Overlapping shifts for attending physicians in a busy pediatric emergency department have decreased patient handoffs and reduced opportunities for patient harm.
To boost patient safety and physician efficiency, Seattle Children's Hospital adopted overlapping emergency room shifts for physicians and achieved a dramatic reduction in patient handoffs, recent research shows.
"A total of 43,835 patient encounters were analyzed. Immediately after implementation of the new model, there was a 25% reduction in the proportion of encounters with patient handoffs, from 7.9% to 5.9%," the researchers wrote in the Annals of Emergency Medicine.
Patient handoffs bear high risk for compromised patient safety. An earlier study of ER shift-change handoffs showed that vital signs were not communicated for as many as 74% of patients, and another study showed errors or omissions occurred in 58% of handoffs.
At the Seattle Children's ER, the original physician shift model featured shifts ranging from 7 to 9 hours long. When there was a shift change, the outgoing and incoming physician would sign out the entire patient list.
The original model had several shortcomings:
Multiple patients were handed off to the incoming attending physician, creating multiple opportunities for communication errors and omissions.
As trainees and nurses waited to review patients with the incoming attending physician, patient care was delayed.
Attending physicians worked at full capacity through their shifts and often stayed late for charting.
Sign-out was stressful during peak arrival times, when patients would arrive during the handoff process.
The new "waterfall" ER physician shifts addressed pitfalls of the old model:
On arrival to the ER, an attending physician assumes a primary role. The next attending arrives 3-5 hours later, assumes the primary role, and immediately starts treating new patients.
The first attending transitions to a secondary role and completes work on existing patients while treating new, less complex patients with the intention of being able to treat and discharge them prior to the end of their shift.
"With overlapping shifts and change in patient care prioritization, the goal was to decrease the number of patients who require handoff at the end of the first attending physician’s shift, and if handoffs had to occur, they would be for patients with less complex disease," the researchers wrote.
Waterfall model implementation
Hiromi Yoshida, MD, MBA, the lead author of the research, told HealthLeaders that the waterfall shifts can be implemented at most ERs that have multiple attending physicians.
She said there are three primary implementation factors:
Getting buy-in from all parties involved in the change, including attending physicians and charge nurses. The waterfall schedule involves cultural changes such as the timing of shifts, so all attending physicians should review the new model individually and at ED division meetings.
Getting support from hospital leadership is crucial to help drive change. The leadership team can help encourage the implementation of the new model and provide support for staff as it is rolled out.
To maximize efficiency and enable patient evaluations, there must be enough patient care space to allow incoming physicians to see new patients.
Efficiency gains
Yoshida said the waterfall staffing model generates several efficiency gains:
Fewer handoffs ease the cognitive workload from interruptions and interactions in busy ERs. "It has been shown that excessive cognitive workload and increased stress negatively affect performance," she said.
With incoming physicians jumping into treating patients instead of spending time receiving handoffs, patient care is not delayed.
Decision-making is focused at the beginning of the shift, when physicians have better decision-making capacity. This also may lead to less decision-making fatigue throughout the shift.
The waterfall model ensures that a rested and refreshed physician is coming in at staggered times, which provides relief for the staff that has already been in the ED for several hours.
In the research, physicians reported an increased ability to leave on time and to complete charts prior to the end of their shift.
There are more opportunities to collaborate and interact with other physicians throughout the shifts instead of just the short period of time during end-of-shift handoffs.
Seattle Children's implemented waterfall shifts in the ER five years ago and the hospital is continuing to fine-tune the model, Yoshida said.
"We are continuing to monitor feedback from the division and improvements are made to the model as the environment changes. This is a QI project and we aim to continuously improve."
Emergency medicine pharmacists can do a lot more than just dispense medications.
Deploying clinical pharmacists in emergency departments can ease staffing shortages, improve patient safety, increase efficiency, and operate cost effectively, recent research shows.
A new generation of emergency medicine (EM) clinical pharmacists can do far more than the medication distribution role that hospital pharmacists have played historically, according to the authors of a research article published in the American Journal of Emergency Medicine.
"EM clinical pharmacists aid in medication selection, optimal dosing and delivery, provision of drug information to patients and the interprofessional medical team, research and scholarly activities, and administrative and operational responsibilities to optimize the efficiency of care delivered to ED patients," the researchers wrote.
1. Staffing shortages: The corresponding author for the research article told HealthLeaders this week that EM clinical pharmacists help ease ER staffing shortages in several ways.
"In an already busy emergency department, emergency medicine pharmacists can help streamline overall pharmacotherapy-related care. Instead of physicians or nurses having to call the central pharmacy with questions, the pharmacist is right in the department and can provide consultation at the bedside. This minimizes phone calls and interruptions," said Nicole Acquisto, PharmD, an associate professor in the Department of Emergency Medicine at University of Rochester Medical Center in Rochester, New York.
EM clinical pharmacist also can take medication burdens off other ER staff members, she said.
"The EM pharmacist also understands the needs of the ED regarding medication availability and order entry in the electronic medical record and can optimize these functions to make overall drug selection, distribution, and administration easier."
