In pediatric settings, care bundles for needle procedures such as lidocaine administration and comfort positioning can significantly reduce pain.
Needles don't have to hurt a child.
In 2014, Minneapolis-based Children's Hospitals and Clinics of Minnesota launched an initiative to close a painful care gap. Patients and families had reported in surveys that needle procedures were their single largest source of pain and anxiety. Staff members surveyed had said needle pain was a low priority.
Over a three-year implementation period, Children's Minnesota attained 95% compliance with best practice strategies for needle procedures and achieved several other measures of success, researchers wrote this month in the journal Pain Reports.
"Comparison of baseline audits with continuous post-implementation audits revealed that wait times for services decreased, patient satisfaction increased, and staff concerns about implementation were allayed," the researchers wrote.
In surveys, the percentage of families who said hospital staff "always did everything they could to help with pain” increased from 78.3% to 85.3%. For the metric "child's pain was always well controlled," family satisfaction increased from 59.6% to 72.1%.
At Children's Minnesota, which features two hospitals as well as 26 primary and specialty clinics, more than 200,000 patients undergo needle procedures such as vaccinations and blood draws annually.
Needle procedures are more than a pain.
Vaccinations are a common needle procedure in children and needles have been associated with vaccine hesitancy. An estimated 25% of adults fear needles, with most fears developing in childhood.
Children's Minnesota followed a four-step process to implement its needle-pain initiative, which is called Children's Comfort Promise.
1. Strategy selection
After conducting the surveys of patients, families, and staff members in 2013, Children's Minnesota performed a review of evidence-based pain management strategies.
The organization chose four bundles of care for needle procedures that would be offered to all patients and families:
For children 36 weeks or older, numbing of the skin with 4% lidocaine cream or needless-less lidocaine application with a disposable gas-propelled injector
For infants as old as 12 months, sucrose or breastfeeding
Comfort positioning such as swaddling and skin-to-skin contact for infants, and sitting on a parent's lap for children over 6 months
Age appropriate distraction, including toys, books, pinwheels, and videos
A key TPS concept that Children's Minnesota embraced was "value stream," which analyzes a current state and designs a future state, as well as examines a service from its beginning to end.
At Children's Minnesota, the TPS process featured identifying multidisciplinary core team members, leadership sponsors, scope, objectives, and metrics. A nurse served as the value stream manager, with support from a lean coach and physician sponsor. Executive sponsorship featured the chief medical officer and chief nursing officer.
3. Rolling implementation
In early 2014, Children's Minnesota launched Children's Comfort Promise at the organization's two outpatient laboratories. The labs were chosen as pilot sites because they had relatively small staffs and high needle-procedure volumes, with more than 30,000 needle procedures annually.
The initiative was rolled out methodically through 2016:
After the lab pilots, five inpatient medical-surgical units began the initiative later in 2014
In 2015, several sites got involved, including both emergency departments, four neonatal units, three critical care units, two short-stay units, radiology, and the outpatient surgery program
In 2016, all 26 ambulatory clinics implemented Children's Comfort Promise
After the pilot phase at the laboratory settings, expansion of the initiative was supported with baseline audit reviews, observations, and findings from the pilot to guide the TPS process.
The audits featured three metrics: the type of needle procedure, whether the four pain avoidance strategies were offered, and whether the staff found the strategies helpful when used.
4. Cultural shift
Measuring and communicating the positive performance of the needle care bundles was crucial to overcoming initial resistance to Children's Comfort Promise from staff members, the researchers wrote.
Three positive results were particularly convincing:
Wait times went down instead of up, contrary to many staff members' expectation
Lidocaine administration did not result in a single case of venous constriction impeding insertion of a needle into a vein
The four care bundle strategies provided immediate benefit to patients
To cement Children's Comfort Promise organization-wide, leadership performance bonuses were tied to attaining target goals. "The new care standard was integrated into all organizational policies, the electronic medical record, and new staff orientation, making nonadherence a performance issue," the researchers wrote.
Best practices for giving bad news over the phone include communicating directly from physician to patient, being supportive, and arranging a follow-up visit.
Conveying breast cancer diagnoses over the phone has been on the rise over the past decade, new research shows.
"Reports of communication problems by cancer patients have been associated with poor compliance with medical treatment and increased distress. Consequently, disparities between physician practices and patient expectations about the mode of bad news delivery may negatively impact breast cancer patient outcomes," the Supportive Care in Cancer researchers wrote.
The researchers examined data from nearly 2,900 patients who had received a breast cancer diagnosis from 1967 to 2017. There were several key findings:
From 1967 to 2006, breast cancer diagnoses were conveyed more often in person than via telephone calls
From 2006 to 2017, more than half of breast cancer diagnoses were conveyed through telephone calls
From 2015 to 2017, 60% of breast cancer diagnoses were conveyed via telephone calls
The researchers say there are two primary reasons why breast cancer patients are receiving more diagnoses via telephone calls.
