Daylong shifts in the emergency room pose a threat to physician health and patient safety, researchers say.
Recently published research shows the cognitive abilities of emergency room physicians were significantly impaired after working a 24-hour shift.
The researchers, who published their work in this month's edition of the Annals of Emergency Medicine, gauged the cognitive function of 40 ER physicians after a night of rest at home, after a 14-hour shift, and after a 24-hour shift.
While there was no difference in cognitive function after a night of rest at home compared to working a 14-hour shift, the researchers found ER physicians posted lower scores for three out of four cognitive functions after working a 24-hour shift.
"The cognitive abilities of emergency physicians were significantly altered after a 24-hour shift, whereas they were not significantly different from the rested condition after a 14-hour night shift," the researchers wrote.
While the research suggests that a 14-hour night shift could be a more optimal schedule for ER doctors, the primary conclusion of the Annals of Emergency Medicine article is that 24-hour shifts should be discontinued.
"Our results mainly suggest that emergency physicians should not continue to work 24 consecutive hours," the researchers wrote.
The risks associated with physician fatigue have been published in earlier research, they wrote. "Chronic tiredness related to long working hours is common among physicians. It has also been clearly established that chronic tiredness negatively affects patient safety."
In their study, the Annals of Emergency Medicine researchers found that ER physicians underestimated the level of their cognitive impairment.
"The lack of correlation that we found between the self-evaluation of tiredness and cognitive performance suggests that emergency physicians were not able to accurately evaluate their tiredness and attention capacity. This could lead to increased risks to their own health and patient safety," the researchers wrote.
Assessing cognition
The researchers assessed four measures of cognitive function: processing speed, working memory capacity, cognitive flexibility, and perceptual reasoning.
Processing speed is important for multitasking. Working memory capacity features short-term memory, which enables decision algorithms and helps determine the level of an emergency. Cognitive flexibility supports strategic capacity and executive functions. Perceptual reasoning, enables understanding of abstract concepts and rules.
ER physicians underwent a three-part assessment:
A questionnaire collected demographic and lifestyle data as well as highlights of the previous night shift
Participants conducted a self-assessment of tiredness, sleep deprivation, and degradation of attention and mood
An examiner evaluated participants' cognitive abilities
The researchers found that ER physicians who work 24-hour shifts experienced decreased functionality in processing speed, working memory capacity and perceptual reasoning. When compared to cognitive abilities after resting at home, decreased performance ranged from 10% to 21%.
The researchers say these decreases in cognitive function likely have negative impacts on emergency departments. "Because these cognitive abilities are involved in the practice of emergency medicine, their decrease is likely to affect abilities such as using a decision algorithm, making a diagnosis, prioritizing emergencies, or multitasking."
Mitigation
Earlier research and the Annals of Emergency Medicine article suggest several methods to avoid sleep deprivation among ER physicians:
Napping and strict sleep hygiene have been proposed
For residents, the Accreditation Council for Graduate Medical Education Task Force recommendsstrategic napping for residents
The Annals of Emergency Medicine say conscious effort is required to achieve strategic napping because of demanding workloads and busy periods in the ER setting
The journal of the Federation of State Medical Boards has published a special issue with a range of perspectives on burnout and wellness, including physician mental health and help-seeking behavior.
Physician burnout has reached crisis proportions and medical regulators need to step up efforts to address the problem, a special issue of the Journal of Medical Regulation says.
"The time has come to help the healers heal themselves—and return to productivity and career fulfillment. As medical regulators, we need to protect the public—the millions of patients whose physicians are impacted by burnout each year," JMR Editor in Chief Heidi Koenig, MD, wrote in the special issue.
The special issue, which was published by the Federation of State Medical Boards, features four articles about physician mental health, FSMB wellness and burnout initiatives, assessment and referral, and help-seeking behavior.
1. Physician mental health
Fear is a primary barrier to care for physicians with mental health conditions, the first article says.
"Most mental health problems can be effectively managed, but real and perceived barriers—such as confidentiality concerns and fear of negative ramifications on one’s reputation, licensure, or hospital privileging—keep many physicians from addressing their mental health needs."
The article includes three recommendations to address physician burnout and wellness:
Community response: Education programs should encourage peers and mentors to help distressed colleagues get care. Active involvement of peers and mentors also promotes normalizing the seeking of help.
