At health systems, hospitals, and physician practices, one-dimensional approaches to burnout are unlikely to succeed.
Physician burnout is a multifactorial phenomenon that requires a multifaceted response, a recently published white paper says.
Recent research indicates that nearly half of physicians are experiencing burnout symptoms, and a study published last October found that burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction.
The Chicago-based Chartis Group's recent white paper calls for healthcare organizations to take a broad approach to solving their physician burnout problems, an author of the report told HealthLeaders.
"When single-threaded solutions are executed in isolation or without an understanding of the full set of factors that are contributing to this epidemic, the impact can be limited and short-lived," said Tonya Edwards, MD, a principal in the I&T Practice at Chartis.
Several factors are often at play when a healthcare organization is experiencing alarming levels of physician burnout, she said.
"What we have tried to do is put together an approach that looks at many of the factors that contribute to provider burnout, including workplace overload, lack of control, breakdown of community, inefficiency, and poor leadership practices such as lack of respect and setting unrealistic performance expectations."
Two-pronged strategy
The white paper has a two-part framework for addressing physician burnout:
1. Operational dimension: At the grassroots, burnout mitigation efforts include process redesign such as streamlining of workflows, assessment and reform of care-team models such as staff fully practicing at the top of their licenses, and optimal use of technology such as realizing the full potential of the electronic health record.
2. Transformational dimension: At an organizational level, Chartis' approach focuses on leadership such as whether senior leaders involve physicians in decision making, culture such as fostering an environment that values collaboration and mutual trust, and engagement such as whether performance expectations well-articulated and understood.
"The first thing that needs to happen is a listening tour. Particularly after joining large organizations, providers feel like administrators are making all of the decisions, and there is a significant loss of autonomy. Physicians no longer feel respected," Edwards said.
Implementing burnout solutions
Every healthcare organization should design physician burnout mitigation efforts that are carefully crafted, Sue Fletcher, engagement manager in the Performance Practice at Chartis, told HealthLeaders.
"We believe we have to assess all of the factors, then tailor the solution based on the unique needs of physicians and the specific setting. The needs of primary care physicians are going to be unique and different compared to those of hospitalists or surgeons," she said.
Imposing physician burnout solutions on a healthcare organization rarely works, Fletcher said. "We have partnered with organizations to assess the specific needs of physicians—working with the care teams and working with the physicians to understand the factors that are causing burnout. Then we work directly with the physicians to figure out observable improvements in their experience."
Establishing and tracking metrics is crucial for a successful physician burnout initiative, Edwards said. "A key factor is making sure we are making measurable improvements. We have to identify key performance indicators. We have to show improvement over time."
Cleveland Clinic is achieving multiple benefits at the health system by creating a high-reliability culture.
High reliability is a high priority at health systems and hospitals across the country.
For example, recent research identified achieving high reliability as the top priority at children's hospitals. And Novant Health in Winston-Salem, North Carolina, has adopted a culture of zero tolerance for hospital-acquired infections, serious safety events, and any harm to patients while they are hospitalized, says Eric Eskioglu, MD, the executive vice president and chief medical officer.
Another example of a healthcare organization prioritizing high reliability is Cleveland Clinic, which began initiatives in 2013.
"There has been a revolution at Cleveland Clinic over the past several years to emphasize a culture of high reliability and safety, as well as to emphasize a team approach to everything we do," says Edmund Sabanegh, MD, main campus and regional hospitals president at the Cleveland-based health system.
Cleveland Clinic's quest to become a high-reliability organization has achieved a trifecta: improved patient outcomes, boosted physician satisfaction, and reduced physician burnout.
"There is a big problem in healthcare with burnout, which is complex and involves lack of job enjoyment, feeling stressed, and work-life balance challenges. All of those things improve when you have a team working together smoothly to get the best outcomes for patients," Sabanegh says.
The correlation between team-based care and physician satisfaction is direct, he says. "Things that help us successfully treat patients—team approaches, checklists, and spreading of responsibility—improve our engagement and satisfaction with our career field."
High-Reliability Components
Cleveland Clinic's high-reliability initiative has revolved around basic team building, policy standardization, real-time operational management, creating a culture of safety, and sustaining redundancy in the clinical setting.
But inconsistency in administrative and operational policies is a major challenge for health systems seeking to attain high reliability, Sabanegh says.
