A doctor offers four recommendations to curb harassment and assault against healthcare providers.
A Massachusetts-based physician is calling on the healthcare community to develop more effective responses to patients who engage in harassment or other negative interactions.
"There is only a relatively small body of literature on harassment in medicine, and it tends to focus on acts committed by colleagues and superiors rather than by patients or clients," Charlotte Grinberg, MD, wrote in an article for Health Affairs.
"Clearly, patients can also be offenders. This should not be ignored."
Grinberg, resident physician at Mount Auburn Hospital in Cambridge, Massachusetts, shares three incidents from her past to illustrate potentially dangerous workplace environments:
When she was a sophomore in college, Grinberg did GED tutoring at a correctional facility. After an inmate masturbated during a tutoring session, she reported the incident to a guard, who said, "These things sometimes happen."
As a second-year medical student, Grinberg volunteered at a homeless shelter, where she connected residents with community resources. After a resident with whom she had worked was charged with raping a store clerk, it changed her: "I kept the visits brief. I avoided physical contact. I didn't give out my phone number or offer to call patients on other days of the week to follow up."
In her third year of medical school, an end-stage liver disease inpatient tried to pull Grinberg into his bed while making sexually suggestive comments. "I wondered if this was somehow my fault, and how I could ever provide care to Steven again," she wrote.
Although all three incidents were reported, only the inpatient encounter was reviewed. "I started feeling little less alone and a little less responsible," Grinberg wrote.
There are rarely easy answers when patients harass or assault their caregivers, she wrote, "Sometimes, these assaults are by-products of diseases such as psychosis and dementia. We wouldn't want to react to someone who lashes out because of dementia in the same way we react to someone who is lashing out for reasons within their control."
She offers four recommendations to curb harassment and assault in healthcare settings:
There is widespread promotion of safety incident reporting. Similarly, healthcare organizations should foster workplace environments where it is safe to report harassment and other negative interactions with patients.
Raise awareness among healthcare staff members about the potential for patients to engage in harassment and assault, and explain the benefits of reporting incidents.
Form a culture that allows caregivers to discuss incidents with patients directly. "Our duty is to serve all patients, no matter what sort of people they are. But this does not mean we need to accept or ignore abuse," Grinberg wrote.
Carefully examine existing interventions to guide the creation of new policies. "Such policies will help doctors like me in the future and ensure that although these things do sometimes happen, there is something we can do about them," she wrote.
A children's hospital has more than doubled its number of submitted incident reports, overcoming challenges such as employees' fear of retaliation for reporting.
Over a three-year period, Children's National Health System in Washington, D.C., more than doubled the number of incident reports filed by employees, creating opportunities to improve quality and safety for patients.
"If we don't know what's going on in our organization, we can't improve," says Rahul Shah, MD, MBA, vice president, chief quality and safety officer. "Any organization that fears increased reporting is missing the boat."
A research study about the incident report initiative was recently published in Pediatric Quality & Safety. Data in the study quantify the achievement at Children's National as follows:
2014 safety event reports totaled 4,668
2017 safety event reports totaled 10,971
Report submission time was decreased by nearly 30%
Number of submitting departments increased by 94%
Anonymous reporting decreased 69%
Overcoming 3 Challenges
Before Children's National, which features the Sheikh Zayed Campus for Advanced Children's Medicine with 316 inpatient beds, doubled their incident report numbers, they identified three incident report challenges that it needed to work through to achieve the goal of improving quality and safety for its patients.
"What we realized is we had to improve technology, we had to change the culture so it was safe to report, and we had to show reporting made a difference," Shah says.
Improve technology
To ease reporting through improved technology, Children's National rolled out mobile reporting with an app-based platform and optimized the platform with specific reporting categories such as falls and compliance. In another effort to save time, the number of mandatory fields in the reporting templates was reduced.
The technology upgrades have made it easier to submit incident reports, helping to cut submission time from 12 minutes to 7 minutes, Shah says. "That's a big 5-minute time saving for a clinical nurse or respiratory therapist who is busy."
Change organizational culture
Creating a culture where employees feel safe to submit incident reports is a significant challenge, Shah says.
The decrease in anonymous reporting reflects well on efforts to assuage fear of making a report, he says.
