Strategies for overcoming ICU instruction obstacles include condensing educational interactions and conducting bedside teaching sessions.
The ICU is a unique care environment that includes teaching of a diverse set of caregivers such as nurse practitioners, physician assistants, medical students, residents, and fellows.
Teaching in an ICU involves several obstacles, according to a recent article published in CHEST.
"Teaching in the ICU comes with unique challenges given the medical complexity of the patients, the time pressure, the diverse levels and professions of learners, and the challenges of communication at the end of life," the researchers wrote.
Overcoming these hurdles includes assigning capable instructors, condensing interaction time with students, and teaching at the bedside.
Instructor qualities
The researchers surveyed internal medicine resident physicians to find out which qualities an excellent ICU teaching physician should possess. Enjoyment of teaching was the most coveted quality:
Enjoyment of teaching residents
Demonstrating empathy and compassion to patients and families
Explaining clinical reasoning and differential diagnosis in the critically ill patient
Treating non-MD staff members respectfully
Showing enthusiasm for topics discussed on rounds
"These teaching tactics can be refined and continuously improved, making them ideal for faculty development. Beyond behaviors that educators can learn, they also need to know the targets for board certification to prepare their learners," the researchers wrote.
Time pressure
There are ways for ICU instructors to overcome busy schedules, Lekshmi Santhosh, lead author of the CHEST article, told HealthLeaders this week.
"We recognize that the ICU clinical environment is extremely fast-pace and that balancing high clinical workload with teaching is always a challenge. Fortunately, there is robust medical educational literature from the outpatient, ED, and inpatient settings discussing how to approach teaching in a time crunch," she said.
The "1-minute preceptor model" and mini-chalk talks are examples of condensing interactions with trainees.
Mini-chalk talks can be banked for future use and should be honed in advance of presentation. Simple symbols are effective such as Venn diagrams and flow charts.
Bedside instruction
The bedside is a prime location for instructing residents and other trainees in the ICU, Santhosh said.
"Learners crave clinically applicable, relevant teaching points delivered just-in-time to reinforce learning: bedside teaching thus engages learners immediately and they crave good bedside teaching. Moreover, it is patient and family centered as it brings patients and families into the educational process in the role of educators. Lastly, bedside teaching is often efficient for teaching faculty as it combines direct patient care with education."
Bedside instruction must also be constrained to the ICU environment, the researchers wrote.
"ICU bedside teaching has to be deliberately and carefully refined. Educators should thoughtfully consider the limited scope of a bedside teaching session and resist the temptation to over-teach. Instead, giving a brief 5-min to 15-min talk at the bedside that is relevant to current or recently admitted ICU patients may be more helpful," they wrote.
Some doctors reject a provocative proposal to delay antibiotics for sepsis patients without shock. But proponents argue antibiotics pose significant risks, too.
Drawing the line on antibiotics for sepsis patients is drawing scrutiny, pitting an antibiotic stewardship perspective against the established reliance on antibiotics.
A recent editorial in Journal of the American Medical Association calls for a more conservative approach for treating sepsis—delaying antibiotics treatment in some cases of sepsis without shock.
With its deadly mortality rate, an aggressive approach to treating sepsis patients with antibiotics is common practice.
Treating patients with possible sepsis or septic shock requires a nuanced approach, the editorial co-authors wrote.
"The need to treat patients rapidly and aggressively ought to reflect on the severity of illness and certainty of diagnosis rather than applied uniformly to all patients. If a patient clearly has a bacterial infection, prompt treatment is indicated. If there is diagnostic uncertainty, however, clinicians should calibrate their response to severity of illness and probability of infection," they wrote.
The proposed approach challenges the standard of care, which calls for rapid administration of antibiotics to all sepsis patients whether they are in shock or not.
Aggressive track
Administering antibiotics to all sepsis patients should remain the standard of care, James O'Brien, MD, director of quality and patient safety at OhioHealth in Columbus, told HealthLeaders this week.
"The data supports that the sicker a patient is—and septic shock is probably the best example—the more likely they are to benefit from antibiotics. But there is evidence of patients with sepsis without shock who also benefit," he said.
O'Brien said a family medical case exemplifies the advisability of administering antibiotics to sepsis patients without shock.
His mother had melanoma removed from her back, then she got confused at home. She went to the hospital with no signs of shock but was treated for sepsis.
"As a result of the care that the hospital provided—getting rapid antibiotics and opening the wound to drain—she recovered. But if we had waited for tests to come back, it's very possible she could have progressed to develop shock. Then you're dealing with somebody whose mortality jumps up significantly," O'Brien said.
"So, I have hard time from the patient's standpoint waiting until they have shock, then all of a sudden we'll jump onboard," he said.
Adverse impacts
Patients face significant risks from antibiotics, Michael Klompas, MD, the lead author of the JAMA editorial, told HealthLeaders this week.
"The risks of antibiotics extend beyond Clostridium difficile alone. They can cause organ damage, interact with other medications, and promote colonization and infection with drug resistant pathogens that then pose downstream treatment problems," said Klompas, an infectious disease physician at Brigham & Women's Hospital in Boston.
