As seen in the news recently, rising maternal morbidity and mortality is an alarming negative health trend across the country. What can health systems and hospitals do to prevent these adverse events and keep patients safe?
One health system, West Orange, New Jersey–based RWJBarnabas Health, which features 13 hospitals, has launched a pair of programs to reduce maternal morbidity and mortality: an obstetrics department collaborative at the health system's eight hospitals that offer birthing services, and an emergency department initiative.
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.
Here are the two approaches that RWJBarnabas implemented to reduce maternal morbidity and mortality rates.
1. Establish an obstetrics department collaborative
RWJBarnabas' OB collaborative was launched three years ago.
"Our OB collaborative is a leadership committee of physicians, nurses, and other stakeholders in our system with the common goal of improving the health of women, children, and our communities," says Suzanne Spernal, DNP, administrative director of Women's Services at Monmouth Medical Center, a RWJBarnabas hospital in Long Branch, New Jersey.
Spernal says the health system started the collaborative effort in 2015, and members meet bimonthly to review metrics, practice guidelines, best practices, research, innovation, and to standardize practices so that patients receive the same quality at any of RWJBarnabas' birthing hospitals.
Reducing Cesarean sections is a top objective of the OB collaborative.
"The OB collaborative has been focused on reducing the number of unnecessary Cesarean sections being performed in all of our facilities. All eight of our birthing hospitals are participating in the New Jersey Perinatal Quality Collaborative initiative, which is designed to reduce the NTSV Cesarean section rate," she says.
NTSV Cesarean section is used on a subset of women considered at lowest risk and appropriate for vaginal birth.
Limiting Cesarean sections is an important component of reducing maternal morbidity and mortality, Spernal says.
"We want to facilitate a vaginal birth because we know that when a woman gives birth by Cesarean section in the first pregnancy, the likelihood of her having a Cesarean section in any subsequent pregnancy is very high. With Cesarean sections come all of the risk factors of maternal morbidity and mortality," she says.
Cesarean sections are associated with four of the most commonly documented causes of maternal mortality: hemorrhage, sepsis, anesthesia complications, and pulmonary embolism, Spernal says.
In addition to reducing Cesarean sections, the OB collaborative is working to address maternal hypertension.
"We are participating in another initiative through the New Jersey Perinatal Quality Collaborative that looks at the recognition and treatment of severe hypertension in pregnancy. With this initiative, we are tracking process measurements that focus on the length of time from the event of severe hypertension to treatment. This is a new initiative for us, so we only have preliminary data, but what we have looks very good," she says.
2. Involve the ER
RWJBarnabas also recently launched an initiative to include the health system's emergency departments in the effort to reduce maternal morbidity and mortality.
The heart of the initiative is a single question asked of female ER patients of child-bearing age: "Have you had a baby in the past 42 days?"
[A yes answer from the patient] "will automatically alert the care team that this is a patient who may require immediate attention and that the protocols for her treatment may be different than a non-postpartum woman in the same-age population," Spernal says.
The ER initiative started with staff education.
"Our first step was making the emergency room care teams aware of the data for the United States and New Jersey. Then we discussed the national guidelines for treatment and the best way to implement the guidelines in our emergency rooms," she says.
RWJBarnabas will likely involve more service lines in the health system's maternal morbidity and mortality prevention efforts, but emergency departments were a logical next step after the OB collaborative, Spernal says.
"We are starting with the emergency room because we know the majority of adverse events happen in the 42-day window and the biggest opportunity to improve outcomes is in our emergency departments. More than likely, that is where patients are going to present," she says.
For example, a woman who recently had a baby and arrives at the ER complaining of calf pain could have a blood clot, she says. "You would fast-track that patient and get her into a room to be seen by a provider. A woman of the same age who has not had a baby and has calf pain could have a muscle injury."
Impact of the approaches
"The data we have shows improvement in clinical outcomes that are typically the cause of maternal morbidity and mortality, such as Cesarean section rates," says Spernal.
"Six of our hospitals have reduced their overall Cesarean section rate from 2017 to 2018. Seven hospitals have reduced their NTSV Cesarean section rate from 2017 to 2018," Spernal says.
The health system is primarily monitoring a pair of clinical metrics to gauge the impact of maternal morbidity and mortality prevention efforts, she says.
"We are looking at Cesarean section rates, and at the process measurement of the time that the patient presents for labor and delivery, then has an event of severe hypertension and receives treatment—the time that the patient's blood pressure is reduced," she says.
RWJBarnabas' maternal health initiatives have not increased costs for the health system, Spernal says.
For example, the ER initiative has not required hiring new staff members.
"We have not had to add new staff. It's really about asking that basic question to identify women right out of the gate. These are patients you want to pay attention to—you want to fast track them once you find out that the answer to the question is yes," she says.
Both the OB collaborative and the ER initiative are generating benefits with no costs, Spernal says.
