to the hospital, get treated, and then – poof, they were gone. The hospital came to a realization that there was a better way to provide care.
They began a process that led to what appears to be a “first-of-its-kind” model, an integrated care network created from the ground up by a hospital venturing out into the community and actively recruiting private primary care doctors and specialists. Now, more than 1,000 physicians from more than 100 practices in the Phoenix metro area are part of the network, joined with the hospital through contracts laden with incentives for meeting care and wellness goals. When good care is being given, the network gets paid, and everyone benefits financially.
“It’s amazing the difference we’re able to provide when we start linking together what used to be very disparate systems,” Mr. Johnson said.
Here are some features of the network:
Every group and practice, including the hospital, is now sharing their data. When a child shows up at the ER, the ER doctor can quickly see things like who the primary care doctor is, allergies, medications, and care history.
- Targets such as asthma control, providing basic wellness exams, and following patients appropriately, are tied to financial rewards.
- Children with complex or special health care needs, and patients who are high utilizers, have a care coordinator assigned to look more closely at their cases.
- A corporate entity created by the hospital and its independent community physician partners has a doctor-heavy board of directors composed of community primary care physicians, specialists, hospital-employed physicians, and hospital administrators.
Some of the care improvements have been dramatic, Mr. Johnson said. One teenager had made 55 ER visits and 21 inpatient visits over 9 months, but the pattern went unnoticed. With new tools – reports drawn from hospital records, insurance records, and records from other doctor visits – the problem became apparent. A care coordinator found that the mother didn’t quite understand how to administer the boy’s medication, prompting repeated medical crises and hundred of thousands of dollars in unnecessary costs. The teenager has since re-enrolled in school and has had no more hospital admissions, Johnson said.
He said that, at first, many community doctors had a “real skepticism” of being too closely tied to a hospital financially, but now doctors are getting in touch with the network about joining.
“There’s a leap of faith that has to happen in the initial stages,” he said. “When you get the insurance companies at the table to really work with you to build the right incentives around truly impactful and quality care, you can really start to move the needle. When you see – with data – that what you’re doing is having success, and they see the additional money coming from the incentives, that really helps.”
Amy Knight, MHA, chief operating officer of the Washington-based Children’s Hospital Association, said that, while other children’s hospitals have migrated toward more integrated care, they either haven’t needed to recruit community physicians as they have in Phoenix, because they already employed many primary care physicians, or market conditions have been such that they haven’t expanded as quickly.
“Phoenix saw a huge opportunity and was very smart about how they approached their own market,” she said. “They are definitely on the front end, the cutting edge of doing that.”
Since its network has expanded, Phoenix Children’s has hosted visitors who hope to draw lessons from their experience, she said.
“I think what most people go away with is: ‘Very interesting, very cool – not sure it would work in our market,’” she said. Still, lessons on thinking about risk and building a governance structure are widely applicable, she said.
“The house may look a little bit different, but some of the things you’re doing inside it may actually all look the same,” Ms. Knight said.
She expects a continued move toward more integrated care networks, despite the on-again, off-again political talk about repealing and replacing the Affordable Care Act.
“There’s probably some people stepping back in hesitancy, but I don’t think that the political discourse right now will necessarily change the trajectory that we’re on.”
About 4 years ago, officials at Phoenix Children’s Hospital stopped and took a look around. The adult health care landscape was zooming toward value-based models and integrating care so that previously separate components were now working together. The health of whole populations mattered more than ever.
But their hospital, they found, accounted for just 9% of the “care touches” – interactions between a patient and a doctor – of their half-million pediatric population. They were not working closely with primary care doctors and independent specialists. Patients would come to the hospital, get treated, and then – poof, they were gone. The hospital came to a realization that there was a better way to provide care.
They began a process that led to what appears to be a “first-of-its-kind” model, an integrated care network created from the ground up by a hospital venturing out into the community and actively recruiting private primary care doctors and specialists. Now, more than 1,000 physicians from more than 100 practices in the Phoenix metro area are part of the network, joined with the hospital through contracts laden with incentives for meeting care and wellness goals. When good care is being given, the network gets paid, and everyone benefits financially.
“It’s amazing the difference we’re able to provide when we start linking together what used to be very disparate systems,” Mr. Johnson said.
Here are some features of the network:
Every group and practice, including the hospital, is now sharing their data. When a child shows up at the ER, the ER doctor can quickly see things like who the primary care doctor is, allergies, medications, and care history.
- Targets such as asthma control, providing basic wellness exams, and following patients appropriately, are tied to financial rewards.
- Children with complex or special health care needs, and patients who are high utilizers, have a care coordinator assigned to look more closely at their cases.
- A corporate entity created by the hospital and its independent community physician partners has a doctor-heavy board of directors composed of community primary care physicians, specialists, hospital-employed physicians, and hospital administrators.
Some of the care improvements have been dramatic, Mr. Johnson said. One teenager had made 55 ER visits and 21 inpatient visits over 9 months, but the pattern went unnoticed. With new tools – reports drawn from hospital records, insurance records, and records from other doctor visits – the problem became apparent. A care coordinator found that the mother didn’t quite understand how to administer the boy’s medication, prompting repeated medical crises and hundred of thousands of dollars in unnecessary costs. The teenager has since re-enrolled in school and has had no more hospital admissions, Johnson said.
He said that, at first, many community doctors had a “real skepticism” of being too closely tied to a hospital financially, but now doctors are getting in touch with the network about joining.
“There’s a leap of faith that has to happen in the initial stages,” he said. “When you get the insurance companies at the table to really work with you to build the right incentives around truly impactful and quality care, you can really start to move the needle. When you see – with data – that what you’re doing is having success, and they see the additional money coming from the incentives, that really helps.”
Amy Knight, MHA, chief operating officer of the Washington-based Children’s Hospital Association, said that, while other children’s hospitals have migrated toward more integrated care, they either haven’t needed to recruit community physicians as they have in Phoenix, because they already employed many primary care physicians, or market conditions have been such that they haven’t expanded as quickly.
“Phoenix saw a huge opportunity and was very smart about how they approached their own market,” she said. “They are definitely on the front end, the cutting edge of doing that.”
Since its network has expanded, Phoenix Children’s has hosted visitors who hope to draw lessons from their experience, she said.
“I think what most people go away with is: ‘Very interesting, very cool – not sure it would work in our market,’” she said. Still, lessons on thinking about risk and building a governance structure are widely applicable, she said.
“The house may look a little bit different, but some of the things you’re doing inside it may actually all look the same,” Ms. Knight said.
She expects a continued move toward more integrated care networks, despite the on-again, off-again political talk about repealing and replacing the Affordable Care Act.