The JAMA editorial lists several other adverse impacts from antibiotics: kidney injury, hepatitis, cytopenias, sever rash, mitochondrial toxicity, and alteration of the microbiome.
There are adverse effects associated with antibiotics, Klompas said.
"Studies estimate that a remarkable 20%-25% of hospitalized patients exposed to antibiotics develop some sort of adverse effect. This flies in the face of the commonly held perception amongst both doctors and the general public that antibiotics are "free"—they are very safe and there's little downside."
Treatment for sepsis
Treatment of sepsis requires the exercise of good medical judgment, O'Brien said.
"It's more art than science now. For me, it winds up at the intersection between patient risk, the severity of illness, and the likelihood of alternative diagnoses. I factor all of those to determine the relative risk of treatment for sepsis versus the relative risk for not treating for sepsis," he said.
Sepsis patients stretch across a continuum, O'Brien said.
"If I have a patient who is elderly, is currently being treated for leukemia, and was recently in the hospital, these are all risk factors for sepsis. If they come in with shock, and I don't have an alternative diagnosis or reason for them to be in shock, I'm going to need to have significant evidence that the patient does not have sepsis."
"Alternatively, I could have a healthy 22-year-old who has no medical problems, has not been in contact with healthcare, and comes in with unclear complaints. There's no signs of shock and the patient is talking. That's someone I am going to be more delayed with."
Physicians are needed most keenly to treat more complicated sepsis cases, O'Brien said.
"There are a whole bunch of patients who end up being in that spectrum—between the polar opposites. In between is where you need a physician to integrate the data and make a decision when there is uncertainty."
Under pressure to deliver value, increase efficiency, and lower costs, health systems and hospitals are seeking ways to advance the capabilities of their physicians.
At least half of the nation's physicians are sick of their jobs at a time when demands on their skills are more critical than ever. In the past, hospital leaders could reliably throw money at the problem. Not so much anymore.
A tried-and-true way to "engage" physicians historically has been through their paychecks to prod along everything from quality incentives to EHR implementation. The kitty of cash that leadership teams had on hand to make physicians happy is almost empty these days, operating margins being what they are. Without income in hand, hospital leaders must rely on some thrifty and tested "satisfiers" that work in any good business: create a reliable team around them, involve them in the business, and add technology that—for one—makes their job easier.
Leaders may recognize an opportunity: that the underlying fundamentals of physician labor are changing. The benefits of high reliability, team-based healthcare takes the physician from being the only voice in the huddle to a leading voice in a coordinated care plan. Bringing physicians into decisions on supply chain creates the beginnings of a business partnership.
Under pressure to deliver value, increase efficiency, and lower costs, three leading health systems are advancing the capabilities of their physicians through a supportive and productive environment.
A 2017 study published by the National Academy of Medicine found that more than half of surveyed physicians were exhibiting substantial signs of burnout.
No health system can address burnout without first understanding one of the root causes: quality of care. At Cleveland Clinic, efforts to become a high-reliability organization since 2013 have achieved a trifecta: improved patient outcomes, boosted physician satisfaction, and reduced physician burnout.
"There is a big problem in healthcare with burnout, which is complex and involves lack of job enjoyment, feeling stressed, and work-life balance challenges. All of those things improve when you have a team working together smoothly to get the best outcomes for patients," says Edmund Sabanegh, MD, main campus hospital president.
The correlation between team-based care and physician satisfaction is direct, says Sabanegh.
"Things that help us successfully treat patients—team approaches, checklists, and spreading of responsibility—improve our engagement and satisfaction with our career field," he says.
1. Happiness Begins With High-Reliability
Cleveland Clinic's high-reliability initiative has revolved around basic team building, policy standardization, real-time operational management, creating a culture of safety, and sustaining redundancy in the clinical setting.
"There has been a revolution at Cleveland Clinic over the past several years to emphasize a culture of high reliability and safety, as well as to emphasize a team approach to everything we do," Sabanegh says.
But inconsistency in administrative and operational policies is a major challenge for health systems seeking to attain high-reliability, says Sabanegh.
"One of the challenges for any large healthcare system is there are many sites for delivery of care. A pitfall that you can have is failing to recognize the nooks and crannies of the system, then having different policies and standard operating procedures for different areas," he says.
Cleveland Clinic, which features 19 acute-care hospitals, has made policy standardization a priority, he says. "We have worked hard to standardize our policies to make sure that a nurse who works in one ward, then works in another location in our system has a similar expectation and similar understanding of processes," he says.
One of Cleveland Clinic's high-reliability cultural initiatives has upended decades of tradition in the health system's operating rooms. As opposed to the top surgeon dominating discussions and decision-making in the OR, the health system has adopted a team-oriented approach including operating room pauses, he says.
