Measures designed for vision-impaired patients include focusing on discharge and medication management, patient safety, and special accommodations.
Caring for vision-impaired patients in the hospital setting poses several unique challenges that institutions and care teams can address.
Recent research found that vision-impaired Medicare beneficiaries and commercial health insurance patients had significantly higher healthcare utilization and costs during and immediately after hospitalization. Pitfalls for vision-impaired patients include difficulty following hospital routines and struggles reading discharge orders and medication instructions. The excess costs were estimated at more than $500 million annually.
It is imperative for hospital staff to actively engage vision-impaired patients and their families, says Lisa Allen, PhD, MA, chief patient experience officer at Johns Hopkins Medicine in Baltimore, which includes the Wilmer Eye Institute.
"The biggest issue is to ask the patient or the patient's family what they need to keep them safe. We need to ask that question to everybody, but that patient engagement question is the most important piece for visually impaired patients. When we assume there is a one-size-fits-all for the visually impaired, we are making a mistake," she says.
Vision-impaired patients are not monolithic, Allen says. "A lot of vision impairment happens late in life. So, you have age-related vision loss, and that's different than the experience of people who were either born blind and educated as blind students or lost their sight early in life and had more opportunities to adapt. In other words, if you are not a braille reader—and many blind people are not braille readers—then having braille is not going to help when you are in the hospital."
Johns Hopkins Medicine and Bascom Palmer Eye Institute share best practices for hospitals and health systems in caring for vision-impaired patients. The best practices include measures designed for three areas: discharge and medication management, patient safety, and special accommodations.
1. Discharge and medication management
In addition to providing discharge instructions in large font type, Johns Hopkins has the capability to audio-record instructions for vision-impaired patients, Allen says. "For people who may not feel comfortable using a smartphone or a computer, having a recording can be helpful."
Johns Hopkins also provides discharge instructions in a format that can be used with a screen reader.
Designing processes and aids for medication management can be vital for vision-impaired patients, she says. "There is special attention paid to the visually impaired patient to make sure they understand their medications and that medications are laid out correctly and patients understand the schedule. Most of the medication packaging has braille; but not every visually impaired patient knows braille, so medication boxes have large print."
2. Patient safety
Johns Hopkins staff are trained to promote safety for vision-impaired patients, Allen says.
"Our call button has braille on it, and it is a large button. Staff show visually impaired patients a couple of different ways to utilize it," she says.
After surgery, all Johns Hopkins patients have a staff member with them when they are getting up for the first time and when they are walking the hallways, which is important for early ambulation.
There is an extra step for vision-impaired patients, Allen says. "Our physical therapists and techs are all trained to ask the vision-impaired or the blind patient, 'How would you like me to best lead you?' It is really important to ask that question because people have different preferences depending on how long they have been blind, how comfortable they are, or their visual impairment."
At the University of Miami Health System's Bascom Palmer Eye Institute, stairwells are designed to lower fall risk for vision-impaired patients, says Eduardo Alfonso, MD, director and chief medical director. "To increase the safety of patients and companions who take the stairs, we lengthened the staircase guard rails so they extend beyond the bottom of the stairs."
3. Special accommodations
Johns Hopkins and Bascom Palmer have implemented a range of special accommodations designed to boost the patient experience of the visually impaired.
All Bascom Palmer and University of Miami Health staff members are trained how to help vision-impaired patients, Alfonso says. Staff members offer guidance to visually impaired patients from check-in to discharge, he says. "It's not just Bascom Palmer staff. Use of sighted guide techniques, providing verbal instructions as needed, and practices to assist people with guide dogs are part of orientation for all UHealth staff."
Johns Hopkins is implementing a Bluetooth way-finding app that can be used from home and while using public transportation, Allen says.
"We made sure when we bought the program that it had voice capability, so it can tell you to go to an elevator, it can tell you that you are at an elevator, it can tell you what floor button to push, and it can guide you throughout the inside of the hospital. It gives the visually impaired patient independence. Often for blind people, they have to wait for transport even though they are perfectly capable of getting around with a guide dog or a cane," she says.
At Johns Hopkins and Bascom Palmer, signage and patient-oriented displays have been designed with vision-impaired patients in mind.