"It's a win for everybody. Obviously, there is no cost to having a meeting and having different people attend to share information. If we are identifying these patients earlier and treating them earlier, then the downstream savings come from a timely admission and treatment for something that may not have been recognized in the appropriate time frame," she says.
Many behavioral health patients boarded in emergency departments are discharged after an inpatient bed request has been made.
Behavioral health patients who are discharged from an emergency department after clinicians request an inpatient bed admission face high risk for return visits to the ED, recent research has found.
Boarding of mental health and substance abuse (MHSA) patients in emergency rooms is one of the most vexing challenges at hospitals across the country. With a shortage of behavioral health inpatient beds in hospitals and mental health facilities, patients can spend days or even weeks boarded in an ER awaiting placement in an inpatient setting.
"MHSA patients who were discharged from ED after bed requests were placed were at greater risk for return visits to the ED. This implicates that these patients require outpatient planning to prevent further avoidable healthcare utilization," researchers wrote this month in American Journal of Emergency Medicine.
The researchers examined post-discharge outcomes for 492 patients at University of Iowa Hospitals & Clinics, The Hawkeye State's only academic medical center.
"An ED revisit within 12 months was significantly higher among patients discharged who had a bed request in place prior to departure (54.0%), than those discharged from the ED (40.9%) or admitted to inpatient care (30.5%)," the researchers wrote.
The most common reason patients were discharged after bed requests was stabilized patient condition (85.1%). For 11.8% of patients, they became frustrated and the provider did not think hospitalization was mandatory. For 2.5% of patients, they left against medical advice.
Rising to the challenge
In addition to a shortage of beds, there are daunting obstacles to providing behavioral health patients with inpatient placement from the ED setting, the researchers wrote.
"As EDs often function as a last resort for psychiatric patients, providing effective psychiatric services are important to ensure patient safety. However, in the ED, the patients are often subject to the complex processes of the mental healthcare system, including medical clearance, insurance verifications, regulatory and institutional requirements, and patient disposition. The complex processes result in psychiatric boarding."
In the absence of increased access to inpatient beds for behavioral health patients, there are strategies to boost support for patients discharged from an ED after a bed request has been made, the researchers wrote.
"[A] recent ED-based study utilizing universal screening plus an intervention consisting of an expanded suicide screening and provision of a self-administered safety plan in the ED followed by a telephone-based intervention holds promise," they wrote.
Emergency psychiatry services, mental health social workers (MHSWs), and mobile crisis outreach (MCO) programs are valuable resources, the lead author of the American Journal of Emergency Medicine research told HealthLeaders.
"The utilization of emergency psychiatry service to reassess boarding patients is important when available. The use of MHSW and MCO is also an option," said Sangil Lee, MD, MS, of the Department of Emergency Medicine at the University of Iowa Carver College of Medicine.
Outpatient care is crucial, he said.
"In a resource-abundant region, these patients simply need to wait for their inpatient bed, but that does not work in most acute care settings in the U.S. When they are released, it is important for these patients to have outpatient resources available, such as an expedited psychiatry visit and follow up provided by an MCO."
Post-discharge outcomes
Compared to other MHSW patients treated in an ED, mortality 12 months after discharge is not higher for behavioral patients released following an inpatient bed request, the American Journal of Emergency Medicine researchers found.
However, patients discharged after an inpatient bed request were found at higher risk for other negative outcomes 12 months after discharge.
For MHSW patients discharged after an inpatient bed request, 24.8% returned to the ED for psychiatric conditions and 16.8% returned for suicidal conditions
For MHSW patients admitted to an inpatient bed, 14.4% returned to the ED with a psychiatric condition and 6.0% returned with a suicidal condition
For MHSW patients who were discharged from the ED with no inpatient bed request, 14.0% returned to the ED with a psychiatric condition and 6.7% returned with a suicidal condition
The decline in primary care physician (PCP) office visits was partially offset by a 129% increase in office visits with nurse practitioners (NPs) and physician assistants (PAs) from 2012 to 2016.
The rise of NP and PA office visits reflects a broader trend toward greater utilization of NPs and PAs in primary care and other healthcare settings.
The recent decrease in office visits to primary care physicians (PCPs) and increase in NP and PA visits is likely linked to three primary factors, Amanda Frost, PhD, senior researcher at HCCI and lead author of this week's report, told HealthLeaders.
First, there has been an expansion in scope of practice laws for NPs and PAs, Frost says. "Scope of practice laws are largely defined by individual states and have changed quite a bit over the last decade. These laws cover things such as whether non-physicians are allowed to prescribe prescriptions, what type of care they can provide, and whether they can practice independently or require physician oversight."
Second, health plan changes are impacting patients' choice of providers, Frost says. "Benefit design features can influence the choices that patients make about where to seek care. For example, under an HMO model, primary care is emphasized, and patients are often required to seek referrals from their PCP prior to seeing specialists. In contrast, Preferred Provider Organization and Point of Service arrangements often do not require PCP referrals for specialist care."
