In adults, shortened length of stay has been linked to higher readmission rates for some conditions.
Shortening hospital length of stay does not increase readmission rates for pediatric patients, recent research shows.
For adults, length of stay has become a key metric for hospital readmissions, with concerns about the quality of discharge care such as patients discharged before they are ready to leave the hospital. Shortening hospitalization length of stay for adults is associated with a higher risk of readmission for some conditions.
The authors of the recent research, which was published in JAMA Pediatrics, say their finding likely reflects well-managed length of stay for pediatric patients.
"In children's hospitals, the majority of children may already be staying in the hospital for the appropriate amount of time. As a result, efforts to avoid readmissions should focus on other aspects of hospital discharge care," the researchers wrote.
The lead author of the research told HealthLeaders that most adults and children have fundamentally different length of stay experiences.
"When compared with adults, more pediatric hospitalizations are due to acute illnesses that are either self-limited or require interventions that can improve health with a short LOS. Adults with more chronic conditions may get more benefit from some additional time for improvement as well as discharge planning," said James Gay, MD, professor of pediatrics and medical director for utilization and case management, Monroe Carell Jr. Children's Hospital at Vanderbilt in Tennessee.
Gay and his team found little benefit from extending length of stay for pediatric patients.
"Keeping all children in the hospital longer may prevent some readmissions—as our study showed—but the cost is just too great for the relatively few readmissions prevented," Gay said.
Evaluating length of stay impact
Gay and his colleagues examined data from the Children's Hospital Association, including clinical and billing information from 49 children's hospitals.
The research team reviewed more than 950,000 pediatric hospitalizations.
There were 314 potential reasons for an admission and only six (1.9%) conditions had higher readmission rates with a shortened length of stay
The outlier conditions included asthma, cellulitis, and nephritis and nephrosis
The time estimated to prevent a single readmission ranged from 18 hospital-bed days for nephritis and nephrosis, to 148 days for newborns
The cost of preventing a single readmission through length of stay was prohibitive, ranging from $41,000 for nephritis and nephrosis to $1.4 million for dorsal and lumbar spinal fusion.
Rising to readmissions challenge
As they seek effective strategies to reduce readmissions, children's hospitals should be able to adopt some approaches from acute care hospitals, Gay said.
"In adults, improved discharge planning, follow-up telephone calls, and home visits have been shown to reduce readmissions for some patient populations. So, it seems logical that improved discharge planning and follow-up are potential targets for reducing preventable pediatric readmissions, too," he said.
Children's Hospitals will have to move cautiously, Gay said.
"Mounting evidence suggests that some post-discharge interventions such as follow-up home or office visits may actually be associated with more frequent readmissions in children. Is it just that the sicker patients—who are more likely to need readmission in the first place—are more likely to seek post-discharge care? Perhaps, but at this point, it's not clear and we continue to seek effective means of reducing pediatric readmissions."
Following length of stay best practices
Length of stay for individual patients should not be set rigidly, and providing efficient treatment in the hospital and effective discharge planning with the patient can safely shorten hospital stays, Gay said.
"We can shorten the LOS to the greatest extent possible while providing the patient with the best means to return to their previous health baseline," he said.
Some patients can go home earlier than others, Gay said. "We must remember that patients often do not require complete return to baseline while in the hospital and it may be appropriate for the recovery period to extend beyond the discharge date."
Federal and state rules have enabled spending on nonmedical services that have health benefits such as food security.
Managed care organizations (MCOs) are on the leading edge of efforts to strike a better balance between health and social service expenditures, a recent article in JAMA says.
Evidence is mounting that countries with higher social services spending such as disability, unemployment, and housing have better population health outcomes. Among Organization for Economic Co-Operation and Development (OECD) countries, higher social services spending is associated with higher life expectancy, lower infant mortality, lower prevalence of chronic diseases, and lower all-cause mortality.
MCOs are taking a leading role in addressing social determinants of health, the JAMA article authors wrote.
"By expanding the scope of service delivery as part of managing population health risk, managed care companies can invest in services and supports that meet their members' health-related needs, benefit from reduced spending on medical care, and leverage business principles to justify resource reallocation," they wrote.
The Centers for Medicare & Medicaid Services (CMS) have enabled MCO expenditures for social services.
