More emergency departments are helping to manage the care of medically complex older adults.
Among older adults, frequent utilizers of the emergency department tend to have multiple comorbidities, pain-related diagnoses, and injury-related visits, new research found.
Older adults are associated with high ED costs and resource consumption. Compared to other patients, older adults use the ED at higher rates, have long ED stays, and need more medical interventions during their visit.
The new research published in Annals of Emergency Medicine found that frequent geriatric utilizers of the ED accounted for an out-sized portion of visits. While frequent geriatric utilizers represented 5.7% of the patients in the study, they accounted for 21.2% of all ED visits.
"Although the ED is often portrayed as a significant and costly portion of [healthcare] spending, much of this is attributed to the increasing trend of community-based providers relying on EDs to evaluate patients with complex disease who were previously admitted to the hospital, as evidenced by an increase in high-intensity ED visits. As a result, the ED's role in delivering care for a large proportion of the population is expanding, especially for older and sicker patients," the researchers wrote.
There were three primary predictors of frequent geriatric ED utilization:
1. Multiple comorbidities: Patients over 65 with three or more comorbidities had the highest odds of frequent ED use (odds ratio 7.2).
2.Pain: The second most likely factor for frequent geriatric ED utilization was primary diagnosis of pain (5.5 odds ratio).
3. Injury: The geriatric ED frequency odds ratio for an injury-related visit was 3.8.
"Geriatric frequent users are likely to have comorbid conditions and be treated for conditions related to pain and injuries. These findings provide evidence to guide future interventions to address these needs that could potentially decrease
frequent ED use among geriatric patients," the researchers wrote.
Managing frequent geriatric ED users
Among geriatric patients, identifying factors that can lead to frequent ED visits and providing supportive services are crucial to improving care and lowering costs, the lead author of the Annals of Emergency Medicine research told HealthLeaders.
"EDs are increasingly playing a pivotal role in the care of these patients. EDs throughout the United States have started to develop and implement geriatric-specific policies and protocols. These include comprehensive health risk screening, consultations with specialists such as geriatricians and pharmacists while patients are in the ED, referrals to memory clinics and other specialty clinics when a need is identified, and redesigning patient care areas to meet the needs of older patients," said Edward Castillo, PhD, MPH, Department of Emergency Medicine, University of California, San Diego.
Designing health programs across the continuum of care can be effective in managing older patients who are frequent ER users, he said.
"Intervention programs across the continuum of care would allow providers more opportunities to implement prevention strategies or treatment plans that can help alleviate the need for frequent ED visits and hospitalizations in older patients," Castillo said.
Older patients often have complex medical conditions that require care after they leave the ED, he said. "Wraparound services in the primary care, ED, and post-ED setting that take into consideration the patients' and their caregiver's wellbeing are necessary to successfully manage these patients."
Conducting a sepsis screening during emergency medical service transport to an emergency department reduces time to treatment.
Emergency medical service screening for sepsis speeds administration of the Surviving Sepsis Campaign 3-hour bundle of treatment, new research shows.
On an annual basis, sepsis affects about 1.7 million American adults and the infection is linked to more than 250,000 deaths. Timely application of the 3-hour bundle has been associated with reduced mortality.
In the new research, EMS crews conducted sepsis screening of patients before emergency department arrival, a co-author of the study told HealthLeaders.
"We implemented a standard operating procedure for sepsis screening—seven questions for the emergency department RN to ask EMS in any adult patients excluding trauma. When sepsis was suspected, the radio RN would notify the charge nurse to help get them into a room. The key takeaways are that implementing a sepsis screening tool for EMS to use is feasible and it helps to expedite care in these patients," said Megan Rech, PharmD, MS, an emergency medicine clinical pharmacist and adjunct assistant professor, Department of Emergency Medicine, Stritch School of Medicine, Loyola University, Chicago.
In the primary finding of the research, 3-hour bundle compliance was significantly higher using the EMS sepsis screening tool compared to a control group, 80.0% vs. 44.2%, respectively.
The bundle has four main components: measurement of serum lactate concentration, fluid resuscitation, blood cultures prior to antimicrobials, and broad-spectrum antibiotics for suspected or documented infection.