Third, physician shortages are driving patients to seek alternatives to PCP caregivers, she says. "Patients may increasingly see nurse practitioners and physician assistants as a substitute for primary care physicians, especially in areas with PCP shortages where scheduling an office visit to a PCP is more difficult."
Key data points
To the extent that patients are shifting away from PCP office visits to see NPs and PAs, the cost savings is minimal, according to the HCCI report, which is based on employer-sponsored insurance data.
In 2016, the average cost of an office visit to a PCP was $106, and the average cost of an office visit to an NP or a PA was $103, the report says.
The report has several other primary findings:
Across all types of providers, there was a 2% overall drop in total office visits
In 2012, 51% of office visits for patients under age 65 were to PCPs and that figure dropped to 43% in 2016
The rise in visits to NPs and PAs accounted for only 42% of the drop in PCP visits
On a state-by-state basis, the decrease in PCP office visits ranged from 6% in Washington, D.C., to 31% in North Dakota
On a state-by-state basis, increases in NP and PA office visits ranged from 37% in New Mexico to 285% in Massachusetts
Whether it is delivered by PCPs or NPs and PAs, primary care offers a high level of value for patients, the report says.
"Access to PCPs helps keep healthcare costs low, as spending is lower on PCPs than specialists or emergency care. Primary care also helps keep people healthier and out of emergency rooms," the report says.
The role of NPs and PAs in primary care is evolving, the report says.
"Having more NPs and PAs provide primary care may ease potential shortages in PCPs and allow PCPs to focus on more clinically complex primary care. However, the laws governing scope of practice for these non-physician providers vary widely by state. In some states, NPs and PAs have full practice authority, while in others they are restricted from independent practice and require the oversight and billing of a physician."
Patients with both heart failure and chronic obstructive pulmonary disease have a high cost of care, but there are multiple strategies to limit readmissions.
Improving clinical management of patients with both heart failure (HF) and chronic obstructive pulmonary disease (COPD) can lower cost of care, research published this month shows.
Readmissions are among the most prominent areas to reduce cost of care. Earlier research found that a regional general hospital experienced negative total margins in both COPD and HF, costs that could have been avoided by limiting readmissions.
Healthcare clinical leaders who seize opportunities to limit readmissions not only lower cost of care, but can also boost quality of life for patients and avoid financial penalties under the Hospital Readmissions Reduction Program for HF.
"Patients with both COPD and HF pose particularly high costs to the health-care system. These diseases arise from similar root causes, have overlapping symptoms, and share similar clinical courses. Because of these strong parallels, strategies to reduce readmissions in patients with both conditions share synergies," researchers wrote this month in the journal CHEST.
The CHEST researchers focus on 10 approaches to reduce readmissions for patients with both HF and COPD that your health system can adopt.
1. Make accurate diagnoses
Particularly for COPD, hospitalization is often the first opportunity for accurate diagnosis, the researchers wrote.
"Hospitalization for an acute exacerbation often represents the first time COPD is diagnosed in an individual patient. This may be attributed to the fact that spirometry is underused in outpatient settings to establish the diagnosis of COPD," they wrote.
Several tests, including echocardiography, can diagnosis HF in COPD patients.
"Because spirometry is not thought to be accurate during acute HF exacerbation, anatomic assessment of lung parenchyma with CT scan may offer valuable adjunctive information at reasonably high sensitivity and specificity. In addition, chest CT scan may offer valuable ancillary information regarding right heart size,
the diameter of the pulmonary artery, and the presence of coronary calcification," the researchers wrote.
2. Strive for early detection of exacerbations
To reduce readmissions, early detection of patients with both COPD and HF is helpful for two reasons, the researchers wrote.
First, specialists can be involved quicker, which allows for faster determinations about root causes of patients' COPD or HF. Specialist involvement also quickens development of treatment plans.
"Second, early identification during hospitalization allows time to deploy multidisciplinary interventions, such as disease management education, social work evaluation, follow up appointment scheduling, and coordination of homeservices. These interventions are less effective, and are often not implemented, if initiated toward the end of hospitalization," the researchers wrote.
Early detection of exacerbations can also allow care teams to perform risk stratification, particularly for HF, they wrote. "It may be possible to identify the 20% to 30% of the population who are at low risk for readmission. These patients, if identified early, may be good candidates for observation care and may not need intensive services."
3. Ensure specialist management in the hospital
Specialists not only maximize the quality of inpatient care but also can play a key role at the time of discharge, the researchers wrote. "Because specialists are often tasked with the outpatient follow-up of HF and COPD, specialist involvement while in hospital allows for treatment plans to be created in continuity with those that will be effected as an outpatient."
4. Address root causes
HF has several correctable root causes, the researchers wrote. "Identification of and treatment of occult ischemic heart disease, valvular heart disease, systemic hypertension, and pulmonary hypertension all have potential to make the HF syndrome more tractable."