"One of the challenges for any large healthcare system is there are many sites for delivery of care. A pitfall that you can have is failing to recognize the nooks and crannies of the system, then having different policies and standard operating procedures for different areas," he says.
Cleveland Clinic, which features 19 acute-care hospitals, has made policy standardization a priority, Sabanegh says. "We have worked hard to standardize our policies to make sure that a nurse who works in one ward, then works in another location in our system has a similar expectation and similar understanding of processes."
One of Cleveland Clinic's high-reliability cultural initiatives has upended decades of tradition in the health system's operating rooms. As opposed to the top surgeon dominating discussions and decision-making in the OR, the health system has adopted a team-oriented approach, including operating room pauses, he says.
"If we have a surgery and anyone in the room is unsure of equipment status or a missing supply like a sponge, there can be a pause. Any member of the team can say, 'I want to look at where we are before we proceed any further with this procedure.' It could be the most junior member of the surgical team or it could be the most senior member."
To achieve real-time operational management, Cleveland Clinic adopted a reporting system based on tiered huddles this year.
"Every morning, on every nursing unit, there is a huddle of the team. They discuss what has gone right, opportunities, and concerns for the day ahead," Sabanegh says.
The discussions at the ward level are reported to hospital leadership, including the president, chief nursing officer, chief medical officer, and chief quality officer.
The hospital leadership's huddle is reported to health system leaders. Information gathered through the tiered reporting allows senior leadership to act quickly at any location in the organization, he says.
"As the hospitals' president, I am hearing every day from every hospital in our system about their challenges and opportunities for the day ahead. What is our workload and how can we balance it? What kind of infrastructure support do we need? What kinds of repairs are needed?"
Gathering timely information from throughout the health system is invaluable from both management and labor perspectives, he says.
"Real-time operational management gives us both an early warning system for problems and challenges for the entire enterprise, and a great venue to communicate up and down the organization. Everybody is hearing about challenges at other places and how those challenges are being solved."
Cultural considerations
Culture is essential to creating a high-reliability organization, Sabanegh says. "We are working very hard to create a culture of safety and high reliability. Every time the leaders of the organization speak, they talk about this theme."
Staff members are encouraged to identify quality concerns with public recognitions such as awards. "We don't want to be in a reactive mode. Our system fails when we have a serious safety event. What we want to identify is the near miss or something that could turn into a serious safety event down the road," Sabanegh says.
Although redundancy is often equated with waste, Cleveland Clinic sees value in redundancy in the clinical setting, he says.
"We still believe some redundancy is necessary. We are leveraging technology to assist in catching things; but, in this generation, technology will not replace the need to have multiple sets of eyes looking at a challenge."
Education and communication have been key elements of engaging physicians in high-reliability efforts at Cleveland Clinic, Sabanegh says.
Educational programs that support the health system's high-reliability efforts include Solutions for Value Enhancement (SolVE). "Physician leaders learn about high reliability, performance improvement, and tackling processes with risk and opportunity while avoiding risk. We have trained thousands of people in our organization in these areas," he says.
High-reliability benefits
Cleveland Clinic also communicates with clinicians about the benefits associated with high-reliability organizations, he says.
Engaged clinicians have helped Cleveland Clinic achieve significant high-reliability gains. The average 30-day readmission rate has fallen from 14% to 12.65%, which represents 2,100 patients per year who did not require a readmission.
Outpatient hypertension control has increased from 66% to 76%, with 15,000 more patients at prescribed goals. Cleveland Clinic estimates improved hypertension care has saved about 100 lives.
"We have seen a steady improvement in our quality outcomes, a reduction in serious safety events, and improvements in our readmissions—all things that are important to our patients and improve when our care team makes sure we are highly reliable," Sabanegh says.
Any invasive procedure in neonatal intensive care units puts tiny patients at risk of harm.
A Utah-based hospital has dramatically reduced the number of invasive procedures endured by patients in the facility's neonatal intensive care unit.
Procedures such as blood draws, central line insertions, and radiological exams can cause a range of harm to fragile neonates, including deadly bloodstream infections such as sepsis.