2. Patient safety: Acquisto and her coauthors say medication errors are common in the ER setting in processes including prescribing, dispensing, and administration. EM clinical pharmacists can limit many of these errors, they wrote.
"Including clinical pharmacists on the ED team leads to increased error interception and fewer medication errors. ED pharmacists are well equipped to correct the majority of prescription-related errors, especially those containing multiple medication orders and those prescribed by EM residents. A prospective multicenter study of four geographically diverse academic and community EDs found EM pharmacists caught 364 medication errors during a 1000-hour study period."
3. Increased efficiency: There are multiple opportunities to insert EM clinical pharmacists into an ER workflow and realize efficiency gains, the researchers wrote.
These workflow opportunities include: drug therapy consultation after the ER physician has evaluated a patient, medication procurement and preparation for critically ill patients, drug therapy monitoring after the administration of medication, recommendations for discharge prescriptions, and patient education and counseling at time of discharge.
4. Cost-effectiveness: A study cited in the American Journal of Emergency Medicine research indicates that interventions by EM clinical pharmacists such as avoided medication errors significantly reduce ER costs. The study over a six-month period found 9,568 interventions by EM clinical pharmacists generated cost savings of $845,592.
Acquisto told HealthLeaders that EM clinical pharmacists cut costs on several fronts: cost avoidance from optimizing pharmacotherapy and preventing medication errors and adverse effects, preventing readmissions through antimicrobial stewardship and culture follow-up, and streamlining care to improve physician and nurse productivity.
Acquisto said EM clinical pharmacists also improve hospitals organizationally.
"Since the ED collaborates with several consult services throughout the hospital in addition to emergency medicine—trauma, critical care, infectious disease, neurology, toxicology, and cardiology—the EM pharmacist can act as the pharmacy liaison. As the expert on the medication use system and related workflow in the ED, the EM pharmacist can contribute to organizational initiatives," she said.
Survey finds overemphasis on physical health and treatment compared to underlying components of health such as diet and environmental factors.
There is a gap between what primary care physicians (PCPs) discuss with their patients and several core elements of health, a recent survey found.
The survey, which was conducted by The Harris Poll on behalf of Samueli Integrative Health Programs, features responses from more than 2,000 adults. The data shows a disconnect between what PCPs are discussing with their patients and many underlying determinants of health.
The survey found 74% of conversations between PCPs and their patients were focused on physical health, but discussions of other key health factors were far less frequent:
Non-medication approaches to health such as massage: 10%
Wayne Jonas, MD, executive director of Samueli Integrative Health Programs at H&S Ventures in Alexandria, Virginia, and a practicing family physician, presented the survey data during an online press conference this week. He said PCPs are not discussing enough of the underlying factors and social determinants that account for about 80% of health, including education, employment, income, family and social support, and community safety.
"Unfortunately, fewer than half were discussing core determinants of health that we know are in the 80% of what produces good health. For example, diet and sleep habits were discussed by only 44% and 40%, respectively, during office visits. Even fewer—only 20%—talked about why it was important to be healthy; in other words, what aligns in your life goals and your health goals," he said.
The survey's finding on PCP discussions with patients about behavioral health were striking, said Jonas, former director at the Office of Alternative Medicine for the National Institutes of Health.
"Mostly alarmingly, even though a large portion of the population suffers from mental health conditions such as depression and anxiety, only about a third of the conversations with doctors engaged in these psychological conditions."
The survey also showed PCPs were out of sync with the topics that many patients want to discuss, Jonas said.
"We found that for many of these areas, people did want to have these conversations with their doctor. About 45% said they wished they talked about their life goals—what matters to them and how it aligns with their health goals. Surprisingly, even more younger adults—those 18 to 24—indicated they wanted to talk about the behavioral determinants of health with their doctors more than they did."
Promoting broader discussions
Jonas acknowledged that the volume-driven, fee-for-service payment model prevalent in PCP offices is ill-suited for broader discussions about health with patients.
"This is a major problem and one that I hear all the time. I struggle with it myself in my own practice—finding enough time to address what matters to the patient about chronic conditions and management of chronic conditions. … What we really need to do is restructure how we do primary care—especially for chronic diseases—to allow more time for conversations."
Jonas said he has found ways to spend more time with his patients, with transformative impact.
"A lot of chronic pain patients are referred to me. They have had many visits and they have spent 20 minutes getting pills and procedures several times. No one has sat down with them and asked how they can be empowered to improve their own pain and lives, and how they can set up a team to manage their care themselves. If we do that, oftentimes we can break the cycle of dependency on continued medical care that occurs in the 20-minute visit."
Broadening discussions about health with patients is a crucial part of shifting to value-based care, Jonas told HealthLeaders before the press conference.
"Physicians need to make time to address what is of value to patients. It's a shift in our thinking. This could be as simple as integrating a few questions into a routine office visit to evaluate those aspects of a patient's life that facilitate or detract from healing. Doing this can help our healthcare system transition to a value-based care model and directly impact goals like the Triple Aim."