Addressing root causes of COPD is more difficult, they wrote. "Regarding COPD, particularly in younger patients or patients in whom exposure to cigarette smoke has not been high, consideration should be given to … referral for evaluation for lung volume reduction surgery or lung transplantation."
5. Use evidence-based therapies
"Medical therapies improve outcomes for both HF and COPD. These should be initiated in hospital where feasible because initiation of therapy while in hospital or soon after discharge likely translates into improved rates of outpatient therapy," the researchers wrote.
For HF, several kinds of medications have shown effectiveness such as beta-blockers, angiotensin receptor blockers, and aldosterone antagonists. "Not only are there long-term outcome benefits for these therapies, evidence suggests early
initiation of HF therapies can reduce 30-day readmissions," the researchers wrote.
There are fewer evidence-based therapies linked to reduced readmissions for COPD, but earlier research has shown that noninvasive positive pressure ventilation reduces readmission at 28 days compared with oxygen alone.
6. Engage patients in their care
Enlisting HF and COPD patients as active participants in care and monitoring exacerbations is essential, the researchers wrote.
"Many strategies for engaging patients in care have been tested, including teach to goal, motivational interviewing, and teach-back methods of activation and engagement. Often these methods are time intensive. Because physician time is increasingly constrained, a team approach is particularly useful. Patient activation strategies focus on developing critical health behaviors in patients that can engender better health," they wrote.
7. Establish feedback loops
Creating mechanisms for care plan course corrections is critical to outpatient success, the researchers wrote.
"Feedback loops can allow for clinical stabilization before rehospitalization is necessary. Self-care plans for both COPD and HF have been found to be effective. Nurse-led telephone follow-up for COPD and HF at 48 to 72 hours may also help support patients post-discharge."
8. Schedule follow-up appointments
Before hospital discharge, a follow-up appointment should be established with an advanced practice provider or nurse with pharmacist support.
"The purpose of early follow-up is (1) to identify and address gaps in the discharge plan of care, (2) to retailor the discharge plan of care to better suit the patient in the outpatient environment, (3) to reinforce critical health behaviors, and (4) to advance the plan of care, time permitting," the researchers wrote.
9. Address other comorbidities
Multiple comorbidities such as septicemia and renal dysfunction are common for patients with COPD and HF, the researchers wrote.
"This underscores the need for involvement of the primary care physician for assistance in managing comorbidities. In a study evaluating process of care metrics associated with better outcomes in patients hospitalized with HF,
partnering with community physicians and arranging to send discharge summaries to the primary physician were among the strategies most associated with lower readmission risk."
10. Arrange home health services
For HF patients, home services such as physical therapy, patient education, and medication instruction have been associated with reduced readmission rates at three to six months. Telehealth has shown effectiveness in managing COPD.
CDC official provides update on baffling neurological disorder that causes paralysis in one or more limbs.
Acute flaccid myelitis is a polio-like illness that has afflicted about 400 children over the past four years. There is no known cause. There is no known cure.
"There are currently no targeted therapies or interventions with enough evidence to endorse or discourage their use. We recommend that clinicians expedite neurology and infectious disease consultations to discuss treatment and management," Nancy Messonnier, MD, director of the National Center for Immunization and Respiratory Diseases, said in a briefing Tuesday.
The rare neurological disorder—less than 1 in a million Americans contract AFM annually—mimics polio with weakness in one or more limbs. Some patients have recovered quickly. Paralysis has persisted in others.
Most of the confirmed AFM cases have been in children, according to the Centers for Disease Control and Prevention (CDC). As of November 5, there were 80 confirmed cases this year, mostly in children between 2 and 8 years old, Messonnier said.
"As a mom, I know what it is like to be scared for your child, and I understand parents want answers. CDC is a science-driven agency. Right now, the science doesn't give us an answer," she said.
Limited treatment options
The CDC plans to release new treatment and care management guidance this week, Messonnier said.
"Since 2014, we have been working with clinicians treating AFM patients. In the next day or two, we are posting updated considerations that reflect the significant experience of those clinicians. Unfortunately, because we don't yet know the cause of all AFM cases, these considerations are not as specific as we would like," she said.
The CDC issued interim considerations for clinical management of AFM in November 2014. Although clinicians had tried corticosteroids, plasmapheresis, interferon, antivirals, and other targeted therapies, none of them were deemed safe or effective in the treatment of AFM.
The interim considerations include three primary recommendations for clinical management:
Patients with respiratory muscle weakness should be considered for ICU admission
Patients undergoing MRI should be closely checked with methods including telemetry, pulse oximetry, and blood pressure monitoring
As soon as patients are clinically stable, they should undergo intensive physical therapy, which could improve functional outcomes and prevent muscular atrophy, joint contractures, and other conditions resulting from severe and persistent limb weakness
Search for a cause
Diagnosis of AFM is primarily clinical—patients present the sudden onset of flaccid limb weakness—and MRI exam results showing spinal cord lesions mainly in gray matter and spanning at least one vertebral segment.
