The adoption of an EMR-based screening tool and a sepsis treatment bundle drove down mortality rates markedly over four years.
A sepsis surveillance and treatment initiative at Frederick Memorial Hospital has slashed the facility's mortality rate for the deadly infection.
On an annual basis, sepsis affects about 1.7 million American adults and the infection is linked to more than 250,000 deaths.
From 2012 to 2016, Frederick Memorial Hospital implemented sepsis surveillance and treatment measures that reduced the infection's mortality rate by 65%.
"In 2012, we recognized that our mortality level was one-and-a-half times what the expected values were based on coding and auditing of charts, and patient comorbidities. So, we started to drill in on the root causes. What we found was that we did not have good bundles or processes that were in place to even identify patients who were at risk of sepsis," says Debra O'Connell, RN, manager of performance improvement at the Frederick, Maryland-based facility.
Screening tool adoption
Frederick Memorial's first step toward addressing its sepsis challenge was developing an EMR-based screening tool.
"There is a screen shot that provides the clinical staff and the nurses with some fundamental questions about the patient's status. It asks about vital signs, it asks about whether there are potential sources of infection, it asks about mental status changes, it asks about white blood cell levels—it asks questions and the nurses fill in the blanks. Then the tool calculates a score, and if patients have a score above a value of 2, it prompts the nurse to get additional orders from the physician because the patient may have sepsis," O'Connell says.
The screening tool underwent a clinical trial at Frederick Memorial, then it was implemented in the emergency department and as an as-needed tool associated with specific chief complaints, she says.
"If a patient came into the emergency department complaining about frequent urination and it could have been a potential urinary tract infection, the nurses could implement our sepsis detection tool. If the tool indicated the patient could be septic, we would implement the appropriate interventions. We would implement the bundle that is now known as the Sepsis Core Measure."
The next step was to make the screening tool available to clinicians and nurses throughout the hospital, O'Connell says. "After we implemented the tool in the emergency room, nurses on the medical floors and the intensive care unit could use it as a screening tool if they were suspicious that a patient could be septic."
In 2017, Frederick Memorial started using the screening tool for active surveillance of all inpatients.
"We recognized there were some opportunities to revise the screening tool and change it from an ED screening tool to more of a sepsis surveillance screening tool, so that all patients who were admitted to the hospital would be screened on admission, then two times per day after admission. That allows us to capture patients who may be hovering with sepsis," she says.
Some members of the nursing staff initially resisted the daily screening of all inpatients, but the reduced mortality rate played a decisive role in achieving widespread adoption of the surveillance effort, O'Connell says.
"We don't want to miss opportunities to capture sepsis because it is a severe disease process. You can go downhill very quickly; and once that process starts to progress, if the appropriate actions are not in place patients can progress into septic shock and die. That is the point of trying to capture sepsis by screening two times a day."
2 keys to success
O'Connell says there were two essential elements in Frederick Memorial's successful sepsis prevention initiative.
Physician champion leadership: "The biggest thing is finding some physician champions who can help drive the processes, the culture change, and education of the entire staff. We had a physician leader in our organization who helped drive this initiative and who helped educate our providers."
Sharing the data: "The other piece is showing the outcomes—being transparent with information. Once we were able to demonstrate that there were benefits from the screening tool, identifying septic patients, and that our treatments were decreasing mortality rates, that made a big difference with our staff."
New research shows how specific impairments can determine the likelihood of increased healthcare services utilization among older cancer patients.
For older cancer patients, geriatric assessments can predict hospitalization rates and long-term care utilization as well as guide interventions, new research indicates.
The country's aging population is having a profound impact on the healthcare sector, according to the American Hospital Association. For example, more than 60% of baby boomers are expected to have multiple chronic conditions after reaching retirement age, more than one-third of boomers are expected to be obese, and about a quarter of boomers are expected to have diabetes.
The recent research, which was published in Journal of Oncology Practice, found that geriatric assessments could be a key component of reducing healthcare utilization by older cancer patients.
"Our findings suggest the importance of a geriatric assessment in predicting adverse healthcare use including the frequency of hospitalizations and long-term care use. Geriatric assessment-focused interventions should be targeted toward high-risk patients to reduce long-term adverse healthcare use in this vulnerable population," the researchers wrote.
Researchers examined data collected from 125 cancer patients who underwent geriatric assessments. They found specific impairments were associated with hospital and long-term care utilization.