"If we have a surgery and anyone in the room is unsure of equipment status or a missing supply like a sponge, there can be a pause. Any member of the team can say, 'I want to look at where we are before we proceed any further with this procedure.' It could be the most junior member of the surgical team or it could be the most senior member."
To achieve real-time operational management, Cleveland Clinic adopted a reporting system based on tiered huddles this year.
"Every morning, on every nursing unit, there is a huddle of the team. They discuss what has gone right, opportunities, and concerns for the day ahead," Sabanegh says.
The discussions at the ward level are reported to the hospital leadership level, including the president, chief nursing officer, chief medical officer, and chief quality officer.
The hospital leadership's huddle is reported to the health system leadership. Information gathered through the tiered reporting allows senior leadership to take action quickly at any location in the organization,
he says.
"As the hospitals' president, I am hearing every day from every hospital in our system about their challenges and opportunities for the day ahead. What is our workload and how can we balance it? What kind of infrastructure support do we need? What kinds of repairs are needed?" Sabanegh says.
Gathering timely information from throughout the health system is invaluable from both management and labor perspectives, Sabanegh says.
"Real-time operational management gives us both an early warning system for problems and challenges for the entire enterprise, and a great venue to communicate up and down the organization. Everybody is hearing about challenges at other places and how those challenges are being solved," he says.
Culture is essential to creating a high-reliability organization, he says. "We are working very hard to create a culture of safety and high-reliability. Every time the leaders of the organization speak, they talk about
this theme."
Staff members are encouraged to identify quality concerns with public recognitions such as awards. "We don't want to be in a reactive mode. Our system fails when we have a serious safety event. What we want to identify is the near miss or something that could turn into a serious safety event down the road,"
Sabanegh says.
Although redundancy is often equated with waste, Cleveland Clinic sees value in redundancy in the clinical setting, he says.
"We still believe some redundancy is necessary. We are leveraging technology to assist in catching things; but, in this generation, technology will not replace the need to have multiple sets of eyes looking at a challenge," he says.
Education and communication have been key elements of engaging physicians in high-reliability efforts at Cleveland Clinic, Sabanegh says.
Educational programs that support the health system's high-reliability efforts include Solutions for Value Enhancement (SolVE).
"Physician leaders learn about high-reliability, performance improvement, and tackling processes with risk and opportunity while avoiding risk. We have trained thousands of people in our organization in these areas,"
he says.
Cleveland Clinic also communicates with clinicians about the benefits associated with high-reliability organizations, he says.
Engaged clinicians have helped Cleveland Clinic achieve significant high-reliability gains.
The average 30-day readmission rate has fallen from 14% to 12.65%, which represents 2,100 patients per year who did not require a readmission.
Outpatient hypertension control has increased from 66% to 76%, with 15,000 more patients at prescribed goals. Cleveland Clinic estimates improved hypertension care has saved about 100 lives.
"We have seen a steady improvement in our quality outcomes, a reduction in serious safety events, and improvements in our readmissions—all things that are important to our patients and improve when our care team makes sure we are highly reliable," Sabanegh says.
2. Save Physicians and Patients With Predictive Modeling
Predictive modeling is not brand-new technology, but its utility has advanced into care scenarios that have the potential to improve patient care and give physicians a critical tool.
NorthShore University HealthSystem is using prediction models to give physicians important information about their patients. The health system has about 20 prediction models to target high-risk patients for factors such as cardiac arrest and readmission.
Prediction models help physicians decide whether their patients need interventions, says Nirav S. Shah, MD, an infectious disease specialist at NorthShore.
"The prediction modeling is refining the patient population, so that when you perform an intervention you can find the highest-risk patients. Instead of performing interventions on an entire population, we can limit the intervention to a small subset of the patients," he says.
In NorthShore's cardiac arrest prediction model, a patient's risk level for cardiac arrest helps determine whether an intensive care consultation is held. The model has resulted in fewer patients having cardiac arrest and a trend toward decreased mortality, Shah says.
NorthShore is preparing to take a leap forward in its prediction modeling efforts with a cutting-edge technology.
"The most exciting thing we are doing is embarking on a journey to integrate all of our prediction models into a single engine," he says.
Combining prediction models will expand the utility of the data for physicians and population health initiatives.
"Most institutions are getting more and more into these prediction models, but they are each in their own silo. Each prediction model has its own lexicon of risk. What we are doing is trying to combine every prediction model into a large engine, so we can subdivide patients," Shah says.
Subdividing a patient population will help NorthShore manage high-risk patients with multiple morbidities, he says. "We may have an intervention for high-risk readmission patients that could be an intervention for patients who are also high-risk heart failure."
One of the top goals of NorthShore's Clinical Analytics Prediction Engine (CAPE) is establishing a powerful data-driven learning capability, Shah says.
"We are finding a way to sub-segment our entire patient population using analytics and prediction models, so we can target specific patient populations. Then we will use this engine to quickly learn whether interventions on patients or subgroups of patients make sense."
Running randomized trials can take months to a year to complete, but CAPE will run randomized trials much faster, he says.