In 2016, CMS amended the Medicaid managed care rule to prompt Medicaid MCOs to help patients with nonmedical expenses that were considered crucial to achieving health outcomes and cutting costs.
Under the CMS Accountable Health Communities Initiative, many Medicaid MCOs assess patients' unmet social needs, including housing instability, food insecurity, utility needs, interpersonal violence, and transportation requirements.
An increasing number of states are requiring Medicaid MCOs to address social determinants of health as part of contractual agreements. In New York, The Empire State's Value Based Payment Roadmap requires MCOs to offer startup funds for partners in Value Based Payment agreements who are conducting social determinant of health interventions.
Berwick's perspective
MCOs cannot take on social determinants of health single-handedly.
"Even if all MCOs were appropriately incentivized to invest in upstream social services for their members, the sum of these investments would be insufficient to create the system for providing social services and blending them with medical services to optimally serve all U.S. residents," the JAMA article authors wrote.
Healthcare organizations must build partnerships to address social determinants of health in the communities they serve, Don Berwick, MD, former CMS administrator, told HealthLeaders at last month's IHI Forum.
"Cincinnati Children's Hospital Medical Center is working with dozens of organizations in the city with the shared goal of improving outcomes for 60,000 disadvantaged kids in Cincinnati. They are not trying to do it alone," he said.
Hospitals can also look for economic opportunities to engage distressed communities, Berwick said. "Hospitals account for about $750 billion of economic activity—employment, construction activity, and supply chain."
Opportunities to generate partners through economic activity include hiring from those communities, using construction firms from those communities, purchasing products in those communities, and investing in community infrastructure such as housing.
"We're going to spend the money anyway. Why don’t we spend it where we can work on progressive income redistribution and opportunities?" he said.
This approach features a collaboration between the clinical team and a nurse practitioner specialized in palliative care.
In oncology outpatient clinics, a structured, scheduled, and systematic approach can deliver palliative care to cancer patients at any stage of their illness, recent research shows.
Previous research has shown that combining palliative care with oncologic care generates several benefits, including increased survival and improved symptoms, quality of life, and satisfaction with care. In cost savings, providing palliative care to cancer patients reduces utilization of emergency and intensive care.
"Rapid growth over the past two decades has increased the availability of palliative care specialists from 25% to 75% in U.S. hospitals with more than 50 beds. However, access to such specialists in the outpatient setting remains limited, and in all care settings, workforce shortages and other factors constrain the role of these specialists in meeting the palliative care needs of patients," researchers wrote recently in the Journal of Oncology Practice.
The researchers found that a systematic assessment of palliative care needs from the time of diagnosis reveals actionable information and opportunities to utilize palliative care, the lead author of the study told HealthLeaders this week.
Nurses play a crucial role in the palliative care model featured in the study, said Anjali Varma Desai, MD, assistant attending, Supportive Care Service & Hospital Medicine Service, Memorial Sloan Kettering Cancer Center in New York.
"Oncology nurses and teams can excel in their role as providers of primary palliative care, which is then augmented by access to palliative care specialists," she said.
The oncologic palliative care model at Memorial Sloan Kettering has four primary elements.
1. Adopting collaborative approach
Offering palliative care to all newly diagnosed patients with cancer was a collaborative effort between oncology clinic teams and palliative care specialists. With nursing staff carrying the heaviest workload, the oncology clinic teams focused on primary/nonspecialist palliative care and enlisted specialists for clinician support and direct patient consultation.
2. Systematic assessments
On a visit-based schedule, patients reported symptoms, decision-making preferences, illness understanding, and core values.
During every clinic visit, patients rated 10 physical, psychological, and spiritual symptoms using a scale from 0 to 10.
During visit 1 (first follow-up visit after cancer diagnosis) patients were asked about preferences for receiving medical information and designation of a healthcare proxy.
During visit 2, patients reported their understanding of the expected course of their illness and treatment.
During visits 3 and 4, an intervention led by the oncology nurse featured discussions of the patient's core values. These discussions are an opportunity for the patient to express preferences about specific care goals.
During visit 4, caregivers provided an assessment of their well-being.
3. Implementing palliative care
Palliative care services were offered in two Memorial Sloan Kettering outpatient clinics, with an attending oncologist and oncology registered nurse on staff. Palliative care assessments including symptoms, information preferences, treatment understanding, and patient values were pretested then implemented incrementally.