In 2008, Dixie Regional Medical Center in St. George, Utah, launched an initiative to reduce infections and other harms linked to invasive procedures in the Intermountain Healthcare facility's NICU. The program—preventing pain and organisms from skin and catheter entry or POKE—has achieved impressive results:
"In the beginning, we were trying to reduce infection in the neonates. We knew that every time we punctured their heels over a 24-hour period there was an increased chance of sepsis. We knew that if we kept lines in for longer than seven days, there was an increased chance of central line-associated bloodstream infections. We have only had one CLABSI in more than 10 years," says Jeannette Cutner, BSN, RN, a nurse manager at Dixie Regional.
POKE has been adopted at other Intermountain hospitals as well as several other health systems such as Loma Linda University Health, University of Alabama at Birmingham, and Florida Hospital.
Providing value-added care
The POKE program is based on core principles, says R. Erick Ridout, MD, a neonatologist at Dixie Regional. "The most important first step was aligning the team under the idea of all care needing to be value-added, and care that was not value-added represented harm."
Care team culture is critically important, he says.
"The most important thing is recognizing that just culture is the foundation for everything—that means folks are accountable for the care they provide, and they will support things we can improve. That builds a virtuous cycle that drives toward safety and zero instances of harm."
There are several elements to drawing the line between invasive procedures that add value in the NICU and those that do not add value, Ridout says.
"At first, the only way we could identify care that was value-added was looking at the literature, but that was woefully lacking. So, we had to rely on a highly engaged team. And the only way to have a highly engaged team is to have everyone feel valued, which requires leadership managing the team from a position of humility, deep respect, and deference for those at the frontline."
Observation of the patient is crucial in the POKE program, he says. "You fall back on the reams of data the baby already provides."
"If we look at a pre-term baby who is thriving, gaining appropriate weight every day, with normal temperature—checking all the boxes—conducting labs on that baby to make sure it is normal does not help. It hurts the baby. That's a very common practice—babies are routinely put through pokes, and labs are run every Monday, Wednesday, and Friday to demonstrate babies are normal when they are telling you they are normal already," Ridout says.
Implementing POKE
The first step to implement the POKE program was gathering data, he says. "We first started out rudimentarily on paper, then we programmed a database to record every single decision we made and what it meant on behalf of the patient."
Data is a powerful staff motivator when launching the POKE program at a health system or hospital, Cutner says.
"If you give 50 or 60 RNs something that is measurable every day—which is something we talk about daily with our parents and grand rounds in the morning—everyone is aware of the interventions that were done to the baby the day before. It used to be in the 40 to 70 range, and now it's down to near zero. We build a case for every poke every day," she says.
Cultural change requires significant effort, Cutner says.
"It takes leadership and building up all of the charge nurses who work inside the unit to where they all want to be at 100% when they come to work and do what's best for the baby. You need lines of communication between each other and between the disciplines, so no one is afraid to speak up."
New data shows that patients discharged from a skilled nursing facility to home face the highest risk of readmission in the first two days after SNF discharge.
Efforts to reduce hospital readmissions should include effective SNF-to-home transitions and appropriate skilled nursing facility length of stay, new research indicates.
For hospitals across the country, readmissions have become a crucial metric with quality and financial dimensions. A hospital's readmission rate is a key indicator of care quality and the effectiveness of discharge planning. Since 2012, Medicare has been penalizing hospitals financially for readmissions linked to several targeted conditions such as pneumonia.
The new research, which was published in the Journal of the American Medical Directors Association, features Medicare claims data collected from more than 67,000 heart failure hospitalizations in which patients where discharged to a SNF then to home.
The research includes several key data points:
24.2% of patients discharged from SNF to home were readmitted to a hospital within 30 days of SNF discharge
The risk of readmission was highest in the first two days after SNF discharge
Readmission risk declined with longer SNF length of stay
"Interventions to improve post-discharge outcomes have primarily focused on hospital discharge. This evidence suggests that interventions to reduce readmissions may be more effective if they also incorporate the SNF-to-home transition," the researchers wrote.
Improving SNF-to-home transition
To reduce hospital readmission, the SNF-to-home transition is likely crucial, according to the researchers.
"Heart failure patients discharged from hospital to SNF are more medically and functionally complicated than the overall Medicare HF population. … Therefore, patients discharged from SNF may benefit from discharge planning because during an SNF stay medications may be started or adjusted, diets may be monitored, and lab tests may be obtained, which may need post-SNF discharge follow-up," they wrote.
The lead author of the research, Himali Weerahandi, MD, MPH, told HealthLeaders the next step for investigators is to scrutinize the SNF-to-home transition.