Stigma reduction: Policies must make it safe for staff members to seek support or treatment, as early as possible after onset of distress.
Licensing: Mental health questions in state licensing documents have the unintended effect of driving distressed clinicians underground. These questions should focus on competence rather than illness. Mental health questions should be phrased the same as physical health questions.
2. FSMB initiatives
The FSMB plans to be in the vanguard of efforts to address physician burnout and wellness.
About two years ago, the regulatory association formed a workgroup of state medical board members and stakeholders to study burnout and wellness.
"This was a timely decision for the FSMB as it positioned the organization alongside several others at the forefront of working to identify and address what has become an epidemic," the second article says.
Burnout and wellnessrecommendations that the FSMB workgroup adopted in April are included in the JMR special issue.
In addition to the workgroup, FSMB is participating in a collaborative effort to find solutions to burnout led by the National Academy of Medicine.
Individual state medical boards also have been launching burnout and wellness initiatives. Licensing changes allow physicians to not report a potential impairment as long as they are receiving treatment, the article says.
UC San Diego launched HEAR in 2009. Over the previous decade, there had been one medical student or physician suicide every year.
Hundreds of medical professionals have received help through the program, the article says.
"Through June 2017, 1,537 UC San Diego healthcare personnel have been screened, 320 individuals have dialogued with a counselor either in person, by phone or electronically, and more than 300 have been referred confidentially for evaluation and treatment by a mental health professional."
The HEAR program has two essential elements:
Education and outreach: Lifting stigma and supporting help-seeking behavior
Proactive approach: Identifying at-risk clinicians for support and care referrals
HEAR appears to have impacted suicides at UC San Diego, the article says.
"There have been two suicides among UC San Diego medical and pharmacy students, residents, fellow and physician faculty since 2009, and none in nurses or other professional health care staff since they were added to the HEAR umbrella."
The figures are small but significant, the article says.
"Although the numbers are too small to perform statistical analysis, based on the rate of suicide in the UC San Diego academic and clinical community before 2009, we have observed six fewer suicides than in the same timespan previously."
To evaluate ISP, researchers gathered data from six medical schools from 2007 to 2013. The ISP online questionnaire was completed by 1,449 medical students, residents, and faculty physicians, with 97.5% reporting some degree of stress but only 5.3% receiving care.
ISP is designed to identify people at risk of suicide by offering anonymous online screening. A counselor reviews the screening information, then posts a confidential response to the ISP website. After the screening assessment, ISP participants can exchange confidential messages online or get a referral for care.
Researchers found participant engagement with the ISP service was robust—81.2% returned to the ISP website to see the counselor's screening response.
Out of the 1,449 ISP participants in the study, 131 either asked to speak with a counselor in person or requested a mental health referral.
ISP, which is a key component of HEAR, is a viable option for suicide prevention for healthcare professionals, the article says.
"The core components of ISP—participant anonymity, allowing participants to feel more comfortable addressing their concerns, and personalized interactive engagement with experienced counselors—offer an innovative method of overcoming barriers to help-seeking."
Researchers find synergies that help accountable care organizations with advanced primary care physicians succeed financially and deliver high-quality care.
Advanced primary care boosts the savings rate and quality performance of accountable care organizations, research released this week says.
Researchers found a symbiotic relationship between ACOs and advanced primary care models such as patient-centered medical homes, the report says.
"Systems that already provided advanced primary care had a strong foundation on which to build an ACO, while becoming an ACO helped advanced primary care systems succeed by encouraging structural changes that align well with the PCMH model."
ACOs and advanced primary care share several keys to success, the researchers wrote.
"Many successful ACOs rely on good care coordination using care managers; robust and timely electronic health record information; increased access to care through means such as patient web portals and expanded office hours; and a focus on safety and quality improvement."
Two primary findings of the report are that ACOs with advanced primary care physicians have an increased likelihood of financial and quality of care success.
1. Shared savings gains
In their quantitative analysis, the researchers focused on 333 ACOs that participated in the Medicare Shared Savings Program in 2014. MSSP success was measured by shared savings earned and quality measure performance.
In MSSP, an ACO is given a total-cost-of-care spending benchmark based on historical performance. The ACO can earn shared savings payments if care expenditures are below the spending benchmark.