The EMS sepsis screening tool had seven elements:
1. Respiratory rate: N20 breaths per minute
2. Heart rate: N90 beats per minute
3. Systolic blood pressure: b90 mm Hg
4. Documented fever or history of temperature: N100.9 °F or b96.8 °F
5. Onset of mental status change
6. Oxygen saturation: b90%
7. Suspected infection
"There is great potential in the pre-hospital setting for earlier recognition of sepsis in patients arriving to the ED via EMS. Early recognition of sepsis will allow medical personnel to initiate sepsis protocol and decrease an important variable in sepsis mortality: time. We demonstrated that the use of a pre-hospital sepsis screening tool was associated with significant improvement in 3-hour bundle compliance, likely due to improved recognition of sepsis," Rech and her co-authors wrote.
Approaches to repaying medical school debt include loan forgiveness programs, loan consolidation, living within a budget, and locum tenens opportunities.
Most physicians who graduated from medical school in 2015 or earlier are still carrying student loan debt, with one-third owing more than $250,000, a new survey found.
Medical school debt is believed to impact choice of specialty and to exert upward pressure on pricing for physician services. Annually, a new class of doctors graduates with student loans totaling $2.6 billion, with the median student debt per physician estimated at $194,000.
A new Weatherby Healthcare survey based on data collected from 500 practicing physicians nationwide who graduated from medical school at least four years ago found 65% of the doctors are still paying off student loans.
"Every physician has a unique situation, so it's important to carefully consider how the repayment strategy you choose will affect your future. Do your research, talk to colleagues who are further down the road in repaying their debts, and seek help from a loan repayment expert. Making the right choices for you early on can result in significant long-term savings," Weatherby President Bill Heller says.
The medical staffing company's survey generated several key data points:
34% of indebted survey respondents expected to take at least a decade to pay off their student loans
Of the 35% of respondents who had paid off their student loans, 47% achieved the feat within two years of graduating medical school
60% of respondents said that purchasing a home had increased their debt load and slowed repayment of their student loans
For repayment strategies, 66% were interested in loan forgiveness programs, 45% wanted to learn about loan consolidation and refinancing, 39% wanted to find out how to live within a budget, and 29% were interested in locum tenens opportunities
Comparing physician student debt to other college loans
Although physicians take on significantly more student loan debt than other college graduates, many can pay off their loans relatively quickly, Heller says.
"Like most professions, the amount of medical school debt can vary widely among physicians; based on which medical school they attend as well as their access to grants, scholarships, military benefits, and family support. Most physicians finish residency with more than $150,000 in student loans, and it's not uncommon for new doctors to have debt of $300,000 or more. Compare this to the general college graduate average of $29,800," he says.
As is the case for all college graduates, the time it takes physicians to pay off their student loans depends on several factors, including loan balance, specialty, work setting, pursuit of loan forgiveness, and repayment strategies, he says.
"According to a Wisconsin survey, the average time to pay off student loans for the general population of college graduates was 21.1 years. If a physician chooses to participate in an income-driven repayment plan, it can take 20 or even 25 years before they are debt free. However, it seems a minority choose this option. Of the physicians we surveyed who had already paid off their debt, 6% said it took more than 10 years to pay off their loan."
New guidelines for bariatric surgery update recommendations that were set more than two decades ago.
A co-author of new guidelines for bariatric surgery says more patients, clinicians, and payers should embrace surgical interventions to treat obesity.
From 2015 to 2016, 39.8% of Americans over age 20 were obese, according to the Centers for Disease Control and Prevention (CDC). For the same time period, 20.6% of adolescents were obese, the CDC says. In 2008, the estimated annual medical cost of obesity was $147 billion.
Stacy Brethauer, MD, a surgeon at Ohio State University Wexner Medical Center in Columbus, Ohio, who helped draft the new guidelines for bariatric surgery, says millions of obese patients could benefit from surgical approaches to their condition if payers would cover the procedures.
"People make lifestyle choices that predispose them—or lead to—specific cancers and cardiovascular disease, and yet nobody hesitates to provide effective treatment for those problems," he says.
New bariatric surgery guidelines
The American Society for Metabolic and Bariatric Surgery (ASMBS) recently adopted a new set of guidelines that recommend surgical interventions for Class I obesity patients, who have a Body Mass Index (BMI) from 30.0 to 34.9 kg/m2. Obese patients with a BMI of 35 or higher have met the criteria for surgical interventions for more than two decades.