"Given the importance the discharge process is for hospitalized patients, I believe this is also very important for patients who are discharged from SNF, particularly since they are likely to be frail or cognitively impaired, and thus more susceptible to issues that may arise during vulnerable transition periods. Given the high readmission rates we see with our study, our next steps are to go into SNFs to speak with providers, patients, and their caregivers to identify what the current discharge process is like at SNFs, and how it could be improved," she said.
Hospital discharge best practices could point the way to improving SNF-to-home transitions, said Weerahandi, an assistant professor in the Department of Medicine and Department of Population Health at NYU School of Medicine, New York.
When patients are discharged from hospital to SNF, ideally a medication reconciliation and discharge summary describing the hospital course should go with the patient to the SNF, and verbal hand-offs should occur from the physician and nurse at the hospital to their counterparts at the SNF. Likewise, a similar process should occur between the SNF provider and the primary care provider when the patient is ultimately discharged home," she said.
A new study shines light on medical errors and malpractice cases in pediatric care.
The types of malpractice claims involving children change over time, with infants under age 1 experiencing the highest severity injuries, a recent study found.
Earlier research found medical errors involving hospitalized children ranged from 1.81 to 2.96 per 100 discharges, and children at highest risk included those with special medical needs or dependence on a medical technology.
In a study published last month, The Doctors Company examined more than 1,200 claims filed on behalf of children. The data was segmented into four age categories: neonates, first month; first year, 1 to 11 months; child, 1 to 9 years; and teenager, 10 to 17 years.
"Diagnosis-related allegations were the most common allegation in all but the neonate age group. Age groups older than neonates experienced diagnosis-related claims in 34% to 44% of all claims and lawsuits in their age group," the study says.
The research includes several other key data points:
Obstetricians were named in the highest percentage of cases at 24%
37% of the cases resulted in a payment to the claimant
The median indemnity payment was $250,000, and the median expense to defend those claims was nearly $100,000
Brain injuries accounted for the highest percentage of claims for all age groups: neonates, 48%; first year, 36%; child, 15%; and teenager, 11%
Children in the first-year category of the claims experienced the highest death rate at 30%
Neonates were a high-risk category in the malpractice cases for several reasons, the lead author of the study told HealthLeaders.
"Care for neonates is problematic because babies in their first month of life are very vulnerable to harm. The birth process can be traumatic. Injuries suffered during childbirth include brain damage, brachial plexus injuries, lacerations from forceps, injuries to the scalp from vacuum-assisted deliveries, and infections," said Darrell Ranum, JD, vice president of patient safety and risk management at The Doctors Company.
Diagnosis difficulty
Making accurate diagnoses in pediatric care can be daunting, Ranum said.
"Diagnosing patients is challenging because symptoms may not be specific to one or two conditions. Physicians must factor numerous pieces of information into their differential diagnosis. Diagnosing children can be more challenging than diagnosing adults. Younger children may not be able to articulate what they are feeling. Parents often contribute useful information; but in some situations, language barriers make this interaction more difficult."
Parents may fail to share crucial care clues, he said. "In some cases, parents may not talk about information because they don't remember to tell their physician, or they don't understand the clinical significance of the information. Family history that includes inherited conditions is one example of information that may be overlooked."
Mitigation measures
There are several approaches to avoid medical errors and malpractice claims involving children, Ranum said.
"Develop systems that support physicians and other healthcare providers. Clinicians should not depend on memory to make clinical decisions. Like everyone else, clinicians can be distracted, overloaded with information from multiple sources, and impacted by their feelings following unpleasant interactions."
Examples of support systems include good documentation and structured reminders, he said.
"Tracking systems for vaccinations, lab tests, radiographic studies, and medication orders that require monitoring all help clinicians to provide the right care at the right time. Many claims in primary care are related to lost test results or X-ray findings that would have prompted a clinical response. With no tracking system, physicians are often unaware of what they don't know."
Training can be pivotal in high-risk situations, Ranum said.
"Many of the conditions that result in patient harm occur infrequently. Rare critical situations resulting in high-severity injuries should prompt simulation training. This prepares clinicians to respond with a prompt and skilled response. Good examples in obstetrics for simulation training include conditions that could result in oxygen deprivation to a fetus before birth and shoulder dystocia during the birth process."