The CDC cautions that an initial MRI of an AFM patient may not show spinal cord lesions, which may not appear until 72 hours after the onset of flaccid limbs.
Viral infection has been a suspected cause of AFM since the first outbreaks of the illness in 2014.
Viruses are the suspected cause of at least two AFM cases this year, Messonnier said. In these cases, spinal cord fluid tested positive for two viruses.
"One had evidence of EVA-71 and one had evidence of EVD-68. One of the cases was an adult who was on immuno-depressive medication, and the other was in a child who had very rapid progression of paralysis," she said.
The findings are clues rather than definitive signs of a cause for AFM, Messonnier said.
"When a pathogen is found in the spinal fluid, it is good evidence that it was the cause of the patient's illness. However, oftentimes despite extensive testing no pathogens are found in the spinal fluid. This may be because the pathogen has been cleared by the body or it is in hiding in tissues that make it difficult to detect. Another possibility is that the pathogen triggers an immune response in the body that causes damage to the spinal cord."
Physician champions can help health systems and hospitals overcome challenges associated with changing supply items.
Changing devices, implants, and other products is challenging to hospital supply chain functions—often causing resistance from clinicians wedded to existing supply items.
That is why health systems and hospitals can drive change and value in their supply chains with the help of physician champions. And one system is doing just that.
Kettering Health Network is tapping the clinical expertise of physicians to tackle these predicaments. Trisha Gillum, director of supply chain management at the Dayton, Ohio–based health system, says physicians can play diverse roles in supply chain.
"It can be as small as a physician champion on a single project, to being a physician champion for a service line, to being on the payroll for supply chain," she says.
Here are three reasons to enlist physician champions to improve your supply chain.
1. Physician champions actively engage in supply chain projects
Gillum says the best physician champions for medical supply changes are personally engaged in the effort. "They are willing to understand both the financial and the clinical nuances to a project. They are also willing to speak with their peers—to be a cheerleader or champion for a project."
When Kettering identifies engaged and respected physicians who are interested in serving in the champion role, the doctors receive training from The Advisory Board Company. Physician champion programs at this Washington, D.C.–based consultancy range from individual sessions to a physician leadership track that has sessions held over several months.
Two primary elements of the education programs are business instruction and learning about the nuances of the changing healthcare industry.
"Many physicians are not in tune with everything that is going on in the hospital environment," Gillum says. "They don't understand when we say we need to save money. So, there is education about financial pressures and clinical pressures."
Another educational goal is giving physicians leadership skills, she says.
"We are asking them to step out of their traditional roles and communicate with their peers at an advocacy level. To do that, we not only need to provide the data to support product conversations, but also give them the tools necessary to have those conversations."
2. Physician champions contribute valuable input into supply choices
Physician champions play a potentially decisive role in proposed supply changes, Gillum says.
"If you really want a physician to get engaged, they will bring their own mindset about what the answers should be. You cannot expect a physician to come onboard and rubberstamp the process," she says.
Supply chain managers and other leaders should be open to opposing views from physician champions, she says. "They are going to want to engage in the process. They are going to want to modify it. So, you may end up in an entirely different place than you expected."
When physician champions object to proposed supply changes, open communication is essential, Gillum says.
"You have to be transparent. You can't ask a physician to own something like a cost-savings initiative unless you are willing to say how much we are going to make on a procedure. You have to be willing to share all of the data and to give physician champions all the facts to make intelligent decisions," she says.
Supply chain managers should treat physician champions as valued teammates, Gillum says. "You have to realize that you have asked physicians to play a supply chain role and to provide information. If you disregard what they are saying, you are going to lose partners."
The best-case scenario for physician champions is when they take ownership of a supply change project, she says.
"I had a physician who went out and talked with every one of his peers who performed a particular procedure. He convinced every one of them that we needed to make a change. He was able to accomplish more in those conversations than I could have accomplished in months of conversations with the same group of physicians," she says.
3. Physician-champions help decide supply changes that impact patients
Health systems and hospitals benefit from physician champion participation in supply chain, and the clinicians benefit as well.
Gillum says the two primary benefits for clinicians who assume physician champion roles are gaining experience that helps them compete for hospital administration jobs and helping to decide supply changes that could impact their patients.
"I had one physician say he was passionate about the supplies he used on his patients. The best way physicians can control the supplies that they get is to be part of the conversation and part of the decision," she says.
Inappropriate utilization of cardiac telemetry is wasteful spending with no significant clinical benefit.
Eliminating inappropriate use of cardiac telemetry can generate significant cost savings for health systems and hospitals, recent research shows.
Healthcare spending accounts for about 18% of the country's gross domestic product, with the figure expected to reach nearly 20% by 2025. Wasteful spending is estimated to represent about one-third of healthcare expenditures.
Cardiac telemetry is an observation tool that allows continuous monitoring of electric and other heart signals.
Research published this month in the American Journal of Cardiology found a significant level of wasteful utilization of cardiac telemetry at a 432-bed tertiary hospital. The researchers examined data from 250 consecutive patients admitted to telemetry-capable beds:
The patients were hospitalized a total of 1,640 days, with 1,399 days on telemetry.