The new guidelines feature eight points and recommendations:
1. Class I obesity is linked to several other diseases, decreases longevity, and diminishes quality of life. Class I obesity patients need durable treatment.
2. Nonsurgical treatments for Class I obesity are often ineffective.
3. The longstanding BMI inclusion threshold of at least 35 kg/m2 is arbitrary and was established in the era of high-risk open surgery. Current surgical techniques for bariatric and metabolic surgery are much safer than in the past.
4. For patients with Class I obesity, bariatric surgery should be offered for suitable patients such as those who do not achieve substantial weight loss with nonsurgical methods.
5. Patients with Class I obesity and Type 2 diabetes are strong candidates for bariatric surgery.
6. The primary laparoscopic surgical interventions for obesity—adjustable gastric banding, Roux-en-Y gastric bypass, and sleeve gastrectomy—are safe and effective in the treatment of Class I obesity. The results of these procedures in Class I obesity patients are similar to results achieved in severely obese patients.
7. Patients who undergo surgical interventions for obesity should receive perioperative and long-term nutritional, metabolic, and nonsurgical support such as measures in the ASMBS Clinical Practice Guidelines.
8. For Class I obesity patients, the best evidence for bariatric and metabolic surgery supports the procedures for patients aged 18 to 65.
Surgical options
Gastric bypass and sleeve gastrectomy are the best surgical options for Class I obesity patients, Brethauer says. "Both of those procedures are considered good metabolic operations in terms of diabetes and metabolic improvement."
For Class I obesity patients, the ideal patient for gastric bypass or sleeve gastrectomy has diabetes that is not well controlled with medical therapy and continues to have to escalate their medical therapy, he says.
"In general, gastric bypass is a more powerful operation for diabetes in terms of getting patients off all their medications and achieving remission of their diabetes. In the long term, both operations achieve good control of glucose levels in patients, but patients with gastric bypass are more likely to achieve remission off medication," Brethauer says.
Obesity is not simply a matter of will power alone, he says.
"Obesity is a disease that consists of genetic factors that lead to predisposition; environmental factors, which have a lot to do with calorie-dense food that is easily available and cheap; and behavioral factors linked to an increasingly sedentary lifestyle. Those three factors all go into our obesity epidemic."
Although long-term societal efforts should be launched to address the environmental and behavioral components of the obesity epidemic, many obese Americans could benefit from surgical interventions now, Brethauer says.
"There are already millions of people who are suffering with obesity, and they need to be offered treatment for it. Typically, diet, behavioral therapy, and even medications do not offer good long-term results once someone has already become severely obese."
Hartford Hospital's ADAPT program has decreased length of stay and readmissions attributable to delirium.
Hartford Hospital has developed a comprehensive approach to addressing delirium in the hospital setting.
In-hospital delirium has been associated with several negative patient outcomes, including increased risk of death, increased risk of a prolonged or permanent cognitive impairment, increased readmissions, and increased risk of developing dementia after hospitalization.
"We know the more severe the delirium is and the longer it lasts, the worse the outcome," says Christine Waszynski, DNP, APRN, coordinator of inpatient geriatric services at Hartford Hospital, which is based in Hartford, Connecticut.
Patients who experience delirium during a hospitalization also can develop a form of post-traumatic stress disorder, she says.
"They have recurrent or unresolved issues related to their experience during a delirium episode. It can have an extremely negative impact on their life. They "remember" bad things that happened to them during their hospitalization and have to reconcile that it is really their perception of what happened—people really were not attacking them and aliens were not abducting them for testing."
In 2011, Hartford Hospital launched Actions for Delirium Assessment, Prevention, and Treatment. The ADAPT program has achieved impressive results. From 2013 to 2018, delirium-attributable days at the hospital decreased 40%. From 2012 to 2019, readmissions have fallen 14% for patients who experience delirium during a hospitalization.
The ADAPT program has three key components: screening, prevention, and treatment and management.
1. Screening for delirium
The ADAPT program features delirium screening in the inpatient and the emergency department settings.
For the inpatient setting, nurses screen all patients for delirium using the Confusion Assessment Method. When a patient is identified at high-risk for delirium, a care pathway is triggered, says Robert Dicks, MD, chief of geriatric medicine at Hartford Hospital.