"On the academic side, you use randomized controlled trials, where you take populations, get consent from them to be part of the study, use resources such as the people who design these studies, then it takes six months to a year to enroll patients and analyze the data. … We will be able to speed up deciding whether an intervention makes sense from six months to a year, to a couple of weeks," Shah says.
CAPE's capabilities will deepen NorthShore's understanding of its patients.
"We are essentially using this new engine to create a learning health system, which will allow us to continuously learn from the patient population. Instead of creating randomized controlled trials that are separate from patient care, we are building the ability to conduct these trials into our system of care," he says.
Physician engagement and winning over skeptics is a crucial element of launching prediction modeling initiatives, Shah says.
"We have a track record of implementing predictive models. Initially, it can grate some physicians when they feel their autonomy is being taken over by algorithms. You have to show you are improving patient care. In the end, all providers want to improve patient care," he says.
Demonstrating positive outcomes for patients is powerfully persuasive for even the most doubtful physicians, he says. "Even if it's an algorithm that physicians feel is supplanting some of their autonomy, if they see that a prediction model is resulting in better outcomes, that will click a lightbulb immediately and they will buy into it."
Rather than diminishing physician autonomy, prediction modeling is already helping many physicians make wiser decisions, Shah says.
"Physicians use a lot of algorithms already. The Model for End-Stage Liver Disease (MELD) score shows whether someone is at high risk for death if they have liver cirrhosis. There are all kinds of tools that already exist that providers do not complain about," he says.
Shah predicts CAPE—which is being built in the health system's Epic electronic medical record, will be appealing to physicians who view EMR data entry as a waste of time.
"You are essentially putting in a lot of data, and it's not giving you valuable information in return. You can show physicians that prediction models are providing them with key insight for outcomes that are important to them and that the data they are entering has a return on investment," Shah says.
In addition to using prediction models to supplement physician decision-making, NorthShore has been improving Epic's user experience for years, Shah says.
"We were the first to adopt Epic on the inpatient and outpatient sides. So, there are many things that we have done from an optimization standpoint—providing physicians with dashboards and other capabilities to help them make the best decisions for their patients," he says.
An Epic improvement adopted this summer helps inpatient clinicians pick the right antibiotic for patients before culture data is available, he says.
"When someone comes in for treatment, we often do not know which antibiotics are going to work for the patient. We want to find the perfect antibiotic for any given patient, so we can reduce the risk of the patient getting worse and reduce the risk of resistance," Shah says.
The new antibiotics capability in Epic includes data from What's Going Around—a graphical representation of five illnesses in Chicago's northern suburbs such as strep throat and flu-like illness.
The key was creating a program that draws several patient variables directly from Epic, Shah says.
"It uses infectious disease guidelines, it uses prediction modeling, and it uses the What's Going Around epidemiological tool. All of that information is integrated into a single decision-making tool that allows a provider to determine the best antibiotic for their patients before there is culture data to guide therapy," he says.
3. Physicians Empowered to Help With Supply Chain
Kettering Health Network is tapping the clinical expertise of physicians to improve clinically integrated supply chains, which support value-based care with physician engagement, data analytics, point-of-use management, and strategic contracting.
Trisha Gillum, director of supply chain management at Kettering, says physicians can play diverse roles in a clinically integrated supply chain.
"It can be as small as a physician champion on a single project, to being a physician champion for a service line, to being on the payroll for supply chain," she says.
Gillum says the best physician champions for medical supply changes are personally engaged in the effort. "They are willing to understand both the financial and the clinical nuances to a project. They are also willing to speak with their peers—to be a cheerleader or champion for a project."
When Kettering identifies engaged and respected physicians who are interested in serving in the champion role, the doctors receive training from The Advisory Board Company. Physician champion programs at this Washington, D.C.–based consultancy range from individual sessions to a physician leadership track that has sessions held over several months.
Two primary elements of the education programs are business instruction and learning about the nuances of the changing healthcare industry.
"Many physicians are not in tune with everything that is going on in the hospital environment," Gillum says. "They don't understand when we say we need to save money. So, there is education about financial pressures and clinical pressures."
Another educational goal is giving physicians leadership skills, she says.
"We are asking them to step out of their traditional roles and communicate with their peers at an advocacy level. To do that, we not only need to provide the data to support product conversations, but also give them the tools necessary to have those conversations."
In a clinically integrated supply chain, physician champions play a potentially decisive role in proposed supply changes, Gillum says.
"If you really want a physician to get engaged, they will bring their own mindset about what the answers should be. You cannot expect a physician to come onboard and rubberstamp the process," she says.
Supply chain managers and other leaders should be open to opposing views from physician champions, she says. "They are going to want to engage in the process. They are going to want to modify it. So, you may end up in an entirely different place than you expected."
When physician champions object to proposed supply changes, open communication is essential, Gillum says.
"You have to be transparent. You can't ask a physician to own something like a cost-savings initiative unless you are willing to say how much we are going to make on a procedure. You have to be willing to share all of the data and to give physician champions all the facts to make intelligent decisions," she says.