First, modes of communication have changed over the past decade.
"The digital age has increased the use of telemedicine for cancer care, especially for patients living far from cancer centers. … Consequently, our study suggests that some physicians have decided to talk to their patients about test results sooner over the telephone and before the posting of the test results versus later at a clinic visit," the researchers wrote.
Second, more patients are requesting test results over the phone.
"Some patients are actively involved in their care and request delivery of bad news over the telephone. This mutual decision between the healthcare provider and patient about when, where, and how to communicate medical results is a natural sequel to the cultural shift toward patient autonomy and shared decision-making," the researchers wrote.
Best practices
There are several best practices for delivering bad news such as a breast cancer diagnosis, according to Natalie Long, MD, a family physician at University of Missouri Health Care in Columbia, Missouri. Four out of seven of the co-authors for the Supportive Care in Cancer research are affiliated with the University of Missouri. Long was not a co-author.
First, try to anticipate how the patient would like to be informed—a telephone call, in-person visit, or portal message. Try to determine whether the patient's preference will change based on the results.
Bad news should be conveyed in a caring and informative manner.
Any time bad news is delivered it should be given directly by the physician to the patient. Bad news should not be conveyed by staff, via voice mail, or through a family member.
In-person discussions should be held in a private and quiet location.
For telephone conversations, the physician should ask whether now is a good time to talk before delivering the news. If the time is not good, an alternative time should be arranged.
Set the context and prepare the patient by leading with an introductory statement to allow the patient to prepare for the possibility of bad news such as, "Unfortunately, the biopsy results are not what we were hoping for."
Bad news should be delivered clearly and unequivocally, followed by a pause to allow the patient to process the news.
The physician should be supportive because the patient is likely to have an emotional response. Empathy can include supportive phrases and physical contact, if appropriate.
Securing close follow up is crucial, especially if bad news is given over the phone. This allows the patient to prepare questions and bring supportive friends or family members.
Medical education
Medical schools should develop curriculum for delivering bad news over the phone, Long says.
"University of Missouri School of Medicine's curriculum now includes additional training for first-year medical students to talk about situations and techniques for breaking bad news over the phone. We teach students to use the same principals we use for in-person notification and apply those techniques over the phone," Long says.
Timing and empathy are crucial factors.
"The first goal is to make sure the patient is in a good place to talk, not in a car, at the store, or in the middle of a work setting. The students are taught skills related to listening, empathy, offering a good follow-up plan, and ensuring the patient has a support system to process the news," Long says.
Arranging follow-up visits in-person are also essential.
"We also talk to our students about the importance of offering a follow-up visit to go over the results in more detail. It gives the patient time to process the news before we talk about next steps in the treatment. Often, the patient is only able to process a small amount of information when delivering bad news, so an in-person follow up will allow time to provide a more detailed explanation," she says.
Medical students should be prepared to hold these conversations, Long says. "By teaching our medical students a patient-centered approach to notification, we are leading the next generation of physicians to inject humanity into healthcare."
Rural healthcare providers can pursue multifaceted strategies to improve care availability, accessibility, and affordability.
Care access is a pressing problem in rural areas of the country because it impacts the quality of care that patients receive, according to a recent National Quality Forum report.
"Access and quality are intertwined and difficult to de-link," the NQF report says.
The report's recommendations on care access in rural areas are based on several assumptions:
Long distances to care sites and lack of transportation are major barriers to care access
Telehealth is a potential solution but has drawbacks such as needing to travel to a medical practice to use a secure telehealth service
Staffing shortages such as limited numbers of specialists are a driver of care access problems in rural areas
Quality measures for healthcare providers could be improved by risk adjustment for factors in the rural environment, including social determinants of health and transportation needs
Risk-adjusting quality measures for social factors would benefit rural healthcare providers and their patients, says Elisa Munthali, senior vice president for quality measurement at NQF, which is based in Washington, DC.
"Risk adjusting would make measures a fairer assessment of the quality of care that providers give to rural residents. It would account for the challenges they are facing that can prevent them from providing more comprehensive care," Munthali told HealthLeaders this week.
"To the extent that we want to recognize those challenges in measurements, it would be good for providers because we could start talking about the actual quality they are delivering for their residents," she says.
To improve rural care access, the NQF report focuses on three sets of recommendations: availability, accessibility and affordability.
1. Availability
The report says the most important elements of healthcare availability in rural areas are access to after-hours and same-day appointments, access to specialty care, and timeliness of care.