To assess the impact of advanced primary care on ACOs in MSSP, the researchers segmented the ACOs into quartiles, with the lowest quartile having no PCMH physicians and the highest quartile having 42.6% of physicians in PCMHs.
The researchers found that ACOs with PCMH physicians had modest but significantly higher shared savings compared to ACOs with no PCMH physicians.
"The savings rates of ACOs in the second highest and the highest quartiles for PCMH PCP share were on average 1.3 and 1.2 percentage points, respectively, higher relative to those in the lowest quartile group. The magnitudes of the estimates were non-trivial given that the mean savings rate was 0.6% for the study sample," the researchers wrote.
2. Quality boost
In 2014, MSSP had 33 quality measures. PCMH primary care physicians improve ACO quality performance, the report says.
"ACOs with a higher PCMH PCP share demonstrated higher quality as well, specifically in health promotion scores, health status scores, preventive service scores and chronic disease management scores."
Specific areas of higher quality performance included diabetic and coronary artery disease composite measures, pneumococcal vaccination, depression assessments, and tobacco screening.
SSM Health's new chief quality officer values performance improvement and a high-reliability approach.
The first-ever chief quality officer at SSM Health has set a lofty goal for the health system.
"My vision is to have the highest quality healthcare of anywhere in the country within the next five years by any measure. All of the models are different; so, if you want to score well on those, you have to do well in virtually everything," says Alexander Garza, MD, MPH, who became chief quality officer in January.
The health system features 24 hospitals and 9,900 clinicians.
Laura Kaiser, who has served as president and CEO of the St. Louis, Missouri–based health system since May 2017, is committed to quality and patient safety. Kaiser's decision to hire a chief quality officer for the whole health system demonstrates that commitment, Garza says.
HealthLeaders spoke recently with Garza. Following is a lightly edited transcript of that conversation.
HL: What are the primary quality challenges at SSM?
Garza: There are five areas we are focusing on this year. Sepsis mortality is one. It's a very expensive condition to treat, so there is a financial reason for addressing it.
We are engaged in two infection prevention initiatives. One for central line-associated blood infections and the other for catheter-associated urinary tract infections. By and large, these are infections that are within our control.
The fourth focus is readmission reduction. This metric applies to the whole health system—it measures how well we are organized in moving patients from acute care, to postacute, to ambulatory, and how good we are at recognizing risk for readmission.
The fifth focus is opioid reduction and dealing with our opioid epidemic. We are addressing it through multiple phases of care—the emergency department, inpatient, ambulatory, and our behavioral health and additional services.
HL: At a national scale, what are some of the most significant quality challenges?
Garza: What I get concerned about is people being too metric-focused when we are talking about quality. The performance metrics are part of quality, but there's also the patient experience and how well you are doing performance improvement as an organization. We teach our clinicians to do good healthcare work, but we don't train them as well to do performance improvement.
From our health system's point of view, I would rather [that] people focus on how to look at quality and how to do performance improvement. That would do much more good for us than focusing on a percentage or comparing us to a benchmark.
Quality is an umbrella term that includes more than metrics—infection prevention, regulatory issues, and safety.
My vision is moving our clinicians and our staff away from meeting specific metrics to thinking more from a high-reliability organization point of view. The goal is to be perceptive of what is going on around you, then making sure you can prevent errors that come up while adhering to best practices.
HL: Give an example of the high-reliability approach.
Garza: One of our Oklahoma facilities came up with a tracking system to make sure they were eliminating all of the risks associated with catheter-associated urinary infection. They bought into performance improvement.
It wasn't me coming down and saying, "You have to prevent urinary tract infections." The staff recognized the infections were not good for our patients. They developed a performance improvement system to treat our patients best, lower the risk, and improve performance all at the same time.
HL: Two decades after publication of "To Err is Human," patient safety remains an area of concern such as the estimated 400,000 deaths annually linked to medical errors. Why does patient safety remain a vexing problem?
Garza: Healthcare has not reached a tipping point where patient safety is the No. 1 priority. We talk about it a lot, and we have made good strides, but we haven't reached [that] point yet. You see it in other industries, when they step back and say change is needed.
Part of it is generational—as new physicians, new nurses, and new physician assistants come onboard, they will be graduating from programs that have an increased emphasis on quality. A new attitude is being built into them as professionals.