4. Engaging patients
During visit 1, the oncologist and registered nurse told patients that palliative care would be a part of their cancer care such as attention to symptoms.
The outpatient clinics adopted a Care, Coach, Consult model. The oncologist and registered nurse provided primary palliative care, with the nurse on the frontline. The nurse practitioner specializing in palliative care coached multiple oncology teams and was a resource for direct care and advice on symptom management, communication, and care planning.
This year's expected developments include a new electronic recertification process for physician assistants.
This year will feature several significant trends and developments for physician assistants, says Dawn Morton-Rias, EdD, PA-C, president and CEO of the National Commission on Certification of Physician Assistants (NCCPA).
Physician assistants (PA) are widely viewed as part of the solution to the country's physician shortage. By 2030, the physician shortage is expected to grow to as many as 120,000 doctors, according to the Association of American Medical Colleges.
Physician assistants are a dynamic segment of the healthcare sector workforce, according to NCCPAstatisticsreleased in July 2018.
From 2015 to 2017, the number of PAs grew more than 13%.
The number of PAs per physician rose 23% from 2015 to 2017, increasing to 128 PAs per 1,000 physicians. Two of the highest PA-per-physician ratios were occupational medicine at 621 PAs per 1,000 physicians and orthopedic surgery at 537 PAs per 1,000 physicians.
In 2017, the average salary of PAs was nearly $108,000.
The ranks of PAs are filled with relatively young professionals. In 2017, 78.5% of physician assistants were under the age of 49.
The family medicine and general practice area had the highest concentration of physician assistants (19.9%), followed by surgical subspecialties (18.5%).
Morton-Rias expects four trends and developments will significantly influence the physician assistant profession this year.
1. Easing physician shortage
Physician assistants will continue to play a key role in easing the country's physician shortage, Morton-Rias says.
"Given the youth of the profession, the broad-based knowledge and skills of PAs, and the ability to provide services across all disciplines, PAs can ease physician shortages and improve access to care," she says.
The relatively young age of PAs—which averages about 38—and their propensity to stay in the profession is a bright spot in the healthcare workforce.
"The attrition rate is very low, and when we compare the PA profession to some of the other healthcare professions where the average age is in the 40s or 50s, there's a concern because you have a bolus that will be retiring out," Morton-Rias says.
The relative youth of PAs helps address the physician shortage in ways beyond actuarial considerations, she says. "The youth of the PA profession will help in increasing access to care. These are young, energetic folks who are entering the profession."
2. Modernizing certification exams
Starting this month, NCCPA will start offering electronic administration of the 10-year recertification exam for PAs, allowing PAs to take the exam on their phone, laptop, tablet, and desktop computers.
"This assessment that we are piloting is in keeping with the emerging trends in assessment and utilizing technology. In the PA profession, we have always relied on the testing methods where you sat in a test center after memorizing a lot of information," Morton-Rias says.
The electronic platform NCCPA has developed is the first major step toward modernizing certification exams at the accrediting organization, she says.
"In this assessment method, PAs can answer questions in real time, with about a minute to respond to a question. If they get the question right, they know right away, so it reaffirms their knowledge. If they get a question wrong, they are corrected right away, and they are given resources to improve their knowledge base."
Other primary facets of the new assessment method include completing 25 questions each quarter (there are a total of 100 questions and PAs have 11 weeks to complete each 25-question set). The questions cover a broad swath of core medical knowledge, and the assessment tool has the ability to allow test takers to delay answering questions that display images by switching from their phone or tablet to a device with a larger screen.
"This assessment utilizes technology and it provides real-time information in the same way people practice medicine today. Physicians are also starting to pilot this approach," Morton-Rias says.
3. Updating state PA legislation
Changes in the practice of medicine are prompting state lawmakers to reform the way PAs are regulated, Morton-Rias says.
"States are modernizing their legislation as it relates to PA practice because the healthcare industry has changed from PAs working for one doctor to more providers working in health systems. As this change has occurred, some of the states still have laws that are outdated and don't reflect the new flexibility."
She says the legislative changes include reforming scope of practice, supervision, and delegation of authority.