Team-based care is crucial to boost availability, the report says.
"This could mean bringing additional nonphysician providers into the practice, as well as supporting nonphysicians in maximizing their scope of practice. By supporting clinicians such as nurse practitioners and physician assistants to practice to the 'top of their license,' practices may be able increase the number of available appointments."
Team-based care should be paired with patient education, the report says.
"Many individuals prefer to see a medical doctor instead of another type of practitioner, in some cases because they may believe that no other practitioner will have needed knowledge or skill to meet their care needs. Thus, practices, health plans, states, and national campaigns should educate consumers about the various types of qualified practitioners who are available."
Telehealth could help ease the shortage of specialists in rural areas, but there are challenges linked to telehealth in rural areas such as regulatory and licensing restrictions, the report says. For example, telehealth providers are often required to be in the same state as the patient.
To promote timeliness of appointments, the report says effective referral relationships and strong care coordination with referral sites are crucial.
2. Accessibility
To obtain healthcare service in rural areas, the report focuses on language interpretation, health information, health literacy, transportation, and physical accommodation.
For language interpretation, the report recommends interpreter services via phone or web-based platforms when interpreters are not available on-site.
Regarding health information, the report calls for better access to information from payers, particularly about providers who are in-network or out of network.
The report makes a pair of recommendations about improving health literacy: educating both patients and clinicians about the importance of patient engagement, and improving clinician-patient communication in general.
Transportation is one of the most daunting care access hurdles in rural areas. The report offers several recommendations to rise to the challenge:
Establishing partnerships with transportation services such as taxis
Contracting with bus services
Hiring drivers
Working with community partners such as nursing homes when conducting community needs assessments
Leveraging paramedics and other community health workers
3. Affordability
Total out-of-pocket costs and delayed care because of the inability to pay are the essential aspects of affordability for rural residents, the report says.
"The shift to higher deductible plans or other forms of underinsurance, lack of medical insurance, and network inadequacy are key factors that cause rural patients to delay care," the report says.
Healthcare providers can assist rural patients to afford care by helping them understand their insurance coverage, the report says. Providers can monitor the balances patients owe after insurance payments and increase literacy about insurance such as the financial consequences of picking a high-deductible health plan.
Training care teams to deal with disrespectful behavior includes role modeling and rehearsing.
Clinicians do not have to endure disrespectful patients and family members.
That's the message from a Utah-based physician who is training her care team to address inappropriate behavior at the bedside that creates an unhealthy workplace.
"Ignoring disrespectful behavior shuts everybody down. You get off track—it's disruptive. It's like ignoring an elephant in the room," says Amy Cowan, MD, MS, a physician at George E. Wahlen Veterans Affairs Medical Center in Salt Lake City, and a faculty member of the Department of Internal Medicine at the University of Utah in Salt Lake City.
"What I have found is disrespectful behavior erodes the team," she says.
Inappropriate behavior can temporarily paralyze care team members, she wrote.
"When I walk into an examination room, I expect the general interaction to proceed in a predictable manner, and usually it does. Sometimes, however, a patient or family behaves or reacts in an unexpected or outrageous way, which is surprising, shocking, or even confusing. I often find myself stunned, feet weighted, mouth paralyzed. My mind whirls to make sense of the unexpected departure from the customary script."
Tactics and training
This week, Cowan told HealthLeaders how she handles these situations and how she is training care team members to react.
"I try to keep it simple. If I can normalize for my team that freezing happens, then people can notice it in themselves that it is happening. Then they can call upon one simple phrase. I call on phrases like 'cut it out' or 'let's keep it professional.' It has to be something you can think of quickly before things get ramped up," she says.
Cowan has made training to address disrespectful behavior part of the rounding process.
"Before we round, I will pose a question to the group: 'When was a time when you were a target?' Or, 'When was a time when you noticed someone's bad behavior targeted toward someone else?'" she says.
"We talk about what was noticed, what went well, what they could have done different. That segues into how I deal with inappropriate behavior. For me, it's finding that line I can think of quickly on the fly. When you freeze, you have to have something you can call upon quickly to say, so you can move on."
In preparing care team leaders to address disrespectful behavior, role modeling is key, Cowan says.
"Part of this is role modeling that it is OK to create an environment of compassion where people are kind to each other. Part of that role modeling is making it clear that you don't have to tolerate super disrespectful behavior."
Rehearsing is also crucial, she says. "If I keep practicing, even though I will freeze, maybe I will feel more comfortable leaning into that discomfort of confronting someone."
Re-engaging patients
After addressing inappropriate behavior, Cowan circles back to most patients to find out why interactions went awry.
"I have to really mean it. I have to be authentic that I am curious about where the behavior is coming from. I don't do it for everybody. For some patients, I am not going to explore the hate," she says.