Making safety a front-and-center issue is a multi-level process.
There are obvious things like making sure we are doing surgery on the right side. You also need to identify the right safety policies, implement those policies, and hold people accountable. You always ask for two forms of identification from patients; you mark the surgical side; you have timeouts in the OR—these are all parts of those policies.
Senior leadership needs to show that they have bought into this as well. They need to make safety one of their priorities. When the executives at the system, regional, or hospital level promote safety, it helps change the culture.
HL: How do you engage physicians to participate in quality initiatives?
Garza: Whether they deserve it or not, physicians can get the reputation of not being participatory, but I think they do want to participate. It's all in how we get them to the table and how we engage them. We need to show that it is worthwhile to participate.
There are simple things like setting up meeting times that are convenient and asking for their opinion on how things could work. For example, as part of our patient safety surgical checklist we were talking about spine surgery and surgery on the wrong level of the spine. Adding [spine level] to the surgical checklist seemed like an easy answer to me. I sent the proposal to our orthopedists, and I got three emails and three phone calls on why it wasn't a good idea.
It was great. When I spoke with them, they thought they had a better approach. So, I had three different orthopedic spine surgeons from three different regions of our system coming together to work on this.
It showed [physicians] do think about these things seriously, and we need to give them the opportunity to solve problems.
Building a physical therapy program in the emergency room setting includes engaging stakeholders, estimating clinical volume, and finding qualified therapists.
Emergency department physical therapy (ED PT) offers multiple benefits and is poised to spread across the country, researchers say.
Physical therapists augment ED care teams, the researchers reported this month in the American Journal of Emergency Medicine.
"Patients receiving ED PT benefit from the physical therapist's expertise in musculoskeletal and vestibular conditions and from the individualized attention provided in a typical bedside evaluation and treatment session, which includes education on expected symptom trajectory, recommendations for activity modulation, and facilitated outpatient follow-up," the researchers wrote.
While common in Australia and the United Kingdom, ED PT has established a modest foothold in the United States, with programs at 23 health systems as of 2014.
The researchers say there are three key steps to create an ED PT program: engaging stakeholders, estimating clinical volume, and staffing PT positions with qualified professionals.
1. Stakeholder engagement
Most ED physical therapists are drawn from a health system's or hospital's physical therapy department because using existing organizational infrastructure is often the most efficient option, the researchers wrote.
"Engagement with physical therapy departmental leadership is a foundational step in establishing an ED PT program."
Engaging the ED leadership is also essential because PT services are provided in ED patient rooms or hallways.
Bed capacity is a potential stumbling block to engaging ED leadership, who can be concerned that prolonged patient stays reduce bed capacity. Timely PT consults are the solution, the researchers wrote.
"We posit that prolonged lengths of stay likely reflect a delay in initiating the PT consultation request, and a formal workflow for early PT consultation is likely to make this process more efficient."
Finally, ED care providers such as resident and attending physicians, nurse practitioners, physician assistants, and registered nurses should be consulted to gauge their support for an ED PT service.
2. Clinical volume estimation
The researchers highlight physical therapy visit data at several EDs.
On the low end of the scale with one full-time physical therapist in the ED, Barnes-Jewish Hospital in St. Louis posted 565 annual PT ED visits in 2009 with an annual ED-visit census of 62,000.
On the high end of the scale with two full-time physical therapists, Indiana University Methodist Hospital in Indianapolis posted 2,000 annual PT ED visits in 2014 with an annual ED-visit census of 102,000.
"The experience of these ED PT programs may indicate that consult volume is constrained by the number of FTE physical therapists rather than annual ED census," the researchers wrote.
3. Physical therapist qualities
Strong communication skills are essential for ED physical therapists, the researchers wrote.
"An ideal ED physical therapist will have good patient communication skills, given the volume of information that patients are likely to receive in a short period of time from the ED care team."
Mirroring a crucial ER physician skill, ED physical therapists must be flexible and improvisational, the researchers wrote.
"ED physical therapists must also function as a 'jack-of-all-trades' and should therefore have a wide range of clinical skills that can be adapted to address the variety of patient problems encountered in the acute care setting."
PT ED: Clinical Care
Physical therapy has three primary clinical applications in the ED:
Acute musculoskeletal injuries are most frequently neck or back pain, but also include hip, knee and shoulder pain.