4. Expanding specialty care roles
PAs are shifting away from their roots in primary care to specialty care, Morton-Rias says. "Although the profession began with primary care and general medicine mostly in underserved areas, medicine has become highly specialized and the PA profession is becoming specialized as well."
She says as many as 70% of PAs are working in specialty practice, including surgical specialties such as orthopedics, neurosurgery, and cardiothoracic surgery.
The transition to specialty care presents a challenge to PAs, she says. "PAs are carrying two responsibilities. One is to maintain expertise in their current practice discipline; the other is maintaining core medical knowledge that is useful across all disciplines."
PAs are well-prepared to rise to the challenge, Morton-Rias says. "PAs have a very solid educational process and fount of knowledge that they develop through a rigorous educational training. It's a full-time immersion type of training, so PAs enter medicine with a deep knowledge base."
Healthcare organizations have an opportunity to benefit from providing high-quality care that generates positive patient experience.
Patient experience is the primary driver of patients' consumer loyalty at health systems, hospitals, and physician practices, according to a recent Press Ganey report.
Consumer loyalty not only impacts finance but also enables population health efforts and care coordination such as long-term care of patients with multiple chronic illnesses.
is five times more likely to influence brand loyalty than conventional marketing tools such as billboards, or television, print, or radio ads, the report says.
More than 1,000 adults were surveyed for the report.
Healthcare organizations can tap the power of patient experience, the report says.
"To harness that influence, providers should capitalize on the power of word-of-mouth marketing by viewing the patient experience as an essential part of their acquisition strategy. By gaining a deep understanding of what gets people talking about positive patient experiences, identifying opportunities to advance the conversation and disseminating key information, healthcare systems can naturally align the mission of delivering safe, high-quality, patient-centered care with the business of acquiring and retaining consumers."
Cultivate consumer loyalty
There are four activities that should be a part of a healthcare organization's patient acquisition and retention strategy, Chrissy Daniels, MS, a partner in the Medical Practice/Consumerism & Transparency at Press Ganey, told HealthLeaders recently.
Give every patient a voice. Maximize the volume and timeliness of feedback by leveraging delivery of surveys via text and email in addition to standard outreach.
Identify factors that drive and erode loyalty. In order to enable targeted improvement strategies, it is important to be able to identify positive loyalty metrics such as likelihood to recommend.
Use natural language (NLP) processing to analyze comments. NLP ensures that every opportunity for service recovery is identified. NLP also allows aggregation of comments into clear brand equities and liabilities, allowing for proactive management of both experience and brand.
Post ratings and reviews in physician profiles. Ensure that future patients have the most convenient access to all the information they seek by including comments—both positive and negative—and ratings of current patients.
Elevate search engine optimization and online user experience
There are two primary ways for healthcare organizations to maximize their presence in search engine results and to boost online patient experience, Daniels said.
Build a great website: Your website is your brand. Make sure it represents your practice. Build a site that is mobile friendly, loads fast, and utilizes proper quality design standards to ensure a great user experience.
Earn quality reviews: When patients are looking for a healthcare provider, they are looking for quality and volume of reviews—so are search engines. Paying attention to the volume and quality of your reviews online is extremely important, and it is also a huge part of local SEO for doctors.
Address negative reviews
Negative reviews online from patients can be an opportunity to improve patient experience, the Press Ganey report says.
"Although no physician likes to be the subject of negative reviews, these findings should reassure physicians that a single negative comment—particularly if it is an outlier among favorable comments—is not going to keep patients from selecting that provider. The real opportunity is to focus on any emerging patterns from negative comments and to target those areas for improvement."
Physicians can help their cancer patients benefit from social media while avoiding drawbacks.
Oncologists should help cancer patients be savvy about social media, recent research shows.
Earlier research has shown that judicious patient use of social media can improve health outcomes. However, benefits of social media for cancer patients such as psychosocial support and patient engagement can be offset by drawbacks including misinformation and privacy violations.
With social media's potential for both benefits and harms for cancer patients, oncologists and other healthcare providers have an obligation to help patients use social media wisely, researchers wrote this month in Journal of Oncology Practice.
"Oncology professionals are encouraged to speak with their patients about social media and to suggest best practices to enjoy the positive and circumvent the negative aspects of social media. As social media platforms continue to modify the social landscape, the oncology community must recognize and act on their influence on patients with cancer," the researchers wrote.