"Updated signage with high contrast colors and consistent lighting, and door signage in braille are prime examples. In addition, we are updating patient surgical display boards to make them easier to read, including a different font and color enhancements," Alfonso says.
Room utilization is a key component of patient experience for vision-impaired patients, Allen says.
"All patients are oriented to their room; but, certainly with the visually impaired patient, we make sure that they understand how far the bathroom is, where the bathroom is located, and how to use the equipment in the room. The other piece is training our food service staff to announce when they come into a room. They need to make sure that food is within easy reach. We want to make sure that happens for all patients but especially for the vision impaired," she says.
At inpatient units, Johns Hopkins has clinical customer service coordinators whose training includes working with the visually impaired, Allen says. "For example, there was a visually impaired woman whose husband was having surgery. The customer service coordinator made sure she got to the cafeteria, made sure she had coffee or water if she wanted it, and helped her find a place to take her guide dog outside. So, we are very sensitive and want to make sure that people's needs are met."
Initiatives involving healthcare organizations, housing groups, and government agencies require trust and communication across diverse industries.
Developing organizational relationships is a key element in addressing housing as a social determinant of health, a recent report from the National Housing Conference says.
Research has shown that access to affordable housing has a powerful impact on health outcomes. For example, homelessness hinders management of chronic diseases such as diabetes, and many patients face financial struggles balancing housing costs and medication expenses.
To bolster housing at community scale, establishing trust and effective communication across industries is crucial, the National Housing Conference report says. "Successful projects often bring together partners from various government agencies, nonprofit and for-profit housing providers as well as healthcare organizations like hospitals and health insurers. No single entity can tackle the challenges around health and housing alone but through their shared strengths and resources, progress is being made."
The report highlights three housing development initiatives that involve relationship building efforts.
1. Housing is Health Initiative, Portland, Oregon: Central City Concern, which is a Portland-based nonprofit group focused on homelessness, built relationships with six healthcare organizations including Kaiser Permanente Northwest to help finance nearly 400 new housing units. The effort generated a $21.5 million investment from the healthcare partners.
Central City Concern conducted boardroom sessions with its healthcare partners to emphasize the importance of affordable housing to population health. The nonprofit also enlisted representatives from healthcare organizations to serve on the group's board of directors.
2. Creating Homes Initiative, Tennessee: For the past two decades, the Tennessee Department of Mental Health and Substance Abuse Services has developed affordable housing opportunities across the state, including independent living arrangements at rental properties and private homes. From 2001 to 2016, the agency's Creating Home Initiative developed more than 15,000 affordable housing options.
The Tennessee Department of Mental Health and Substance Abuse Services employs seven regional housing facilitators, who have developed relationships with several other state agencies and community partners. Agencies that have provided financial support for the Creating Home Initiative include the Tennessee Housing Development Authority, Federal Home Loan Banks, the federal department of Housing and Urban Development, and the U.S. Department of Agriculture.
3. Massachusetts housing and health pilot program:LeadingAge Massachusetts—a trade association of nonprofit providers of aging services—and the Long-Term Quality Alliance are leading an initiative to provide coordinated services to residents of affordable senior housing communities in The Bay State. The pilot program is drawing funds from health insurers to finance on-site service providers in affordable housing such as resident service coordinators and wellness nurses. The health insurers are hoping to reduce hospitalizations and emergency room visits.
The University of Massachusetts-Boston is a key partner in the pilot program, monitoring costs and health outcomes.
Managing health and housing collaborations effectively
There are several factors to consider when building health-oriented housing development partnerships, David Dworkin, president and CEO of the National Housing Conference, told HealthLeaders. "The primary elements are understanding the business model of your prospective partner, building trust, data sharing, financial alliances, and strong leadership."
Relationship building in health and housing collaborations can be challenging, he said. "These are necessary partnerships between extraordinarily diverse entities, from government agencies to healthcare providers, and housing developers to health insurers."
Harnessing a blend of nonprofit and for-profit organizations can be difficult because they have different business models and accounting practices, Dworkin said. "Many of these organizations may be significantly siloed, so understanding who the decisionmakers are and who the substantive experts are is also critical as they will ultimately have to come together to close a partnership arrangement."
Teamwork on community assessments is pivotal when healthcare organizations participate in affording housing projects, he said.