"People will say they are making an anonymous report out of fear and to avoid retaliation. We worked on that aspect of our culture. We believe the decrease in anonymous reporting is a surrogate for our culture improving," he says.
Shah continues, "We adopted the concept of a just culture, where everyone in the organization gets treated in the same way. We partnered with human resources to ensure that we embodied, espoused, and showed employees that we had a just culture."
Children's National also adopted a positive philosophy for incident reports, he says.
"Many organizations call these documents incident reports. We call them safety reports, which takes away a pejorative and negative connotation. The whole initiative was called 10,000 Good Catches and when people make good catches, we celebrate them," Shah says.
Other efforts to gain trust and reporting participation from Children's National staff have included one-on-one outreach, naming a monthly Reducing Harm Hero, and the awarding of "Zero in on Zero Harm" pins.
Staff members also know their incident reports are being reviewed at a senior executive level, Shah says. "I read every incident report in the organization. I made that pledge about three-and-a-half years ago, when we had 4,000 incident reports. I still stand by that pledge when we have 11,000 incident reports."
One of Shah's subordinates also reads all incident reports, as does the chief risk officer and a deputy. "Everyone in the organization knows that when they file an incident report, at least four leaders will look at it," he says.
Show reporting makes a difference
Showing employees that their incident reports make a difference also can be challenging. But Shah cites two examples of incident reports that led to significant quality or safety improvements.
Example 1: Code Simulation Program
In one instance, a patient required resuscitation at a Children's National satellite clinic. "That is pretty much all the incident report said," Shah says.
Based mainly on the incident report, Children's National decided to spread its emergency code simulation program from the main hospital to the satellite clinics. The simulation program focuses on cardiac arrest and other resuscitation emergencies. Children's National subject-matter experts developed the program, which is also staffed internally.
Shah believes the new code training has saved at least one life.
"Six months later, a child was having a seizure in one of our satellite clinics, turned blue, and needed resuscitation. It took EMS about 10 minutes to get to the clinic. By the time EMS arrived, the child was intubated, stabilized, and properly coded."
Example 2: Safe Restraint Techniques
Another example of incident report impact involves behavioral health patients.
"One area that hospitals all over the country struggle with is behavioral health and violence in those patients. We had a safety event report regarding violence toward staff from behavioral health patients," Shah says.
Several safety changes were adopted, he says. "From that safety event report, we asked, 'How can we keep our staff safe?' Now, we have training. We have Kevlar sleeves for our employees to use. We have different techniques for restraining patients."
National Children's incident report initiative has far exceeded Shah's expectations.
"To see those 11,000 reports come in, they are almost changing in front of my eyes. I'm seeing them getting rich with information and opportunities for improvement. People are trusting me and the organization, and they know we have their back," Shah says.
The health system's multipronged initiative promotes doctors' well-being.
Cleveland Clinic is expanding efforts to address physician burnout that the health system began a decade ago with a coaching and mentoring program.
Cleveland Clinic has not only launched new physician health initiatives but also adopted a new philosophy.
"We made a strategic decision when we started our efforts a couple years ago to focus on well-being rather than burnout. We prefer to focus on getting well and staying well," says Susan Rehm, MD, executive director of physician health at Cleveland Clinic.
Last year, internal engagement survey data shows modest but statistically significant improvement in several key measures for physician satisfaction at Cleveland Clinic. The data is represented on a scale of 0 to 5:
+.04 for engagement
+.03 for continuous improvement
+.04 for well-being
+.04 for trust
+.04 for communication
Financial impact?
Gauging the financial impact of the well-being programs is imprecise because it is difficult to assess turnover, says Rehm. Tracking physicians who leave the health system due to burnout is a work in progress, she says.
However, turnover prevention goes a long way financially, she says. "The literature suggests that turnover of a physician costs the organization somewhere between $250,000 and $500,000. It wouldn’t take too many retained doctors to completely pay for the programs."
Cleveland Clinic's well-being programs have been staffed internally, so costs have been low.
"Because we used existing resources, the amount of new money that went into these programs was relatively small," Rehm said. "The biggest investment is training up clinicians to participate in these activities. If you take a surgeon out of the operating room for a day, that's potentially a big-ticket item that impacts us in areas like patient access."