The researchers highlighted five benefits for cancer patients from social media.
1. Promotes patient engagement and empowerment
The researchers reviewed 170 studies of patients using information technology, which showed 89% of the studies found positives impacts on health such as weight loss. In addition, 83% of the studies found enhanced patient engagement such as text messaging for diabetes patients to access clinical data.
The researchers also found social media can help empower patients by giving them an opportunity to mentally process their cancer experience. Earlier research has shown empowered patients are more likely to attend checkups and screenings.
2. Provides psychosocial support
Earlier research has associated social support with better physical and mental health. Social media communities can help cancer patients who do not have in-person social support by reducing social isolation. Social media can also help cancer patients have conversations about emotional, spiritual, and physical treatment barriers.
3. Offers informational support
Social media can help cancer patients find oncology information. Social media can also spark incidental learning such as hashtag searches on Twitter that inadvertently connect cancer patients with online support communities. Video platforms such as YouTube can overcome healthcare literacy barriers.
4. Enhances the physician-patient relationship
Cancer patients should not use social media to interact with their physicians, but accessing oncology information through social media can increase confidence in relationships with physicians. Experiencing physicians sharing oncology information on social media can improve patients' perceptions of medical professionals in general and improve relationships with their healthcare providers.
5. Finds clinical trials and cancer research education
Social media can help cancer patients find clinical trials for particularly isolated populations who can be reached through social media advertising. Patients with rare forms of cancer can join social media groups targeted at their diagnosis, where they can connect with trial recruiters and other research opportunities.
The Journal of Oncology Practice researchers also highlighted five social media drawbacks for cancer patients.
1. Substitute for in-person support
"Social support from social media ranges from infrequent and unstructured to regularly scheduled formal online support groups," the researchers wrote.
Behavior on social media can interfere with in-person assessment and treatment. Social media use can become impulsive, which could impede in-person interactions.
2. Misinformation
Online health information is often unreliable compared to information from healthcare providers. Online research should form building blocks for conversations with caregivers. Cancer patients should also keep a vigilant eye on conflicts of interests such as healthcare professionals not disclosing their ties to medical supply and pharmaceutical companies, then promoting them on social media.
With the untrustworthy nature of information online, cancer patients should be skeptical of information gathered through social media and fact check with healthcare providers.
3. Financial exploitation
For cancer patients, financial perils on social media include unproven cancer cure claims such as vitamins and special diets. Another risk is medical ads on social media that promote unnecessary procedures and treatments.
4. Information overload
Cancer patients who have Internet access can be overwhelmed with medical information. Earlier research has linked information overload with anxiety over the inability to comprehend the avalanche of information and harness it for decision-making.
5. Compromised privacy
Social media users face privacy risks. Social media are public forums, so cancer patients should avoid posting private information. Patients should avoid sharing information that could be identifiable such as age, disease type, sex, and location.
How physicians can help
There are three primary ways healthcare providers can help cancer patients navigate social media safely and effectively, according to The Journal of Oncology Practice researchers.
Experience cancer-related social media, including exposure to content that patients are viewing.
Help patients navigate the benefits and drawbacks of social media such as gauging the social media sophistication of a patient or cautioning patients to be skeptical about information found through social media.
To limit privacy risks, physicians should not offer medical advice via social media or interact with their own patients via social media.
Avoiding air medical transfers of newborns from community hospitals to tertiary hospitals saves an average of $18,000 per flight.
Intermountain Healthcare's neonatal telehealth service has improved quality of care at community hospitals and reduced risky transfers of critically ill newborns, recent research published in Health Affairs shows.
Earlier studies have shown that 10% of newborns require breathing assistance, and 1% need resuscitation. Although hospital-based clinicians who care for newborns attend biannual newborn resuscitation programs, researchers have found key skills decline within months of course attendance.
Intermountain's neonatal telehealth service provides clinical and educational support at 17 Intermountain facilities and four partner hospitals that do not have neonatologists on staff. The telehealth service provides access to neonatologists based at four Intermountain tertiary hospitals with neonatal intensive care units (NICUs).
This week, a co-author of the Health Affairs research told HealthLeaders that the neonatal telehealth service is a valuable capability at community hospitals.