"When a nurse identifies a patient who screens as abnormal, the clinicians are notified on the spot that they have a patient who is at high risk for delirium and they are engaged at that point. Then the preventive measures kick in," he says.
In the emergency department setting, nurses screen every patient over age 65 with a Single Question in Delirium (SQID) screening technique. These patients are asked whether they have been more confused lately. If a patient has a family member or someone else with them, that individual also is asked the question about the patient.
If the answer to the SQID question is "yes," a patient gets an intentional test—counting backward from 20 to one. "Attentional deficit is the key element of delirium. You must be inattentive to be delirious," Waszynski says.
2. Preventing delirium
Once a patient has been identified at high-risk for delirium, the ADAPT program calls for a range of preventive measures by clinicians, nurses, and hospital volunteers.
Clinicians focus on three kinds of preventive measures: avoiding administration of deliriogenic medications such as Ativan and fentanyl, avoiding the abrupt discontinuation of medications such as opioids and steroids, and avoiding several medical interventions when they are deemed unnecessary such as telemetry and urinary catheters.
Most nursing preventive measures are basic best practices such as moving the patient around, ensuring patients get as much uninterrupted sleep at night as possible, making sure patients have their sensory aids such as glasses, and providing assistance for eating and drinking.
Volunteers provide several preventive services to patients at high-risk for delirium, including socializing with patients, encouraging cognitive activities such as word searches, and assisting patients with walking.
Other preventive measures include an "all about me" poster placed in a patient's room. "It has basic information about patients such as what they like to be called, what they like to eat, the important people in their life, their dog's name, and what activities they enjoy," Waszynski says.
3. Treating and managing delirium
"When a nurse screens a patient as abnormal, it is an urgent situation," Dicks says.
The first step in treating delirium is determining the cause of the condition, he says. "It may be a drug-induced delirium. It may be a medication that was inappropriately stopped. It may be drug interactions. There's always the risk that infection and an abnormality in the blood can cause delirium. A new injury or stress can cause delirium. All of those factors are dealt with based on a systematic review."
Once clinicians feel secure that they have an explanation for delirium or the patient is responding in an expected way, there is a consult with one of three specialties—geriatrics, neurology, or psychiatry—for a second opinion. "Providers want to make sure that they are not dealing with something atypical, that there is not some other workup that is justified, and that the treatment they have approved is appropriate," Dicks says.
Clinicians apply best practices "across the board" related to treatment strategy, he says. "There are certain medications that we believe are more effective and better tolerated than other medications, and we guide clinicians to those medications in our protocol. When those medications are ineffective or contraindicated, we have second-line and third-line treatment strategies."
Cost-effectiveness of ADAPT
An Institute for Healthcare Improvement blog post highlights the cost-effectiveness of Hartford Hospital's ADAPT program.
Accounting for longer lengths of stay and higher costs of care per day, delirium adds more than $22,000 to an inpatient stay at Hartford Hospital. The total costs of the ADAPT program are about $50 per patient.
"From the Hartford Hospital data and analysis applied to it, one might reasonably conclude that even under the most conservative scenarios, ADAPT should at least break even and probably perform far better than that," the IHI blog post says.
Earlier research has shown that decreases in hospital competition have a negative impact on quality and increase prices of medical services. In theory, as insurers consolidate hospitals may view boosting quality as a key bargaining strategy because patients could pressure payers to keep hospitals in-network.
An article published recently in Health Services Research found evidence in support of the theory about insurer consolidation. "Changes in patient satisfaction are positively associated with increases in insurance concentration and negatively associated with increases in hospital concentration," the HSR researchers wrote.
The HSR article, which features information collected at more than 3,000 hospitals, generated two primary data points:
1. Patient rating of hospitals: Compared to a market with 20th percentile insurance concentration and 80th percentile hospital concentration, a market with 80th percentile insurance concentration and 20th percentile hospital concentration increases the number of patients who rate hospitals highly from 66.9% to 67.9%.
2. Patient recommendation of hospitals: Compared to a market with 20th percentile insurance concentration and 80th percentile hospital concentration, a market with 80th percentile insurance concentration and 20th percentile hospital concentration increases the number of patients who definitely recommend hospitals from 69.7% to 70.8%.