“There’s probably some people stepping back in hesitancy, but I don’t think that the political discourse right now will necessarily change the trajectory that we’re on.”
About 4 years ago, officials at Phoenix Children’s Hospital stopped and took a look around. The adult health care landscape was zooming toward value-based models and integrating care so that previously separate components were now working together. The health of whole populations mattered more than ever.
But their hospital, they found, accounted for just 9% of the “care touches” – interactions between a patient and a doctor – of their half-million pediatric population. They were not working closely with primary care doctors and independent specialists. Patients would come to the hospital, get treated, and then – poof, they were gone. The hospital came to a realization that there was a better way to provide care.
They began a process that led to what appears to be a “first-of-its-kind” model, an integrated care network created from the ground up by a hospital venturing out into the community and actively recruiting private primary care doctors and specialists. Now, more than 1,000 physicians from more than 100 practices in the Phoenix metro area are part of the network, joined with the hospital through contracts laden with incentives for meeting care and wellness goals. When good care is being given, the network gets paid, and everyone benefits financially.
“It’s amazing the difference we’re able to provide when we start linking together what used to be very disparate systems,” Mr. Johnson said.
Here are some features of the network:
Every group and practice, including the hospital, is now sharing their data. When a child shows up at the ER, the ER doctor can quickly see things like who the primary care doctor is, allergies, medications, and care history.
- Targets such as asthma control, providing basic wellness exams, and following patients appropriately, are tied to financial rewards.
- Children with complex or special health care needs, and patients who are high utilizers, have a care coordinator assigned to look more closely at their cases.
- A corporate entity created by the hospital and its independent community physician partners has a doctor-heavy board of directors composed of community primary care physicians, specialists, hospital-employed physicians, and hospital administrators.
Some of the care improvements have been dramatic, Mr. Johnson said. One teenager had made 55 ER visits and 21 inpatient visits over 9 months, but the pattern went unnoticed. With new tools – reports drawn from hospital records, insurance records, and records from other doctor visits – the problem became apparent. A care coordinator found that the mother didn’t quite understand how to administer the boy’s medication, prompting repeated medical crises and hundred of thousands of dollars in unnecessary costs. The teenager has since re-enrolled in school and has had no more hospital admissions, Johnson said.
He said that, at first, many community doctors had a “real skepticism” of being too closely tied to a hospital financially, but now doctors are getting in touch with the network about joining.
“There’s a leap of faith that has to happen in the initial stages,” he said. “When you get the insurance companies at the table to really work with you to build the right incentives around truly impactful and quality care, you can really start to move the needle. When you see – with data – that what you’re doing is having success, and they see the additional money coming from the incentives, that really helps.”
Amy Knight, MHA, chief operating officer of the Washington-based Children’s Hospital Association, said that, while other children’s hospitals have migrated toward more integrated care, they either haven’t needed to recruit community physicians as they have in Phoenix, because they already employed many primary care physicians, or market conditions have been such that they haven’t expanded as quickly.
“Phoenix saw a huge opportunity and was very smart about how they approached their own market,” she said. “They are definitely on the front end, the cutting edge of doing that.”
Since its network has expanded, Phoenix Children’s has hosted visitors who hope to draw lessons from their experience, she said.
“I think what most people go away with is: ‘Very interesting, very cool – not sure it would work in our market,’” she said. Still, lessons on thinking about risk and building a governance structure are widely applicable, she said.
“The house may look a little bit different, but some of the things you’re doing inside it may actually all look the same,” Ms. Knight said.
She expects a continued move toward more integrated care networks, despite the on-again, off-again political talk about repealing and replacing the Affordable Care Act.
“There’s probably some people stepping back in hesitancy, but I don’t think that the political discourse right now will necessarily change the trajectory that we’re on.”
Choosing location after discharge wisely
Of all the care decisions we make during a hospital stay, perhaps the one with the biggest implications for cost and quality is the one determining the location to which we send the patient after discharge.
Yet ironically, we haven’t typically participated in this decision, but instead have left it up to case managers and others to work with patients to determine discharge location. This is a missed opportunity, as patients first look to their doctor for guidance on this decision. Absent such guidance, they turn to other care team members for the conversation. With a principal focus on hospital length of stay, we have prioritized when patients are ready to leave over where they go after they leave.
In terms of cost during hospitalization and for the 30 days after discharge, for common conditions such as pneumonia, heart failure, COPD, or major joint replacement, Medicare spends nearly as much on postacute care – home health, skilled nursing facilities, inpatient rehabilitation, long-term acute care hospitals – as for hospital care.1 Further, an Institute of Medicine analysis showed that geographic variation in postacute care spending is responsible for three-quarters of all variation in Medicare spending.2 Such variation raises questions about the rigor with which postacute care decisions are made by hospital teams.
Perhaps most striking of all, hospitalist care (versus that of traditional primary care providers) has been associated with excess discharge rates to skilled nursing facilities, and savings that accrue under hospitalists during hospitalization are more than outweighed by spending on care during the postacute period.3
All of this leads me to my point: Hospitalists and inpatient teams need a defined process for selecting the most appropriate discharge location. Such a location should ideally be the least restrictive location suitable for a patient’s needs. In the box below, I propose a framework for the process. The domains listed in the box should be evaluated and discussed by the team, with early input and final approval by the patient and caregiver(s). The domains listed are not intended to be an exhaustive list, but rather to serve as the basis for discussion during discharge team rounds.
Identifying patient factors informing an optimal discharge location may represent a new skill set for many hospitalists and underscores the value of collaboration with team members who can provide needed information. In April, the Society of Hospital Medicine published the Revised Core Competencies in Hospital Medicine. In the Care of the Older Patient section, the authors state that hospitalists should be able to “describe postacute care options that can enable older patients to regain functional capacity.”4 Inherent in this competency is an understanding of not only patient factors in postacute care location decisions, but also the differing capabilities of home health agencies, skilled nursing facilities, inpatient rehabilitation facilities, and long-term acute care hospitals.
Dr. Whitcomb is chief medical officer at Remedy Partners in Darien, Conn., and cofounder and past president of the Society of Hospital Medicine. Contact him at wfwhit@comcast.net.
References
1. Mechanic R. Post-acute care – the next frontier for controlling Medicare spending. N Engl J Med. 2014;370:692-4.
2. Newhouse JP, et al. Geographic variation in Medicare services. N Engl J Med. 2013;368:1465-8.
3. Kuo YF, et al. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med. 2011;155(3):152-9.
4. Nichani S, et al. Core Competencies in Hospital Medicine 2017 Revision. Section 3: Healthcare Systems. J Hosp Med. 2017 April;12(1):S55-S82.
Framework for Selecting Appropriate Discharge Location
Patient Independence
- Can the patient perform activities of daily living?