"Hospitals can use their community benefit dollars toward financing affordable housing, but affordable housing must first be identified as a community health need. For this reason, it's important for affordable housing advocates and providers to be at the table when community health needs assessments are being conducted to raise the importance of affordable housing for healthy outcomes and develop impactful strategies that can be measured and financially accounted for."
Every second counts for patient outcomes when a stroke blocks blood flow to areas of the brain.
For stroke patients who undergo intra-arterial thrombectomy (IAT), mobile stroke units generate faster surgical treatment times compared to emergency medical service transport, recent research shows.
"Time is brain" has been a maxim in stroke care for more than a decade. Research published earlier this year indicates brain cell loss during acute ischemic stroke (AIS) ranges from 35,000 cells per minute to more than 27 million cells per minute in "fast progressor" patients.
Intravenous administration of tissue-type plasminogen activator (tPA) and IAT are two of the primary standard-of-care interventions for stroke. IAT is performed mainly at tertiary care hospitals.
In research published recently by Stroke, mobile stroke units (MSUs) were associated with a 10-minute gain in a key IAT workflow metric: emergency room arrival to treatment time, or door-to-puncture-time (DTPT). The median DTPT time for MSU patients was 89 minutes compared to 99 minutes for emergency medical services patients.
Several factors contribute to DTPT time rates, including getting patients to the right hospital at the right time, identification of a large vessel occlusion by imaging, and alerting the appropriate teams involved in patient care, the lead author of the Stroke article told HealthLeaders.
"Mobile stroke units can make many of these factors happen more quickly, due to the availability of experts on the mobile stroke unit, the ability to do imaging in the field, and direct communication between the mobile stroke unit and hospital teams," said Alexandra Czap, MD, a vascular neurology fellow at UTHealth's McGovern Medical School in Houston.
The 10-minute gain in DPTP time for patients undergoing IAT is significant, she said. "As neurologists, we know that time is brain. Studies show patients can lose up to 27 million brain cells per minute, so we know that every second counts toward helping them preserve brain function."
MSU care teams can complete several preliminary steps necessary to perform IAT such as computed tomography of the brain, neurologist assessment, tPA eligibility screening, tPA treatment when appropriate, and baseline lab testing. "Several prehospital steps performed in an MSU, including acquisition of clinical history, examination, imaging, and evaluation and administration of tPA are potentially timesaving in IAT triage pathways," Czap and her coauthors wrote in Stroke.
The large sample size of The All of Us Research Program is expected to spawn big opportunities.
More than 175,000 participants have enrolled in The All of Us Research Program, which is set to have at least 1 million people enrolled over several decades.
Collecting data—such as biospecimens, health questionnaires, and electronic health records—from 1 million people will create a sample size capable of generating studies that account for individual differences in lifestyle, socioeconomic factors, environment, and biologic characteristics. The data repository has the potential to boost precision diagnosis, prevention, and treatment.
"Advances in genomics and biosensors have set the stage for refined taxonomies of disease, which may help to guide prognosis, improve existing treatments, and aid in the development of new therapies. Most important, advances in genomic analyses have helped to identify the underlying causes of disease in individual patients. However, many efforts have been hampered by an inadequate sample size and a lack of diversity among participants," All of Us researchers wrote this week in the New England Journal of Medicine.
The All of Us program received funding from the National Institutes of Health in 2016 and began enrolling participants in 2018. As of July 2019, biospecimens had been collected from 175,000 people.
The research program is designed to collect data from underrepresented groups. So far, more than 80% of participants are from groups that have been underrepresented in biomedical research.
Enrolling 1 million people will help address the dearth of diversity in research repositories and promote precision medicine, the corresponding author of the New England Journal of Medicine article told HealthLeaders.
"The paradox of precision medicine, to better treat the individual, is it takes large populations to better understand what is happening at the individual level. It is especially important that we capture diversity—about one-third of the United States is African American, Hispanic, or Native American, but only about 3% of existing genome-wide association studies cover these populations. It is important to capture this diversity and explore," said Joshua Denny, MD, a professor of medicine and biomedical informatics at Vanderbilt University Medical Center.