"Prefrail/frail status, instrumental activities of daily living impairment, and limitations in climbing stairs were associated with increased hospitalizations. Prefrail/frail status, instrumental activities of daily living impairment, presence of falls, prolonged Timed Up and Go, and limitations in climbing stairs were associated with long-term care use," the researchers wrote.
Deploying interventions
Conducting geriatric assessments in older cancer patients can target areas for intervention, the researchers wrote.
"Our results demonstrate that impairments predominately in the physical function and functional status domains of the geriatric assessment are particularly related to increased healthcare use. This suggests interventions focused on these impairments may be important for improving outcomes. Impairments in instrumental activities of daily living and limitations in climbing stairs or walking short distances are great examples of the types of interventions that occupational therapists and physical therapists treat."
The lead author of the research, Assistant Professor Grant Williams, MD, at the University of Alabama at Birmingham, told HealthLeaders there are several other promising interventions in addition to occupational and physical therapy.
Nutrition
Comorbidity management
Treatment of behavioral health conditions such as anxiety and depression
Social work assistance for older patients with limited social supports
"There are several trials in process that are looking at how geriatric assessment-directed interventions can improve outcomes and we are eagerly awaiting the results," Williams said.
The country's physician burnout epidemic is taking a heavy toll on emergency department clinician trainees.
Three-quarters of emergency department residents are experiencing symptoms of physician burnout, recent research indicates.
Other research has found that nearly half of physicians nationwide are experiencing burnout symptoms, and a study published in October found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction. Burnout also has been linked to negative financial effects at physician practices and other healthcare organizations.
The recent research, which was published in Annals of Emergency Medicine, found that the prevalence of burnout among ED residents was 76.1% in a survey of more than 1,500 of the early-career physicians.
"The majority of U.S. emergency medicine residents responding to this survey reported symptoms consistent with burnout, highlighting that physician burnout in the emergency medicine profession seems to begin as early as residency training," the authors of the research wrote.
The study's data indicate that ED residents have different rates and causes of physician burnout compared to independently practicing ER doctors and clinicians in other specialties.
Nearly three-quarters of the ED residents in the study reported high levels of depersonalization; whereas, earlier research found 38.9% of attending emergency physicians reported high levels of depersonalization. Other earlier research found 34.6% of clinicians in non-emergency medicine specialties reported high levels of depersonalization.
"We hypothesize that this more negative and cynical attitude toward patients results from working more clinical hours in the ED as a resident, having a greater clerical burden, and interacting more with consultants, admitting services, and ancillary staff as a trainee," the Annals of Emergency Medicine researchers wrote.
Daunting challenges for residents
The lead author of the research, Michelle Lin, MD, told HealthLeaders that emergency medicine is a hotbed for physician burnout.
"Because the physician pool is a very heterogenous population, you can't compare our study results—which focus on emergency medicine trainees—and the entire physician population. However, if you slice it by specialty, it is known that emergency medicine has among the highest rates of physician burnout in the 60% to 80% range, depending on which metrics and studies you look at," she said.
The prevalence of physician burnout among ED residents is alarming, said Lin, a professor of emergency medicine at University of California San Francisco and an ER physician at Zuckerberg San Francisco General. "Our study of emergency medicine residents demonstrates that shockingly most are starting their careers already burned out even before they become attending physicians."
Addressing physician burnout
Physicians are inherently resilient, and wellness initiatives that focus on "fixing" clinicians have been shown to have little to no benefit in alleviating burnout, Lin said.
"While education about stress management may be helpful for some physicians, we are advocating for more system-wide, organizational changes. For example, administrative burden such as using cumbersome electronic medical records and inefficient intra-hospital communication systems are straining emergency physicians, who already are in a stressful, time-critical, and task-switching work environment."
Achieving systemic change is particularly important for ED residents, she said.
"For resident physicians, they also have an extra layer of stress, which is to learn the practice of emergency medicine and learn a new hospital system. Although changing the ingrained practices of healthcare will take some time, we suggested the use of ED scribes in the more immediate-term as an example of a way to offload some task-switching burden."
Measuring ED resident burnout
Lin's research team used three measures of physician burnout for ED residents. A restrictive definition of the condition found 18.2% of residents were experiencing burnout, and a more inclusive definition found 80.9% were experiencing burnout.