- Can the patient ambulate?
- Is there cognitive impairment?
Caregiver Availability
- If the patient needs it, is a caregiver who is capable and reliable available? If so, to what extent is s/he available?
Therapy Needs
- Does the patient require PT, OT, and/or ST?
- How much and for how long?
Skilled Nursing Needs
- What, if anything, does the patient require in this area? For example, a new PEG tube, wound care, IV therapies, etc.
Social Factors
- Is there access to transportation, food, and safe housing?
Home Factors
- Are there stairs to enter the house or to get to the bedroom or bathroom?
- Has the home been modified to accommodate special needs? Is the home inhabitable?
Of all the care decisions we make during a hospital stay, perhaps the one with the biggest implications for cost and quality is the one determining the location to which we send the patient after discharge.
Yet ironically, we haven’t typically participated in this decision, but instead have left it up to case managers and others to work with patients to determine discharge location. This is a missed opportunity, as patients first look to their doctor for guidance on this decision. Absent such guidance, they turn to other care team members for the conversation. With a principal focus on hospital length of stay, we have prioritized when patients are ready to leave over where they go after they leave.
In terms of cost during hospitalization and for the 30 days after discharge, for common conditions such as pneumonia, heart failure, COPD, or major joint replacement, Medicare spends nearly as much on postacute care – home health, skilled nursing facilities, inpatient rehabilitation, long-term acute care hospitals – as for hospital care.1 Further, an Institute of Medicine analysis showed that geographic variation in postacute care spending is responsible for three-quarters of all variation in Medicare spending.2 Such variation raises questions about the rigor with which postacute care decisions are made by hospital teams.
Perhaps most striking of all, hospitalist care (versus that of traditional primary care providers) has been associated with excess discharge rates to skilled nursing facilities, and savings that accrue under hospitalists during hospitalization are more than outweighed by spending on care during the postacute period.3
All of this leads me to my point: Hospitalists and inpatient teams need a defined process for selecting the most appropriate discharge location. Such a location should ideally be the least restrictive location suitable for a patient’s needs. In the box below, I propose a framework for the process. The domains listed in the box should be evaluated and discussed by the team, with early input and final approval by the patient and caregiver(s). The domains listed are not intended to be an exhaustive list, but rather to serve as the basis for discussion during discharge team rounds.
Identifying patient factors informing an optimal discharge location may represent a new skill set for many hospitalists and underscores the value of collaboration with team members who can provide needed information. In April, the Society of Hospital Medicine published the Revised Core Competencies in Hospital Medicine. In the Care of the Older Patient section, the authors state that hospitalists should be able to “describe postacute care options that can enable older patients to regain functional capacity.”4 Inherent in this competency is an understanding of not only patient factors in postacute care location decisions, but also the differing capabilities of home health agencies, skilled nursing facilities, inpatient rehabilitation facilities, and long-term acute care hospitals.
Dr. Whitcomb is chief medical officer at Remedy Partners in Darien, Conn., and cofounder and past president of the Society of Hospital Medicine. Contact him at wfwhit@comcast.net.
References
1. Mechanic R. Post-acute care – the next frontier for controlling Medicare spending. N Engl J Med. 2014;370:692-4.
2. Newhouse JP, et al. Geographic variation in Medicare services. N Engl J Med. 2013;368:1465-8.
3. Kuo YF, et al. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med. 2011;155(3):152-9.
4. Nichani S, et al. Core Competencies in Hospital Medicine 2017 Revision. Section 3: Healthcare Systems. J Hosp Med. 2017 April;12(1):S55-S82.
Framework for Selecting Appropriate Discharge Location
Patient Independence
- Can the patient perform activities of daily living?
- Can the patient ambulate?
- Is there cognitive impairment?
Caregiver Availability
- If the patient needs it, is a caregiver who is capable and reliable available? If so, to what extent is s/he available?
Therapy Needs
- Does the patient require PT, OT, and/or ST?
- How much and for how long?
Skilled Nursing Needs
- What, if anything, does the patient require in this area? For example, a new PEG tube, wound care, IV therapies, etc.
Social Factors
- Is there access to transportation, food, and safe housing?
Home Factors
- Are there stairs to enter the house or to get to the bedroom or bathroom?
- Has the home been modified to accommodate special needs? Is the home inhabitable?
Of all the care decisions we make during a hospital stay, perhaps the one with the biggest implications for cost and quality is the one determining the location to which we send the patient after discharge.
Yet ironically, we haven’t typically participated in this decision, but instead have left it up to case managers and others to work with patients to determine discharge location. This is a missed opportunity, as patients first look to their doctor for guidance on this decision. Absent such guidance, they turn to other care team members for the conversation. With a principal focus on hospital length of stay, we have prioritized when patients are ready to leave over where they go after they leave.
In terms of cost during hospitalization and for the 30 days after discharge, for common conditions such as pneumonia, heart failure, COPD, or major joint replacement, Medicare spends nearly as much on postacute care – home health, skilled nursing facilities, inpatient rehabilitation, long-term acute care hospitals – as for hospital care.1 Further, an Institute of Medicine analysis showed that geographic variation in postacute care spending is responsible for three-quarters of all variation in Medicare spending.2 Such variation raises questions about the rigor with which postacute care decisions are made by hospital teams.
Perhaps most striking of all, hospitalist care (versus that of traditional primary care providers) has been associated with excess discharge rates to skilled nursing facilities, and savings that accrue under hospitalists during hospitalization are more than outweighed by spending on care during the postacute period.3
All of this leads me to my point: Hospitalists and inpatient teams need a defined process for selecting the most appropriate discharge location. Such a location should ideally be the least restrictive location suitable for a patient’s needs. In the box below, I propose a framework for the process. The domains listed in the box should be evaluated and discussed by the team, with early input and final approval by the patient and caregiver(s). The domains listed are not intended to be an exhaustive list, but rather to serve as the basis for discussion during discharge team rounds.
Identifying patient factors informing an optimal discharge location may represent a new skill set for many hospitalists and underscores the value of collaboration with team members who can provide needed information. In April, the Society of Hospital Medicine published the Revised Core Competencies in Hospital Medicine. In the Care of the Older Patient section, the authors state that hospitalists should be able to “describe postacute care options that can enable older patients to regain functional capacity.”4 Inherent in this competency is an understanding of not only patient factors in postacute care location decisions, but also the differing capabilities of home health agencies, skilled nursing facilities, inpatient rehabilitation facilities, and long-term acute care hospitals.
Dr. Whitcomb is chief medical officer at Remedy Partners in Darien, Conn., and cofounder and past president of the Society of Hospital Medicine. Contact him at wfwhit@comcast.net.