The All of Us initiative will improve understanding of health and disease in two primary ways, he said. "By revolutionizing how we improve health and treat disease—moving beyond 'one-size-fits-all' healthcare designed for the 'average' patient, and by ensuring that healthcare is tailored to the things that make us unique—our lifestyle, environment, and genes."
Denny expects the initiative will generate thousands of medical research projects.
Following initiative participant health and outcomes over decades
Participation in the All of Us program is guided by several features:
After granting consent, program participants complete baseline health and demographic surveys
Program participants grant access and sharing rights to electronic health record (EHR) data
Program participants provide biospecimens and physical measurements
Program participants can provide Fitbit data to the All of Us program, which plans to include data from other monitoring devices
Other data collected from program participants includes billing codes, laboratory and medication data, and narrative content
"With a plan to follow the health and outcomes of participants over decades, the All of Us program should enable research that provides an improved understanding of health and disease, which in turn would support accurate diagnoses, rational disease-prevention strategies, treatment selection, and the development of targeted therapies," the researchers wrote in NEJM.
The bounty of data is expected to generate groundbreaking opportunities, they wrote. "Our hope is that identification of risk factors and biomarkers—including environmental exposures, habits, and social determinants—will improve population health by bringing about more efficient and accurate diagnosis and screening, better understanding of diverse populations, more rational use of existing therapeutics, and the development of new treatments."
A Penn State College of Medicine vice dean who also works as a clinical psychiatrist shares his perspectives on medical staff burnout.
The stakes are high for physicians when it comes to burnout—it is estimated that a doctor commits suicide every day. Research indicates that nearly half of physicians nationwide are experiencing burnout symptoms. A study published in October 2018 found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction.
"Organizations should be moving forward in a systemized way on burnout. We know enough to recognize that burnout is corrosive. It's time to act," says Dan Shapiro, PhD, vice dean for faculty and administrative affairs at Penn State College of Medicine in Hershey, Pennsylvania.
Shapiro and several colleagues recently published a journal article about a five-tier hierarchy that they developed to help healthcare administrators prioritize interventions that address medical staff burnout. He has been involved in initiatives to ease burnout among Penn State Health's clinicians and nurses for nearly two years.
HealthLeaders recently spoke with Shapiro to get his perspective on efforts to address medical staff burnout. Following is a lightly edited transcript of that conversation.
HealthLeaders: Why are you interested in the topic of staff burnout in the medical setting?
Shapiro: I'm a clinical psychologist, and I saw my first physician as a patient in 1995.
I started noticing patterns. Physicians would come much later to treatment than other people—I realized that we had acculturated them to deny their own needs.
One of the first things we do with medical students is introduce them to the cadaver. What's happening in their heads and their hearts is, "Oh my god! Oh my god!" But they learn not to show emotion and to be professional. They hide what is going on inside of them. They learn to put their forehead down and grind it out in the service of their patients. We need doctors and nurses who can do that, but that means they look for help way later than the average person.
I was recruited to be a chair at Penn State's medical school and became a vice dean. That's when I became interested in efficient ways of measuring and impacting the pervasive burnout problem among my colleagues—both the physicians and the nurses.
HL: A recent article in JAMA Psychiatry warns ofthe dangerassociated with confusing medical staff burnout with major depressive disorder. How have these varying diagnoses played out in your psychiatric practice?
Shapiro: I have data because we are using depression screening inventories along with burnout inventories, and the ratio is about 5-to-1. I have five burned out folks to at least one who screens positively for depression. And in all the work that I do, I also look for suicidal ideation.
The reason we use the burnout hierarchy is that it prioritizes interventions for administrators, and the first level is this exact topic—"Do you have an adequate mental health safety net? Do you know the percentage of your folks who have screened positive for major depression, suicidal ideation, and binge drinking or other substance use?"
When a physician, a nurse, or another health professional filling out our surveys indicates they have had any suicidal ideation, the first thing that pops up is a list of resources. Then, if there has been more than one episode of suicidal ideation in the past year, we break confidentiality and personally reach out to the patient.
HL: How does the five-tier hierarchy that you helped develop aid healthcare leaders in prioritizing burnout interventions?
Shapiro: The hierarchy is based on Maslow's Hierarchy, so it has some inherent logic for administrators. One of the issues they face is that there are more than 80 factors that have been associated with burnout. That's overwhelming.