Supply chain managers should treat physician champions as valued teammates, Gillum says. "You have to realize that you have asked physicians to play a supply chain role and to provide information. If you disregard what they are saying, you are going to lose partners."
The best-case scenario for physician champions is when they take ownership of a supply change project, she says.
"I had a physician who went out and talked with every one of his peers who performed a particular procedure. He convinced every one of them that we needed to make a change. He was able to accomplish more in those conversations than I could have accomplished in months of conversations with the same group of physicians," she says.
Gillum says the two primary benefits for clinicians who assume physician champion roles are gaining experience that helps them compete for hospital administration jobs and helping to decide supply changes that could impact their patients.
"I had one physician say [that] he was passionate about the supplies he used on his patients. The best way physicians can control the supplies that they get is to be part of the conversation and part of the decision," she says.
Photo credit: Nirav S. Shah, MD, infectious disease specialist, NorthShore University HealthSystem (Jean-Marc Giboux/Getty Images)
In addition to the high sepsis mortality figure, the research in the Journal of the American Heart Association found five predictors of sepsis mortality: older age, male sex, chronic obstructive pulmonary disease, low log serum vitamin D, and high platelet count.
Targeting chronic heart failure patients with these predictors could drive down sepsis deaths among CHF patients with reduced left ventricular ejection fraction.
"Sepsis is a major contributor to death in people with CHF and has a different risk marker profile from other modes of death, suggesting that it may be amenable to targeted preventative strategies," the researchers wrote.
The sepsis predictors stand out, the researchers wrote. "Crucially, the variables most strongly associated with sepsis death showed a distinct profile compared to other noncardiovascular death, progressive heart failure, sudden cardiac death, and all-cause death."
Unexpected sepsis mortality
The high percentage of sepsis deaths among CHF patients was a surprising result, Richard Cubbon, PhD, a top researcher for the JAHA article, told HealthLeaders last week.
"We had not expected such a large proportion of people with heart failure to die of sepsis, but other studies have shown that sepsis is an important cause of hospitalization in people with heart failure," said Cubbon, a senior lecturer in the Leeds Institute of Cardiovascular and Metabolic Medicine at The University of Leeds, United Kingdom.
Several mechanisms could be at play for CHF patients with sepsis, he said.
"Heart failure can alter your immune response, which may increase the risk of developing infections. Some of the risk factors we identified, such as advancing age and chronic lung disease may also aggravate this phenomenon. Once infection is established, the heart must increase its pumping activity to meet the body’s increased metabolic demands—if it cannot meet these demands, vital organs receive inadequate blood supply and start to fail, which is a hallmark of sepsis."
Intervention strategies
The JAHA research, which featured 1,800 patients, indicates clinicians could be doing more to prevent sepsis infections such as administering influenza and pneumococcus vaccinations.
"Infection prevention strategies already exist, but they are not systematically offered to people with heart failure. So, patients and clinicians should consider the potential benefits of these strategies," Cubbon said.
Once sepsis is present in CHF patients, timely treatment is essential, he said.
"Early detection and treatment of sepsis is also known to improve survival, and so increasing awareness of the symptoms and signs of sepsis among patients and clinicians is also important. Clinicians should also be aware of the high risk of adverse outcomes when managing sepsis in people with heart failure."
For clinical applications, natural language processing can be used to search EMRs for information in both discrete fields and chart notes.
Natural language processing could be one piece of solving the EMR information overload puzzle.
"It's a necessary part of taking your EMR to the next level," says Walter Niemczura, director of application development at Drexel University's information technology department.
To mine clinical data, NLP scours electronic medical record systems for keywords and phrases related to patient care, generating information that can improve billing, efficiency, and population health initiatives.
"When we first started NLP and everything was on the research side, we talked about the time that could be saved doing research. Now, we're at the point where we can use NLP as part of an AI solution to improve care and improve the business," Niemczura says.
NLP can efficiently review physician notes from patient visits, he says.
"For example, a patient goes to our HIV clinic and the patient is billed for HIV, but the patient is not coded for hepatitis C even though they may have been prescribed hep C medications. Instead of manually reviewing every chart—no organization has that manpower—we can come up with a daily NLP task to see whether there was a missed billing opportunity," Niemczura says.
Automated chart review
Drexel clinical researchers used NLP to sift through 5,700 patient records for HIV and hepatitis comorbidity. "We reduced the number of candidates to 1,150," Niemczura says.
The project demonstrated the potential for efficiency gains from NLP, he says. "We were able to reduce chart review to 20% of the population. The original effort was five months, and we got it down to less than a week."
Using NLP to search chart notes was a key capability in the comorbidity effort, Niemczura says.
"If you were just looking at the codes in discrete fields, you came up with 677 patients, but there is more information in the notes. For patients who were HIV coded, the hep C patients could be absent in the codes but listed in notes. So, there were an additional 443 comorbid patients in the notes," he says.
NLP staffing
Niemczura says experienced IT staff should be involved in NLP projects.