Cowan holds these conversations later in the shift or the next day.
"I come back and say, 'Is this a good time?' Then I just say it, 'Yesterday during rounds, this is what I observed. What did you mean by that?' Oftentimes, I find there was some sort of incident that happened when I wasn't there. Maybe a nurse or other doctor was rude to the patient, or the patient and the family didn't feel a doctor was on their side. There was some sort of unmet need or something was going on behind the scenes. You drill down and figure out how we can do better with our communication."
Most of these follow-up conversations generate a positive result, but some don't, she says. "Sometimes, I end up reinforcing that we have to be respectful to each other."
An ASC leader and orthopedic surgeons share their success strategies for conducting safe invasive procedures at ASCs.
Ambulatory surgery centers (ASCs) are on the frontline of efforts to shift healthcare outside the hospital walls in several specialties, including endoscopy, ophthalmology, and pain management. And within those efforts, physician leaders are reinforcing the safety advantages of ASCs for invasive procedures, according to an ASC leader, surgeons, and scientific data.
Amid questions and concernsthat ASCs could be less safe than hospitals, several physician leaders share successful strategies they use to make their ASCs safer.
"The advantage we have in the ASC environment is that we are smaller. That helps us be closer with our employees, and we communicate with them daily," says Rebecca Craig, RN, CEO of Harmony Surgery Center and Peak Surgical Management in Fort Collins, Colorado.
Asheesh Gupta, MD, MPH, an orthopedic surgeon at Bethesda, Maryland-based Centers for Advanced Orthopaedics, agrees that ASCs have an advantage: "I think it's safer for the patient."
"I can do hip arthroscopy surgery in an hour to an hour and 15 minutes. At the hospital, the exact same procedure takes two to two-and-a-half hours because nobody knows the setup, and they don't have the same staff every day. It's like I'm doing the procedure for the first time every time, and that leads to more complications for the patient because they are under anesthesia longer and have longer traction time," Gupta says.
Research published earlier this year in the Journal of Health Economics found ASCs on average provide higher-quality care than hospital outpatient departments (HOPDs):
After a procedure, ASC patients are less likely to visit an emergency room or have a hospital inpatient admission than HOPD patients.
ASC patients have fewer ER visits because of adverse events compared to HOPD patients. On the day of surgery, 0.1% of ASC patients visited an ER. From one to seven days after surgery, 0.52% of ASC patients visited an ER. From eight to 30 days after surgery, 1.41% of ASC patients visited an ER.
Data indicates that reduced medical complications is a possible reason why ASC-based procedures result in fewer ER visits than HOPD-based procedures. On the day of surgery, 0.02% of ASC patients visited an ER for a medical complication. From one day to seven days after surgery, 0.07% of ASC patients visited an ER for a medical complication. From eight days to 30 days after surgery, 0.17% of ASC patients visited an ER for a medical complication.
The relatively low number of hospital visits after ASC-based procedures applies to both low-risk and high-risk patients, indicating even high-risk patients can be treated safely in the ASC setting.
5 elements of ASC facility safety
Craig, who is the immediate past president of the Ambulatory Surgery Center Association, says there are five primary elements that underpin ASC safety:
1. There are fewer patients with dangerous infections such as MRSA in ASCs, she says.
"If you are having a knee replacement, a gall bladder removal, or a hernia repair, you don't want to be anywhere near the superbugs that a hospital has to deal with. So, that is probably the most significant infection control difference," she says.
2. Small staff size and procedure specialization fuels care coordination in the ASC setting, Craig says.
"We work very closely with all team members, passing along pertinent patient information at every point of care and hand-off transition. Whether the ASC is a large multispecialty facility center with 100 employees or a two-procedure room endoscopy ASC with 25 employees, it is a finely orchestrated flow centered on the patient," she says.
3. Well-run ASCs adhere to a wide range of safe surgery checklists, industry guidelines, and regulations, Craig says.
4. ASCs have the potential to retain a high percentage of their perioperative staff, Craig says. "One of the advantages in the surgery center environment is we don't have weekend or holiday shifts. We don't work on call or come back to work for emergency cases in the middle of the night. So, that is a staffing advantage."
5. Procedure specialization drives efficiency in the ASC setting, she says.
"In the ASC environment, we are nimble, which allows us to quickly address any roadblock in our process that could cause us to be inefficient or could be a potential patient safety issue. We utilize patient satisfaction, physician satisfaction, employee satisfaction, turn-over time, on-time starts, and many other benchmarks to drive our quality assurance and performance improvement," Craig says.
ASC surgical safety practices
Gupta, and Barry Waldman, MD, an orthopedic surgeon at Centers for Advanced Orthopaedics, say safety practices are key in patient selection, and preoperative, perioperative, and postoperative care.