Medical education
Jonas also told HealthLeaders that changes are required in medical education to improve the quality of primary care.
"Medical education is lacking in key areas that are fundamental to a patient's health. … The key areas that need to be added to most office visits are behavioral and lifestyle, social and emotional, and mental and spiritual. Medical training sharply limits the ability of physicians to make healing their primary mission, and the current model of care does not allow for much time to capture the personal, social, behavioral, and environmental factors that contribute to most chronic diseases."
Nutrition and prevention should be enhanced in medical education curriculums across the country, he said.
"Medical students receive minimal education on nutrition, yet we know that diet influences a great deal of a person's health and risk for developing disease. Our medical training needs to expand outside of the realm of diagnosis and treatment and focus on prevention as well."
Bellin Health shares how the health system achieved the top composite quality score in the first performance year of Next Generation ACO.
While the Next Generation ACO program has generated modest financial gains, top-performing participants are posting strong quality metric scores.
Next Generation ACO has more than 30 quality measures, including access to specialists, medication reconciliation, and depression screening.
In quality performance, Bellin Health was the top quality metrics performer in the first year of Next Generation ACO. In 2016, the Green Bay, Wisconsin–based health system posted the highest composite score (64.54% out of a potential 100%) for the ACO's quality measures and registered shared savings totaling $1,400,148.
Chris Elfner, director of accountable care strategies at Bellin Health, says quality and shared savings should not be competing goals.
"High-quality care attains shared savings. A lot of providers start with their high-cost, high-risk patients and try to put all kinds of extra resources on them, but if you take a full-population view, you get paid on the low-cost, low-risk patients," he says.
He continues, "You benefit from keeping patients low cost and low risk. The way you do that is by achieving quality—by closing care gaps, by managing chronic conditions, and by making sure people are taking care of their health. Although that approach raises the cost of care in some areas for low-cost, low-risk patients, it lowers the total cost of care, which generates shared savings."
Bellin Health shares its strategies to scoring well in the quality measures for Medicare's newest accountable care model.
1. Internal tracking of quality performance
Bellin Health participates in several ACO contracts. To avoid an overwhelming administrative burden, the health system tracks quality metric performance according to internal standards, which capture most of the Next Generation measures, Elfner says. "We are tracking in real time. We have dashboards built into our Epic system that are tracking the Next Gen ACO metrics—not exactly, but we track the critical metrics in a way we feel they should be calculated."
Tracking the ACO quality metrics at the patient level is essential to encourage providers to achieve quality metrics, he says.
"It's tracked at the point of care—at the patient level. When a provider or clinician brings up a patient chart, there is a sidebar report that has all of the quality measures [symbolized] as red, green, or not applicable. They can see that information, and we have other information in that sidebar such as whether the provider is in the Next Gen ACO. For us, that means [the providers] are eligible for waivers and the $25 wellness visit payment," Elfner says.
Physicians can view the quality metrics from a pair of perspectives, he says. "When they log in, providers see those metrics for their panel of patients, or the population for their specialty."
Tracking quality data in real time also gives Bellin Health the ability to identify and influence low-performing clinicians in a timely manner, says Naomi Wedin, executive director of Bellin Health Partners.
"We rely heavily on the physicians and the physician leaders that we have in the organization. They talk with their peers and get their peers to understand the importance of why things need to be done—not just from a reporting standpoint but also from the standpoint of the overall care of the patient," she says.
Metrics data helps drive those conversations.
"We provide information that helps support the need to have various quality measures achieved. For example, there are annual wellness visits for the Next Gen population, and this is one of the ways we close care gaps and meet quality measures," Wedin says.
2. Solitary measurement
At Bellin Health, a simplified approach to quality measurement is an important element of success in the Next Generation ACO quality scores.
"Our approach to quality measures has always been that we needed to define quality for our care in a single and solitary way; so, rather than looking at HEDIS metrics and Next Gen metrics, we have a collaborative here in Wisconsin called the Wisconsin Collaborative for Healthcare Quality that has slightly different versions of the same metrics," Elfner says.
The solitary approach is better for physicians and the health system, he says.
For example, he says Bellin wants to avoid having providers working with multiple quality metrics for a single clinical measure such as A1C control. "We have always defined quality internally and tried to achieve whatever that quality is, then match those metrics to the payer-contracted metrics. To me, that's the biggest best practice," Elfner says.
3. Understanding the data
Comprehension and capabilities are crucial to success in Next Generation ACO quality measures, he says.
"As a contract starts, you need to understand what the quality metrics are and what needs to be captured to meet those quality metrics. Then, you need to make sure the system and the EMR can capture those metrics. The next question is whether we have an [administrative] process in place to capture those metrics. The last question is whether we have an automated way of calculating," Elfner says.
The Next Generation ACO program is geared to generate accurate information, and Bellin Health has seized on the opportunity that the high-quality data presents, Elfner says.