She stands by the 76.1% burnout rate, which was determined using key elements of the most widely accepted measurement instrument: the Maslach Burnout Inventory (MBI) tool.
"We feel confident about our reporting of a 76% resident burnout rate because we enrolled more than 1,500 emergency medicine residents, applied the validated MBI tool, and scored the responses based on the most common definition," Lin said.
Clostridium difficile infections in the hospital setting have the biggest treatment price tag, researchers say.
Infections linked to multidrug-resistant organisms (MDROs) cause a significant cost burden for U.S. healthcare, recent research shows.
The development of antibiotic-resistant infections is one of the most severe public health problems in the country, according to the Centers for Disease Control and Prevention. About 23,000 Americans die annually from an antibiotic-resistant infection, the CDC says.
The national price tag for treating infections linked to MDROs in the hospital setting is at least $2.39 billion, according to the recent research, which was published in the journal Health Services Research.
The researchers also tallied the treatment cost per inpatient hospital stay for methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile (C. difficile), and other MDROs.
Treatment of infection with MRSA cost about $1,700
Infection with C. difficile cost about $4,600
Infection with another MDRO cost about $2,300
Infection with multiple MDROs cost about $3,500
"We find the highest incremental and total costs for C. difficile and the lowest incremental costs for MRSA, consistent with estimates from previous reports. The higher costs appear to be driven largely by a higher average length of stay, but may also be due to additional testing and increased risk for ICU admission with C. difficile," the researchers wrote.
In 2014, the President's Council of Advisors on Science and Technology made several recommendations to combat antibiotic resistance, including surveillance of MDROs in healthcare settings and the community, anti-microbial stewardship campaigns, precautions to limit exposure, and education of patients and physicians about the dangers of overprescribing antibiotics.
Calculating superbug economics
The lead author of the Health Services Research article, Kenton Johnston, PhD, MPH, told HealthLeaders that determining the cost effectiveness of efforts to reduce MDRO infections is challenging.
"Essentially, you are comparing the costs of MDRO-reduction efforts to the savings generated by those efforts. The costs of MDRO-reduction efforts would be the programmatic costs of interventions. This is tricky because the interventions are wide-ranging throughout society such as hand-washing campaigns. The savings part is also tricky because the savings also accrue throughout society," said Johnston, an assistant professor at the College for Public Health & Social Justice, St. Louis University.
Johnston's research team only examined hospital costs of efforts to combat MDRO infections.
"A systematic review of the literature on just the cost side of this equation found that the cost of measures to combat and eradicate MDROs ranges from $331 to $66,772 per MDRO-positive patient. This is obviously an unacceptably huge range for calculating the cost side of the equation alone. As a result, more research needs to be done," he said.
A new collaborative approach is designed to improve birth outcomes, decrease cesarean section procedures, and increase patient engagement.
Maternal morbidity and mortality continue to be a devastating trend in U.S. healthcare, as reported in The Washington Post last November.
Complications from C-sections such as hemorrhaging are widely considered to be a contributing factor to the country's high maternal mortality rate. The federal Centers for Disease Control and Prevention have been monitoring maternal mortality since 1986. The number of pregnancy-related deaths has risen steadily since the monitoring effort began, from 7.2 deaths per 100,000 live births in 1987 to 18.0 deaths per 100,000 live births in 2014.
In December, the federal government took a step toward addressing maternal mortality with passage of the Preventing Maternal Deaths Act.
To decrease C-sections and improve birth outcomes, Ariadne Labs, a collaborative of Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health in Boston, launched the Team Birth Project in 2018 at a handful of sites across the country to recast the hospital-based birthing process.
The Team Birth Project features two primary elements: efforts to improve communication between the mother, the family, and the clinical care team; and a pair of decision-making tools.
1. Create a labor storyboard and implement team huddles
Under the Team Birth Project model, birth plans are living documents throughout the birth process, says Margie Bridges, DNP, a perinatal clinical nurse specialist at Overlake Medical Center. The Bellevue, Washington, facility is one of the pilot sites for the initiative.
"Historically with birth plans, the patient and the family may have talked to their doctor during an office visit then brought it to labor, when it got tucked into a chart. It wasn't a living document that got changed as conditions changed," she says.
To make sure birth plans are considered during labor, the Team Birth Project calls for clinical care teams to mount a whiteboard in the birthing room that reflects the mother's preferences. At Overlake, 24 x 36-inch whiteboards are affixed to a door facing the mother.