References
1. Mechanic R. Post-acute care – the next frontier for controlling Medicare spending. N Engl J Med. 2014;370:692-4.
2. Newhouse JP, et al. Geographic variation in Medicare services. N Engl J Med. 2013;368:1465-8.
3. Kuo YF, et al. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med. 2011;155(3):152-9.
4. Nichani S, et al. Core Competencies in Hospital Medicine 2017 Revision. Section 3: Healthcare Systems. J Hosp Med. 2017 April;12(1):S55-S82.
Framework for Selecting Appropriate Discharge Location
Patient Independence
- Can the patient perform activities of daily living?
- Can the patient ambulate?
- Is there cognitive impairment?
Caregiver Availability
- If the patient needs it, is a caregiver who is capable and reliable available? If so, to what extent is s/he available?
Therapy Needs
- Does the patient require PT, OT, and/or ST?
- How much and for how long?
Skilled Nursing Needs
- What, if anything, does the patient require in this area? For example, a new PEG tube, wound care, IV therapies, etc.
Social Factors
- Is there access to transportation, food, and safe housing?
Home Factors
- Are there stairs to enter the house or to get to the bedroom or bathroom?
- Has the home been modified to accommodate special needs? Is the home inhabitable?
QI enthusiast to QI leader: Sheri Chernetsky Tejedor, MD
Armed with a background in engineering, Sheri Chernetsky Tejedor, MD, SFHM, had already adopted a mindset of system reliability and design improvement when she began her journey in hospital medicine at Johns Hopkins University in Baltimore.
After completing her studies there, Dr. Tejedor was quick to find a place at Emory Healthcare in Atlanta and began working toward a future in health care quality improvement (QI).
“I gravitated early on toward what was essentially quality improvement work,” Dr. Tejedor told The Hospitalist.
Dr. Tejedor worked with two mentors at a community hospital associated with Emory University who helped influence her success in QI: Mark V. Williams, MD, FACP, MHM, who is now the director of the Center for Health Services Research at the University of Kentucky in Lexington, and Jason Stein, MD, SFHM, who is currently a hospitalist at Emory University Hospital.
“They wanted to develop quality improvement expertise and get some of us trained,” she said. “These advocates, or mentors, were critical for me. They are people who went above and beyond to help with career planning and thinking through possibilities.”
Dr. Tejedor and Dr. Stein traveled to Intermountain Healthcare, a not-for-profit health system based in Salt Lake City that focuses on medical innovation, to participate in a rigorous quality training program.
“It was extremely intense,” said Dr. Tejedor. “You worked over several months to get a certificate from the Institute for Healthcare Delivery Research, and it’s all focused on quality improvement methodology.”
After completing this program, Dr. Tejedor continued on her quality improvement path by focusing on research while also simultaneously working part time and taking care of her three young children. During this phase of her career, Dr. Tejedor and her colleagues published a study on idle central venous catheters, which became a primary reference for part of the ABIM Foundation’s Choosing Wisely® campaign.
Dr. Tejedor said that, in addition to research, she explored different leadership roles, such as taking charge of central line teams and nurses working on device insertion practices. Her successful projects drew notice, and soon Dr. Tejedor and Dr. Stein helped to implement a stronger focus on quality improvement at their organization.
“Our health system was very entrenched in that QI culture,” Dr. Tejedor said. “After Jason and I went to Intermountain, many of the Emory Healthcare leadership also got trained in Utah, and we ultimately built a quality course at Emory that mirrored it.”
Dr. Tejedor’s research evolved to intersect with clinical informatics. She leveraged the organization’s electronic medical record to test her work.
“[The EMR] is ubiquitous, and that was a good way to reach staff, test interventions, and get data,” Dr. Tejedor said. “I built a lot of tools that were helpful for the health system.”
One of these tools was a device to monitor central line infections that was linked with clinical informatics as part of a large grant project. This led to another leadership opportunity: She assumed the role of chief research information officer and director for analytics at Emory Healthcare in 2013.
In 2014, Dr. Tejedor began working with the Centers for Disease Control and Prevention as the first hospitalist and informatics specialist on the Healthcare Infection Control Practices Advisory Committee, where she continues to hold a position. She is also a medical advisor for the CDC’s Division of Healthcare Quality Promotion, focusing on electronic quality measures.
For those hospitalists pursuing QI, exposure to formal training is essential, Dr. Tejedor said. That may not mean flying to Utah, she noted, but garnering a deeper understanding of informatics is crucial.
When it comes to leadership, Dr. Tejedor recommends that those looking to take charge develop social skills and embrace parts of medicine that may be unfamiliar yet essential.
“Learn a little bit about the business side, which you may not know much about as a doctor taking care of patients,” she said. “Learn just enough to understand what goes into people’s decision making when they are choosing what projects get approved.”
Dr. Tejedor encourages hospitalists to focus on developing relationships because that was one of the keys to her success as a quality improvement leader.
“It’s about gaining the trust of the staff, mutual respect, working with the nurses, and getting to know the leadership and the people who make the financial decisions,” she said. “Even if you have the money for a quality improvement project, it will fail if you don’t work with the various teams to understand their needs and how to make it work for them.”
ezimmerman@frontlinemedcom.com
On Twitter @eaztweets
Armed with a background in engineering, Sheri Chernetsky Tejedor, MD, SFHM, had already adopted a mindset of system reliability and design improvement when she began her journey in hospital medicine at Johns Hopkins University in Baltimore.
After completing her studies there, Dr. Tejedor was quick to find a place at Emory Healthcare in Atlanta and began working toward a future in health care quality improvement (QI).
“I gravitated early on toward what was essentially quality improvement work,” Dr. Tejedor told The Hospitalist.
Dr. Tejedor worked with two mentors at a community hospital associated with Emory University who helped influence her success in QI: Mark V. Williams, MD, FACP, MHM, who is now the director of the Center for Health Services Research at the University of Kentucky in Lexington, and Jason Stein, MD, SFHM, who is currently a hospitalist at Emory University Hospital.
“They wanted to develop quality improvement expertise and get some of us trained,” she said. “These advocates, or mentors, were critical for me. They are people who went above and beyond to help with career planning and thinking through possibilities.”
Dr. Tejedor and Dr. Stein traveled to Intermountain Healthcare, a not-for-profit health system based in Salt Lake City that focuses on medical innovation, to participate in a rigorous quality training program.
“It was extremely intense,” said Dr. Tejedor. “You worked over several months to get a certificate from the Institute for Healthcare Delivery Research, and it’s all focused on quality improvement methodology.”