"[Next Gen's ACO] quality metrics do not vary drastically from any other quality metrics we look at. What the Next Gen ACO gives us, such as claims files, is by far the best information we get from any ACO. It is the cleanest, it's the most consistent, and it's the most useful. We would encourage all private and commercial payer organizations to mimic Next Gen ACO."
A new set of guidelines features recommendations for nearly a dozen focal points where medication errors can be avoided in the hospital setting, including admission, monitoring, and discharge.
The American Society of Health-System Pharmacists has released guidelines on preventing medication errors in hospitals.
The guidelines, which are targeted at health system and hospital settings, are designed to give pharmacists ground rules and best practices to improve patient safety and avoid medication errors.
"Some medication errors result in serious patient morbidity or mortality. Thus, medication errors—including close calls—must not be taken lightly, and risk-reduction strategies and systems should be established to prevent or mitigate patient harm from medication errors," the guidelines say.
The guidelines feature best-practice recommendations in 11 areas and processes where medication errors can occur:
Planning such as an event-reporting system
Selection and procurement
Safe storage
Patient admission
Ordering, transcribing, and reviewing
Preparing
Dispensing
Administration errors such as wrong patient or wrong drug
Monitoring medication effects
Patient discharge
Evaluation of systems and processes to avoid medication errors
Errors or failings can arise at any one of these points and pharmacists are best equipped to address problems, the guidelines say. "Health-system pharmacists have the responsibility and expertise to lead and participate in multidisciplinary committees to examine and improve systems currently in place."
Patient-centered recommendations
At least four of the guideline focal points involve direct interaction with patients or their clinical care teams: patient admission, administration, monitoring, and patient discharge
1. Patient admission: "Prescribing errors commonly occur during hospital admission for many reasons, and patients taking numerous medications are at a higher risk for adverse drug events (ADEs), which can include medication errors," the guidelines say.
Recommendations to avoid ADEs at the time of a patient admission include obtaining a medication history with pharmacy participation and conducting medication reconciliation.
2. Administration: "Common administration errors include wrong patient, wrong route, wrong dosage form, wrong time, wrong dose or rate, and wrong drug. Additional errors in this category may include errors of omission or missed doses," the guidelines say.
Recommendations to avoid administration errors at the bedside include checking patient allergies, obtaining two patient identifiers, and communicating with the patient about medication indications and side effects.
3. Monitoring: "Examples of failing to monitor medication effects include not checking a scheduled blood glucose level and checking the level but not reacting to the level. Incorrect interpretation errors might include checking the blood glucose level but giving the wrong amount of corrective or sliding-scale insulin for the value," the guidelines say.
Recommendations to avoid monitoring errors include training staff to identify common negative effects in patients and establishing protocols to respond to adverse reactions. In addition, clinicians should be trained to monitor medication efficacy through methods such as checking vital signs, performing electrocardiograms, and evaluating laboratory results. Inadequate response to medications should prompt changes in therapy under established protocols.
4. Patient discharge: "Pharmacists' involvement in activities before patient discharge provides a valuable opportunity to prevent potential medication errors. Data show that adverse events are a major cause of avoidable hospital readmissions; more post-discharge adverse events are related to medications than other causes," the guideline say.
Recommendations to avoid medication errors during and after patient discharge include a medication discussion with the patient featuring open-ended questioning and active listening to effectively share information, patient education focused on medications such as insulin administration, and providing the patient with an accurate list of medications to be taken after discharge.
Health systems and hospitals can effectively reduce medication errors, the guidelines say.
"While medication errors cannot always be prevented, organizations can mitigate and reduce harm through robust system redesign, help employees make safe behavioral choices, and understand why people make the choices they make. If system faults and behavioral choices are understood, risk-reduction strategies can be created."
Limiting waste of perishable supplies and other products reduces costs in a way that goes straight to the bottom line.
Editor's note: This article is based on a roundtable discussion report sponsored by Vizient. The full report, Supply Chain Success: Achieving Efficiency Gains, is available as a free download.
Hospitals and health systems can drive supply chain efficiency with waste management efforts such as limiting the waste of perishable products.
To limit waste of products, the onus is on supply chain teams to make sure inventory strategies match how products are used, says Ryan Martter, strategic sourcing manager at Rush University Medical Center in Chicago.
"If we only stock sutures by a box of 12, but clinicians are consuming sutures one at a time and it's a specialty item that they use four or five times a year, the balance in that box is just going back to sit on a shelf. If the box expires and you place a new order, you're buying another full box to use a handful of sutures."
Physician culture is also a key factor in waste management, Martter says.
"Do you have a culture where everything is immediately opened and ready to go before the case even begins? If so, a supply might be on a preference card just in case it is needed, but if it is always being opened and never runs into the scenario where it's needed, it always becomes a wasted item."
The preference card process should be dynamic, says Stephen Downey, Group SVP of supply chain operations at Vizient Inc. in Irving, Texas.
"If you look at other industries, you don't take a bill of materials and say this is it, then only use half those bills every time. That would just not survive in a manufacturing industry. You would adjust your bill," he says.