I compare a physician who is showing signs of burnout to a pilot who sees a warning light that an engine has failed. The pilot has a systematic way of responding to the warning light: checking the speed and heading; determining how much time there is to make a decision; finding out whether there is fuel, air, and spark getting to the engine; and contacting air traffic control.
The advantage of having a prioritized hierarchy for burnout is it starts with interventions that make a major difference such as physiological basics and mental health basics. For physiological basics, you determine whether staff members are eating, sleeping, and hydrating. The percentage of healthcare professionals who are dehydrated at any given time can be more than 40%. We know that dehydration impacts cognition and mood.
HL: For senior healthcare administrators, what are the primary elements of their role in addressing burnout?
Shapiro: First, you must assess the problem, preferably with brief surveys that the physicians will fill out. Then, you need to start systematically addressing a prioritized plan. Our hierarchy produces a dashboard that has ratings on each of the five levels.
Just like the patient safety movement, which started in the late 1990s, it's going to take us a while to address burnout and make real traction. So, we need to have realistic expectations. We also need to be prioritized in how we approach interventions. Engagement surveys can result in thousands of action plans at a health system, and our approach is the exact opposite. We want to pick a few interventions for each healthcare professional group, resource those interventions, have accountability, put action teams together from across several disciplines, and make substantive progress.
HL: What has Penn State done to address burnout?
Shapiro: The No. 1 thing that came out of our assessment was people feeling disrespected by the bureaucracy. So, we created a bureaucracy reduction team. We have systematically reduced the amount of email and automatic trainings. We're letting some people test out of compliance programs. We're thinking through nitty gritty details such as who can send an email to everyone in our organization, who can call a program mandatory, and which policies ought to be mandatory.
Second, we recruited and hired a physician mental health professional with a PhD, and we established a wellness office. Third, we are working to optimize the EMR. Fourth, we are looking at compensation.
Fifth, we are actively recruiting leaders with greater emotional intelligence. Our chair candidates now must go through a simulation, where they interact with a mock disgruntled faculty member. We want leaders who can help faculty navigate the common challenges they face.
We are in the first iteration of our responses to burnout. We are viewing this as a long-term process.
HL: What data are you collecting?
We want to see a 2.5% reduction in burnout.
It's hard for me to believe that we are wasting anybody's time. If you are instituting better security in your emergency department, where 85% of your nurses have been assaulted in the past year, it's hard to think you are wasting your time regardless of the ultimate burnout score. There are a lot of interventions like that. Getting food and water to all the nurses in the ICUs just seems valid.
I'm very interested in what our turnover numbers are going to be. Some of these interventions are going to help health systems and hospitals to keep workers in greater percentages. The turnover rate among nurses is very high—young nurses leave about 16% to 17% of the time over the course of a year. That's enormously high. If you can keep half of that number, the intellectual firepower you are retaining is significant.
I'm interested in the perception of staff about the safety of their organization. We are looking at patient satisfaction data—there's a pretty strong relationship between staff burnout and your patient satisfaction scores.
Dan Shapiro can be reached via email at drdanshaps@gmail.com.
Information drawn from a patient's electronic health record triggers virtual consultation with a specialist.
A new model for electronic consultations has the potential to improve care quality, reduce length of stay, and decrease hospital costs, according to a new journal article.
No single physician can know everything, which requires specialist consultation to effectively manage many conditions. But traditional consults—with chart review, patient history, physical exam, and recommendations—are time consuming and resource intensive. Targeted automatic electronic consultation (TACo) offers an efficient electronic health record-driven approach to specialty consultations.
Under the TACo approach, the EHR identifies patients who meet the criteria for automatic consultation and displays a customized view of patient information to a designated specialist for virtual review, the authors of the new Journal of the American Medical Association article wrote.
"The consultant can choose to provide targeted advice, suggest formal consultation, or neither. Like e-consults, this model allows the specialist to review pertinent information in the EHR and offer a rapid response. Unlike regular e-consults, these targeted automatic consults are triggered by patients' EHR data rather than a consultation request. Unlike automatic formal consults, the TACo model enables efficient virtual consultation," they wrote.