"We use a synchronous, video connection with bedside teams. These teams provide hands on care for the newborn and may be guided through procedures by the neonatologists. These specialists provide their expertise for newborns that are delivered at rural or community hospitals that were previously not typically managed at these hospitals, but often transported to larger facilities," said Stephen Minton, MD, neonatology medical director at Intermountain's Utah Valley Hospital in Provo.
Minton's research team examined newborn transfer data over a yearlong period at eight hospitals participating in the neonatal telehealth program. The researchers found that the program reduced the odds of a neonatal transfer 29.4%. This figure was associated with an estimated 67 fewer transfers annually and cost savings of $1.2 million.
Avoiding transfer of critically ill babies helps support the financial viability of community hospitals and has clinical benefits such as averting the risk handoff communication errors and high-altitude flights.
The neonatal telehealth program features several services and benefits.
For newborns such as premature infants who require transfer to a NICU, neonatologists are available to guide pre-transport stabilization until the specialized neonatal transport team arrives
Neonatologists, who are familiar with unique newborn physiology and emergency procedures, act as subject matter experts and coach bedside teams for infants who have serious conditions such as infections
When a need for neonatologist assistance is identified prior to delivery, a consultation can be scheduled prior to birth
Synchronous resuscitation support at the bedside creates educational opportunities for hospital staff to learn from neonatologists
The costs to implement the neonatal telehealth service were limited, Minton said. "No additional FTE were added for the newborn critical care program, only the dedicated efforts of physician champions. The service was implemented with technology and implementation support from telehealth team."
The American College of Physicians is promoting principles that are designed to support authentic participation of patients and family members in clinical care.
Patient- and family-centered care is an approach to healthcare featuring partnerships between healthcare providers, patients, and family members, according to an American College of Physicians position paper published this month in Annals of Internal Medicine.
Research has shown that patient-centered care is essential to achieve the Triple Aim—improving patient experience and health outcomes while simultaneously reducing costs. Patient-centered care also generates other benefits such as reducing hospital admissions and surgical procedures.
"Increasing evidence shows that patient and family partnership in care can improve health outcomes, practice efficiency, and patient and professional satisfaction. Patient- and family-centered strategies have been shown to reduce use of healthcare resources, result in fewer referrals and diagnostic tests, and lower healthcare costs," the ACP position paper says.
The four ACP principles for patient- and family-centered care include enacting strategies.
Principle 1: Treat patients and families with dignity and respect
The unique nature of every patient and family should be respected, and their preferences and values should be incorporated into delivery of healthcare. Research has shown that patients consider dignity and respect in behaviors such as recognizing the patient as an individual and paying attention to the patient's needs.
Communicating respectfully with the patient as a whole person during interviews and office visits
Listening to patients without interrupting
Asking patients whether they want family members and caregivers involved in healthcare discussions
Inquiring about whether patients have religious or cultural beliefs that should be accounted for in treatment
Principle 2: Include patients and families as active partners in care
Patients and families should participate in care to a degree of their choosing, and their perspectives should be recognized. Patients should be engaged in their care through shared decision making and collaborative goal setting.
Include patients and family members during bedside-rounds discussions
Honor patient preferences on following recommendations
Provide educational material such as after-visit summaries to increase patient knowledge
Principle 3: Give patients and families chances to impact health systems
Patients and families should help design, improve, and evaluate health systems and hospitals. Patients and families can contribute in ways that augment the perspectives of healthcare professionals. For example, patients and families have helped redesign waiting rooms, evaluate educational materials, as assess patient portal functionality.
Seek patient and family perspectives through surveys or focus groups
Include patients on committees for performance measurement and clinical guidelines
Request patient comments on purchases of capital equipment
Principle 4: Enlist patients and families in educating healthcare professionals
As the healthcare sector shifts toward team-based care, patients and families can play a key role in educating clinicians and other staff members. As opposed to a focus on diagnosis and treatment of disease, medical education is increasingly directed at teamwork and patient partnership, which are well-suited for involvement of patients and families.
Include patients and family members in teaching rounds
Pair medical students and residents with chronic-illness patients to help them navigate their care
Invite patients and families to serve on curriculum committees
Better antibiotic stewardship is needed to decrease inappropriate antibiotic prescriptions in ambulatory care settings, according to CDC researchers.