Five of Cleveland Clinic's most prominent physician health programs are a blend of old and new initiatives:
1. Wellbeing Day
In January 2017, the 11-hospital health system established Wellbeing Day, granting time off for healthy activities. "We specify that it should be a day spent doing something that contributes to one's personal well-being," Rehm says.
Wellbeing Day is both a concrete and a symbolic effort, she says. "Wellbeing Day was a good start to demonstrate how Cleveland Clinic endorses well-being for the physician staff."
2. Coaching improvement
Nine years ago, Cleveland Clinic started a basic coaching and mentoring program, which featured a daylong orientation for staff members who wanted to be coached or to be a coach.
The program has grown over the years, including the addition of advanced peer coaches three years ago.
"An advanced peer coach receives four days of advanced training. They can help peers [with] career issues who need more intensive help than the average person looking for career development advice. We have trained more than 100 people in advanced peer coaching," Rehm says.
An internal questionnaire found that both coaches and the people they coach benefit. "We found that both were much more satisfied with their work and their lives," she says.
3. Engagement consulting
In 2017, the health system's professional staff affairs office took on a consulting role linked to a series of town halls that featured staff suggestions for operational changes. The engagement consulting features marshaling of resources and program development.
Engagement consultants also help managers with well-being–related staffing. "A couple of our departments and institutes have designated either engagement officers or well-being officers within their group to oversee well-being programs," Rehm says.
4. EMR ease
Since 2016, Cleveland Clinic has launched several initiatives to make the health system's electronic medical record more user-friendly, such as:
Developing two apps that allow viewing and interaction with the EMR on handheld devices
Freeing physicians of sole responsibility for routine tasks such as prescription refills
Cleveland Clinic's IT staff has been a crucial element of EMR enhancement initiatives, Rehm says.
"With every change that comes through, there are consultants from our information technology division who … help us with how we interact with the medical record, so we're not wasting a lot of time doing things that could be done more efficiently," she says.
5. Promoting empathy
For several years, all new hires at Cleveland Clinic have been required to take R.E.D.E. communication training. Empathy is a key ingredient in the Relationship: Establishment, Development, and Engagement training.
"The R.E.D.E. approach is an example of relationship-based communication. It can involve the use of empathy to bring out a patient's experience with their illness, their expectations, and how they wish to proceed," Rehm says.
R.E.D.E. has shown positive results with physicians, she says. "After going through the R.E.D.E. training, physicians reported feeling more empathy and less burnout."
To decrease burnout and increase resilience, you must deconstruct burnout into its component parts, understand the interplay between stressors and rewards, measure clinician experience, and design interventions.
Clinician burnout is a complex problem that can be addressed with thorough examination of working conditions and carefully targeted interventions, according to a Press Ganey reportreleased this week.
"The approach rests on the premise that the stressors and rewards that contribute to burnout risk derive from different sources, and the way individuals and teams respond to these stressors and rewards varies based on job responsibilities, personal values and professional experiences," the report says.
The report, "Burnout and Resilience: A Framework for Data Analysis and a Positive Path Forward," calls for a four-point approach to reduce burnout and increase resilience among medical staff:
Deconstructing burnout into actionable components
Understanding the interrelationships between burnout components
Measuring the clinician experience as it relates to components of burnout
Designing interventions that boost resilience and reduce burnout
1. Deconstructing burnout
The Press Ganey report deconstructs burnout by categorizing stressors and rewards as inherent to a caregiver's role or the result of external forces. "Deconstructing burnout into relevant component parts allows leaders and organizations to identify and manage each appropriately," the report says.
Inherent components of burnout and resilience:
The emotional drain linked to providing care to the ill
Witnessing suffering
The daily pressure of making clinical judgments that affect patients' lives
Rewards include the joy of helping people, doing meaningful work, and respect from patients, staff, and the community
External rewards include compensation, prestige, and recognition from patients
2. Interrelated stressors and rewards
The interplay between stressors and rewards is the key to understanding physician burnout, the report says. "These stressors and rewards define the clinician experience, and the balance between them influences clinicians' vulnerability to burnout."
It is crucial to not only identify components of burnout but also understand how those components interact, according to the report. "The balance is not a simple, linear equation. … The relationship is modulated by the dynamics of the different sources of stress and reward and their interconnectedness."