Previous research has shown patient access benefits from e-consult programs such as a Veterans Affairs study that found e-consults reduced response time by 92% to 95%, slashing consultation access time from 34.4 days to 2.4 days.
TACo approach to diabetes consults
The University of California San Francisco Diabetes Service has adopted the TACo model for inpatient screening:
On a daily basis, the EHR screens inpatients for four criteria—Type 1 diabetes, insulin pump use, and hyperglycemia or hypoglycemia in the previous day
For targeted patients, the EHR presents pertinent data for diabetes specialists such as glucose trends, insulin dose, fluid and nutritional information, and lab tests
After reviewing targeted cases virtually, specialists can make management recommendations in a brief consult note
The UC San Francisco TACo approach has generated significant benefits, including a 39% decrease in the proportion of patients with hyperglycemia and a 36% decrease in hypoglycemic events.
TACo opportunities
Five factors are likely to drive future adoption of the TACo model, the JAMA article says:
1. Consultations that are commonly requested
2. Patients that primary care teams find difficult to manage or challenging to connect with timely consultations
3. Patients that do not require detailed chart review
4. Patients that do not require visits with consulting clinicians
5. Triggering consultations with objective data such as a clinical test result that is conducive to EHR-based screening
"Because this model would likely increase the total number of consults, any investment in consultant time would have to be offset by improvements in care and decreased costs. If this approach results in improved quality, reduced lengths of stay, and decreased hospital costs, the business case for health system support could be strong, particularly when payments to the system are capitated or bundled," the JAMA article says.
More emergency departments are helping to manage the care of medically complex older adults.
Among older adults, frequent utilizers of the emergency department tend to have multiple comorbidities, pain-related diagnoses, and injury-related visits, new research found.
Older adults are associated with high ED costs and resource consumption. Compared to other patients, older adults use the ED at higher rates, have long ED stays, and need more medical interventions during their visit.
The new research published in Annals of Emergency Medicine found that frequent geriatric utilizers of the ED accounted for an out-sized portion of visits. While frequent geriatric utilizers represented 5.7% of the patients in the study, they accounted for 21.2% of all ED visits.
"Although the ED is often portrayed as a significant and costly portion of [healthcare] spending, much of this is attributed to the increasing trend of community-based providers relying on EDs to evaluate patients with complex disease who were previously admitted to the hospital, as evidenced by an increase in high-intensity ED visits. As a result, the ED's role in delivering care for a large proportion of the population is expanding, especially for older and sicker patients," the researchers wrote.
There were three primary predictors of frequent geriatric ED utilization:
1. Multiple comorbidities: Patients over 65 with three or more comorbidities had the highest odds of frequent ED use (odds ratio 7.2).
2.Pain: The second most likely factor for frequent geriatric ED utilization was primary diagnosis of pain (5.5 odds ratio).
3. Injury: The geriatric ED frequency odds ratio for an injury-related visit was 3.8.
"Geriatric frequent users are likely to have comorbid conditions and be treated for conditions related to pain and injuries. These findings provide evidence to guide future interventions to address these needs that could potentially decrease
frequent ED use among geriatric patients," the researchers wrote.
Managing frequent geriatric ED users
Among geriatric patients, identifying factors that can lead to frequent ED visits and providing supportive services are crucial to improving care and lowering costs, the lead author of the Annals of Emergency Medicine research told HealthLeaders.
"EDs are increasingly playing a pivotal role in the care of these patients. EDs throughout the United States have started to develop and implement geriatric-specific policies and protocols. These include comprehensive health risk screening, consultations with specialists such as geriatricians and pharmacists while patients are in the ED, referrals to memory clinics and other specialty clinics when a need is identified, and redesigning patient care areas to meet the needs of older patients," said Edward Castillo, PhD, MPH, Department of Emergency Medicine, University of California, San Diego.
Designing health programs across the continuum of care can be effective in managing older patients who are frequent ER users, he said.
"Intervention programs across the continuum of care would allow providers more opportunities to implement prevention strategies or treatment plans that can help alleviate the need for frequent ED visits and hospitalizations in older patients," Castillo said.
Older patients often have complex medical conditions that require care after they leave the ED, he said. "Wraparound services in the primary care, ED, and post-ED setting that take into consideration the patients' and their caregiver's wellbeing are necessary to successfully manage these patients."