Communication is also crucial, he said. "An essential strategy is being prepared for questions or concerns raised by parents and other caregivers. Office staff should know what concerns should prompt a physician's review or immediate care. These calls are often the first opportunity to address life-threatening conditions."
Establishing a 'fast track' for low-acuity patients improves efficiency in emergency departments.
Creating a "fast track" process in an emergency department that separates patients with high- and low-acuity conditions significantly reduces length of stay, recent research shows.
Excessive length of stay in emergency departments contributes to ER overcrowding, patients leaving without being seen, and decreased patient satisfaction.
Establishing a fast track capability for patients with low-acuity conditions improves ER efficiency, researchers wrote recently in the Journal of the American Medical Association.
"After the initiation of the Fast Track process in December 2015, and without making any other changes to ED workflow or staffing, there was a 25% decrease in the length of stay of patients with low-acuity conditions (from 190 minutes to <150 minutes) and the rate of patients leaving without being seen decreased from 8% to 4% in just five months. At the same time, patients with moderate- and high-acuity conditions who were discharged had reduced length of stay in the ED and stable or reduced rates of leaving without being seen."
The Fast Track process has five elements:
1. Workflow: The Fast Track care pathway for low-acuity patients features a standardized workflow to manage patients, including specific roles and actions for each staff member such as rooming patients and delivering discharge instructions. Separating low-acuity patients and creating a standardized workflow helps ER staff to estimate the resources needed to meet patient demand.
2. Process management: Standardized staffing processes include adaily team huddle at the beginning of each shift to set expectations such as assigning medical assistants to specific procedures for wound care preparation and nurse practitioner approaches to charting and discharge practices. Department leaders coach standard processes for rooming, documentation, procedures, and discharges.
3.Data drivers: Daily data reports are generated and shared with frontline and executive staff to enable adjustments to new processes.
4.Dedicated work space: Positioning the Fast Track team in a separate area of the emergency department increases the capacity to manage more complex patients in other parts of the ED.
5.Enlisting leaders: Engaging hospital leadership such as the CEO, chief medical officer, and chief quality officer in daily data-driven huddles, weekly planning sessions, and quarterly workshops boosts the ED improvement initiative.
Determining acuity levels
In establishing the Fast Track model, the initiative team took three approaches to determine low-acuity conditions, the lead author of the JAMA article, Mary Mercer, MD, MPH, told HealthLeaders.
Safety parameters were set, including strict exclusion of patients with abnormal vital signs.
The Emergency Severity Index (ESI) nursing triage tool was used to determine which patients would be most likely to be discharged and would be most likely to need the lowest level of resources and tests. This set of patients have low admission rates.
The Fast Track triage process also involves identifying patients who are ESI outliers. For example, patients with chest pain, headache, and abdominal pain, even if initially triaged as an ESI 4 or ESI 5 level, often had much longer lengths of stay than other patients with that triage level because of the risk of a serious condition such as a heart attack or surgical condition.
"We used both aggregate data and direct observation to determine types of patient visits that would be amenable to being safely and efficiently seen in Fast Track," said Mercer, an associate clinical professor in UCSF's Department of Emergency Medicine and EMS base hospital medical director at Zuckerberg San Francisco General Hospital.
Keys to Fast Track success
There are three crucial components to achieving Fast Track success, Mercer said. "What we were trying to highlight in this manuscript were the ingredients needed for implementing sustainable change in a way that used the critical elements of an organizations' culture to align improvement work with the organization's strategic objectives."
Executive leadership: The Fast Track initiative was the first of several improvement efforts to launch a lean management system at Zuckerberg San Francisco General Hospital. The executive team's commitment to embarking on the lean system and seeking to better understand and support frontline initiatives was apparent from the beginning and throughout the process.
Interdisciplinary approach: People of all relevant disciplines in the ED from physicians, nurses, nurse practitioners, clerks, and medical assistants were involved in the design, testing, implementation, and monitoring of the new program. Each staff member's job had to be easy to execute repeatedly and consistently. Interdisciplinary team members helped to coach their peers in an ongoing fashion to ensure consistency of the process.
Daily data reporting and department-wide huddle: Sharing information in real-time is critically important to monitor the performance of Fast Track, elicit ideas for improvement, and update how the executive team and other staff members are supporting the initiative.