1. Patient selection
Some patients are not appropriate for surgery in an ASC, with medical, surgical, and motivational considerations.
"First and foremost, the patient has to get medical clearance, which can include clearance from other specialists such as cardiologists or pulmonologists, depending on what other disease processes they have. Based on those processes, other specialists may recommend an inpatient setting for closer monitoring and follow up," Gupta says.
High-risk medical conditions often disqualify a patient for surgery at an ASC, he says. "If someone has coronary artery disease and high-risk factors related to the heart, instead of sending a patient home the same day of surgery they may want to monitor them overnight or two nights."
Several medical factors can disqualify a patient for ASC care, Waldman says. "You don't want anyone who has a high-end seizure risk, someone who is obese, someone who is going to have trouble with physical therapy, or someone with a lot of comorbidities."
2. Preoperative care
"Traditionally, outpatient total joint replacement—hip and knee—was performed in the inpatient setting. Patients would stay in the hospital for two to five days. Now, we have to change those expectations. You can go home the same day, and the outcomes are the same if not better. You don't have the germs that are in hospitals, which potentially seed the wound," Gupta says.
Planning is an important part of the preoperative phase of care at ASCs to ensure the patient's well-being, he says.
"We share what time to show up, what time the surgery is, how long the surgery will be, how long you will be in recovery, and when you are going to go home. We also discuss whether the patient will need an assistive device and whether someone will be at the center to take the patient home," he says.
3. Perioperative care
On the day of surgery, mobility and medications are top concerns to ensure safety for the patient, Waldman says.
"With anesthesia, you need to make sure that patients can get up and walk. You need to make sure patients can urinate after surgery, and make sure they are on their antibiotics; sometimes we have to do IV doses in the center before the regular doses at home. We also have a physical therapist at the center to make sure patients are walking correctly."
4. Postoperative care
Postoperative care is more intense for ASC patients compared to hospital patients, Waldman says.
"We do physical therapy more often with our outpatient cases. Patients will work with a therapist five days a week for five days straight. We also see them back in the office sooner; for a lot of patients, I will see them three to five days after surgery. I will check the wound and make sure there are no complications. We want to be much more on top of them than the hospital patients because they are not being watched in a hospital."
Gupta makes sure patients set up their postoperative appointments.
"I also give patients a physical therapy referral, so they can schedule that along with their postoperative visit. I try to take care of as many questions and issues that I can preoperatively; so that postoperatively, patients can hit the ground running."
With high costs, risks of adverse events, and scant evidence of effectiveness, surgery for chronic pain is a prime example of overutilization of healthcare services.
There is inadequate evidence to justify surgical procedures to treat chronic pain, recent research shows.
"Given their high cost and safety concerns, more rigorous studies are required before invasive procedures are routinely used for patients with chronic pain," researchers reported this month in the journal Pain Medicine.
Chronic pain is a widespread and costly condition in the United States, affecting more than 100 million people and costing as much as $635 billion annually.
The Pain Medicine research features a review of 25 clinical trials involving 2,000 patients with conditions including lower back pain, arthritis, angina, abdominal pain, and endometriosis.
The researchers compared outcomes for invasive procedures and sham procedures. In a sham procedure, the patient goes through the rituals of a surgical procedure such as preparations and set up, anesthesia if needed, and tissue penetration. However, the tissue is not manipulated in a way that is thought to correct the underlying problem, and the patient is closed up or the instrument withdrawn.
For adverse events, there was a significantly higher risk for invasive procedures (12%) than sham procedures (4%).
The risks associated with surgery for chronic pain are too high and more clinical trials should be conducted, the researchers wrote.
"The risks of surgical and invasive procedures are not minor and appear to be higher with real compared with sham procedures. Risks in both groups include anesthesia, permanent injury to the body, psychologic stress, and time, cost, and productivity losses. Without more rigorous examination, large numbers of patients are exposed to risky and possibly unnecessary procedures."
The lead author of the research, Wayne Jonas, MD, executive director of Samueli Integrative Health Programs at H&S Ventures in Alexandria, Virginia, says physicians and chronic pain patients should consider surgery carefully.
"Right now, the scientific evidence does not justify doing these procedures for chronic pain. However, patients and circumstances vary, and physicians and patients need to decide individually what's appropriate for any particular patient. Taking this evidence and discussing it with the patient in shared decision-making is the best approach," Jonas told HealthLeaders last week.
"It takes a multidisciplinary team of healthcare professionals at its center to help manage chronic pain. Yet one of the things the U.S. healthcare system as a whole systematically fails at is fostering coordinated care. Most care is piecemeal with little communication among providers. So, people with chronic pain are left to jump from provider to provider, often undergoing unnecessary, costly, duplicative procedures, and taking ineffective drugs—with ultimately little relief."