Conducting a sepsis screening during emergency medical service transport to an emergency department reduces time to treatment.
Emergency medical service screening for sepsis speeds administration of the Surviving Sepsis Campaign 3-hour bundle of treatment, new research shows.
On an annual basis, sepsis affects about 1.7 million American adults and the infection is linked to more than 250,000 deaths. Timely application of the 3-hour bundle has been associated with reduced mortality.
In the new research, EMS crews conducted sepsis screening of patients before emergency department arrival, a co-author of the study told HealthLeaders.
"We implemented a standard operating procedure for sepsis screening—seven questions for the emergency department RN to ask EMS in any adult patients excluding trauma. When sepsis was suspected, the radio RN would notify the charge nurse to help get them into a room. The key takeaways are that implementing a sepsis screening tool for EMS to use is feasible and it helps to expedite care in these patients," said Megan Rech, PharmD, MS, an emergency medicine clinical pharmacist and adjunct assistant professor, Department of Emergency Medicine, Stritch School of Medicine, Loyola University, Chicago.
In the primary finding of the research, 3-hour bundle compliance was significantly higher using the EMS sepsis screening tool compared to a control group, 80.0% vs. 44.2%, respectively.
The bundle has four main components: measurement of serum lactate concentration, fluid resuscitation, blood cultures prior to antimicrobials, and broad-spectrum antibiotics for suspected or documented infection.
The EMS sepsis screening tool had seven elements:
1. Respiratory rate: N20 breaths per minute
2. Heart rate: N90 beats per minute
3. Systolic blood pressure: b90 mm Hg
4. Documented fever or history of temperature: N100.9 °F or b96.8 °F
5. Onset of mental status change
6. Oxygen saturation: b90%
7. Suspected infection
"There is great potential in the pre-hospital setting for earlier recognition of sepsis in patients arriving to the ED via EMS. Early recognition of sepsis will allow medical personnel to initiate sepsis protocol and decrease an important variable in sepsis mortality: time. We demonstrated that the use of a pre-hospital sepsis screening tool was associated with significant improvement in 3-hour bundle compliance, likely due to improved recognition of sepsis," Rech and her co-authors wrote.
Approaches to repaying medical school debt include loan forgiveness programs, loan consolidation, living within a budget, and locum tenens opportunities.
Most physicians who graduated from medical school in 2015 or earlier are still carrying student loan debt, with one-third owing more than $250,000, a new survey found.
Medical school debt is believed to impact choice of specialty and to exert upward pressure on pricing for physician services. Annually, a new class of doctors graduates with student loans totaling $2.6 billion, with the median student debt per physician estimated at $194,000.
A new Weatherby Healthcare survey based on data collected from 500 practicing physicians nationwide who graduated from medical school at least four years ago found 65% of the doctors are still paying off student loans.
"Every physician has a unique situation, so it's important to carefully consider how the repayment strategy you choose will affect your future. Do your research, talk to colleagues who are further down the road in repaying their debts, and seek help from a loan repayment expert. Making the right choices for you early on can result in significant long-term savings," Weatherby President Bill Heller says.
The medical staffing company's survey generated several key data points:
34% of indebted survey respondents expected to take at least a decade to pay off their student loans
Of the 35% of respondents who had paid off their student loans, 47% achieved the feat within two years of graduating medical school
60% of respondents said that purchasing a home had increased their debt load and slowed repayment of their student loans
For repayment strategies, 66% were interested in loan forgiveness programs, 45% wanted to learn about loan consolidation and refinancing, 39% wanted to find out how to live within a budget, and 29% were interested in locum tenens opportunities
Comparing physician student debt to other college loans
Although physicians take on significantly more student loan debt than other college graduates, many can pay off their loans relatively quickly, Heller says.
"Like most professions, the amount of medical school debt can vary widely among physicians; based on which medical school they attend as well as their access to grants, scholarships, military benefits, and family support. Most physicians finish residency with more than $150,000 in student loans, and it's not uncommon for new doctors to have debt of $300,000 or more. Compare this to the general college graduate average of $29,800," he says.
As is the case for all college graduates, the time it takes physicians to pay off their student loans depends on several factors, including loan balance, specialty, work setting, pursuit of loan forgiveness, and repayment strategies, he says.