Preference cards should be adjusted for what gets consumed, Downey says. "Everybody feels a sense of success when you realize what you saved through that process, but it's a continuous improvement."
Surgical technicians and physicians should document the supplies and implants that are used during a procedure, says Theodore Pappas, who works in supply chain management at Mayo Clinic in Jacksonville, Florida.
"They have to tell us what they're using—if they are opening and not using items and wasting product. We need to be able to identify that. We have to be able to collect that information and share it with the stakeholders. … That kind of cost goes right to the bottom line. If you can eliminate waste, that reduces your cost significantly," he says.
Hoarding prevention
In addition to cutting costs, efficient product management also limits hoarding of supplies, Pappas says.
"When it comes to waste and product on the shelf, you talk about hoarding and hiding things in drawers and other types of activities that caregivers are accustomed to in certain circumstances. In many cases, we are failing as a supply chain if we allow that to happen—we are not putting the right things in the right place at the right time so it's easily attainable for caregivers," he says.
Clinician hoarding often leads to waste of perishable products, Pappas says.
"If a supply is readily available for them, they are not going to have to hoard it the next time. We also need to teach them why that's important and the implications of hoarding. You need to share the cost of expired product expense," he says.
Changing behaviors
Waste management often requires changing behaviors among clinical care teams.
Altering the behavior of staff members should be a collaborative process, Downey says.
"You help everybody understand what the organization is up against and why you're working on change. You're trying to help care teams do their job better. Together, you look at waste and the information that has been gathered. You also have to accept that changing habits and behavior is not going to happen quickly. You can't expect that everybody leaves on Friday and on Monday there's an entirely new process," he says.
Pappas says sharing waste information data with staff is critical to achieve changed behaviors such as sharing the overall expired product that's being wasted. "You need to share information in various formats. It's not just an email. It's not just a conversation. It's both, and it's also presenting the information to the teams involved."
View the complete HealthLeaders Media Roundtable report: Supply Chain Success: Achieving Efficiency Gains.
Nearly 12% of Takotsubo Syndrome patients are readmitted to a hospital within 30 days of an inpatient stay, recent research shows.
Patients are far less likely to die from broken heart syndrome than they are to die from a heart attack, but that doesn't mean providers can safely ignore the risks associated with the less-severe condition.
Patients diagnosed with broken heart syndrome, or Takotsubo Syndrome (TTS), still face a significant risk of hospital readmission, recent research shows.
"Two thirds of the hospital readmissions within 30-days of TTS occurred in the first two weeks post-discharge, highlighting the need for careful follow-up in these vulnerable patients," researchers wrote this month in an article published in the European Heart Journal—Quality of Care and Clinical Outcomes.
The research compares TTS to acute myocardial infarction (AMI) for measures including predictors, readmissions, mortality, and cardiovascular risk factors.
Broken heart syndrome features transient left ventricular dysfunction with symptoms and electrocardiography results that mimic heart attack, the researchers wrote.
There are about 12,000 cases of TTS each year, accounting for 1-2% of all acute coronary syndromes, according to lead author Nathaniel Smilowitz, MD, an assistant professor at the New York University School of Medicine.
Mortality for broken heart syndrome is much lower than that for a heart attack. During a first admission for TTS, mortality was 2.3%, while the mortality rate for acute myocardial infarction admissions was 10.2%, according to the research.
Despite the lower mortality rate, broken heart syndrome poses a significant risk for readmission—which carries potential health risks for patients and possible financial penalties for providers.
Health and financial risks
Among TTS survivors, 11.9% were readmitted within 30 days, and mortality associated with readmission was 3.5%, the researchers found. The most common readmission cause was heart failure at 10.6% of readmissions.
Among the heart attack survivors in the study, 16.7% were readmitted within 30 days.
For TTS survivors, the researchers found age, malignancy, peripheral vascular disorders, chronic lung disease, heart failure, drug abuse, and anemia were predictors of 30-day hospital readmissions.
Although broken heart syndrome is not one of the conditions listed under Medicare's Hospital Readmissions Reduction Program, some broken heart syndrome cases are likely drawing HRRP penalties, Smilowitz told HealthLeaders.
"These patients may be improperly diagnosed with myocardial infarction, and myocardial infarction readmissions are subject to penalties in HRRP. Therefore, hospital readmissions for the proportion of TTS patients who are assigned AMI diagnosis codes may contribute to penalties under HRRP," he said.
More research is needed to optimize treatment of TTS in the inpatient setting and post-discharge, but there are indicated treatments and guidance for follow-up care, Smilowitz said.
"The care of Takotsubo Syndrome in the acute setting depends on the clinical presentation, the severity of left ventricular dysfunction, and the presence of left ventricular outflow tract obstruction or shock. There are unfortunately no randomized clinical trials guiding the treatment of Takotsubo patients, but large observational studies have indicated better long-term outcomes among Takotsubo patients treated with ACE inhibitors," he said.
Monitoring TTS patients after discharge is essential to avoid readmissions, Smilowitz said.