There are several options for treating chronic pain that do not involve invasive procedures or addictive medications such as opioids, he says.
"The American College of Physicians, the Centers for Disease Control and Prevention, the National Institutes of Health, and many other national bodies have recommended nonpharmacological approaches for the treatment of chronic pain. These include acupuncture, yoga, massage, and other such approaches. In addition, behavioral medicine has been demonstrated for many decades to be effective for chronic pain."
There are opportunities for value-based healthcare to benefit from cost-effectiveness analysis.
The healthcare economics toolbox is maturing and playing an increasingly valuable role for physicians and administrative leaders.
In particular, cost-effectiveness analysis and value-based healthcare, which are the primary tools of healthcare economics, are intersecting and drawing valuable insights from each other, recent research shows.
The lead author of the research, Joel Tsevat, MD, MPH, professor of medicine at UT Health San Antonio, is a cost-effectiveness analyst who is calling for a convergence of his discipline and value-based healthcare.
"We have been trying to quantify bang for your buck for thousands of clinical treatment or prevention paradigms. What I realized is we have been living in parallel worlds: the cost-effectiveness analysts and the value-based healthcare people," Tsevat told HealthLeaders this week.
Timeframe is one of the key differences between value-based healthcare and cost-effectiveness analysis, he says.
"Value-based healthcare tends to look at shorter-term outcomes. Bundled payments are 90-, 60-, or 30-day episodes. Accountable care organizations are year-to-year analyses of how they are doing compared to how they did the previous year or relative to a benchmark. Cost-effectiveness analysis generally takes a long-term view or a patient's lifetime view."
At the very least, healthcare leaders need to understand the different approaches, says Tsevat, who is also affiliated with the University of Texas at Austin's Dell Medical School. "These concepts are affecting care. Value-based healthcare is affecting care more overtly now because it is affecting reimbursement."
Cost-effectiveness analysis is a crucial tool for healthcare leaders who gauge the tradeoffs between patient benefits and therapies with astronomical costs such as expensive medications. "The rubber is hitting the road. We can't afford million-dollar treatments," he says.
Physicians can no longer afford to turn a blind eye to costs, Tsevat says.
"Historically, we were taught to provide whatever care is best, regardless of cost. If the patient needs an expensive medication or an expensive treatment, the physician is trained to do that. But as providers we are also becoming stewards of the healthcare economy, like it or not."
Physicians should be trained to understand cost-effectiveness analysis and value-based healthcare, he says. "Physicians have to understand these concepts. We have to understand tradeoffs."
Converging disciplines
Cost-effectiveness analysis and value-based healthcare can draw valuable elements from each other, Tsevat says.
Cost-effectiveness analysis is generally performed from a societal perspective or healthcare sector view, and the discipline would benefit from drawing on value-based healthcare's patient-centered approach, he says.
"If you have HIV or hepatitis C, the community might place a lower rating or value on that health state than you as a patient would, because it's your life. So, cost-effectiveness analysis could learn more about individualizing outcomes at the patient level."
Tsevat says value-based healthcare could benefit from the capability of cost-effectiveness analysis to gauge tradeoffs—the costs for the benefit.
"It's all well and good to eliminate waste and low-hanging fruit such as imaging for routine back pain that has little or no benefit. But after you have eliminated waste, there is going to be point where you start making tradeoffs. There are a lot of things that we do that have a little bit of benefit, but there is a question of whether it is worth the cost," he says.
The research examined 47 studies involving more than 42,000 physicians. "This meta-analysis provides evidence that physician burnout may jeopardize patient care; reversal of this risk has to be viewed as a fundamental healthcare policy goal across the globe," the researchers wrote.
In the study, patient safety incidents were adverse events such as diagnostic errors. Low professionalism included weak communication with patients and lack of empathy. Patient satisfaction featured patient-reported data.
The researchers found physician burnout has a negative impact on patient safety, professionalism, and patient satisfaction:
Overall physician burnout doubled the odds of involvement in patient safety incidents. All three dimensions of physician burnout—emotional exhaustion, depersonalization, and reduced personal accomplishment—were linked to involvement in patient safety incidents.
Overall physician burnout doubled the odds of low professionalism. Depersonalization was associated with the highest propensity for unprofessionalism with a 3-fold increased risk.
Overall physician burnout doubled the odds for low patient satisfaction. Depersonalization was linked to a 4.5-fold increased risk.
The researchers also found that physicians early in their career have a higher propensity for unprofessionalism. "The … association of burnout with low professionalism was significantly larger across studies based on residents and early-career physicians, compared with studies based on middle- and late-career physicians," the researchers wrote.