Interpreting the data
The lead author of the HSR research told HealthLeaders that the impact of shifting market concentration is modest but significant.
"We find that a large but not implausible change in market structure causes a 4 percentage point movement in the distribution of patient experience scores, which we don't view as trivial. In more human terms, an additional 1% of hospital inpatients in that market would report having a positive experience," said Caroline Hanson, who recently earned her PhD from the Department of Health Policy and Management at Johns Hopkins Bloomberg School of Public Health in Baltimore.
Hanson and her coauthors also found that insurance market consolidation has a relatively higher beneficial impact on care quality in markets where the hospital market is more concentrated. "This suggests that when a hospital market is not concentrated, other hospitals exert enough competitive pressure that insurance concentration has no additional impact on quality," the researchers wrote.
A children's hospital chief executive becomes the first leader of New Jersey health system's pediatrics service line.
RWJBarnabas Health has named the president and CEO of one of the health systems three children's hospitals to lead the organization's newly created pediatrics service line.
Warren Moore, MA, FACHE, will serve as senior vice president of pediatric services at the West Orange, New Jersey–based health system. Moore, who has worked in the organization for two decades, will continue serving as president and CEO of Children's Specialized Hospital.
HealthLeaders recently spoke with Moore to get his perspectives on managing the systemwide pediatric service line. Following is a lightly edited transcript of that conversation.
HealthLeaders: Why did you pick pediatrics as your main field of interest?
Moore: In some ways, pediatrics picked me. In 1998, I was about eight years into my healthcare career, which had all been on the adult side, and I was asked to work at Children's Specialized Hospital. I was a relatively new father—I had a 1-year-old and a 4-year-old. Once I toured Children's Specialized and watched the wonderful care that was given to kids, there was an immediate emotional connection for me as a new dad.
HL: For a health system or a hospital, what are the benefits of establishing a pediatrics service line?
Moore: From the perspective at RWJBarnabas Health, we have many places throughout the system where we are providing excellent care for children. For example, there's the Children's Hospital of New Jersey, Children's Specialized Hospital, and NICUs throughout the system. We have incredible services for kids, and what we have now is an opportunity to bring these great but disparate services into one system of care. We want to focus on our overall population and how we can get to the point where we can effectively care for more than a half million children in our service area.
HL:Limiting clinical care variation is a primary objective in prominent services lines such as cardiology. Is limiting variation a primary objective in pediatric service lines?
Moore: Absolutely. One of the challenges in pediatrics is it involves a large group of services—there are multiple service lines within pediatrics. We have cancer care, we have cardiac care, and we have care for medically complex children. From that standpoint, we have an opportunity with a pediatrics service line to look at best practices and how we can bring those best practices to children across our health system.
HL: Conversations about care variation can be difficult—particularly in pediatrics given the intense emotional connection that many clinicians have with their patients and their patients' families. How do you have that conversation?
Moore: In my 21 years in pediatrics, I have found that when you bring the conversation down to what is best for the kids, everyone pays attention. When we have sound data, and when we can show that we can treat patients better, very few clinicians push back. You must focus the conversation on the child and what is best for the child. You need the hard data that shows the best care for particular situations.
HL: What are your goals for the pediatrics service line at RWJBarnabas?
Moore: For us, it's similar to what we look at for adult care. Our goal is to promote health in the communities that we serve. There are about a million children in our health system's geographic area. In the next five years, we are focused on how we can provide coordinated, safe, high-quality, compassionate, and family-centered care. That means we need to develop a network of primary care, subspecialty care, and ambulatory care for approximately half of the market—about 500,000 kids.
HL: How do you think pediatric care at RWJBarnabas will look different five years from now?
Moore: The big thing that will look different is we will have a large ambulatory and primary care network. Right now, we work with informal relationships in pediatrics across New Jersey. I believe formalized networks of care are important in our future as we move away from fee-for-service to value-based care, which involves generating the best outcomes for children.
HL: What is one of the most significant challenges in pediatric care?
Moore: It's the funding. Traditionally, pediatrics has not been fully funded across the spectrum of healthcare compared to the adult side.