"Our study shows that heart failure may complicate Takotsubo Syndrome in the near term, so we now recommend close follow up after discharge to evaluate for signs and symptoms of heart failure, which can be treated appropriately with medical therapy such as diuretics."
Characteristics and predictors
The researchers found several distinguishing characteristics and predictors for broken heart syndrome compared to heart attack:
TTS patients were more often to be women (89%) compared to female heart attack patients (41%)
Cardiovascular complications were less common during a first admission for TTS patients compared to AMI patients. For example, 2.7% of TTS patients experienced cardiac arrest compared to 4.4% of AMI patients.
TTS patients were younger and more likely to have a history of depression, psychosis, alcohol or drug abuse, hypothyroidism, rheumatoid arthritis, collagen vascular disease, and chronic pulmonary disease than AMI patients.
There are important distinctions between patients with broken heart syndrome and heart attack patients, the researchers wrote.
"Patients with TTS had a lower incidence of underlying cardiovascular risk factors and established cardiovascular disease than patients with AMI. In contrast, TTS patients were more likely to have psychiatric disease diagnoses in comparison to patients with AMI," they wrote.
Mortality rates are lower for broken heart syndrome compared to heart attack, but TTS is a deadly condition, the researchers wrote.
"Although outcomes of TTS appear favorable when compared to acute MI, patients with TTS have a substantial risk of in-hospital death and 30-day readmission among survivors. Thus, TTS is associated with morbidity and mortality in thousands of patients in the U.S. each year."
In-house leadership coaches make determined and sustained efforts to help physicians change behaviors that can derail their careers.
Physician leaders can benefit from in-house staff development programs.
"Internal physician coaching has been a real success for us," Keith Olson, MS, director of physician consulting services at Ann & Robert H. Lurie Children's Hospital of Chicago, said during a presentation this week at the MGMA annual conference in Boston.
Olson said in-house physician leader training has several advantages over consultants or sending physicians to leadership programs, including a higher degree of effectiveness in changing people's behavior.
"Other organizations send physicians to an executive program—two weeks at Harvard, Stanford, or Kellogg in Chicago. What I hear from physicians who come back from these programs is, 'It was a great experience, and I met some great people.' Then three weeks later not one behavior has been changed. Those programs also are very expensive," he said.
In-house leadership coaches can make a determined and sustained effort to help physicians change behaviors—such as constantly interrupting their peers—that can derail their careers, Olson said.
"The difference is that instead of going to a program and getting information, we're talking for weeks on end about the behaviors they pull out of structured materials and want to get better at. I keep these behaviors in front of them."
Measuring success
Lurie Children's Hospital currently has 45 doctors enrolled in the organization's physician leadership program. Participants are meeting with Olson every two weeks, monthly, or quarterly.
After his presentation at the MGMA conference, Olson told HealthLeaders that there are four primary measures of success for an in-house physician leadership program:
Since participation in executive coaching should be elective—and physicians have a low tolerance for anything that wastes time—high demand and continued participation in ongoing coaching is an indicator that participants view a program as worthy.
In a successful program, peer referrals should be a major source of participants.
Annual feedback should be gathered from participants asking about the effectiveness of the program and getting input about what will make the program more effective.
The ultimate indicator of success is that growth and development are seen in the participants by their leaders and peers.
Growth has been a key measure of success for the leadership program at Lurie Children's Hospital, he told HealthLeaders. "It's exploded in growth, and that is one indicator of success because it's elective."
Competencies and learnings
During his presentation at the MGMA conference, Olson shared core competencies for leadership coaches and the lessons that have been learned from the leadership program at Lurie Children's Hospital.
There are a pair of essential leadership coaching competencies, he said.
"One is the coaching skills, the trust-building skills, and the listening skills—these are skills that help change people's behavior. As one of my clients said to me, 'Keith, you are politely blunt.' To get people to change their behavior, you have to be able to be politely blunt."
The other core competency is physician-centric. "The other bucket is understanding a physician's world," Olson said.
"Surgeries run long, clinics run long, and grant proposals are due. A physician's world is a chaotic place. We keep trying to cram a traditional approach to leadership development on the physician's world, and it fails."
He said Lurie Children's Hospital has learned several lessons from operating an in-house physician leadership program:
Leadership programs should be perceived as an investment in key talent, not a place where people who are behaving badly are sent.
Leadership coaches must adapt to the physician's world such as being flexible to odd work hours. Coaches should not get upset when meetings are cancelled or rescheduled.
Leadership coaches should encourage physician leaders to develop tools and techniques to have a sustainable path in their lives. The drive that got physicians through residency, fellowship, and the early phase of their careers is not only unsustainable but also a potentially toxic influence on leadership abilities.
Having an internal leadership coach creates the ability to have ad hoc sessions in a timely manner. Internal coaches tend to be readily available when a leadership program participant needs to talk with someone about pressing issues such as a stressful conversation involving negative feedback.
The health system has implemented a behavioral health integration program that features mental health screening at primary care clinics.