With training in vestibular conditions, physical therapists are well-suited to treat peripheral vertigo, such as giving patients self-directed therapeutic maneuvers and assessing discharge safety.
Gait training and assessment in the ER is a prime service area for physical therapists, with several clinical applications including home safety and disposition planning for orthopedic devices such as crutches and knee scooters.
ED PT programs are generating positive results, the researchers wrote.
"Initial reports from U.S. hospital systems that have established ED PT services have cited increased provider and patient satisfaction, decreased wait times, and decreased rates of admission to the hospital for patients with orthopedic conditions."
Medicare's bundled payment programs are profoundly impacting the way acute-care providers are working with their post-acute care partners.
Hospitals and health systems participating in federal hip and knee replacement bundles are adopting two post-acute care strategies: limiting referrals to skilled nursing facilities and integrating with SNFs.
For hospitals, establishing strong relationships with SNFs can drive positive clinical outcomes and financial gains, researchers say.
The research features 22 hospitals and health systems that participated in Medicare's Comprehensive Care for Joint Replacement (CJR) model or its Bundled Payments for Care Improvement (BPCI) program from August 2017 to November 2017.
Under CJR and BPCI, hospitals face increased responsibility for post-acute care.
"These programs shift the financial responsibility for post-discharge care to hospitals and set incentives for stronger coordination between hospitals and post-acute care providers, including SNFs," the researchers wrote.
The hospitals and health systems in the Health Affairs research project took two approaches to the increased financial risk associated with bundled payments—reduced SNF referrals and closer SNF integration.
1. Limiting SNF referrals
Shifting patients away from SNFs was a primary response to bundled payments, the researchers wrote.
"A common response to bundled payment participation was to reduce SNF referrals for joint replacement patients and to shift discharges to home, with or without home health."
The researchers say there were four primary methods of limiting SNF referrals:
Risk stratification of patients before surgery, including targeting patients for pre-operative medical optimization such as weight loss
Education of patients who expected discharge to a SNF based on prior experience or the experience of friends and family. Hospitals adopted discharge planning that included presurgical education for patients.
Home care supports were provided to patients such as meal preparation and medication reminders.
Hospitals enhanced relationships or integrated with home health agencies to boost transitions of care. One chief medical officer told the researchers that his hospital acquired a home health company and they expected to merge their electronic medical records (EMRs).
2. SNF partners
Fifteen hospitals and health systems in the Health Affairs research project established networks of preferred SNFs to impact quality and cost, the researchers wrote.
All 22 organizations tried at some level to work closer with SNFs, they wrote. "While some hospitals reported efforts to reduce SNF use, all twenty-two hospitals employed new strategies to include SNFs in care management."
The researchers found several methods for hospitals and health systems to integrate with SNFs:
Sharing clinicians across hospital and SNF settings
Rounding in SNFs by hospital-based internists, geriatricians, and specialists
Placing hospital-based physicians in SNF medical directorships
More than two thirds of the hospitals and health systems in the Health Affairs research project reported that they formed preferred SNF networks in response to bundled payment incentives, the researchers wrote.
"Hospitals reported having formed preferred networks as one way to exert influence on the quality and cost of care, focusing on SNFs that historically received larger shares of their discharged patients."
Market geography was another key driver for preferred SNF networks, they found.
In selecting potential SNF partners, hospitals and health systems had limited access to SNFs that ranked well in Nursing Home Compare's star ratings, the researchers wrote.
"In any given market the number of available SNFs with high ratings was often limited. Many hospitals thus developed their own metrics, which included hours of therapy offered, SNF leadership churn, and quality of medical directorships."
The premier university and its health system have adopted an approach to wellness that focuses on promoting efficiency, supporting resilience, and creating a culture of wellness.
Personal resilience is only part of Stanford University's burnout strategy for physicians and other employees.
"Wellness is much more than that. It's about the culture. It's about giving people the tools they need to succeed. It's also about getting in the flow and being engaged in our work," Patricia Purpur de Vries, director of the Stanford Health Promotion Network, said this week at the Virtual Health Care Summit in Boston.
Stanford has been focusing intently on physician burnout since 2013. Internal survey data from 2013 to 2016 showed burnout was a potentially devastating financial liability.