Implications and recommendations
The findings of the research have implications for healthcare costs and clinical care improvement.
The researchers found that physician burnout compromises care safety, and earlier research has shown that adverse events cost several billions of dollars annually. "Physician burnout therefore is costly for healthcare organizations and undermines a fundamental societal need for the receipt of safe care," the researchers wrote.
Addressing physician burnout is an opportunity to improve patient safety and the quality of care. "Our findings support the view that existing care quality and patient safety standards are incomplete; a core but neglected contributor is physician wellness," the researchers wrote.
The JAMA Internal Medicine study offers three recommendations to ease physician burnout:
Healthcare organizations should score physician depersonalization with other quality measures to drive interventions for improving quality and patient safety
Reporting for quality of care and patient safety should be standardized across healthcare organizations to boost understanding of physician burnout and its association with patient care deficiencies
Healthcare organizations should do more to support physicians in the early stages of their careers.
Supporting physicians when they are residents is crucial, the researchers wrote.
"Residents will be responsible for healthcare delivery for over two decades in the future. Investments in their wellness and professional values, which are largely shaped during early-career years, are perhaps the most efficient strategy for building organizational immunity against workforce shortages and patient harm."
Adopting an early warning system and deploying care bundles for the infection are keys to treating sepsis patients.
A pair of health systems have made strides in improving their treatment of sepsis with new screening protocols and standardized bundles of care for the deadly infection.
More than 1.7 million people contract sepsis annually in the United States, with 270,000 fatalities, according to the Centers for Disease Control and Prevention. About 1 in 3 of patients who die in a hospital have sepsis, the CDC says.
In response to the sepsis threat to patients and the sepsis core measure established in 2015 by the Centers for Medicare & Medicaid Services, DeKalb Medical in Decatur, Georgia, and AHMC Healthcare in Alhambra, California, have adopted early warning intervention systems for the infection and sepsis care bundles.
The early warning invention systems feature electronic alerts and staff training to heighten awareness of sepsis signs and symptoms. The sepsis care bundles feature treatment protocols for three hours and six hours after diagnosis.
1. Early detection screening
DeKalb launched its sepsis initiative in early 2017, beginning the process by examining data to determine care gaps.
"It became apparent that the majority of our sepsis population was coming through our emergency room, with some sort of infectious process already starting. So, we focused on our emergency room locations, and took time to look at sepsis as an organization in terms of how it presented," says Christina English, RN, performance improvement coordinator at DeKalb.
DeKalb adopted an approach that leveraged both data and clinical care team capabilities, with the help of IBM Watson Health CareDiscovery.
"We looked at different chief complaints associated with sepsis and some of the clinical presentations, then developed electronic alerts, nursing processes, and physician order sets to address these patients when they come through the door," she says.
Electronic alerts are generated through DeKalb's electronic health record.
"We hardwired alerts that are based off a combination of chief complaint and presenting vital signs comprised of SIRS criteria. So, once a patient meets several SIRS criteria and they have a chief complaint associated with an infection process, the nurse and the physician get an alert," English says.
Staff training and coordination are critical components of DeKalb's early warning intervention system for sepsis.
"We made sure pharmacy and the labs department [were] looped in, we had a lot of collaborative effort with the physician staff, and there was a clinical education component," she says.
AHMC started its sepsis care initiative in 2015. Educating staff is an essential element of the health system's screening processes for sepsis, says Jonathan Aquino, MHA, corporate chief quality officer of AMHC and CEO of San Gabriel Valley Medical Center in California.
"We have done a lot of training in all areas of the hospital—our emergency department frontline staff, physicians, floor nurses, and our leadership team. We have a number of screening protocols that are now in place; we check for sepsis at almost every juncture," he says.
Sepsis screening occurs in several settings, Aquino says. "There is a sepsis screening protocol in triage, at the time of admission, [and] for shift changes."
The AMHC nursing staff plays a key role in screening and intervention, he says. "Once we get indications from the screening process, our nursing teams start a process to initiate the sepsis bundle of care."
AMHC physicians have empowered the nursing staff to initiate sepsis interventions, Aquino says.
"Our physicians have allowed us to use nurse-driven protocols to initiate the bundle. Our medical executive committees have said that if the nurses see signs of sepsis or catch it in triage, we should execute the bundle right away. We don't wait for the doctors," Aquino says.
2. Sepsis care bundles
The treatment of sepsis patients at AHMC and DeKalb mirrors the recommendations of the CMS sepsis core measure.
The sepsis core measure features intervention sets that clinicians should initiate in three-hour and six-hour timeframes for patients who have reached severe sepsis or septic shock.