"According to a Wisconsin survey, the average time to pay off student loans for the general population of college graduates was 21.1 years. If a physician chooses to participate in an income-driven repayment plan, it can take 20 or even 25 years before they are debt free. However, it seems a minority choose this option. Of the physicians we surveyed who had already paid off their debt, 6% said it took more than 10 years to pay off their loan."
New guidelines for bariatric surgery update recommendations that were set more than two decades ago.
A co-author of new guidelines for bariatric surgery says more patients, clinicians, and payers should embrace surgical interventions to treat obesity.
From 2015 to 2016, 39.8% of Americans over age 20 were obese, according to the Centers for Disease Control and Prevention (CDC). For the same time period, 20.6% of adolescents were obese, the CDC says. In 2008, the estimated annual medical cost of obesity was $147 billion.
Stacy Brethauer, MD, a surgeon at Ohio State University Wexner Medical Center in Columbus, Ohio, who helped draft the new guidelines for bariatric surgery, says millions of obese patients could benefit from surgical approaches to their condition if payers would cover the procedures.
"People make lifestyle choices that predispose them—or lead to—specific cancers and cardiovascular disease, and yet nobody hesitates to provide effective treatment for those problems," he says.
New bariatric surgery guidelines
The American Society for Metabolic and Bariatric Surgery (ASMBS) recently adopted a new set of guidelines that recommend surgical interventions for Class I obesity patients, who have a Body Mass Index (BMI) from 30.0 to 34.9 kg/m2. Obese patients with a BMI of 35 or higher have met the criteria for surgical interventions for more than two decades.
The new guidelines feature eight points and recommendations:
1. Class I obesity is linked to several other diseases, decreases longevity, and diminishes quality of life. Class I obesity patients need durable treatment.
2. Nonsurgical treatments for Class I obesity are often ineffective.
3. The longstanding BMI inclusion threshold of at least 35 kg/m2 is arbitrary and was established in the era of high-risk open surgery. Current surgical techniques for bariatric and metabolic surgery are much safer than in the past.
4. For patients with Class I obesity, bariatric surgery should be offered for suitable patients such as those who do not achieve substantial weight loss with nonsurgical methods.
5. Patients with Class I obesity and Type 2 diabetes are strong candidates for bariatric surgery.
6. The primary laparoscopic surgical interventions for obesity—adjustable gastric banding, Roux-en-Y gastric bypass, and sleeve gastrectomy—are safe and effective in the treatment of Class I obesity. The results of these procedures in Class I obesity patients are similar to results achieved in severely obese patients.
7. Patients who undergo surgical interventions for obesity should receive perioperative and long-term nutritional, metabolic, and nonsurgical support such as measures in the ASMBS Clinical Practice Guidelines.
8. For Class I obesity patients, the best evidence for bariatric and metabolic surgery supports the procedures for patients aged 18 to 65.
Surgical options
Gastric bypass and sleeve gastrectomy are the best surgical options for Class I obesity patients, Brethauer says. "Both of those procedures are considered good metabolic operations in terms of diabetes and metabolic improvement."
For Class I obesity patients, the ideal patient for gastric bypass or sleeve gastrectomy has diabetes that is not well controlled with medical therapy and continues to have to escalate their medical therapy, he says.
"In general, gastric bypass is a more powerful operation for diabetes in terms of getting patients off all their medications and achieving remission of their diabetes. In the long term, both operations achieve good control of glucose levels in patients, but patients with gastric bypass are more likely to achieve remission off medication," Brethauer says.
Obesity is not simply a matter of will power alone, he says.
"Obesity is a disease that consists of genetic factors that lead to predisposition; environmental factors, which have a lot to do with calorie-dense food that is easily available and cheap; and behavioral factors linked to an increasingly sedentary lifestyle. Those three factors all go into our obesity epidemic."
Although long-term societal efforts should be launched to address the environmental and behavioral components of the obesity epidemic, many obese Americans could benefit from surgical interventions now, Brethauer says.
"There are already millions of people who are suffering with obesity, and they need to be offered treatment for it. Typically, diet, behavioral therapy, and even medications do not offer good long-term results once someone has already become severely obese."