Typically, our reimbursement for care is less than you see on the adult side. And when you are dealing with kids, 50% or more of your patients are going to be on Medicaid as the insurance. So, Medicaid funding is always at the forefront of what we are thinking about financially. In graduate medical education, typically per slot on the pediatric side we get about 50% of what Medicare pays for graduate medical education. The same is true for cancer research—pediatrics is negatively proportionate to the adult side.
For the past 20 years, a big focus for me has been how do we keep moving the dial toward adequate funding to make sure we ensure the future for kids and make sure they all reach their full potential.
HL: How is operating a children's hospital different from operating a general acute care hospital?
Moore: To have a good outcome for a child, we need to engage the family and treat the entire family. Obviously, a child is dependent on parents or other caregivers or siblings. Without a healthy home environment, a child does not have a good chance of a positive outcome.
I realized early in my career at Children's Specialized the need to completely and holistically engage a family in the care of a child. We must make sure that the caregivers are in the right mindset and have the supports they need to take on the challenges of caring for their child. One of the most gratifying things for me working in pediatric care is watching our team wrap its arms around a family and truly make sure that we have them set up for success with their child.
HL: How do you fully engage family members and other caregivers?
Moore: We have focused on getting the voice of families into everything we do. So, we have "family faculty." We hire parents and caregivers of current or former patients, and we engage them in two broad categories.
One category is to give them an actual job function to help bridge the communication between families and our clinical team—they broker the space and help build the trust we need to build. The other category is to utilize them from a policy and operations standpoint. We have a member of either our family faculty or our voluntary family advisory council on every committee in our organization—from the board of trustees, to the patient safety committee, to our operating committees, to our performance improvement committee. So, the voice of families is literally in everything that we do.
In a recent survey, out-of-pockets costs and wait times had a limited impact on patient choice of care settings.
When patients choose a care setting, the main drivers are the nature of medical conditions and patient characteristics, new survey data indicates.
In recent decades, healthcare providers have developed several alternatives to traditional physician office and emergency room visits, including urgent care centers, retail clinics, telemedicine, and app-driven home health visits.
Survey data collected from more than 5,000 University of California-Irvine employees shows patients make rational choices of care settings based largely on medical condition severity and patient characteristics, a journal article published in Health Services Research shows.
"Out‐of‐pocket costs and wait time had minimal impact on patient preference for site of care. Choices were driven primarily by the clinical scenario and patient characteristics," the HSR researchers wrote.
Survey participants were given 10 clinical scenarios of varying severity, then they were asked to pick a preferred care setting. The survey generated several key data points:
Most survey participants chose physician office visits for chronic conditions and child well-visits.
For clinically severe and time-sensitive scenarios, survey participants were inclined to choose the ER or urgent care. For example, 68.9% chose the ER for chest pain, and 41.9% chose urgent care for a deep cut.
In non-time-sensitive scenarios, physician office visits were highly preferred. For example, 45.4% preferred physician office visits for immunizations.
For diarrhea, parents were much more likely to "wait and see" for themselves (29.9%) than for their children (5.8%). For most parents, a physician office or urgent care center was the preferred setting to take children for treatment of diarrhea.
Increases in out-of-pocket expenses generated single-digit percentage point changes in patient preferences for care settings. For physician office visits, a 20% increase in out-of-pocket costs decreased the likelihood of a survey respondent picking that setting by 3.6 percentage points. For urgent care, a 20% hike in out-of-pocket costs decreased selection of that care setting by 1.5 percentage points.
Interpreting the data
The survey results for out-of-pocket costs indicate payers would have to make significant changes to benefit structures to increase utilization of alternatives to tradition physician office visits and ERs. The lead author of the HSR article told HealthLeaders that payers could make substantial hikes in out-of-pocket costs to influence care setting preferences.
"If the insurer wanted to encourage virtual physicians visits, rather than having virtual visits at equal cost to an actual physician office, which it is now for most University of California-Irvine employees, the insurer could lower the cost of virtual visits to a few dollars and increase the cost of an actual office visit," said Dana Mukamel, PhD, a professor of medicine, public health, and nursing at UCI.
In addition to medical condition severity and patient characteristics, patient familiarity with a care setting was a significant preference driver, she said. "In general, we found that people were more likely to choose those providers that they had an experience with in the previous 12 months."