Information on the whiteboard has crucial information such as the birth team, which includes the mother; a plan for the baby such as monitoring; a plan for the mom such as pain management; and a plan for labor progress.
The whiteboard is the "story of the labor," says Lisbeth Jordan, MD, a hospitalist and OB Hospitalist Group site director at Overlake. "It is updated regularly—what's going on with the baby, how the labor is progressing, and next steps with the provider. It's a storyboard to help the family be aware of what they want, how the baby is doing, and how the labor is going."
Birth plan huddles are held at key points during labor, Bridges says. "The huddles get the core team together when decisions are being made. Huddles are held when you would normally consult the doctor, and you include the patient."
The huddles can be held even when the physician is unable to be at the bedside, the nurse specialist says. "We get them on the phone for a conference call in the birthing room. We put the doctor on the speakerphone, and we go over the whiteboard to review changes in preferences, give status reports on the mom and the baby, and raise concerns."
Boosting communication can help avoid C-sections, Bridges says. "Sometimes, it's tricky to understand why a mom has a C-section. There are so many variables and variation. If we look very clearly at the three lanes—mom, baby, and labor progress—and have a plan, we can avoid some cesarean births."
Open communication can be pivotal in avoiding a cesarean birth, Jordan says. "There is a shared understanding of what is going on. So, the story plays out, and the provider checks in with the nurse and the family. The idea is that it is a collaborative, team effort that can reduce unnecessary C-sections because there is shared knowledge about the whole process of labor."
2. Use admission decision and C-section criteria tools
The Team Birth Project has a duo of decision-making tools to help reduce C-sections, Bridges says.
"There is an admission decision aid that helps us decide whether a patient needs to be admitted to the hospital. We know if we admit someone too early—the mother is well and the baby is fine—it starts the clock ticking and increases the rate of cesarean sections. If the patient is hospitalized, we start to intervene."
The second decision-making tool helps determine whether conditions for ordering a C-section are present, she says. "We also have an aid that we can use during the process of labor that focuses on the mom, the baby, and labor progress that tells us whether we have met the minimal criteria to even consider a C-section. It tells us whether it is safe to keep going with a vaginal birth."
Generating results
While the Team Birth Project pilots are in their infancy, the early results are promising.
In February, Boston 25 News (WFXT-25) reported that South Shore Hospital in South Weymouth, Massachusetts, had achieved a 4% reduction in the facility's C-section rate through Team Birth Project implementation. South Shore was the first hospital to launch in the initiative in April 2018.
Patient experience gains are also evident, Jordan says. "The initial motivation of this initiative was to decrease C-section rates and the research outcomes are pending, but we are finding the increased communication has transformed the relationships in the entire team. Communication improves outcomes, so it may be that the most significant outcome is not decreased C-sections but a better experience for the family."
Happier families have also been noted at another pilot organization: Kirkland, Washington-based EvergreenHealth.
"We are seeing amazing things in terms of patient satisfaction—they leave the hospital feeling that they understand what happened to them. They get to write their own birth story. It's an important change in how we deliver care because we are providing care with the patient and not giving care to the patient," says Angela Chien, MD, an obstetrician-gynecologist at EvergreenHealth.
Inappropriate electrocardiographic monitoring results in wasteful spending and decreased quality of care.
Following practice standards through an electronic order set boosts the appropriate use of electrocardiographic monitoring without increasing adverse events, recent research shows.
Earlier research demonstrated that inappropriate use of cardiac telemetry results in significant wasteful spending. Over monitoring has also been associated with quality and safety concerns such as clinician alarm fatigue.
In findings published this month in the American Journal of Critical Care, researchers conclude that ECG monitoring should only be used in situations specified under American Heart Association (AHA) guidelines.
"ECG monitoring should be restricted to patients who might benefit from it and should be discouraged in patients at low risk for arrhythmias that require treatment. ECG monitoring is often not ordered for a specific clinical concern, but instead is used as an extra patient-safety mechanism or as a substitute for frequent monitoring of vital signs," the AJCC researchers wrote.
The research was based on data collected from nearly 300 patients hospitalized in medical, surgical, neurological, oncological, and orthopedic care units. Order sets based on the AHA guidelines were placed into the hospital's electronic health record and education about appropriate use of telemetry was offered to hospitalists and medical residents.