The researchers found that only 334 telemetry days were appropriate based on established national guidelines.
Compared to a patient's non-telemetry hospital day, the cost of telemetry was about $34 per day.
For the patients in the study, the hospital could have saved $37,000 by eliminating inappropriate telemetry utilization. The estimated annual savings from a similar patient cohort would have been more than $500,000.
The researchers found no significant clinical benefit from overutilization of cardiac telemetry.
For the 250 patients in the study, 16 significant arrhythmias were detected during their hospitalizations. All of the arrhythmias were detected during appropriate telemetry days.
There were similar findings for clinical decisions driven by telemetry days and code calls, the researchers wrote.
"All five code calls were due to respiratory arrest, with four being on appropriate telemetry days and one on an inappropriate telemetry day. There were 18 significant clinical decisions motivated by telemetry findings during appropriate telemetry days, with only one such decision made on an inappropriate telemetry day," they wrote.
Appropriate utilization
There are two sets of national standards for the appropriate utilization of cardiac telemetry: the 2004 American Heart Association Practice Standards and 1991 American College of Cardiology guidelines.
Under the 2004 AHA practice standards and 1991 ACC guidelines, there are more than a dozen indications for cardiac telemetry including the following:
Patients emerging from sedation or anesthesia for procedures
The AHA and ACC directives are likely a key component of eliminating inappropriate utilization of cardiac telemetry, the American Journal of Cardiology researchers wrote.
"Potential reasons for telemetry overuse include lack of awareness of the AHA/ACC guidelines, nonadherence to these guidelines, lack of provider awareness of ongoing telemetry use, and a lack of telemetry auditing. These causes have been described in previous studies and should be a target for future study and intervention."
Addressing inappropriate utilization
This week, the lead author of the research told HealthLeaders that some hospitals are trying to address inappropriate utilization of cardiac telemetry.
"Some centers are instituting daily huddles regarding ongoing care in order to improve quality and reduce waste," said Daniel Morin, MD, MPH, medical director of cardiovascular research at John Ochsner Heart and Vascular Institute in New Orleans.
"These meetings may include review of which patients are on telemetry. These patients are then reviewed for whether they should remain on telemetry, and if not, telemetry may be discontinued, at a significant savings as we discussed in our paper. Conversely, when an indication for telemetry is present for a nonmonitored patient, telemetric monitoring can be initiated."
National data indicates the Hospital Readmissions Reduction Program is having a positive impact on patients under 65 as well as patients with Medicaid and private insurance coverage.
Medicare's Hospital Readmissions Reduction Program (HRRP) is having a positive impact beyond Medicare beneficiaries and beyond the medical conditions targeted in the initiative, recent research shows.
"There appears to be a systematic improvement in readmission rates for patient groups beyond the population of fee-for-service, older, Medicare beneficiaries included in the HRRP," researchers wrote this month in the American Journal of Medicine.
The primary implication of the research is that health systems and hospitals have made broad improvements to quality of care rather than changes aimed only at Medicare beneficiaries treated for the conditions targeted by HRRP.
In 2012, the Centers for Medicare & Medicaid Services started financial penalties for high readmission rates for three conditions: acute myocardial infarction (AMI), heart failure and pneumonia. Under HRRP, hospitals are penalized if they have higher than expected risk-standardized readmission rates.
The American Journal of Medicine researchers examined data from the Healthcare Cost and Utilization Project's Nationwide Readmissions Database (NRD), a nationally representative all-payer database. They focused on readmission rates across six age-insurance groups for the three HRRP targeted conditions as well as conditions not targeted by HRRP. The data features nearly 60 million hospitalizations and more than 18 million readmissions.
The six age-insurance groups were patients over 65 with Medicare, Medicaid, or private insurance; and patients younger than 65 with Medicare, Medicaid, or private insurance.
Broad readmission gains
The NRD data shows reductions in readmissions rates across all six age-insurance groups.
Readmissions for AMI patients over 65 declined significantly for all three forms of healthcare coverage: the readmission rate for patients with Medicare coverage dropped from 19.2% in 2010 to 15.5% in 2015; for the privately insured, the readmission rate dropped from 14.6% to 12.4%; and for patients with Medicaid coverage the readmission rate dropped from 23.4% to 18.3%.
Readmissions for AMI patients under 65 also declined significantly: decreased readmission rates for privately insured and Medicaid patients mirrored the lower readmission rates for patients over 65. Medicare patients under 65 experienced a modest decrease in readmission rates from 19.7% to 18.6%.
Similar to AMI, readmission rates for heart failure decreased significantly for all six age-insurance groups.
Readmission rates for pneumonia decreased for all six age-insurance groups, but the decline was significantly larger for patients over 65 compared to those under 65.