For example, physicians are admired for mastering medical knowledge, but keeping up with the flood of medical information can lead to anxiety and self-doubt.
3. Measuring the clinician experience
Addressing burnout requires collecting data on multiple measures, the report says.
"Leaders focused on reducing burnout and improving resilience in the clinician workforce should be prepared to measure engagement with sufficient thoroughness and frequency that the data allow segmentation, benchmarking and detection of change."
Press Ganey has developed an eight-point assessment tool to measure clinician resilience. The first four questions gauge capacity to disengage from work:
I can enjoy my personal time without focusing on work
I rarely lose sleep over work
I can free my mind from work when I am away from it
I can disconnect from work communications during my free time
The last four questions in the assessment tool measure engagement with work.
I care for patients equally even when it is difficult
I see every patient as an individual with specific needs
The work I do makes a real difference
My work is meaningful
4. Designing interventions
The report says there are four steps to developing an organization strategy for enhancing resilience and decreasing burnout:
Communicate the gravity of burnout, accept responsibility for addressing external stressors, and offer resources for coping with inherent stressors
Measure engagement and resilience of physicians, nurses and other key personnel, benchmark at unit levels, and monitor change associated with interventions
Promote inherent rewards to boost clinician engagement
In a survey, 91% of emergency medicine physicians say they have recently experienced a drug shortage and 44% say their facilities are inadequately prepared for a surge of patients during a disaster.
The vast majority of emergency room physicians face shortages of key medications and doubt whether their organizations are "fully prepared" for a disaster, polling datashows.
The poll's findings were released today by the American College of Emergency Physicians in Washington, DC. The survey, which was conducted from April 30 to May 7, has 247 respondents.
"Hospitals and emergency medical services continue to suffer significant gaps in disaster preparedness, as well as national drug shortages for essential emergency medications. These shortages can last for months, or longer, and constitute a significant risk to patients," ACEP President Paul Kivela, MD, FACEP, said in a prepared statement.
The poll's findings are alarming. "Emergency physicians are concerned that our system cannot even meet daily demands, let alone during a medical surge for a natural or man-made disaster."
Most emergency medicine doctors are facing struggles with drug shortages, according to the ACEP poll:
91% of ER physicians reported experiencing the shortage or absence of a critical medication in the previous month
For ER physicians who reported medication shortages, 41% said they have shortages for as many as five drugs and 43% said they have shortages for as many as 10 drugs
69% of respondents said drug shortages have "increased a lot" over the previous year, and 16% said drug shortages have "increased a little"
97% of respondents said their primary emergency department has been forced to use an alternative to a medication because of drug shortages
36% of respondents said drug shortages have negatively impacted patient outcomes
88% of respondents said they have lost time with patients because drug shortages force them to search for alternative medications
The poll's findings on disaster preparedness are similarly sobering:
When asked whether their ERs were prepared for a surge of patients during a disaster, 27% of the physicians said their facility was "not completely" ready and 17% said their facility was "not at all" ready
Only 22% of respondents said their hospital has access to real-time data on regional healthcare resources, and 13% said their hospital has no access
ACEP wants Congress to examine a regionalized approach the Pandemic and All Hazards Preparedness and Advancing Innovation (PAHPAI) Act that includes:
Increased coordination among public health and safety services, emergency medical services, medical facilities, trauma centers, and other entities in a region.
Tracking resources, including inpatient bed capacity, emergency department capacity, trauma center capacity, on-call specialist coverage, and ambulance diversion status with regional communications and hospital destination decisions.
Consistent, region-wide prehospital, hospital, and inter-facility data management systems.
ACEP supports the inclusion in PAHPAI of legislation that makes military trauma teams available to civilian trauma centers.
For the past several years, drug shortages have become a growing problem across the nation in virtually all areas of care delivery.
An Ohio hospital's provider-in-triage model is generating clinical, financial, and strategic benefits, including lowering its rate of ER patients who leave without being seen.
Grandview Medical Center in Dayton, Ohio, has adopted an optimized version of the provider in triage model for its emergency department, increasing the percentage of patients seen by a doctor within 10 minutes from 38% to 71%.
"This allows a provider to get a first glance at the patient and do a preliminary history and physical. The provider can then put in orders for tests that we can get started in the front while we are waiting on beds in the back," says Nikole Funk, DO, medical director at Grandview Medical Center.