Telemedicine visits were a recent offering to UCI employees, which worked against their selection in the survey's care scenarios, but this preference pattern will likely change over time, Mukamel said. "I expect that as more people gain experience with this option, we will see more people making this choice."
To reduce patient harm, BJC HealthCare focused on pressure ulcers, adverse drug events, healthcare-associated infections, falls, and venous thromboembolisms.
A health system can not only slash patient harm incidents but also sustain the reduction efforts over time.
Medical errors are a leading cause of death in the United States, with estimates of the lives lost annually ranging as high as 440,000. Nonlethal but serious errors such as incidents that lead to permanent harm are estimated to impact as many as 4 million patients annually.
In 2008, St. Louis-based BJC HealthCare launched a patient safety and quality improvement initiative that was designed to dramatically reduce patient harm events over a five-year period and sustain the reductions for an additional five years.
"A combination of project management discipline, rigorous surveillance, and focused interventions, along with system-level support of local hospital improvement efforts, led to dramatic reductions in preventable harm and long-term sustainment of progress," BJC staff members wrote this month in The Joint Commission Journal on Quality and Patient Safety.
The initiative achieved eye-popping results. During the intervention period from 2009 to 2012, total harm events fell 51.6%. An additional 2,600 harm events were avoided from 2013 to 2017, realizing a 74.9% reduction in harmful incidents through the entire course of the initiative.
BJC, which features 15 nonprofit hospitals, focused on five classes of harm events to garner these gains, according to The Joint Commission journal article.
1. Pressure ulcers
Before the initiative was launched, the top cause of patient harm at BJC was pressure ulcers.
To help reduce the incidence of pressure ulcers, BJC developed an electronic health record-based surveillance system for the condition that tapped data in nursing documentation. Best practices were adopted across the health system, including pressure redistribution and patient turning, skin care and moisture management, listing of pressure ulcer events on medical unit display boards, and educational efforts to enlist patients and families in detection and prevention.
2. Adverse drug events
At BJC, hypoglycemia accounted for 75% of adverse drug events, with over-sedation accounting for the next highest percentage of ADEs at 16%.
The health system investigated the causes of severe hypoglycemia through examination of nursing data collected on an online portal after adverse events. The investigative effort led to the development of a pioneering benchmark for severe hypoglycemia.
Hypoglycemia interventions included limiting bedtime snacks, which data analysis showed increased risk of early morning hypoglycemia. The health system also used a locally developed clinical decision support tool—the Pharmacy Expert System—to deploy an algorithm that identified patients at high risk for severe hypoglycemia. When patients were identified at high risk, a diabetes nurse educator, charge nurse, or pharmacist would adjust diet and medication as necessary.
Efforts to avoid over-sedation followed a similar roadmap, with initial efforts aimed at identifying causes such as inappropriate dosing based on a patient's health history or condition. Interventions included changing narcotic dosages in order sets and engaging clinicians who were prescribing medications in excess of guidelines.
3. Healthcare-associated infections
Before launching its harm reduction initiative, BJC had conducted a decade-long effort to reduce healthcare-associated infections (HAIs), but there were still gains to be made. The health system focused on the three most common HAIs at the organization's hospitals: central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and Clostridioides difficile infection (CDI).
For CLABSI, a standardized central line insertion kit and insertion checklist was deployed throughout the health system. For CAUTI, efforts focused on removing indwelling urinary catheters as soon as medically possible.
For CDI, housekeeping procedures were developed for cleaning isolation rooms as well as daily and discharge patient rooms. When CDI was detected, an intervention was conducted featuring core cleaning standards, hand hygiene, and presumptive isolation.
From 2009 to 2017, BJC achieved a 40.6% reduction in HAIs.
4. Falls with injury
Surveillance for falls with injury was conducted with an online reporting tool crafted at BJC. The surveillance data revealed variation in falls, with some medical units showing significantly higher rates of falls than others. The high-fall units were targeted for interventions such as increased use of electronic health record-based fall risk assessment tools and deployment of core prevention standards.
5. Venous thromboembolism
Efforts to prevent venous thromboembolism centered on making sure patients got appropriate VTE prophylaxis. The primary intervention was mandatory order sets in the EHR, including alerts when VTE prophylaxis was not ordered.