"Unstructured data is not an academic query that you can learn in school—you learn from a lot of experience. So, the more experienced the user is, the quicker they can generate the end result."
IT specialists also can help integrate information from multiple computer systems and programs, Niemczura says.
"Having an informatics department involved is helpful because NLP technology is not just a standalone system. When there are billing opportunities or opportunities to improve patient care, researchers and clinicians don't have the ability to integrate the output from the NLP system into other systems such as the EMR," he says.
Lean approaches to NLP are feasible.
"You are better served with an informatics department, but it is certainly something that a physician could take the time to learn. Someone involved with research could learn it," Niemczura says.
EMR mining operation
The St. Louis-based Mercy health system's NLP initiative includes gauging the performance and outcomes of medical devices and searching patient records by disease symptoms.
"We were able to capture a lot of key cardiology from our notes. We put those results into a data platform that included all of the discrete data that we were able to get from our EMR and created a complete data set on a heart failure patient population," said Kerry Bommarito, PhD, manager, data science/performance analyst-enterprise at Mercy.
NLP allowed Mercy to collect a rich set of medical device information, she says. "We were able to show the life cycle of a heart failure patient to see risk factors for heart failure, medications, labs performed, date of heart device implantation, and outcomes such as ejection fraction results."
The project showed NLP has the potential to ease the EMR burden on physicians, Bommarito says.
"We could have asked physicians to document this information into discrete fields, but they already spend so much of their time documenting. Continuously asking them to enter more things into discrete fields takes away time they actually get to practice medicine and be with patients," she says.
Mercy has also used NLP to search for patient symptoms such as shortness of breath, dizziness, fatigue, and peripheral edema. From the onset, the project faced a linguistic obstacle, Bommarito says.
"There is no one routine way that a physician talks about a patient's symptom—everyone says the symptoms differently. Physicians will say, 'history of,' or 'patient does not have,' or 'patient denies,' or 'patient asked about.' There is a lot of work looking for patterns when finding symptoms like shortness of breath—physicians can abbreviate it to SOB or use synonyms like disnea," she says.
NLP eases the collection of EMR information, Bommarito says.
"There were things that we were looking for that we could not get out of discrete fields in our medical record system. We knew physicians were putting this information in procedural reports, discharge summaries, and patient progress notes. So, we are looking to use natural language processing to get information out of the notes and put it into a structured format."
Hospital admission for a serious condition over a weekend or holiday has been linked to compromised patient outcomes, but researchers have found discharges may not be susceptible to the 'weekend effect.'
Discharge over weekends or holidays does not appear to impact readmission rates for major cardiac surgery patients, new research shows.
The finding runs counter to earlier research that has shown a negative impact on outcomes for major illness patients admitted to hospitals over weekends or holiday.
"Given the vast literature demonstrating the impact of the 'weekend effect' on admission outcomes, we expected a similar phenomenon surrounding the complex discharge process after cardiac surgery," Yas Sanaiha, MD, lead author of the new research in The Annals of Thoracic Surgery, told HealthLeaders this week.
"Our team was somewhat surprised to find that day of discharge did not impact adjusted odds of readmission," said Sanaiha, a resident physician in the Division of General Surgery at the David Geffen School of Medicine at UCLA.
The research features more than 4,800 cardiac surgery patients discharged from a UCLA Health hospital, with 20% discharged on a weekend or holiday. For all patients, the readmission rate within 30 days was 11.3%. The readmission rates for weekends (11.4%) and holidays (10.9%) were closely comparable.
"In this retrospective single institution study of patients undergoing elective major cardiac operations, weekend or holiday discharge was not associated with worse readmission performance after adjusting for patient comorbidities and intraoperative variables," Sanaiha and her fellow researchers wrote.
The research team found three predictors of readmission for the patients in the study. "Use of preoperative b-antagonist medications, tobacco use, and surgical site infections were independent predictors of rehospitalization within 30 days," they wrote.
Gauging 'weekend effect'
Readmission reduction is a complex challenge with multiple variables, Sanaiha told HealthLeaders.
"Hospital readmission reduction programs have focused on various measures such as patients with more severe baseline comorbidities, postoperative complications, poor social support, discharge to facilities other than home, among a variety of factors that impact continuity of outpatient care such as transportation for postoperative visits. To further complicate matters, each patient population and operation likely confer variable significance to risk factors, undermining a standardized method of identifying high risk-patients," she said.
The range of readmission variables motivated Sanaiha's research group to evaluate one potentially modifiable aspect of the discharge process—day of discharge. Specifically, the researchers sought to determine whether the "weekend effect" of worse outcomes after admissions for heart attack, stroke, sepsis, and other serious conditions over weekends and holidays also applied to discharges.
"This effect has been attributed to decreased staffing and increased transitions of care. The aim of the current study was to evaluate whether this 'weekend effect' also applied to the discharge process, which is an equally resource intensive phase of hospitalization that requires medical providers to be familiar with a patient and family's needs," Sanaiha said.