The intervention resulted in an increase of appropriate ECG monitoring from 48.0% to 61.2%, with no significant increase in adverse patient events. Medical residents received the most education on appropriate ECG monitoring, and they showed higher adherence to practice standards compared to hospitalists, increasing their appropriate use of telemetry monitoring from 30.8% to 76.5%.
"Use of electronic order sets is an effective and safe way to enhance appropriate electrocardiographic monitoring," the researchers wrote.
The lead author of the AJCC research told HealthLeaders there are five primary considerations when implementing ECG electronic order sets.
1. Gathering the right team
"Involve end-users of the order set, including staff nurses, hospitalists, intensivists, and cardiologists. As the results of our study demonstrated, education is an important component of the practice change, so it's important to have a team member with knowledge and skill in education," said Kristin Sandau, PhD, RN, professor of nursing at Bethel University in St. Paul, Minnesota, and staff nurse, at United Hospital, Allina Health, St. Paul.
"Clinical nurse specialists are a critical part of the team as they bring not only clinical expertise in the content area but also skills and knowledge of practice changes at the nurse and system levels. The experts from our informational technology team included a nurse who is a key member of our EHR staff," she said.
2. Setting baseline metrics
"Allow adequate time to prepare and obtain baseline measures. Preparation time should include pilot-testing at a small site and revising. What are the best feasible ways for you to measure pre- and post-implementation outcomes? This can be challenging because some outcomes are very difficult to measure, such as wait times for an ICU, ED, or telemetry bed," Sandau said.
3. Embedding leadership
"Be sure to have physician and nurse champions who are ready to receive both positive and constructive feedback as the team works to make technology an asset rather than burden to busy clinicians. You should expect that adjustments and tweaks will be ongoing as you face new challenges," she said.
4. Impacting staff members
"It is critical that you consider scope of practice and direct impact on clinicians. Other sites have implemented practice standards in the EHR that require the staff nurse to answer a series of questions about a patient then make a choice to discontinue telemetry based on a set of parameters. We made a dedicated effort at our site to avoid putting the responsibility on the staff nurse," Sandau said.
Sandau's team assigned responsibility for discontinuing ECG monitoring to clinicians. "We've built prompts for nurses and prescribers to share, but we felt it was ultimately the responsibility of the prescriber to discontinue telemetry."
5. Sharing the implementation experience
"By sharing what works and what was not as helpful, we can help smooth implementation for others and shorten the time it takes for research to be integrated into day-to-day practice," she said.
New research helps identify which breast cancer patients are likely to quit going to follow-up visits.
Within the five years following a diagnosis for Stage I or II breast cancer, 21% of patients stop seeing physicians for follow-up care, a recent study says.
Breast cancer is the second most common form of cancer for American women, with about 12% of women developing the condition, according to the American Cancer Society. Breast cancer has a high level of lethality—only lung cancer kills more women annually.
The corresponding author of the recent research, which was published in the Journal of Oncology Practice, told Healthleaders that there are several reasons why follow-up care is crucial for recovery.
"It is important for patients to know that during follow-up appointments they are being evaluated for recurrence, evaluated for early detection of new primary tumors, and to make sure they are up to date with other cancer prevention activities. In addition, information is rapidly changing, so keeping up with the oncologist is important to make sure the care is current," said Dawn Hershman, MD, MS, a professor of medicine and epidemiology at Columbia University Medical Center in New York.
Hershman's research team examined data from more than 30,000 patients who were 65 and older. They found several key points.
In the first year after diagnosis, 85.8% of patients saw a medical oncologist and 71.9% saw a radiation oncologist in addition to a surgeon
Two-thirds of the patients visited all three kinds of providers in the first year after diagnosis
In the five years after diagnosis, 21% of patients stopped follow-up visits
Factors predictive of discontinued follow-up care included older age, single relationship status, patients with low-grade tumors, and patients with hormone receptor-negative breast cancer
Encouraging follow-up care
Surgeons and oncology specialists can take steps to increase follow-up care for breast cancer, the researchers wrote.
"Coordination of follow-up care between oncology specialists and other providers may reduce discontinuation rates as well as the redundancy of visits, thereby increasing clinical efficiency. Identifying patients who are at risk for early discontinuation of follow-up will eventually allow for the promotion of public health initiatives to improve access to care," they wrote.