After struggling with a triage bottleneck, Grandview decided to try the provider-in-triage model last summer.
"We do have a high-volume, inner-city hospital, and we had just one triage nurse. The process was to triage one patient at a time, then send patients to the back if a bed was available," Funk says. "The triage process can take about 5 to 7 minutes; so, if you have three patients check in, you can fall 21 minutes behind."
How Grandview optimized provider in triage
Grandview now has a team approach to triage, with a physician and two nurses comprising the provider-in-triage team.
The nursing staff played a key role in launching the provider-in-triage model. "We included the nursing staff and identified a select few who could educate [their peers] and be champions of the process," Funk says.
The select cadre of nurses helped Funk in the early stage of the initiative, which started in July 2017. "I personally worked all of my shifts as the provider in triage to refine the process with selected nursing staff before we brought in the other two physicians who were going to be providers in triage."
Lab work and other testing is crucial in realizing the potential for efficiency gains from the provider-in-triage model.
"We are utilizing the time it takes to get a radiological study or get lab tests done during the time that patients are waiting to see a provider," Funk says.
However, Grandview had to innovate to overcome a challenge associated with testing under the provider-in-triage model.
"Most times, it is the low-acuity patients who get tired of waiting. Even though they may have had labs drawn or radiological tests done, they were sent to a waiting room, and sometimes they leave from there," says Dawn Sweet, clinical nurse manager at the 344-bed hospital.
'Results-pending' waiting room
Grandview's solution was to create a special waiting area for patients awaiting test results.
"We keep patients in the department. We have a results-pending area now; so, our low-acuity patients have their tests completed, go to our results-pending area, and can be discharged from there," Sweet says.
Data reflect patient satisfaction with the provider-in-triage approach at Grandview:
Before provider in triage: 1.8%–2.2% left-without-being-seen rate
After provider in triage: 1.1% left-without-being-seen rate
Patients leaving against medical advice have also fallen, with that rate running at about 1%
"With other institutions that have trialed this process, the left-without-being-seen rate has gone down but the against-medical-advice rate has gone up. That has not been true for us. With our facility, both numbers went down," Sweet says.
"With our process, we have been able to retain nearly all of our patients through the full length of their care. They are not waiting as long for tests and results," she says.
Benefits of provider-in-triage model
Grandview is generating clinical, financial, and strategic benefits from adoption of provider in triage.
In an emergency department, more efficient use of time can save lives and alleviate needless suffering, Funk says. "There have been multiple instances across the country of critical patients waiting in an emergency department waiting room."
The provider-in-triage approach helps emergency departments quickly identify critically ill patients, she says. "We've had some critical diagnoses picked up on patients who otherwise would have been sitting in our waiting room."
The provider-in-triage model has generated at least two financial benefits for Grandview, which is part of the Kettering, Ohio–based Kettering Health Network.
First, the ER has decreased the number of patients leaving without being seen. "Financially, you are capturing all of those patients," Funk says.
Second, word of mouth is spreading across the community, she says. "We have had people come in and say, 'We hear that you don't have a long wait here.' That also increases your revenue."
Strategically, adoption of provider in triage has Grandview well-positioned for the closureof nearby Good Samaritan Hospital. Dayton-based Premier Health plans to close Good Samaritan by July.
"We are anticipating an annual patient volume increase between 20,000 and 25,000 with that closure. Without this new process, we would not have been able to survive. We are already seeing a 10% to 15% increase in patients," Funk says.
She says the provider-in-triage model is a good fit for ERs with high hold hours of patients; high rates of left-without-being-seen patients; and high influxes of walk-in patients.
For evaluating vascular surgery patients, a handheld device available on Amazon for $50 provides a low-cost and simpler alternative to other frailty measures.
Using a grip strength test to evaluate surgical patients for frailty is a high-value assessment, says the leader of a research team that published a study on grip strength testing this month.
"We were looking for something quick, easy, cheap, and reliable, and that is a rare combination in healthcare," says Matthew Corriere, MD, MS, an associate professor at the University of Michigan in Ann Arbor and a vascular surgeon at Michigan Medicine.