An effective hospital discharge process created by Cleveland Clinic is pivotal in the handoff of patients to postacute-care providers.
Hospital discharge is a complex process involving the primary care team, which can include residents, interns, fellows, nurse practitioners, physician assistants, and other staff members in addition to the attending physician.
Without a thorough discharge summary and completed medication reconciliation, postacute-care teams can be bewildered, and patients can be at risk of costly readmissions. Research has linked readmissions to poor communication and poor care coordination between hospitals and primary care providers.
Amy O'Linn, DO, a hospitalist and physician lead for enterprise readmission reduction at Cleveland Clinic, says an efficient discharge process is about patient safety.
"There can be medication errors, side effects, and confusion after a discharge if we don’t get it right," O'Linn says.
To strengthen the patient handoff process from acute to postacute care, Cleveland Clinic created a new discharge checklist to improve discharge summaries and medication reconciliation. According to the Ohio Hospital Association, the goal of the new process was to "achieve a 100% completion rate on all discharge medication reconciliations and discharge summaries prior to a patient leaving the hospital."
Since the new discharge checklist was established, the completion rate for medication reconciliation at Cleveland Clinic's main campus has increased from about 88.0% to 98.7%, and the completion rate for discharge summaries at Cleveland Clinic's main campus has increased from 58% to 80%.
In March, the Ohio Patient Safety Institute awarded Cleveland Clinic with the Acute Care Best Practice Award for the health system's development of the new discharge checklist.
The Cleveland-based health system's discharge checklist, which was implemented in November 2018, has two components: a medication reconciliation document and a discharge summary.
1. Medication reconciliation
"The discharge medication list has been reconciled with the medications the patient was previously taking at home and the medications the patient was taking in the hospital. The medication discharge list is the final list that the patient receives, [and it] is very valuable. Without a completed, signed-off list, the patient does not know what to take," O'Linn says.
The medication reconciliation document is a mandatory step in Cleveland Clinic's new discharge process, she says. "It's a hard stop. The patient cannot leave the campus until the medication list is signed off by the primary care team."
2. Discharge summary
Although completion of a discharge summary is not absolutely required to discharge a patient, it is a Cleveland Clinic policy and nearly as essential as medication reconciliation, O'Linn says.
Under the health system's discharge summary policy, there are 18 elements in the document, including admission date, discharge date, chief primary complaint when the patient came to the hospital, discharge disposition, and the medication list. Clinicians are also encouraged to include "the story" of the hospital admission, she says.
"What we are encouraging providers to do is answer key questions: What brought the patient to the hospital? What happened during the hospital stay? And what is the plan going forward? The 18 elements that are part of our policy are not as useful in detailing the story of a hospital stay. The story is where the money is—it's what happened and what's going to happen now," O'Linn says.
Crafting the discharge checklist
A multidisciplinary team at Cleveland Clinic developed the discharge checklist, she says.
"We had the information technology people; we had Epic, who had to make the technical hard stop [in our EHR]. We had strong help from the pharmacists because there is nothing more painful for a provider than to have a Band-Aid or piece of gauze on a medication reconciliation—we took out some medicines and other things that don't need to be reconciled like insulin syringes. We had nursing managers and care management. We worked with documentation specialists, who helped get the word out to the providers."
One of the primary barriers to the new discharge checklist effort was fear, O'Linn says.
"People were afraid that if we made a hard stop for the medication reconciliation, then patients would never leave the hospital. After we worked through the process for a couple of months, we came out knowing we could do this. It did not affect the length of stay. The day we launched, we were nibbling our fingernails, but we never got a call. We had all lines open to help people who had trouble, but everything was OK."
Advising other adopters
Incorporating a new discharge list into a health system's electronic health record is a key step, O'Linn says. The EHR flags discharges that do not have medication reconciliations.
"You can work with your electronic medical record to make this happen. Some of our hospitals have tried to use nursing as the people who stop the line for a shaky discharge or an incomplete medication reconciliation, but that takes a lot of nursing strength and can create uncomfortable encounters," she says.
Support from the C-suite is also critically important.
"The culture change needs to come from the top. The administration needs to say, 'We are going to protect the patient.' The whole reason we were able to do this is because our CEO, Dr. Tomislav Mihaljevic, said we had to do it. He said we couldn't let patients leave without a med list. Without his support from the very top, we could not have done this at the grassroots," O'Linn says.
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.