For conditions not targeted under HRRP, there was a small decrease in readmission rates in most age-insurance groups. For example, among Medicare patients over 65, readmission rates dropped from 16.3% in 2010 to 15.5% in 2015; but among the privately insured, readmission rates dropped from 14.0% in 2010 to 13.5% in 2013, then rose to 13.8% in 2015.
Systematic changes
The data collected in the American Journal of Medicine study indicate HRRP is having a widespread impact on hospital readmissions, the researchers wrote.
"From 2010-2015, 30-day all-cause readmission rates for acute myocardial infarction, heart failure, and pneumonia declined across all age-insurance groups. Readmission rates decreased modestly for conditions not targeted by the HRRP in all age-payer groups, with larger declines among Medicare patients aged ≥65 years," they wrote.
This finding implies hospitals have made extensive changes to clinical care rather than changes targeted only at HRRP-impacted patients, the researchers wrote.
"These patterns are consistent with the hypothesis that implementation of the HRRP was associated with systematic changes in the care of patients and reduced readmission risk beyond the HRRP's target population of fee-for-service Medicare beneficiaries."
A Florida-based community hospital is using AI tools to examine patient data and formulate new treatment protocols for deadly illnesses such as sepsis.
Artificial intelligence (AI) is sometimes seen more as hope and hype than as a solution for healthcare that can improve patient outcomes and reduce costs.
Now, a community hospital in Florida is not only proving healthcare AI can generate observable results in the clinical arena, but also showing that initiatives can be launched and sustained without the deep pockets of a large health system.
Flagler has already realized financial gains from new care pathways for pneumonia and sepsis. The pneumonia and sepsis care pathways have generated nearly $850,000 in costs savings in less than a year. Once care pathways are established for about a dozen other high-risk conditions, cost savings could be as high as $20 million over the next three years, says Michael Sanders, MD, CMIO at Flagler.
For health systems and hospitals seeking to capitalize on AI technology, Flagler is a case study on how AI can be used to develop new care pathways that simultaneously cut costs and improve clinical outcomes.
In 2017, Flagler decided to use AI to mine the hospital's clinical information and focus on deadly and costly conditions. The goal was creating new care pathways for conditions such as sepsis to boost clinical outcomes and drive down cost of care.
Early this year, Flagler signed a three-year AI technology contract with Menlo Park, California–based Ayasdi to help with this initiative.
The AI-powered process reviews thousands of patient records from the hospital, then identifies the patient cohort with the best outcomes, such as the lowest direct variable cost, readmission rate, length of stay, and mortality. The commonalities of this patient cohort drive development of new care pathways such as revision of the emergency department order sets with new treatment protocols.
The hospital also has internally published a new care pathway for COPD, and is set to rollout diabetes, total knee replacement, heart attack, and coronary artery bypass graft pathways next.
"Any hospital can do this," Sanders says.
Here are three ways Flagler implemented AI into its organization to improve patient outcomes and reduce total cost of care.
1. Create a Staffing Strategy
To limit costs, Flagler decided to staff its AI capabilities internally, Sanders says.
"We do not have a data scientist at our hospital. All of this work has been done internally, which I think any community-based hospital can do. We have a couple of folks, including myself and a SQL query guy who has great SQL skills," he says.
Most of the work done by humans in a new care pathway effort involve setting up the parameters and queries for data extraction. Once the data has been verified, the AI tools sift through the hospital's data to combine patients into cohorts.
2. Start With a Simple Pilot
In the pilot phase of Flagler's AI initiative, Sanders wanted to pick a condition with relatively few variables to compute.
Picking the right place to start—pneumonia—was essential to the effort, Sanders says. "I wanted something that would be relatively easy and straightforward, so we could get our feet wet with something that wasn't too complicated."
It took nine weeks to complete the pneumonia project—from data extraction to AI analysis, to refinement of new treatment protocols, to internal publication of the new care pathway.
The next care pathway project—sepsis—took two weeks, with learning gains speeding data extraction and the treatment protocol refinement process.
3. Collect and Crunch Patient Data
Flagler took multiple steps to extract and organize the patient data used to form new care pathways:
Patient data is extracted from the hospital's Allscripts EHR, surgical system, enterprise data warehouse, and financial system
Data is loaded to a cloud technology, where it can be stored and manipulated
Three rounds of semantic and syntactic validation are conducted to make sure the data is accurate
AI tools are used to carve out patient cohorts
Once the analytical work has been completed, the AI team members engage the hospital's physicians to craft the new care pathways.
"We sit down with one physician from every physician group in the hospital. We have been having meetings every first and third Wednesday of the month, and we go through the care paths and make changes that are deemed appropriate based on our evidence and experience," Sanders says.
The new care pathways are used to set treatment protocols in the emergency department and inpatient wards, he says. "We publish the care paths and make changes to the ED order sets and admission order sets based on the care paths, [then] we begin monitoring them."
Operationalizing Care Pathways
Care pathways are road maps for treatment, Sanders says.