As part of a $15 million behavioral health initiative launched last year, Columbus-based OhioHealth is striving to screen nearly all of its primary care patients for depression, anxiety, and suicide risk.
As a study released in June by the Centers for Disease Control and Prevention reports, suicide rates have been rising in nearly every state. In 2016, there were 45,000 Americans over the age of 10 who died by suicide, the CDC says.
To help prevent suicide in the communities it serves, OhioHealth is implementing a behavioral health integration program that features screening at primary care clinics, where patients identified with mental health conditions are enrolled in a course of multidisciplinary treatment.
"This can identify patients in distress when they are seeing their primary care physician, giving us an opportunity to intervene before there is a disastrous outcome," says Dallas Erdmann, MD, system chief of behavioral services at OhioHealth.
Every patient over the age of 16 is screened. Patients who score high on the PHQ-9 questionnaire are referred to a behavioral health provider—either a social worker or a counselor—who helps manage anxiety or depression for six to nine months. A psychiatrist helps supervise the caseload in weekly meetings.
Primary care practices are a logical setting to serve as the backbone of OhioHealth's behavioral health integration program, says Amanda Maynard, DO, an OhioHealth primary care doctor and a physician champion for the program.
"We are the first line of defense for all disease processes. Depression and anxiety are prevalent in society today," she says.
The behavioral health integration program is simultaneously increasing access to mental health services and helping OhioHealth cope with a shortage of psychiatrists, Erdmann says.
"This model supports primary care doctors in caring for mild-to-moderate depression and anxiety. Those are bread-and-butter conditions, and this program frees up psychiatrists to attend to the more complicated cases of refractory depression, bipolar disorder, and psychosis that primary care doctors are uncomfortable attending to because they have not had the training," he says.
OhioHealth launched the behavioral health integration program in late 2017. So far, 15 of the OhioHealth Physician Group's 25 practices have joined the program, with a total of 63 physicians participating.
Key metrics of the program include patient enrollment in integrated services and achievement of a 50% reduction in PHQ-9 scores. As of September, 1,000 patients had enrolled in the program, and about 35% of patients enrolled in the program for at least six months had achieved a 50% reduction in PHQ-9 scores.
OhioHealth has taken a systematic approach to implementing the behavioral health integration program at the organizational and primary care practice levels, with expectations that the effort will be sustainable and effective.
Organizational rollout
Erdmann says there have been four primary steps to implementing the behavioral health integration program at the health system level:
OhioHealth's senior leadership has been actively involved and invested in the effort from its onset.
Physician champions and other crucial individuals were identified at primary care practices to help the senior leadership team problem solve and operationalize the program.
Psychiatric providers have been enlisted to participate in the program and support primary care physicians.
A training program was crafted to prepare clinics to join in the program.
The training process for primary care practices takes about a day and a half, with a select handful of staff members present for instruction, including one physician or nurse practitioner, one practice manager, one medical assistant, and one office specialist, Erdmann says.
"We get fairly in-depth defining the process, setting the workflow, looking for nuances to roll the program out in the particular clinic, identifying some of the roles and responsibilities of the various team members, and cross-training staff members to be able to work as a team," Erdmann says.
Social workers receive supplemental training, he says. "For the behavioral health providers—the social workers—we provide them with additional training in documentation and the care model."
The training is conducted with in-house resources and has been led by Heather Esber, system program manager of service lines for OhioHealth.
Practice implementation
Maynard's practice was one of the first OhioHealth sites to implement the behavioral health integration program.
"We thought our site would be one of the better sites because not only are we downtown but we also have close proximity to a Level 1 trauma center, and we are very close to women's domestic shelters and suboxone clinics. We thought downtown was a good site because of the prevalence of mental illness," she says.
Implementing the behavioral health integration program has not been a heavy burden on the practice, Maynard says. "There were some growing pains such as working the program into the workflow to be effective. It took a week to figure out the best way to do it."
She considers the PHQ-9 questionnaire as collecting a vital sign.
"It was time management. The patients get the questionnaire when they check in at the front desk. They are either filling it out or have filled it out by the time the medical assistant rooms them. Then that information is either handed to the physician or it is placed in the computer system. The physician looks at the questionnaire and decides where to go from there," she says.
The providers in Maynard's practice are comfortable with their treatment role in the behavioral health integration program, she says.
"We are very capable of getting patients on medication for mood disorders; however, 99% of bipolar and schizophrenic patients are also going to need a psychiatrist onboard with us. That is a benefit of this program: these patients can see me in the primary care office, and I can reach out to our psychiatrists who can direct me on medication adjustments," she says.
Patients who score high on the PHQ-9 question related to suicide are immediately referred to an emergency room for evaluation, Maynard says. If the patient has a family member with them, the family member escorts the patient to the ER, which is a block away. If the patient is alone, the patient is transported via ambulance to the ER. After arriving at the ER, patients are held for evaluation for 72 hours.
Sustainable and effective
Erdmann says the behavioral health integration program is expected to be sustainable and cost effective.