Keys to success
Sustaining harm reduction after the five-year intervention period required concerted effort, the BJC staff members wrote in The Joint Commission Journal on Quality and Patient Safety article.
"Each subteam developed a transition plan that designated a specific system-level group to oversee ongoing improvements in that area (for example, the system chief nursing officers' council provided ongoing oversight for falls with injury and pressure ulcers). Surveillance for each harm event continued, and detailed reports were available to the hospitals and responsible groups. Overall reporting of preventable harms was moved to the system quality best-in-class report card, with progressive reduction targets set each year."
Several elements contributed to the overall initiative's success, they wrote. "A combination of project management discipline, rigorous surveillance, and focused interventions, along with system-level support of local hospital improvement efforts, led to dramatic reductions in preventable harm and long-term sustainment of progress."
Misidentifying depression as burnout can have deadly consequences.
The response to physician burnout often overlooks a potentially life-threatening condition: major depressive disorder, physicians say in a new journal article.
Research indicates that nearly half of physicians nationwide are experiencing burnout symptoms, and a study published in October found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction. It is estimated that a physician commits suicide every day.
In a journal article published this month in JAMA Psychiatry, a trio of physicians wrote that the widespread focus on burnout could lead to missed diagnoses of serious mental illnesses among clinicians.
"It is critical that burnout not become the catchall term for emotional distress experienced by physicians. Identifying psychiatric disorders appropriately will enhance the likelihood that the correct treatment is sought. However, as long as stigma and shame are associated with psychiatric disorders, and we have a convenient, ready-made psychosocial formulation to explain away distress in the medical profession, there is a risk that psychiatric illnesses will be less likely to be acknowledged, recognized, and treated appropriately," the physicians wrote.
Symptoms of burnout such as exhaustion overlap with symptoms of major depressive disorder, and signs of MDD in clinicians such as suicidal ideation should prompt a thorough psychiatric evaluation, they wrote.
"Erroneously labeling a physician's distress as burnout may prevent or delay appropriate treatment of MDD, a serious and sometimes life-threatening mental disorder. … Given risks associated with suicidal ideation, it is imperative that the presence of suicidal ideation lead to an evaluation to rule out MDD."
Prejudice is a significant risk factor for distressed clinicians, the physicians wrote.
"Given the robust stigma around psychiatric conditions, the physician may be much more likely to conceptualize her or his problem as burnout rather than a psychiatric disorder. In this scenario, the physician might not seek effective pharmacologic or psychotherapeutic interventions for her or his MDD, but pursue commonly recommended stress reduction and relaxation strategies for burnout, such as yoga, mindfulness classes, or time off from work."
There are several approaches to help ensure that MDD is not mistaken as burnout, they wrote.
"Robust, evidence-based screening tools for depression exist, and many are brief. Complementing any screening for burnout with screens for depression, anxiety, and substance use disorders could mitigate the risk of conflating psychiatric diagnoses and burnout. Creating confidential psychiatric services that are easily accessible to physicians, especially trainees, might make a difference. Web-based and telepsychiatry platforms make this easier than ever. Ultimately, the biggest challenge is rolling back the corrosive effects of stigma."
Rising to the challenge
The lead author of the JAMA Psychiatry article told HealthLeaders that prejudice against medical staff with mental illness should be openly challenged.
"Educating people that it is not about weakness or moral failings is important. Calling out stigma also is key. As we understand more about the biology of MDD, it becomes more and more difficult to distinguish it from other medical conditions," said Maria Oquendo, MD, PhD, chair of psychiatry at the University of Pennsylvania's Perelman School of Medicine in Philadelphia.
Research shows that a substantial portion of clinicians experience MDD, Oquendo said. "Studies of physicians in training suggest that MDD might be present in as many as 25%. An Austrian study of physicians suggested a 10% prevalence of MDD, and that burnout increased the odds of MDD significantly. For those with mild burnout, the risk of MDD was three times greater; for moderate burnout, the risk was 10 times greater; and for severe burnout, the risk it was 47 times greater."
It is possible to achieve diagnostic clarity between burnout and MDD, she said. "MDD has clear diagnostic criteria. Burnout does not. However, whenever an individual meets the criteria for MDD, the diagnosis should be the focus of treatment, even if there are elements in the clinical picture that resemble burnout."