Hormone therapy should be a focal point of public health efforts, Hershman told HealthLeaders. "The most important thing we do during follow-up is to make sure women on hormone therapy stay on their hormone therapy. Making sure these treatments are available to everyone is an important public health initiative."
Educating breast cancer patients about the seriousness of follow-up care is essential, she said. "As a provider, it is hard to know when patients stop following up. Sometimes, patients move or change providers. Patients need to be active in making sure they follow with at least one provider."
Engaging patients and family members is crucial when there are documents specifying physician directives for life-threatening conditions.
For clinicians, there are a handful of approaches to working with physician orders for life-sustaining treatment (POLST) documents in the emergency department setting, according to a recent article in the Annals of Emergency Medicine.
POLST forms are available across the country. Compared to living wills and durable power of attorney documents, POLST forms have been associated with significantly higher decreased odds of resuscitation attempts in the field and increased odds of out-of-hospital death for patients with "comfort measures only" directives.
"POLST forms are more useful than CPR directives in that they describe important broader end-of-life treatment choices than just whether to receive CPR attempts. For example, some patients may not want to go to the ICU; they may not want intubation," the author of the Annals of Emergency Medicine article, Jean Abbott, MD, MH, wrote.
Clinicians should take five approaches to working with POLST forms in the emergency department setting, according to Abbott, who is a professor emerita at the Center for Bioethics and Humanities, Department of Emergency Medicine, University of Colorado, Aurora.
1. Supporting emergency medical service workers
Abbott recently told HealthLeaders that EMS personnel are obligated to honor POLST documents but emergency departments are better equipped to interpret the forms as well as the care preferences of patients and family members. "When a family is overwhelmed enough to call 911, EMS should respond and bring the patient to the hospital. The ED is the place to sort out how to best honor a patient's wishes," she said.
The goal for EMS and ED staff should be to narrow the gap between the care that is provided and the patient's care preferences, Abbott said. "I have done a significant amount of training both with EMS and the ED to get them to a better place than, 'Well, I'll just do everything and if the patient survives, they can just figure out what to do upstairs.'"
2. Honoring POLST orders for CPR and airway management
Even in crisis conditions, ED clinicians should check the "yes" and "no" orders at the top of POLST documents for CPR and intubation, Abbott said. "Though not usually part of the ED situation, there are starting to be lawsuits when clear advance directives—usually in the form of the orders associated with POLST rather than more vague wishes expressed in other advance directives—are ignored."
3. Using POLST information to engage the patient and family members
After the initial crisis has been stabilized, ED clinicians should use POLST forms to engage patients and family members in a discussion about care preferences, Abbott said.
"There is no substitute for a conversation with patients and families to discern the meaning behind various choices—would they want antibiotics for an episode of presumed sepsis, would they want vasopressors for low blood pressure, etc. Much of those choices depend on where the patient is in the arc of their life—do they want a robust attempt to restore them to their pre-crisis state, or was their life already very difficult and they would lean more toward gentle interventions."
4. Considering disposition strategies that align with patient wishes
Based in information in POLST forms, ED clinicians can help patients or their surrogates to establish an action plan for hospital-based care, Abbott wrote in her Annals of Emergency Medicine article.
"Broaching the concept of, for instance, a time-limited trial or of revisiting interventions started in the ED may help the admitting team to later suggest stopping interventions that are not successful in restoring the patient to an acceptable quality of living," she wrote.
5. Preparing patients and families for difficult intervention questions
ED clinicians are well-suited for laying the foundation for discussions about intervention dilemmas, Abbott wrote.
"The ED role includes good documentation and robust communication with admitting teams. The electronic health record note should include topics broached, who was present, and what wishes and intent might have been clarified by the ED team. Palliative care consultation can and should be initiated when appropriate from the ED," she wrote.
Components of Johns Hopkins' SNF collaborative include a rigorous process for selecting partner facilities and establishing a management framework.
Johns Hopkins Medicine has established a skilled nursing facility collaborative to improve the quality and cost effectiveness of postacute care for its patients.
Transferring patients to skilled nursing facilities shortens length of stay in acute care settings but low quality of care at SNFs can lead to hospital readmissions. This dynamic is reflected in a 2013 Institute of Medicine report that found postacute care accounted for 73% of the variation in Medicare spending.