"Our study demonstrated that patients with active smoking and depressed ejection fraction (preoperative heart failure) were at higher odds of readmission. Further, we found that weekend or holiday discharge—after controlling for patient medical complexity, complications, and discharge disposition—did not impact odds of readmission."
Preventing readmission
While Sanaiha's team did not identify individual components of post-acute care that reduce readmissions for cardiac surgery patients, the researchers did glean insights.
"Bundled discharge interventions may diminish the impact of limited weekend staff and restricted outpatient resources on risk of rehospitalization after cardiac surgery," Sanaiha said.
Several elements of the UCLA Health bundle of discharge interventions for cardiac surgery patients likely help reduce readmissions, she said.
"Our discharge protocol includes early postoperative planning of clinic visits, and a thorough educational resource named our 'Healing Heart Handbook' tailored to institutional practices with approachable information about the numerous modifications to patient routine after cardiac surgery. Arguably the most important component of the discharge protocol is accessibility at any time of day to the cardiac surgery team who are familiar with discharged patients," Sanaiha said.
When integrated into the continuum of care, home health helps ensure that patients discharged from acute care settings and skilled nursing facilities do not suffer relapses that require rehospitalization.
Stakes are high with hospitals and health systems facing financial penalties under Medicare's Hospital Readmission Reduction Program for a half-dozen conditions including heart attack, pneumonia, and coronary artery bypass graft. Beyond the HRRP penalties, readmissions increase total cost of care.
As a way to address the readmissions challenge, savvy healthcare clinical leaders at health systems can use home health divisions to reduce hospital readmissions. When properly integrated into the continuum of care at health systems and hospitals, home health becomes a pivotal component of ensuring that patients discharged from acute care settings and skilled nursing facilities do not suffer relapses that require rehospitalization.
Data shows home health services can reduce readmissions:
Recent data from Paramount—a health insurance company affiliated with Toledo, Ohio–based ProMedica—shows that patients who utilize home health services within 14 days of discharge from an acute care facility are about 25% more likely to avoid a readmission within 30 days of discharge.
In a systematic review of heart failure patients published in the Annals of Internal Medicine, home nursing visits reduced readmissions and mortality for as long as six months.
In an observational study published in the journal Health Services Research, a combination of home health services and clinician visits decreased probability of readmission by 8%.
In a study published in the Journal of Post-Acute and Long-Term Care Medicine, patients discharged from skilled nursing facilities to home care with a home health visit within a week of SNF discharge had a reduced hazard of hospital readmission (adjusted hazard ratio of 0.61).
In coordination with a health system's hospitalists and primary care physicians, home health divisions can help avoid patient readmissions by deploying nurses, physical therapists, and personal care attendants into patients' homes after discharge. In addition to skilled nursing and physical therapy, some home health divisions perform infusions, which offers a relatively high-cost service in a low-cost setting.
Home health provides services that can keep patients from having to return to a hospital, says Bob Pritts, MHA, president of SSM Health at Home and Post-Acute Services, a division of St. Louis, Missouri–based SSM Health. "Most patients want to go home, they recuperate better at home, and home health gives them the opportunity to have the option to go home while still getting the care that they need."
SSM Health at Home offers a robust set of services that helps prevent readmissions, he says. "We do wound care, infusion, [and] a number of procedures in the home that have become regular practice. It's all designed to avoid the patient having to go back to the hospital."
Teamwork helps
To avoid readmissions, a team-based multi-disciplinary approach is important, Pritts says.
"If I have a personal care attendant who goes into the home to help with a shower, if she sees something with the patient, she calls the nurse. If I have a physical therapist in the home and they see an issue, they can call the nurse; or the nurse can call physical therapy if the patient is having trouble with balance or with gait. Everybody who is involved with patient care needs to assess that patient every time they come into the home," he says.
Multi-disciplinary teamwork is indispensable to avoid readmissions because no single team member is in the home every day.
"Nursing comes in once a week, and it's hard to identify a problem in visits once per week. Home health aides can be in the home twice per week, and physical therapy is in the home one-to-three times per week. So, you have multiple people in the house and they are all taking care of the patient," Pritts says.
SSM Health at Home care teams also coordinate care with the patient's primary care physician and specialists based on patient needs.
Within a year, the care coordination process will become more technologically advanced, he says. "We are in the process of doing a conversion from our postacute EMR to Epic, which is what the rest of the health system has. Once that is completed, physicians will be able to follow their patients no matter what level of care they are in, as long as there is a medical record and it is documented."
Cost and quality
Home health is a crucial element of limiting readmissions at ProMedica, says Steve Cavanaugh, MBA, president of the HCR ManorCare division of the health system.
"Home care is a critical link. When folks go home, often they are not fully ready to care for themselves, or they have rehab needs and nursing needs to fully complete their recovery. Home health plays an important role because if needs are not met, the patient is likely to suffer a setback and go back to the hospital or another care setting," he says.
ProMedica views home health as an opportunity to lower costs and improve clinical outcomes in the post-acute realm, says President and CEO Randy Oostra, DM, FACHE.