After completing this program, Dr. Tejedor continued on her quality improvement path by focusing on research while also simultaneously working part time and taking care of her three young children. During this phase of her career, Dr. Tejedor and her colleagues published a study on idle central venous catheters, which became a primary reference for part of the ABIM Foundation’s Choosing Wisely® campaign.
Dr. Tejedor said that, in addition to research, she explored different leadership roles, such as taking charge of central line teams and nurses working on device insertion practices. Her successful projects drew notice, and soon Dr. Tejedor and Dr. Stein helped to implement a stronger focus on quality improvement at their organization.
“Our health system was very entrenched in that QI culture,” Dr. Tejedor said. “After Jason and I went to Intermountain, many of the Emory Healthcare leadership also got trained in Utah, and we ultimately built a quality course at Emory that mirrored it.”
Dr. Tejedor’s research evolved to intersect with clinical informatics. She leveraged the organization’s electronic medical record to test her work.
“[The EMR] is ubiquitous, and that was a good way to reach staff, test interventions, and get data,” Dr. Tejedor said. “I built a lot of tools that were helpful for the health system.”
One of these tools was a device to monitor central line infections that was linked with clinical informatics as part of a large grant project. This led to another leadership opportunity: She assumed the role of chief research information officer and director for analytics at Emory Healthcare in 2013.
In 2014, Dr. Tejedor began working with the Centers for Disease Control and Prevention as the first hospitalist and informatics specialist on the Healthcare Infection Control Practices Advisory Committee, where she continues to hold a position. She is also a medical advisor for the CDC’s Division of Healthcare Quality Promotion, focusing on electronic quality measures.
For those hospitalists pursuing QI, exposure to formal training is essential, Dr. Tejedor said. That may not mean flying to Utah, she noted, but garnering a deeper understanding of informatics is crucial.
When it comes to leadership, Dr. Tejedor recommends that those looking to take charge develop social skills and embrace parts of medicine that may be unfamiliar yet essential.
“Learn a little bit about the business side, which you may not know much about as a doctor taking care of patients,” she said. “Learn just enough to understand what goes into people’s decision making when they are choosing what projects get approved.”
Dr. Tejedor encourages hospitalists to focus on developing relationships because that was one of the keys to her success as a quality improvement leader.
“It’s about gaining the trust of the staff, mutual respect, working with the nurses, and getting to know the leadership and the people who make the financial decisions,” she said. “Even if you have the money for a quality improvement project, it will fail if you don’t work with the various teams to understand their needs and how to make it work for them.”
ezimmerman@frontlinemedcom.com
On Twitter @eaztweets
Armed with a background in engineering, Sheri Chernetsky Tejedor, MD, SFHM, had already adopted a mindset of system reliability and design improvement when she began her journey in hospital medicine at Johns Hopkins University in Baltimore.
After completing her studies there, Dr. Tejedor was quick to find a place at Emory Healthcare in Atlanta and began working toward a future in health care quality improvement (QI).
“I gravitated early on toward what was essentially quality improvement work,” Dr. Tejedor told The Hospitalist.
Dr. Tejedor worked with two mentors at a community hospital associated with Emory University who helped influence her success in QI: Mark V. Williams, MD, FACP, MHM, who is now the director of the Center for Health Services Research at the University of Kentucky in Lexington, and Jason Stein, MD, SFHM, who is currently a hospitalist at Emory University Hospital.
“They wanted to develop quality improvement expertise and get some of us trained,” she said. “These advocates, or mentors, were critical for me. They are people who went above and beyond to help with career planning and thinking through possibilities.”
Dr. Tejedor and Dr. Stein traveled to Intermountain Healthcare, a not-for-profit health system based in Salt Lake City that focuses on medical innovation, to participate in a rigorous quality training program.
“It was extremely intense,” said Dr. Tejedor. “You worked over several months to get a certificate from the Institute for Healthcare Delivery Research, and it’s all focused on quality improvement methodology.”
After completing this program, Dr. Tejedor continued on her quality improvement path by focusing on research while also simultaneously working part time and taking care of her three young children. During this phase of her career, Dr. Tejedor and her colleagues published a study on idle central venous catheters, which became a primary reference for part of the ABIM Foundation’s Choosing Wisely® campaign.
Dr. Tejedor said that, in addition to research, she explored different leadership roles, such as taking charge of central line teams and nurses working on device insertion practices. Her successful projects drew notice, and soon Dr. Tejedor and Dr. Stein helped to implement a stronger focus on quality improvement at their organization.
“Our health system was very entrenched in that QI culture,” Dr. Tejedor said. “After Jason and I went to Intermountain, many of the Emory Healthcare leadership also got trained in Utah, and we ultimately built a quality course at Emory that mirrored it.”
Dr. Tejedor’s research evolved to intersect with clinical informatics. She leveraged the organization’s electronic medical record to test her work.
“[The EMR] is ubiquitous, and that was a good way to reach staff, test interventions, and get data,” Dr. Tejedor said. “I built a lot of tools that were helpful for the health system.”
One of these tools was a device to monitor central line infections that was linked with clinical informatics as part of a large grant project. This led to another leadership opportunity: She assumed the role of chief research information officer and director for analytics at Emory Healthcare in 2013.
In 2014, Dr. Tejedor began working with the Centers for Disease Control and Prevention as the first hospitalist and informatics specialist on the Healthcare Infection Control Practices Advisory Committee, where she continues to hold a position. She is also a medical advisor for the CDC’s Division of Healthcare Quality Promotion, focusing on electronic quality measures.
For those hospitalists pursuing QI, exposure to formal training is essential, Dr. Tejedor said. That may not mean flying to Utah, she noted, but garnering a deeper understanding of informatics is crucial.
When it comes to leadership, Dr. Tejedor recommends that those looking to take charge develop social skills and embrace parts of medicine that may be unfamiliar yet essential.
“Learn a little bit about the business side, which you may not know much about as a doctor taking care of patients,” she said. “Learn just enough to understand what goes into people’s decision making when they are choosing what projects get approved.”
Dr. Tejedor encourages hospitalists to focus on developing relationships because that was one of the keys to her success as a quality improvement leader.
“It’s about gaining the trust of the staff, mutual respect, working with the nurses, and getting to know the leadership and the people who make the financial decisions,” she said. “Even if you have the money for a quality improvement project, it will fail if you don’t work with the various teams to understand their needs and how to make it work for them.”
ezimmerman@frontlinemedcom.com
On Twitter @eaztweets
Project improves noninvasive IUC alternatives
Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.
It truly has been a rewarding experience participating in a quality improvement project and I am excited to see what the future holds. Our project, “Reducing CAUTI with Noninvasive UC Alternatives and Measure-vention,” aimed to combat catheter associated urinary tract infections, with a three-pronged approach: by reducing UC placement, performing proper maintenance of IUC, and ensuring prompt removal of unnecessary UC.