Antibiotics stewardship at urgent care centers is in the spotlight after the release of a pair of recent studies.
Appropriate prescribing of antibiotics by healthcare providers is essential to help avoid the development of antibiotic-resistant infections, which the Centers for Disease Control and Prevention calls one of the most severe public health problems in the country. About 23,000 Americans die annually from an antibiotic-resistant infection, the CDC says.
In July, CDC researchers published a study in JAMA Internal Medicine that found inappropriate prescribing of antibiotics for respiratory conditions was highest in the urgent care setting at 45.7% of patient visits. Emergency departments were the second highest at 24.6% of patient visits. The research was based on 2014 data.
"Antibiotic stewardship interventions could help reduce unnecessary antibiotic prescriptions in all ambulatory care settings, and efforts targeting urgent care centers are urgently needed," the CDC researchers wrote.
This fall, DocuTAP, an urgent care electronic health record company, released an antibiotics stewardship report based on 2017 and 2018 data. The DocuTAP research found inappropriate prescribing of antibiotics for respiratory conditions in urgent care centers at 32.4% of patient visits.
"While we all have work to do when it comes to antibiotic prescribing, this data confirms that the rate at which urgent cares are inappropriately prescribing antibiotics is in line with other segments of the healthcare market," the DocuTAP report says.
Laurel Stoimenoff, PT, CEO of the Warrenville, Illinois-based Urgent Care Association, says there are three primary ways that urgent care providers can improve antibiotics stewardship.
1. Self-monitor with EMR
Robust EHR systems allow urgent care centers to monitor the prescribing activity of individual healthcare providers for inappropriate antibiotic utilization, Stoimenoff says.
"The electronic health record can allow you to pull data by prescribing physician. If a diagnosis was bronchitis, I would like to be able to run a query with that diagnosis and the prescribing physician. The electronic health record can help us self-monitor what is happening in our organizations," she says.
2. Encourage proper ICD-10 coding
In addition to having a robust EHR, urgent care centers should mandate healthcare providers to use the most specific ICD-10 code possible to enable antibiotic prescription self-monitoring, Stoimenoff says.
"If research is being done with retrospective evaluations, and you are picking the easiest and most conspicuous diagnosis at the top of the code selections, you are not giving the data that we need to determine whether an antibiotic was appropriate," she says.
3. Educate patients
One of the most daunting challenges of antibiotics stewardship in the urgent care setting is patient expectations, Stoimenoff says.
"About 20% to 40% of our patients do not have a primary care doctor. Oftentimes when they get to us, they are very sick, and they come in with an expectation [that] they are not going to be satisfied unless they walk out of the clinic with an antibiotic," she says.
To address this expectation, healthcare providers should talk with patients about the difference between viral infections—which are inappropriate for antibiotics—and bacterial infections.
"If a patient has a long-term relationship with a primary care physician, the doctor can tell the patient an antibiotic is unnecessary and there is credibility with the patient. If the patient goes to an urgent care and sees a provider for the first time, the patient may say they are not leaving the clinic without an antibiotic," she says.
When patients have an expectation of getting an antibiotic, urgent care providers need to steer the conversation away from antibiotics, Stoimenoff says.
"There are techniques to make the patient feel confident. It's looking them in the eye or sitting down to change the perception of how much time you are spending with the patient. A great thing I have heard providers say is, 'If you were my mother, this is what I would do for her.' That gets the patient thinking they are in the same class as the doctor's family member," she says.
Clinics can also educate patients with posters and videos that explain the difference between viral and bacterial infections.
Limiting business risk
Antibiotics stewardship efforts at urgent care centers and other ambulatory care settings should be supported by a broad public health campaign, Stoimenoff says.
"We need a public relations campaign just like we have had for seatbelts and smoking. People need to understand that antimicrobial resistance is very real and frightening. It's going to continue to happen unless we all change our behaviors, and the consumer has to be part of that equation because of their expectations," she says.
Unless patients are better informed, urgent care centers with judicious antibiotics stewardship should be prepared to face a business risk from bad online reviews on platforms such as Yelp, Stoimenoff says.