For every physician Stanford loses, the replacement cost ranges from $250,000 to $1 million. Burnout-related physician departures can hit the health system's bottom line hard, de Vries said.
"From 2013 to 2016 our burnout rates went up and our professional satisfaction rates went down. We estimated from the number of physicians who left from 2013 to 2016 that we would lose 88 physicians over the next year, which could amount from anywhere between $11 million and $88 million."
Stanford has adopted a three-part strategy to address burnout among its 32,000 employees: creating a culture of wellness, establishing efficiency of practice in the workplace, and promoting personal resilience.
1. Culture of Wellness
Leadership is an essential ingredient to create a culture of wellness, de Vries said. "Under a culture of wellness, we have found out that leader support of employees is absolutely key."
Supervisors and workers are encouraged to develop positive relationships that foster meaningful conversations, she says.
"There are a lot of simple ways we can talk through things and help our leaders see the value of getting the best out of employees. We get the best out of people when they feel motivated and cared for."
2. Efficiency of Practice
There are several components to efficiency of practice, de Vries said. "These are workplace processes and practices that promote safety, quality, effectiveness, and positive patient and collegiate interactions."
At Stanford, employee engagement is a crucial factor in achieving efficiency, she said. "Inefficiency is an enormous problem for us. The inefficiencies in our entire workforce are difficult to address. It stems from people not being engaged in their work."
Employee engagement has become a top priority at the university and its health system, de Vries said.
"If we can tie every employee's worth, value, and mission back to the organization, we are all more likely to be happy in the job we were hired for and hopefully do our jobs with more enthusiasm."
Electronic medical record optimization has also been a priority, she said. "We found the EMR was a huge problem at the hospitals. It was so big, nobody was talking about anything else."
3. Personal resilience
Stanford views personal resilience programs as an old-school but crucial element of combatting burnout and nurturing wellness, de Vries said.
"For personal resilience, we feel that it is our traditional wellness program—how we eat, move, and think. It's important to us. At Stanford, we have amazing fitness facilities, two enormous pools, and tracks. We have world-class facilities that our employees can use for no charge."
Stanford has built up its personal resilience infrastructure beyond fitness facilities, with 1,000 fitness classes and healthy living programs offered annually.
The university also provides wellness incentives, she said. "We have biometric screenings that we offer and 57% of our employees have completed their biometric screenings."
To address social determinants of health, Houston Methodist makes direct interventions with grants and builds community partnerships.
Necessity spurred Houston Methodist to address social determinants of health in the communities that it serves.
Participation in Track 3 of the Medicare Shared Savings Program (MSSP) highlighted the need to address social determinants, says Julia Andrieni, MD, vice president of population health and primary care at the Houston-based health system.
"We realized that if we were not addressing nonclinical factors, we could not impact chronic condition management. Illnesses were just the tip of the iceberg—there were a lot more factors that contributed to health status when you took a holistic view of a patient," Andrieni says.
Houston Methodist joined MSSP Track 3, which features upside and downside risk, in January 2017. The Medicare program and population health efforts have prompted development of several social determinants of health initiatives at the health system, Andrieni says.
"Before MSSP Track 3, we were not addressing factors like transportation, food insecurity, social isolation, and economics such as affordability of medications. If we could not address those factors, we could not impact care," she says.
Here are two ways that the health system addresses social determinants of health in the communities it serves:
"We give out millions in grants every year," Andrieni says.
Patients who do not have a medical home have access to Houston Methodist–supported federally qualified health clinics throughout the Houston area, which gives patients access to care in their neighborhoods.
The health clinics coordinate care with Houston Methodist, says Janice Finder, MSN, BSN, director of population health and performance improvement at the health system. "Appointments can be made prior to discharge and reminder calls are provided by the clinic in case patients have to cancel or change appointments."
In disadvantaged communities, grant funding for the health clinics helps support essential services such as behavioral health, Finder says.
Harris County, which is the largest county in Houston, has a 21% uninsured rate and low access to mental health services, with 1 provider to 1,020 patients. The federally qualified health clinics help address a pressing need, she says.
"Behavioral risks such as anxiety, depression, stress, and substance abuse go untreated. The FQHCs as well as our community-based social workers help to alleviate a small portion of this burden," Finder says.
Another grant-supported program—Homeplate—provides food and daily checks for inpatients after discharge.