"One mechanism employed to improve transitions to SNFs and reduce associated readmissions is to create a preferred provider network. Increasing the concentration of hospital discharges to higher performing facilities is associated with lower rehospitalization rates, particularly during the critical days following discharge," Johns Hopkins staff members wrote recently for an article published in the Journal of Hospital Medicine.
There are three primary steps to establish a SNF collaborative, the article says.
1. Select appropriate SNF partners
The best SNF partners for health systems and hospitals are high-quality facilities and/or SNFs with historically high volume. In the latter case, the SNFs' name recognition with patients and providers can be capitalized and quality can be boosted through improvement initiatives if necessary.
There are several possible quality and clinical outcome criteria for picking preferred SNF partners:
Centers for Medicare & Medicaid Services quality star ratings and Long-Term Care Minimum Data Set measures
Rate of 30-day readmissions
Satisfaction ratings from patients and family members
Emergency department visits
Primary care follow-up within seven days of hospital discharge to the SNF setting
The Johns Hopkins Medicine Skilled Nursing Facility Collaborative features a management framework that established a system-level approach to SNF partnerships based on the shared goals of improving care and reducing costs.
The framework includes three primary elements:
A steering committee that functions as the collaborative's governing body was drawn from all participating Johns Hopkins Medicine (JHM) players. When the collaborative was launched, the steering committed targeted three dozen SNF chains and freestanding facilities to participate in the initiative.
A stakeholder group was formed with broader representation from JHM, including leaders with postacute care expertise such as rehabilitation and emergency medicine. The stakeholder group also included SNF partners and the local CMS-funded Quality Improvement Organization.
Dedicated workgroups lead protocol-based initiatives, data management, and analytics. The initial protocol-based initiative for the collaborative was transitions of care, which featured all affiliated hospitals focusing on a harmonized approach to care transitions. Representatives on the workgroup included members of hospital leadership, Johns Hopkins HealthCare, Johns Hopkins Medicine Alliance for Patients, the JHM home care division, and members of SNF leadership.
3. Foster physician leadership
Enlisting physician leaders to help guide meaningful and broad change is an essential ingredient of an effective SNF collaborative, the Journal of Hospital Medicine article says.
"When devising system-wide solutions, incorporation and respect for local processes and needs are paramount for provider engagement and behavior change. This process will likely identify gaps in understanding the postacute care patient's experience and needs. It may also reveal practice variability and foster opportunities for provider education," the article says.
Investing resources
The lead author of the journal article told HealthLeaders that JHM invested considerable resources to build an effective SNF collaborative.
"The greatest upfront investment was likely the time and effort of individuals across our organization who crafted the vision for this collaborative in alignment with the institutional priority," said Sarah Johnson Conway, MD, medical director of the Johns Hopkins Infusion Center and an assistant professor of medicine at the Johns Hopkins University School of Medicine in Baltimore.
"The coordinating team had representation from population health, care management, hospital administration, health plan, and skilled nursing facility medical leadership. Once the framework was in place, initial investments went toward administrative infrastructure with project management, data and analytics, and medical oversight."
Workplace violence against healthcare workers by patients and patients' family members has reached epidemic proportions at hospitals, but there are strategies hospital leaders can implement to cope with the problem.
Hospitals carry a heavy workplace violence burden, with about three-quarters of U.S. workplace assaults occurring in healthcare settings, according to a report by the Occupational Safety and Health Administration. Workplace violence is prevalent in emergency departments—78% of emergency physicians have reported being targets of workplace violence in the prior 12 months.
The scope of the peril for healthcare workers is so immense that hospitals have an obligation to address assaultive behavior in the workplace, says Laura Monaco, JD, an associate in the Employment, Labor, and Workforce Management practice at Epstein Becker Green in New York.
"We're not just talking about punching or hitting—it's also things like spitting, biting, and shoving. Employers have to be mindful this is an urgent situation that they need to be on top of and have a laser-focus on because it is such a large threat," she says.
There are six steps hospital leaders can take to manage workplace violence against healthcare workers.
1. Know your jurisdiction
The first step for hospital leaders is knowing the applicable laws in their state, Monaco says. "The first thing to consider is where are you—what is your jurisdiction? Many states have specific laws that provide for enhanced criminal penalties when a healthcare worker is assaulted similar to assaults on police officers or firefighters."
It is essential for hospitals to have policies and protocols established to deal with violent episodes at their facilities, Monaco says.