"I would make sure there was a comprehensive educational program for providers and the entire staff. I would want everyone to understand that we were providing good care and that patients should walk away from the clinic feeling we cared about them. It could have negative business effects if patients go online and say, 'I had a $50 co-pay and no antibiotic.' "
The John Hopkins Children's Center approach to cardiopulmonary resuscitation increases compliance with American Heart Association guidelines.
A new approach to cardiopulmonary resuscitation is helping to save children's lives at Johns Hopkins Children's Center in Baltimore.
Pediatric CPR is a challenge in the hospital setting. Every year, more than 6,000 children have in-hospital cardiac arrest and most do not survive to discharge.
In 2013, Johns Hopkins Children's Center started developing a new approach to CPR—Coaching, Objective‐Data Evaluation, Action‐linked phrases, Choreography, Ergonomics, Structured debriefing, and Simulation (CODE ACES2). The children's hospital published research on the approach this month.
Johns Hopkins Children's Center staff can reliably start chest compressions within 10 seconds, the lead author of the research, Elizabeth Hunt, MD, MPH, PhD, told HealthLeaders recently.
"The idea is to teach in medicine similar to how world class chess players, athletes and musicians train—to practice the right way over and over again while getting feedback from an expert mentor. This also helps our resuscitation team to decrease variability," said Hunt, who is director of the Johns Hopkins Medicine Simulation Center and an associate professor at Johns Hopkins University School of Medicine.
Under the CODE ACES2 approach, a debriefing is held after every cardiac arrest to review challenges that the resuscitation team encountered and identify any deviations from best practices.
From 2013 to 2016, more than 300 cardiac arrests were debriefed. During this period, the probability of attaining excellent CPR based on American Heart Association (AHA) compliance for rate, depth, and chest compression fraction rose from 19.9% to 44.3%.
CODE ACES2 has seven essential elements.
1. CPR coach plays monitor role
Use of a CPR coach is a unique aspect of CODE ACES2. The CPR coach monitors the chest compressor and airway manager for compliance with AHA guidelines, allowing the code team leader to focus on higher-level problem solving and managing the patient.
"This means as soon as the CPR coach notices the compressor stop chest compressions for any reason, they are very likely to notice immediately because they are not distracted by other tasks such as giving medications. As soon as they notice the pause, they will personally take over compressions then tell the compressor to take over from them," Hunt said.
2. Data gathered and evaluated
After every cardiac arrest, all data is gathered from the bedside monitor, defibrillator, EHR, and emergency alert systems. Metrics used to analyze the data include chest compression depth, chest compression rate, and time from loss of pulse to initiation of compressions.
Data is a key facet of CODE ACES2 debriefings. "Areas of high and low guidelines compliance are discussed during the debriefing to identify event factors that hinder or enhance performance," Hunt and her fellow researchers wrote.
3. Action-linked phrases encouraged
CPR team members speak observations aloud and link them with resuscitation actions such as, "There's no pulse, I'm starting compressions," which can decrease the time to starting compressions.
4. Choreography mapped out
The resuscitation team should have a shared mental model of how the team interacts with a room, the equipment, the patient, and each other. To keep resuscitation activities going, the CPR coach and code team leader are trained to direct team members to continue their tasks while next steps are discussed.
5. Ergonomics diagrammed
Johns Hopkins Children's Center used pre- and post-event "room diagramming" to attain the best room layout for a patient in cardiac arrest. Pre-event room diagrams include the location of surgeons, nurses, chest compressors, and defibrillators. The diagram plans were practiced in monthly resuscitation simulations. Unnecessary furniture and equipment were removed.
Room diagrams drawn after an event are part of data presented at debriefings.
6. Debriefing embraced
A CODE‐ACES2 debriefing takes about 45 minutes and starts with a privacy and confidentiality acknowledgement. The debriefing features clinical data analysis, review of peer-to-peer debriefing forms, examination of relevant therapy such as pharmacy, and critiques of CPR quality.
Staff members who participate in the briefing include the physician or nurse who was attending the patient before the cardiac arrest, the rescuer who initiated chest compressions, code team leader, CPR coach, airway manager, and pharmacist.
7. Simulations inform and prepare resuscitation teams
The optimal position of the CPR coach opposite from the chest compressor was determined through simulations, along with the positioning for the code team leader and defibrillator. Simulation has helped perfect other facets of the CODE‐ACES2 approach such as placement of the backboard.