"Food is one of the primary social determinants affecting health. We have found that many patients who come out of the hospital do not normally require Meals on Wheels or similar programs, but they may need help with meals and a daily check for the first 14–30 days postop," Finder says.
Homeplate also provides meals to newly diagnosed diabetic patients so they can get used to weighed and measured portions.
Homeplate gives food to a patient's family, too.
"We have found when one is hungry many are hungry, and the patient will give their meal to other family members and even their pet. Homeplate provides meals for the entire family and the pets," Finder says.
Drivers who deliver food for Homeplate check on patients and ask basic health-related questions, such as whether appointments have been attended and medications picked up. "If there is a "no" answer, the driver calls our nursing staff, and we handle the alert," she says.
Homeplate has increased patient satisfaction and lowered readmissions, Finder says.
2. Partnerships
Community partnerships are the health system's primary focus to address social determinants, she says. "As a health system, we probably can't be providing transportation and food and actually be the resource for social determinants, but we have partnerships."
Selecting appropriate partners is essential to the success of social determinant initiatives, Andrieni says. "You need to have partners who are aligned with your goals, and you should outline those goals and the outcomes you are working for. The right partner will help you track shared goals and help manage outcomes."
Partnerships with community organizations should be formal business relationships, Finder says.
"You need to set up a legal structure and contract with the organizations you are partnering with, and make sure that you are keeping the confidentiality of your patients," she says.
Three of Houston Methodist's social determinant partnerships help close key care gaps, such as home health, care coordination, and elder resource services:
Grand-Aides
Houston Methodist has a home health partnership with Houston-based Grand-Aides, which provides health workers who support nurses in the home setting.
From August 2016 to December 2017, the partnership with Grand-Aides generated $101,000 in ROI for Houston Methodist. Grand-Aides helped avoid 18 readmissions, which garnered a cost savings of $216,000.
Golden Care Program
As part of Houston Methodist's Chaplaincy Office, the Golden Care Program connects uninsured and Medicaid patients with a primary care physician at one of the federally qualified health centers in the Houston area. Appointments are made for patients before they leave the hospital and are scheduled for seven to 10 days after discharge.
Additional patient services include coordinating community and congregational resources for at-home services, such as patient transportation and food delivery.
Baker Ripley Sheltering Arms
The Baker Ripley Sheltering Arms program helps elders who need assistance accessing general resources such as transportation, health benefits, and care needs. The service targets people with dementia or cognitive impairment who may need case management services or care consultant services for patients and caregivers.
Addressing social determinants of health has had a significant impact on Houston Methodist, Andrieni says. "It has helped us meet our goals to decrease readmissions, to decrease ED utilization, and to be proactive in managing nonclinical as well as clinical issues with our medical and clinical pharmacy staff."
Houston Methodist has more opportunities to close social determinant gaps, Andrieni says. "We have started on this journey, but there is a lot more to do. As we understand our population more and more, we are going to pick up on other gaps that we need to address."
Recommendations fall into three categories: communication, tracking, and acknowledgement of an information review and associated actions.
Healthcare IT has a key role to play in limiting diagnostic errors and botched medication changes, an ECRI Institute report says.
"Results can be—and often are—missed when the loop of receipt, acknowledgment, and action remains open. The resulting consequences stem from these now delayed, missed, and incorrect diagnoses. A closed loop provides timely and effective therapies and mitigates diagnostic error," the report says.
Healthcare IT can help ensure that patient data requiring action is delivered to the right people at the right time in the right format, but the challenge can be daunting.
"Information throughout the healthcare delivery process is transmitted between entities such as laboratory, radiology, and pathology testing facilities, pharmacies, and other providers, all with a potential for interruptions of communication," the report says.
Diagnostic errors have negative impacts on patients and provider bottom lines.
A 2015 Institute of Medicine report, "Improving Diagnosis in Health Care," asserted that every American will experience a meaningful diagnostic error at some point in their lifetime.
On the financial front, diagnostic errors are responsible for about $34 billion in annual U.S. malpractice payments.
The ECRI Institute report's recommendations feature three categories: communication, tracking, and acknowledgement of an information review and associated actions.