Home health is a way for health systems to help bend the cost curve on the local, regional, and national levels, Oostra says. "When you start thinking about general trends in healthcare—affordability and costs of healthcare in America—there is a cost differential between treating patients in a hospital and treating patients in a home setting."
ProMedica acquired HCR ManorCare this year. The division features 110 hospice locations across the country, about 30 home health locations primarily in the Midwest and Mid-Atlantic states, and dozens of SNFs.
Cavanaugh says a primary goal at HCR ManorCare is to become an integral component of ProMedica's continuum of care. "We see ourselves as being part of an integrated care delivery model—using home health and hospice as one of the ways to manage costs and improve outcomes."
"One of the things that has been really eye-opening for us in home health and hospice is that ProMedica has done a lot of good work on being a leader in social determinants of health. They do screenings and put active interventions in place," he says.
"We need to implement both a clinical plan of care and address social issues that get in the way of people getting healthy and staying healthy. We have to find ways to make that work—it can't always be us alone because we have to partner with others in the community and find the right resources," Cavanaugh says.
For health systems that are considering establishing a home health division, Pritts says regulatory considerations related to the Centers for Medicare & Medicaid Services are prominent.
"Medicare is looking at new ways to stratify which patients we see and how often we see them. You need to have a clinical person in place to keep you compliant with all of the changes CMS is making for home health," he says.
As health systems continue to expand into retail clinics, telehealth and other nontraditional offerings, gauging patient expectations and engagement are primary goals.
Navigating, measuring, and marketing are crucial to successfully establishing healthcare services beyond the hospital walls, according to a pair of patient access executives at this week's ATLAS conference in Boston.
"The entry points into the system are complex—there are a lot of different entry points into your health system. Hard wiring all of those so you can create some sort of seamless experience is a challenge," said Julie O'Toole-Black, vice president of access and operations at Indianapolis-based Community Health Network.
Along with measuring performance and marketing new service offerings, helping patients to navigate increasingly complex and sprawling integrated health networks is essential.
Providence St. Joseph Health has pursued a two-pronged navigation strategy for patients, said Karen Appelbaum, MHA, director of patient engagement and operations at the Renton, Washington-based health system.
"We thought of it partly as a digital strategy—designing better digital tools so people could self-serve and navigate to their best options. But that does not happen overnight and we're not quite there," she said.
"The other part is our contact center strategy—we call it our patient engagement center. While we are building our digital tools, we want to have great human service to help people navigate care."
Providence St. Joseph has made the two approaches complementary, Appelbaum said. "We have been able to learn from our human service to inform the digital strategy. With the data we have been collecting from the contact center, we have been building a chat bot to help patients navigate to the right setting."
Measuring new offerings
Providence St. Joseph monitors several measures to gauge the performance of nontraditional services such as the health system's Express Care Clinic retail settings, Appelbaum says.
"We look at factors such as our new patient acquisitions—how many new patients are we bringing into our system. We also look at how well we are tethering them to our system—are they connected with us, do they establish primary care? At our contact center, we measure conversion rates—do we set appointments when people call us, do we refer them to Express clinics, do we get them into primary care?"
A key metric has prompted Community Health Network to scrutinize its telehealth partnership with MDLive, O'Toole-Black said.
"It has not met the volumes we set to measure. We've attempted to reach out to those patients to ask how it could be a better experience. What we are hearing time and time again is, 'If you could offer virtual connections with my doctor or with my physician office, that is what I am looking for.'"
Offering telehealth as a service is much more than establishing a technical capability, she said.
"You have to take a progressive approach to an alternative care delivery mechanism and recognize it is not just about the means by which patients access care but also who is being accessed. You can throw out a lot of different options, but if consumers don't feel truly connected with their primary care physician, it may not be a popular solution."
Marketing dimensions
Marketing nontraditional service offerings has internal and external facets, Appelbaum said.
"For internal marketing, one area that came up right away was our primary care providers. In some cases, their response was, 'Don't take my patients.' We had to engage and partner with them. Part of what we showed in those discussions was we were going to lose consumers anyways if we did not meet their needs," she said.
Appelbaum said the external marketing challenge was similarly pressing because many of the health system's PCP panels were full. "Patients could not get in for months. So, we needed help from our primary care offices. Rather than just turning someone away, we asked them to set up appointments months out but also to refer patients to one of our Express clinics."
Community Health Network has a multifaceted marketing strategy for its nontraditional services, O'Toole-Black said.
"We have a connected-care strategy that is both digital and voice. We engage patients through our website, through direct marketing, and through Facebook and various other social media to make sure we permeate the external environment with our service offerings," she said.
O'Toole Black said external communications about services such as Community Health Network's retail clinic partnership with Walgreens cannot be one-way.
"The typical metrics for success are market share, conversion rate, and patient volume, but mining the voice of the customer is key. As we stand up these alternative sites of care like Walgreens, we have to keep listening to our consumers."
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.