To date, our project has demonstrated qualitative success. Specifically, we have implemented a pipeline to perform “measure-vention,” or real-time monitoring and correction of defects. The surgical care intensive unit (SICU) was identified as an appropriate candidate for a pilot partnership due to its high utilization of UC. A daily report of patients with UC is generated and then checked against the EMR for UC necessity. Subsequently, we contact the unit RN for details and physicians for removal orders, when possible. Simultaneously, this enables us to reinforce our management bundle in real time. This protocol is being effectively implemented in the SICU and we are hoping to expand to other units as well. Quantitative data collection is still ongoing and hopefully forthcoming.
Previous CAUTI reduction efforts have had variable and partial success. We are very excited to have improved noninvasive IUC alternatives that address staff concerns about incontinence workload, urine output monitoring, and patient comfort. We hope to protect our patients from harm and eventually publicize our experience to help other health care facilities reduce IUC use and CAUTI.
It has been a rewarding experience to participate in a quality improvement project and I am enjoying the challenges of collaborating with a diverse team of medical professionals to improve the patient experience.
Victor Ekuta is a third-year medical student at UC San Diego.
Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.
It truly has been a rewarding experience participating in a quality improvement project and I am excited to see what the future holds. Our project, “Reducing CAUTI with Noninvasive UC Alternatives and Measure-vention,” aimed to combat catheter associated urinary tract infections, with a three-pronged approach: by reducing UC placement, performing proper maintenance of IUC, and ensuring prompt removal of unnecessary UC.
To date, our project has demonstrated qualitative success. Specifically, we have implemented a pipeline to perform “measure-vention,” or real-time monitoring and correction of defects. The surgical care intensive unit (SICU) was identified as an appropriate candidate for a pilot partnership due to its high utilization of UC. A daily report of patients with UC is generated and then checked against the EMR for UC necessity. Subsequently, we contact the unit RN for details and physicians for removal orders, when possible. Simultaneously, this enables us to reinforce our management bundle in real time. This protocol is being effectively implemented in the SICU and we are hoping to expand to other units as well. Quantitative data collection is still ongoing and hopefully forthcoming.
Previous CAUTI reduction efforts have had variable and partial success. We are very excited to have improved noninvasive IUC alternatives that address staff concerns about incontinence workload, urine output monitoring, and patient comfort. We hope to protect our patients from harm and eventually publicize our experience to help other health care facilities reduce IUC use and CAUTI.
It has been a rewarding experience to participate in a quality improvement project and I am enjoying the challenges of collaborating with a diverse team of medical professionals to improve the patient experience.
Victor Ekuta is a third-year medical student at UC San Diego.
Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.
It truly has been a rewarding experience participating in a quality improvement project and I am excited to see what the future holds. Our project, “Reducing CAUTI with Noninvasive UC Alternatives and Measure-vention,” aimed to combat catheter associated urinary tract infections, with a three-pronged approach: by reducing UC placement, performing proper maintenance of IUC, and ensuring prompt removal of unnecessary UC.
To date, our project has demonstrated qualitative success. Specifically, we have implemented a pipeline to perform “measure-vention,” or real-time monitoring and correction of defects. The surgical care intensive unit (SICU) was identified as an appropriate candidate for a pilot partnership due to its high utilization of UC. A daily report of patients with UC is generated and then checked against the EMR for UC necessity. Subsequently, we contact the unit RN for details and physicians for removal orders, when possible. Simultaneously, this enables us to reinforce our management bundle in real time. This protocol is being effectively implemented in the SICU and we are hoping to expand to other units as well. Quantitative data collection is still ongoing and hopefully forthcoming.
Previous CAUTI reduction efforts have had variable and partial success. We are very excited to have improved noninvasive IUC alternatives that address staff concerns about incontinence workload, urine output monitoring, and patient comfort. We hope to protect our patients from harm and eventually publicize our experience to help other health care facilities reduce IUC use and CAUTI.
It has been a rewarding experience to participate in a quality improvement project and I am enjoying the challenges of collaborating with a diverse team of medical professionals to improve the patient experience.
Victor Ekuta is a third-year medical student at UC San Diego.
Text paging practices need improvement, standardization
Clinical question: What is the content and structure of patient care–related text paging sent in the inpatient setting?
Background: Text paging has become a common form of communication among members of the inpatient multidisciplinary team, but there are potential risks and downsides of text paging, including disruptiveness, inefficiency, and potential patient safety issues.
Study Design: Modified case-study approach.
Setting: The medical inpatient service of an academic tertiary care hospital.
Synopsis: 575 text-page messages relating to 217 unique patients were analyzed in the study. The majority of the messages were sent from nonphysicians to physicians. Common themes that were identified included lack of standardization of textmessage content and format, lack of indicators of the urgency of the message, and lack of clarity within the message. Pertinent information sometimes was missing from the messages, and it was not always clear whether the sender was requesting a response from the recipient.
Bottom line: Text-paging practices may raise patient safety issues that could be addressed by implementation of a standardized, structured approach to this form of communication.
Citation: Luxenberg A et al. Efficiency and interpretability of text paging communication for medical inpatients: A mixed-methods analysis. JAMA Intern Med. 2017;177(8):1218-20.
Dr. Wachter is an assistant professor of medicine at Duke University
Clinical question: What is the content and structure of patient care–related text paging sent in the inpatient setting?
Background: Text paging has become a common form of communication among members of the inpatient multidisciplinary team, but there are potential risks and downsides of text paging, including disruptiveness, inefficiency, and potential patient safety issues.
Study Design: Modified case-study approach.
Setting: The medical inpatient service of an academic tertiary care hospital.
Synopsis: 575 text-page messages relating to 217 unique patients were analyzed in the study. The majority of the messages were sent from nonphysicians to physicians. Common themes that were identified included lack of standardization of textmessage content and format, lack of indicators of the urgency of the message, and lack of clarity within the message. Pertinent information sometimes was missing from the messages, and it was not always clear whether the sender was requesting a response from the recipient.
Bottom line: Text-paging practices may raise patient safety issues that could be addressed by implementation of a standardized, structured approach to this form of communication.
Citation: Luxenberg A et al. Efficiency and interpretability of text paging communication for medical inpatients: A mixed-methods analysis. JAMA Intern Med. 2017;177(8):1218-20.
Dr. Wachter is an assistant professor of medicine at Duke University
Clinical question: What is the content and structure of patient care–related text paging sent in the inpatient setting?
Background: Text paging has become a common form of communication among members of the inpatient multidisciplinary team, but there are potential risks and downsides of text paging, including disruptiveness, inefficiency, and potential patient safety issues.
Study Design: Modified case-study approach.