"The pathway includes everything, from the moment patients enter the ER to when they are admitted and discharged. There are two sets of orders involved—the care that is given in the emergency department and the care that is given after admission," he says.
Positive patient outcome data has fueled physician engagement in the AI-driven care pathways, Sanders says.
"We had 557 patients with septic shock. For all but 19 patients, the sepsis order set was used. When we looked at the data, the mortality in our hospital is below the national average at 9%. If a patient had the sepsis order set used, they had a readmission rate of 6%. If we look at the group where the order set was not used, the readmission rate was 21%."
If you are going to change your discharge model for at-risk geriatric patients, there are four elements you are going to need.
Geriatric inpatient care and the transition of patients to postacute care are among the most daunting challenges for health systems and hospitals because of the possibility of patient functionality losses in the inpatient setting and costly readmissions after discharge.
In one effort to rise to these challenges, Philadelphia-based Penn Medicine has launched Supporting Older Adults at Risk, or SOAR. SOAR which served its first patient in January, is modeled after the "flipped" discharge program crafted at Sheffield Teaching Hospitals in the United Kingdom.
Penn Medicine has modified the U.K. approach to "flipped" discharge, which features in-home patient assessments after hospital discharge more prominently than in-hospital assessments at discharge, says Rebecca Trotta, PhD, RN, director, nursing research and science, at the Hospital of the University of Pennsylvania in Philadelphia.
"We tried to adhere to the central tenets of flipped discharge: maintaining a geriatric focus; having comprehensive services, not just medical services; and offering services early and intensively," she says.
SOAR has served 46 patients so far, and the early data is promising, Trotta says. A primary goal of the initiative is decreasing hospital length of stay, which has dropped about 1.5 days for SOAR patients.
Lowering length of stay reduces risks associated with hospital care, she says. "We are thinking about how we can maximize care in the home setting because we know when patients are in the hospital they are at higher risk for falls, functional decline, and delirium."
Flipping the discharge model at Penn Medicine means equipping its SOAR program with the following four elements:
1. Geriatric nurse consultants
Four nurses who serve as geriatric nurse consultants in the inpatient setting are a building block of the SOAR initiative. They are staffed through the department of nursing.
"Their full-time job is to identify older adults upon admission who could benefit from a comprehensive geriatric assessment, to share recommendations and findings with the interprofessional team, to follow up on those recommendations, and to collaborate with caregivers," Trotta says.
The geriatric nurse consultants establish working relationships with patients that underpin the SOAR program, says David Resnick, MEd, MPH, innovation manager for the Acceleration Lab at the Penn Medicine Center for Health Care Innovation in Philadelphia.
"The geriatric nurse consultants spend a lot of time with patients in the hospital conducting assessments and getting to know them and their caregivers, which builds trust. So, we have seen refusals of home care at the door—which happen about 15% of the time with traditional home care—fall to zero with SOAR," he says.
2. Home assessments
SOAR provides home health services through Penn Care at Home, a division of Penn Medicine. When patients return home, a Penn Care at Home staff member conducts an assessment.
The home assessments confirm or revise discharge assessments conducted in the hospital including physical therapy and occupational therapy evaluations, she says. "SOAR verifies what is needed. We often find patients need more or different things than we thought in the hospital."
Home assessments help recovering patients to live at home, Trotta says.
"The goal for our older patients is to maximize their ability to take care of themselves, which includes their daily living and functioning. They need to do things like get to the bathroom, prepare food, do laundry, and keep their house clean. Seeing how that unfolds in their real environment lets us see where they might need help versus seeing it in the hospital," she says.
3. Rigorous handoff
"We do a handoff call with the geriatric nursing consultants that includes highlighting key things they have learned about the family and caregivers. They also work on medication reconciliation jointly with the home care team," Resnick says.
Hospital staff and the home care team work together closely for the first 48 hours after a patient has been discharged, he says.
"For the first two days that a patient is home, the home care team is tethered back to the hospital. The home care team can either call or message the acute care provider and talk with the geriatric nurse consultants for issues that arise in the home such as medication discrepancies and other concerns. They are not on their own," he says.
4. Intensive services
SOAR provides a level of service that is more extensive than traditional home healthcare, Trotta says.
"It is organized differently than standard home care. Typically, across the country the average time to the first home visit is at least two to three days. For an older person leaving a hospital without a connection to their next provider for two or three days, there is a risk of something going wrong in that time," she says.
With SOAR, patients get a same-day visit after discharge. They leave the hospital in the morning, then see a home care nurse that afternoon. They also see that same nurse the next day.
Same-day and next-day visits following hospital discharge allow home care team members to address immediate needs such as questions about medications and usage of durable medical equipment, Trotta says. "There is more immediate attention as patients transition from the hospital to the home."
SOAR provides a level of services, which are reimbursable by Medicare and commercial insurance, that is often not included in traditional home care, she says.
"Our patients are defaulted to receive physical therapy, occupational therapy, and social work. In traditional home care, those services can be delayed or not recognized as needed at all," Trotta says.