"The employer should have a policy and protocol for investigating incidents—especially when you are dealing with patients. They should develop standard questions: Was the patient on medication? What medication were they on? Was there a normal or adverse reaction to medication?"
Consistency is crucial, she says. "There need to be procedures in place where—on a standardized basis—the employer can investigate and ask questions because these are case-by-case decisions."
Policies and protocols should promote peaceful resolutions to violent situations, says Sarah Swank, vice chair, Educational Programs, In-House Counsel Practice Group, at the American Health Lawyers Association in Washington, D.C.
"The policies should be based on de-escalation because violence in the workplace can come from different sources. It can come in different levels of intensity. Training and policies based on de-escalation can be very successful," Swank says.
To be effective, policies and protocols for workplace violence should be widely disseminated throughout a hospital's staff, she says. "Training and policies should not just be focused on the hospital security team but also on clinicians and other frontline employees because they can be part of the de-escalation process."
3. Mandate assault reporting
Hospital employees should be required to report workplace violence incidents, Monaco says.
"Anything an employer can do to encourage reporting of these assaults is important—having clear procedures, explaining how employees can make these reports and who they can go to, having steps for managers and supervisors to take once they receive a report of an assault, and knowing how to contact law enforcement authorities. These things should be planned out in advance and streamlined."
Hospital leaders must assure healthcare workers that they will not face retaliation for reporting workplace violence, Monaco says.
"Policies should make it clear that there will be no retaliation against an employee who reports an assault. Nurses and other healthcare workers have a concern that they will be retaliated against—either by patients' family members or other staff who may not agree with the assault reporting. If you mandate reporting and there is no retaliation, then you are encouraging people to come forward when they are assaulted."
Some states require employers to report assaults on healthcare workers to law enforcement, Monaco says. "For example, Connecticut has a law that requires assaults to be reported within 24 hours whether or not charges are pressed."
4. Investigate violent incidents
Hospital-led investigations of workplace violence episodes are opportunities to reduce future assaults on healthcare workers, Swank says. "After a violent incident, The Joint Commission recommends doing a root-cause analysis, which can be helpful in process improvement and improving policies."
To promote effective investigations, hospitals can create dedicated teams to probe workplace violence incidents, Monaco says. "One approach is having an emergency response team—people who respond when these types of issues come up. There can be representatives from the legal department, from HR, and from administration who make decisions in a uniform way about whether to press charges and how to proceed."
5. Enforce policies
Having an emergency response team can boost enforcement of workplace violence policies, Monaco says.
"When you formalize procedures, it's easier to follow through. If there is an emergency response team, and the task of the team is to address workplace assaults, it becomes more difficult to sweep these situations under the rug. There is accountability, which is one way to make sure these kinds of policies are enforced."
Adherence to policies is fundamental to successfully addressing workplace violence, Swank says. "Once a hospital sets a policy, it's important for the hospital to follow the policy. A policy should not be aspirational—it should be easy to follow, easy to understand, and reflective of the hospital's culture."
6. Press charges
For hospital leaders, deciding whether to press charges against patients or their family members who have assaulted healthcare workers can be a daunting challenge, Swank says.
"Oftentimes, it is not the hospital that presses charges against family members or patients who have had a violent incident. The hospital needs to balance supporting its employees without creating a chilling effect on those who want to seek care at the hospital. Achieving this balance is especially difficult when patient violence is part of a patient's medical condition."
If hospital officials decide not to press charges, they can still help staff members who have been assaulted, Swank says. "A hospital can support its employees. For example, if there has been an assault and an employee has pressed charges, the hospital can provide information as part of the charges or the employee can be given time off from work to testify in the criminal case."
Assistance should not be limited to legal aid, she says. "It should be addressed with compassion and sympathy for the people who were injured or were part of the incident."
It is important for hospital leaders to participate broadly in what happens after a workplace assault, Monaco says. "Policies should not forget about the employee once the decision is made whether to press charges. If an employee has been assaulted, they are going to need support and they could need counseling."
Leaders who raise awareness at their hospitals about the potential for pressing charges against patients who have assaulted healthcare workers can have a significant impact, Monaco says.
"Sometimes, the deterrent affect can be achieved even if you don't press charges. It can help to have administrative action ready to go. If a patient commits an assault but it's in a gray area, you can flag the file not only as a warning for other staff members but also as a record that the patient is assaultive. It can be made clear to the patient and family members that if it happens again the hospital will press charges," she says.