Setting: The medical inpatient service of an academic tertiary care hospital.
Synopsis: 575 text-page messages relating to 217 unique patients were analyzed in the study. The majority of the messages were sent from nonphysicians to physicians. Common themes that were identified included lack of standardization of textmessage content and format, lack of indicators of the urgency of the message, and lack of clarity within the message. Pertinent information sometimes was missing from the messages, and it was not always clear whether the sender was requesting a response from the recipient.
Bottom line: Text-paging practices may raise patient safety issues that could be addressed by implementation of a standardized, structured approach to this form of communication.
Citation: Luxenberg A et al. Efficiency and interpretability of text paging communication for medical inpatients: A mixed-methods analysis. JAMA Intern Med. 2017;177(8):1218-20.
Dr. Wachter is an assistant professor of medicine at Duke University
Adopting the patient’s perspective
Editor’s note: “Everything We Say and Do” provides readers with thoughtful and actionable communication tactics that can positively impact patients’ experience of care. In the current series of columns, physicians share how their experiences as patients have shaped their professional approach.
I have been fortunate to have had very few major health issues throughout my life. I have, however, had three major surgical procedures in the last 10 years – two total hip arthroplasties and a cataract removal with lens implant in between. The most recent THA was October 2017. Going through each procedure helped me see things from a patient’s perspective, and that showed me how important little things are to a patient, things which we may not think are all that big a deal as a provider.
Almost all of the medical personnel who came to care for me during my stays identified themselves and why they were there, and that made me feel comfortable, knowing who they were and their role. However, there were a few who did not do this, and that made me uncomfortable, not knowing who they were and why they were in my room. Not knowing is an uncomfortable feeling for a patient.
Almost every registered nurse who came to me with medication explained what the medicine was and why they were administering it, with the exception of one preop RN I met before to my cataract procedure. She walked up to me, told me to open my eye wide, held the affected eye open, and started dripping cold drops into my eye without explanation. She then said she would be back every 10 minutes to repeat the process. I had to inquire as to what the medication was and why there was a need for this process. It was a jolting experience, and she showed no compassion toward me as a patient or a person, even after I inquired.
This was not a good experience. Although cataract surgery was a totally new experience for me, she had obviously done this many times before and had to do it many times that day. However, she acted as if I should have known what she was going to do and as if she need not explain herself to anyone – which she did not, even after being queried.
Everyone during the admission process for all three procedures was solicitous and warm except for one person. Unfortunately, this individual was the first person to greet my wife and me when we arrived for my last total hip arthroplasty. She was seated at the welcome desk with her head down. After we arrived, she kept her head down and asked “How can I help you?” without ever looking up. I did not realize how unwelcome I would feel when the first person I encountered in the surgical preop admissions area failed to make eye contact with me. Her demeanor was nice enough, but she did not even attempt to make a personal connection with me – and she was at the welcome desk!
Overall, I had tremendously good experiences at three facilities in three different parts of the United States, but as we all know, it is the things that do not go well that stand out. I choose to use those things, along with some of the good things, as “reinforcers” for many of the patient-experience behaviors we identify as best practices.
What I say and do
During each patient encounter, I make eye contact with the patient and each person in the room and identify who I am and why I am there. I sit down during each visit unless there is simply no place for me to do so. I explain the procedures that are to take place, set expectations for those procedures, and then use “teachback” to ensure that my discussion with the patient has been effective. Setting expectations is very important to me: If you do not ensure that patients have appropriate expectations, their expectations will never be met and they will never have a good experience. I explain any new medication I am ordering, what it is for, and any possible significant side effects and again use teachback. The last thing I do is ask “What questions do you have for me today?” giving the patient permission to have questions, and then I respond to those questions with plain talk and teachback.
Why I do it
Not knowing what was going on and feeling marginalized were the most uncomfortable things I experienced as a patient. Using best practices for patient experience shows courtesy and respect. These practices show a willingness to take time with the patient and demonstrate my concern that I am effectively communicating my message for that visit. All of these behaviors decrease uncertainty and/or raise the patient’s feelings of importance, thereby decreasing marginalization.
How I do it
I remind myself each day I am on a clinical shift that my goal is to treat each patient like I would want my family (or myself) to be treated, and then I go out and do it. After “forcing” myself to put these behaviors into my rounding routine, they have become second nature, and I feel better for providing this level of care because it made me feel so good when I was cared for in this manner.
Dr. Sharp is chief hospitalist with Sound Physicians at University of Florida Health in Jacksonville, Fla.
Editor’s note: “Everything We Say and Do” provides readers with thoughtful and actionable communication tactics that can positively impact patients’ experience of care. In the current series of columns, physicians share how their experiences as patients have shaped their professional approach.
I have been fortunate to have had very few major health issues throughout my life. I have, however, had three major surgical procedures in the last 10 years – two total hip arthroplasties and a cataract removal with lens implant in between. The most recent THA was October 2017. Going through each procedure helped me see things from a patient’s perspective, and that showed me how important little things are to a patient, things which we may not think are all that big a deal as a provider.
Almost all of the medical personnel who came to care for me during my stays identified themselves and why they were there, and that made me feel comfortable, knowing who they were and their role. However, there were a few who did not do this, and that made me uncomfortable, not knowing who they were and why they were in my room. Not knowing is an uncomfortable feeling for a patient.
Almost every registered nurse who came to me with medication explained what the medicine was and why they were administering it, with the exception of one preop RN I met before to my cataract procedure. She walked up to me, told me to open my eye wide, held the affected eye open, and started dripping cold drops into my eye without explanation. She then said she would be back every 10 minutes to repeat the process. I had to inquire as to what the medication was and why there was a need for this process. It was a jolting experience, and she showed no compassion toward me as a patient or a person, even after I inquired.
This was not a good experience. Although cataract surgery was a totally new experience for me, she had obviously done this many times before and had to do it many times that day. However, she acted as if I should have known what she was going to do and as if she need not explain herself to anyone – which she did not, even after being queried.
Everyone during the admission process for all three procedures was solicitous and warm except for one person. Unfortunately, this individual was the first person to greet my wife and me when we arrived for my last total hip arthroplasty. She was seated at the welcome desk with her head down. After we arrived, she kept her head down and asked “How can I help you?” without ever looking up. I did not realize how unwelcome I would feel when the first person I encountered in the surgical preop admissions area failed to make eye contact with me. Her demeanor was nice enough, but she did not even attempt to make a personal connection with me – and she was at the welcome desk!
Overall, I had tremendously good experiences at three facilities in three different parts of the United States, but as we all know, it is the things that do not go well that stand out. I choose to use those things, along with some of the good things, as “reinforcers” for many of the patient-experience behaviors we identify as best practices.