The Centers for Medicaid & Medicare Services recently approved billing codes for collaborative care that will help fund the behavioral health integration program. "It's a way to encourage this form of treatment. We are preparing to start using them," he says.
Boosting behavioral health services is also expected to reduce total cost of care, Erdmann says.
"This can help reduce the cost of care and improve overall health and healthcare outcomes as we identify and catch illnesses early in a preventative way and identify comorbid factors that impact the outcomes of other disease states," he says.
He cited diabetes as an example.
"If you look at actuarial data for healthcare and healthcare costs, you could take a group of patients who have diabetes and understand the cost per member per month. If you take those same patients and add in a comorbid depression, the cost of care doubles. It doubles because of the impact of depression on the patients' ability to care for themselves," Erdmann says.
The behavioral health integration program is improving OhioHealth organizationally on several fronts, he says.
"It is helping to prepare OhioHealth in a variety of ways to address some of the ongoing issues in healthcare. It helps us view the whole patient, and adopt team-based care. It is helping us identify health issues before they reach a crisis level. And by addressing comorbidities, it is helping us reduce total cost of care," he says.
Maynard says the behavioral health integration program has improved access to vital services.
"Typically, if you put a patient into psychiatry the waiting list can be four to six months. What I have seen as a primary care doctor is some of these patients need to be seen sooner rather than later. This program has created access to resources including psychiatrists who can help us manage patients. It makes us like a one-stop shop for patients," she says.
Patients are benefiting, Maynard says. "We have made a big difference in a lot of these patients' lives. Some were not coming out of their homes. Some were not active with their children. Some had no jobs or aspiration to do anything. In some of my patients, I have seen drastic changes."
New research shows a significant increase in emergency department violence, but there are strategies to address the problem.
Violence against ER physicians is pervasive and increasing, research released this week shows.
In a survey conducted for the American College of Emergency Physicians (ACEP), a majority of the 3,539 doctors polled said they had been the victims of workplace violence recently. About 62% of ER physicians reported being assaulted in the past year, with 24% saying they had been assaulted two to five times.
"The main point is this is a problem that is real, it is increasing, and unfortunately the results of this poll will not surprise any practicing physician," Vidor Friedman, MD, ACEP president-elect and an ER physician in Florida, said during a press conference Tuesday.
The press conference focused on research findings, solutions for violence in ERs, and the impact on patients who witness acts of violence.
In addition to the survey, "ACEP Emergency Department Violence Poll Research Results," unpublished research unveiled on Tuesday showed a significant increase in ER violence in Michigan.
The Michigan research compares survey data from 2005 and 2018. In 2005, about 28% of ER physicians surveyed said some form of violence had been perpetrated against them in the past year. In 2018, the figure had risen to 38% of ER physicians.
Physicians are not the only emergency department personnel enduring violent encounters, the lead author of the Michigan research said during Tuesday's press conference.
"Every job title had violence perpetrated against them. What we found is that the time you spend with the patient increases the chance that violence will be perpetrated against you," said Terry Kowalenko, MD, chair of emergency medicine at Beaumont Hospitals in Dearborn, Michigan.
The ACEP survey features several key findings:
71% of ER physicians reported witnessing an assault at work
97% of assailants were patients
The most common administrative and security responses to physical assaults were to place a behavioral flag in the patient's medical chart (28%) or to have the patient arrested (21%)
27% of ER physicians reported sustaining an injury from a workplace assault
The top five kinds of physical assaults were hit or slap (44%), spit (30%), punch (28%), kick (27%), and scratch (17%)
About 80% of ER physicians reported that workplace violence reduces staff productivity, increases emotional trauma, and extends wait times
The Number One suggestion (49%) to address ER violence was increasing security
69% of ER physicians reported that workplace violence has increased over the past five years
Solving the problem
Kowalenko said there are four approaches to addressing violence in emergency departments: hospital policies, environment changes, staff education, and legal.
Policies related to violence in the ER should be clear and consistently enforced. This approach applies to policies that may seem indirectly related to violence such as rules governing how many visitors can see a patient at one time.
Environmental factors include security, cameras, and "badging" in and out of an ER's treatment area.
Education of staff should not be limited to reacting to violent situations. Training should include identifying potentially violent patients and strategies to defuse potentially violent situations.
More than two dozen states have adopted laws that make assaulting a healthcare worker a felony. These laws make assaulting a healthcare worker equivalent to assaulting a police officer.
Friedman said ER physicians and other staff members should consider pressing charges after a patient assaults them.
"Healthcare workers underreport violence because we want to take care of people. We don't want to create more of a problem when one already exists, but we are enabling the problem to a certain extent," he said.
Impact on patients
In the ACEP survey, 77% of ER physicians reported that emergency department violence undermines patient care.
Patient care suffers when there is violence in an emergency department, Friedman said.
"Emergency room patients can be traumatized to the point where they leave without being seen or treated because they were exposed to acts of violence. It also increases wait times and distracts physicians and nurses from the other patients in the emergency department who need their care," he said.