For example, in the first three hours after a patient has presented with severe sepsis, interventions include administration of antibiotics and lactate testing.
The care clock starts ticking as soon as a patient is identified with severe sepsis or septic shock, Aquino says.
"We know that if we can manage these patients aggressively and improve the continuum of care for sepsis, these patients will go home sooner. We know if we delay lab draws, antibiotics, an X-ray, an EKG, or whatever it may be, a patient's medical condition can progress for the worse. What that means is affecting the length of stay in the hospital and affecting our ability to treat the patient," he says.
Sepsis care impact
For some months and annual quarters, AHMC has achieved 100% compliance with the CMS sepsis core measure, Aquino says. "We didn't get to a success rate of 100% sepsis core measure compliance in some months and quarters overnight. We showed our staff that the clock starts ticking."
From 2016 to 2017, DeKalb has achieved sepsis care gains in several metrics:
The compliance rate for the CMS sepsis core measure increased 27%
Average length of stay for sepsis patients fell 2.3 days
Cost avoidance savings totaled $2.7 million
Mortality rate for sepsis patients decreased 30%, with about 48 lives saved
Although effective sepsis care requires aggressive interventions, the cost of care is justifiable clinically and financially, English and Aquino say.
"Implementing the sepsis core measure has a cost to it—there are medications, labs, and other resources; but it is very easy to justify being proactive when you look at how much sepsis costs on the back end when it progresses to an inpatient stay, or the patient is in shock or ventilated," English says.
Aggressive screening efforts also are clinically and financially effective, she says. "When you catch sepsis early, the treatment is antibiotics and a couple bags of IV fluid. If you don't catch it early, you could have several days in the ICU and ventilation."
Lessons learned
In launching and implementing its sepsis care initiative, DeKalb has learned about the importance of raising awareness and promoting care coordination, English says.
"The most beneficial component to the early warning system is not necessarily that the EHR catches 100% of the cases, but we have seen a positive shift in our nursing practice and awareness of sepsis. We have seen examples where the alert did not go off, but a nurse was already suspicious about sepsis. They can catch sepsis that may have been borderline under the rigid criteria of the electronic screening," she says.
Care coordination is critical to executing effective sepsis care, English says.
"We have also learned that the care of sepsis patients requires a lot of communication and collaboration between the different disciplines. So, it has tested our care continuum model and how we are able to work together in nursing, physicians, and labs."
AMHC's sepsis care initiative has succeeded in part through physician leadership, Aquino says.
"You need physician champions. For sepsis, you need infectious disease physician champions. You need to be able to lean on the leadership for infectious diseases and help them spread the message to the medical staff," he says.
An analysis of New York State's first-in-the-nation mandated reporting and care protocols for sepsis shows improvements in care, even without financial incentives.
The country's first state-mandated reporting initiative for sepsis has increased compliance with sepsis care bundles and helped reduce mortality rates for the deadly infection, recent research shows.
In 2013, the state of New York launched a public reporting initiative for sepsis that required adherence to care bundles for patients with severe sepsis and septic shock. The research, which examined data from April 2014 to June 2016, was published in the Journal of Respiratory and Critical Care Medicine.
"This study demonstrates the association between state-wide mandated public reporting of compliance with sepsis performance measures and outcomes, improving care, and decreasing mortality," the researchers wrote.
The research features 91,357 hospitalizations from 183 hospitals. The sepsis care bundles specify interventions for sepsis patients three hours and six hours after diagnosis. For example, the three-hour bundle includes drawing blood cultures, administration of antibiotics, and measuring of blood lactate levels.
The research has several key findings:
Of the 91,357 sepsis patients, 81.3% were treated under a sepsis care bundle
Compliance with the three-hour care bundle increased from 53.4% to 64.7%
Compliance with the six-hour care bundle increased from 23.9% to 30.8%
Risk-adjusted mortality decreased from 28.8% to 24.4%
Increased care bundle compliance was associated with shorter length of stay
"This study … demonstrates improved care for patients with sepsis as evidenced by increased compliance with performance metrics and decreased risk-adjusted mortality over the first two years of the ongoing initiative. A state-wide initiative using regulations and non-financial incentives appears to have substantially changed care," the researchers wrote.
The study's lead author, Brown University Professor of Medicine Mitchell Levy, MD, told HealthLeaders this week that there were six primary operational burdens on hospitals to comply with the state mandate:
Administration of data abstraction and collection
Incorporation of mandated sepsis care with existing quality improvement efforts
Costs associated with data extraction and analysis
Establishing stakeholder cooperation such as overcoming physician resistance to some elements of the sepsis protocols and care bundles
Identifying patients early for appropriate treatment
Competing priorities from other regulatory initiatives