The communication recommendations are designed to facilitate the efficient flow of information, with all diagnostic results and medications communicated to providers, pharmacists and patients on a timely basis:
Improve the flow of information using standards to format normal, critical, abnormal-noncritical, and abnormal results
Adopt standards for reporting of actionable findings to include results priority and timing of responses to diagnostic testing
Use universally recognizable display icons in the electronic health record for alerts and notifications
Enhance the usability of diagnostic results communications
Automate notification processes with existing EHR capabilities
Optimize alerts to improve notification and reduce alert fatigue
Avoid interruptions of diagnostic results communications
Provide diagnostic findings directly to patient
The report makes four tracking recommendations:
Seek opportunities where health IT can be used to correct deficiencies and improve monitoring
Create accountability for oversight of tracking
Adopt laboratory standards that improve tracking
Establish bi-directional communication between hospital computer systems and third-party systems such as laboratory partners. Bi-directional capability eases the ordering and reporting of laboratory, radiology, pathology, and diagnostic results.
The report makes two recommendations use health IT to acknowledge the review of information and document the action taken:
Use health IT to link and store an acknowledgment and to record the action taken
Develop the capability to communicate actions taken along with acknowledgments or instead of them. For example, diagnostic-results notification messages should be modifiable by the recipient to add the action taken to "close the loop" such as read, acknowledged or patient notified.
In the emergency room setting, agitated patients with delirium experience higher rates of hospital admissions and adverse events, researchers say.
Agitated patients represent a small but challenging portion of emergency department visits, researchers at an urban Level 1 trauma center found.
The researchers, who published their study this month in Annals of Emergency Medicine, screened 43,838 ER patients and found 1,146 (2.6%) were in an agitated state.
Agitated patients can require significant levels of care in the emergency department setting, the researchers wrote.
"We found that severe agitation occurs frequently in the ED, and often requires both chemical sedation and physical restraint to control the patient to allow a comprehensive medical evaluation and to protect medical providers and the patient from injury."
Acute states of agitation can be deadly, the researchers wrote. "Injuries and sudden deaths have been reported among agitated persons during attempts to restrain and care for them in both custodial arrests and medical stabilization."
None of the agitated patients in the Annals of Emergency Medicine research project died.
Data collected in the research project shows characteristics of agitated patients and their care:
84.6% of agitated patients required physical restraint
72.3% required sedation with an intramuscular injection
1.8% required physical restraint and sedation
16% had clinical events that required intervention such as mild hypoxia treated with supplemental oxygen
7% experienced an adverse event—either intubation or hypotension
23% had delirium symptoms
Delirium danger
Delirium is a serious condition for agitated patients, the researchers wrote.
"The rate of clinical and adverse events was much higher in patients with delirium symptoms, with a two-times-higher rate of intubation, two-times-higher rate of hypotension, and two-times-higher rate of hospital admissions."
Excited delirium syndrome, an acute form of delirium associated with extreme physical violence, is particularly problematic.
The American College of Emergency Physicians recognized excited delirium syndrome in 2009. For a diagnosis of excited delirium syndrome under the ACEP guidelines, a patient must exhibit at least six of 10 potential symptoms, including pain tolerance, sweating, agitation, lack of tiring, and unusual strength.
The Annals of Emergency Medicine researchers found that the histories and vital signs of delirium patients were similar, which indicated that different rates of complications for the patients could be caused by the nature of agitation associated with delirium. "This supports the theory that excited delirium syndrome may represent a condition that is higher risk than typical agitation," they wrote.
The stakes are high for excited delirium syndrome patients, the researchers wrote.
"Because the estimated mortality rate of patients with excited delirium syndrome may be as high as 16.5%, it is critical to identify treatments or interventions that may curb the metabolic derangements of patients with suspected excited delirium syndrome."
Recommendations
While more research is necessary to develop comprehensive best practices for the treatment of agitated patients, the researchers highlight several care guidelines.
In a minority of agitated patients, the condition is linked to a medical illness and performing a timely assessment is crucial, the researchers wrote. "Rapid assessment is imperative because previous research has demonstrated that up to 1% of similar patients ultimately require critical care resources while in the ED."
Oral sedatives are probably not appropriate for many agitated patients because they may not be rapid-acting enough or feasible for distraught patients who struggle with compliance.
If parenteral sedation is required, intramuscular injections can accomplish faster sedation than establishing an intravenous line for an agitated patient.