What I say and do
During each patient encounter, I make eye contact with the patient and each person in the room and identify who I am and why I am there. I sit down during each visit unless there is simply no place for me to do so. I explain the procedures that are to take place, set expectations for those procedures, and then use “teachback” to ensure that my discussion with the patient has been effective. Setting expectations is very important to me: If you do not ensure that patients have appropriate expectations, their expectations will never be met and they will never have a good experience. I explain any new medication I am ordering, what it is for, and any possible significant side effects and again use teachback. The last thing I do is ask “What questions do you have for me today?” giving the patient permission to have questions, and then I respond to those questions with plain talk and teachback.
Why I do it
Not knowing what was going on and feeling marginalized were the most uncomfortable things I experienced as a patient. Using best practices for patient experience shows courtesy and respect. These practices show a willingness to take time with the patient and demonstrate my concern that I am effectively communicating my message for that visit. All of these behaviors decrease uncertainty and/or raise the patient’s feelings of importance, thereby decreasing marginalization.
How I do it
I remind myself each day I am on a clinical shift that my goal is to treat each patient like I would want my family (or myself) to be treated, and then I go out and do it. After “forcing” myself to put these behaviors into my rounding routine, they have become second nature, and I feel better for providing this level of care because it made me feel so good when I was cared for in this manner.
Dr. Sharp is chief hospitalist with Sound Physicians at University of Florida Health in Jacksonville, Fla.
Editor’s note: “Everything We Say and Do” provides readers with thoughtful and actionable communication tactics that can positively impact patients’ experience of care. In the current series of columns, physicians share how their experiences as patients have shaped their professional approach.
I have been fortunate to have had very few major health issues throughout my life. I have, however, had three major surgical procedures in the last 10 years – two total hip arthroplasties and a cataract removal with lens implant in between. The most recent THA was October 2017. Going through each procedure helped me see things from a patient’s perspective, and that showed me how important little things are to a patient, things which we may not think are all that big a deal as a provider.
Almost all of the medical personnel who came to care for me during my stays identified themselves and why they were there, and that made me feel comfortable, knowing who they were and their role. However, there were a few who did not do this, and that made me uncomfortable, not knowing who they were and why they were in my room. Not knowing is an uncomfortable feeling for a patient.
Almost every registered nurse who came to me with medication explained what the medicine was and why they were administering it, with the exception of one preop RN I met before to my cataract procedure. She walked up to me, told me to open my eye wide, held the affected eye open, and started dripping cold drops into my eye without explanation. She then said she would be back every 10 minutes to repeat the process. I had to inquire as to what the medication was and why there was a need for this process. It was a jolting experience, and she showed no compassion toward me as a patient or a person, even after I inquired.
This was not a good experience. Although cataract surgery was a totally new experience for me, she had obviously done this many times before and had to do it many times that day. However, she acted as if I should have known what she was going to do and as if she need not explain herself to anyone – which she did not, even after being queried.
Everyone during the admission process for all three procedures was solicitous and warm except for one person. Unfortunately, this individual was the first person to greet my wife and me when we arrived for my last total hip arthroplasty. She was seated at the welcome desk with her head down. After we arrived, she kept her head down and asked “How can I help you?” without ever looking up. I did not realize how unwelcome I would feel when the first person I encountered in the surgical preop admissions area failed to make eye contact with me. Her demeanor was nice enough, but she did not even attempt to make a personal connection with me – and she was at the welcome desk!
Overall, I had tremendously good experiences at three facilities in three different parts of the United States, but as we all know, it is the things that do not go well that stand out. I choose to use those things, along with some of the good things, as “reinforcers” for many of the patient-experience behaviors we identify as best practices.
What I say and do
During each patient encounter, I make eye contact with the patient and each person in the room and identify who I am and why I am there. I sit down during each visit unless there is simply no place for me to do so. I explain the procedures that are to take place, set expectations for those procedures, and then use “teachback” to ensure that my discussion with the patient has been effective. Setting expectations is very important to me: If you do not ensure that patients have appropriate expectations, their expectations will never be met and they will never have a good experience. I explain any new medication I am ordering, what it is for, and any possible significant side effects and again use teachback. The last thing I do is ask “What questions do you have for me today?” giving the patient permission to have questions, and then I respond to those questions with plain talk and teachback.
Why I do it
Not knowing what was going on and feeling marginalized were the most uncomfortable things I experienced as a patient. Using best practices for patient experience shows courtesy and respect. These practices show a willingness to take time with the patient and demonstrate my concern that I am effectively communicating my message for that visit. All of these behaviors decrease uncertainty and/or raise the patient’s feelings of importance, thereby decreasing marginalization.
How I do it
I remind myself each day I am on a clinical shift that my goal is to treat each patient like I would want my family (or myself) to be treated, and then I go out and do it. After “forcing” myself to put these behaviors into my rounding routine, they have become second nature, and I feel better for providing this level of care because it made me feel so good when I was cared for in this manner.
Dr. Sharp is chief hospitalist with Sound Physicians at University of Florida Health in Jacksonville, Fla.
Quick Byte: Take a seat
A survey of 305 inpatients showed that patients who reported that at least one provider sat down while caring for them were more likely to feel that their provider spent appropriate time with them and that their provider kept them well informed. The authors concluded that sitting down at a patient’s bedside improves some aspects of patients’ and families’ experience of their hospital care, and should be included in hospital efforts to improve the patient experience.
Reference
1. Adebusuyi OA et al. Does sitting enhance patient satisfaction in the hospital? [abstract]. J Hosp Med. 2017; 12 (suppl 2). Accessed Aug. 7, 2017.
A survey of 305 inpatients showed that patients who reported that at least one provider sat down while caring for them were more likely to feel that their provider spent appropriate time with them and that their provider kept them well informed. The authors concluded that sitting down at a patient’s bedside improves some aspects of patients’ and families’ experience of their hospital care, and should be included in hospital efforts to improve the patient experience.
Reference
1. Adebusuyi OA et al. Does sitting enhance patient satisfaction in the hospital? [abstract]. J Hosp Med. 2017; 12 (suppl 2). Accessed Aug. 7, 2017.
A survey of 305 inpatients showed that patients who reported that at least one provider sat down while caring for them were more likely to feel that their provider spent appropriate time with them and that their provider kept them well informed. The authors concluded that sitting down at a patient’s bedside improves some aspects of patients’ and families’ experience of their hospital care, and should be included in hospital efforts to improve the patient experience.
Reference
1. Adebusuyi OA et al. Does sitting enhance patient satisfaction in the hospital? [abstract]. J Hosp Med. 2017; 12 (suppl 2). Accessed Aug. 7, 2017.