In vascular surgery, assessing patients for frailty is a key step, Corriere and his fellow researchers wrote. "Frailty is associated with adverse events, length of stay, and nonhome discharge after vascular surgery."
If a patient is found to be frail, it impacts medical decision-making and creates an opportunity for intervention, the researchers wrote.
"Accurate identification … might inform treatment or patient selection, enabling patients and providers to avoid (or at least to minimize) stressors and related risks. Frailty detection might also provide opportunities for prehabilitation through exercise, nutritional, and behavioral interventions to better prepare patients," according to the research paper.
Grip strength testing for frailty has multiple benefits, the researchers found. "Grip strength may have utility as a simple and inexpensive risk screening tool that is easily implemented in ambulatory clinics, avoids the need for imaging, and overcomes possible limitations of walking-based measures."
Testing grip strength is likely to be applicable in fields beyond vascular surgery, Corriere says. "Grip strength testing has potential in any field where you are trying to assess whether to provide a treatment, and trying to decide what the chances are of the patient having a normal life with or without that treatment."
He says other fields such as orthopedic surgery, cardiology, and general internal medicine practices—where physicians often face decisions on whether to refer patients for treatment—could benefit from grip strength testing.
'Low risk and low cost'
Grip strength testing has multiple advantages over other frailty tests, Corriere says.
The primary testing method for frailty is a walking speed test; however, many patients have walking impairments including peripheral artery disease and amputation that disqualify a walking test. Grip strength testing is appropriate for all patients as long as they do not have a hand or arm impairment such as arthritis, he says.
Grip strength testing is logistically easier to manage than other assessments for frailty.
"I had 25 patients in my clinic this week, and the longest I was budgeted to spend with any of them was 30 minutes. If I had tried doing different frailty tests on those patients, it would have been time-consuming and require space and equipment," Corriere says.
Hand dynamometers are compact and relatively inexpensive. Corriere bought the device he used in the research on Amazon for $50.
"These hand dynamometers fit in a drawer or sit on a counter. To me, this is an intervention that is low risk and low cost, while providing very useful information. It's a no-brainer, and it sounds a lot like how we define value," he says.
Financially, improving frailty detection with grip strength testing has several impacts, including better risk adjustment and risk prediction, and avoiding costs.
"When you talk about cost, inpatient rehab, nursing home stays, and increased complication rates are all expensive. The grip strength test allows you to be a lot smarter in selecting patients who are candidates for surgical treatments," he says.
Grip strength testing is better than visual assessments of frailty, Corriere says. "When you rule out frailty with grip strength, it gives you reassurance about not denying an elderly patient a procedure because of assumptions that could be incorrect."
There is little science in visual assessments, he says.
"Some 85-year-olds are robust and remarkably healthy, and they get aggravated when we don't listen to their complaints or we deny them a procedure that they need. Grip strength and frailty assessment can lead to opting into a procedure, and make the patient and provider feel more comfortable," he says.
Having a simple scientific test also helps family members understand the concept of frailty, Corriere says.
"Measuring grip strength is a demonstration of frailty to family members who are there watching it happen. It takes a concept that can be sort of abstract and make it evident to everybody in the room," he says.
Grip strength testing is attractive both clinically and practically, he says. "We were looking for something that could be deployed like another vital sign. This takes very little time, and it can be done on many people."
Researchers find an explosion of economic activity in the genetic testing market over the past decade, with not only thousands of new tests developed but also a sharp increase in spending on genetic tests.
Since the mapping of the human genome 15 years ago, the number of genetic tests has accelerated rapidly, with 75,000 tests on the market and about 10 new tests marketed every day, researchers say.
"Nearly 14,000 tests have come on the market since March 2014," the researchers wrote this month in a study published in Health Affairs.
The researchers focused on data from 2014 to 2017, including a test catalog database and a commercial payer database with 1.7 million claims for genetic tests.
The researchers say the rapid growth in development of genetic tests and spending on genetic tests is the result of multiple forces converging:
Clinical demand for better tools to predict, diagnose, treat, and monitor disease
Better knowledge of the molecular basis of disease
Patient demand
Industry investment
A regulatory environment that allows marketing of genetic tests without Food and Drug Administration approval
The rate and scale of growth in the genetic testing market is remarkable, the researchers wrote. "The clinical sequencing market is growing at compound annual growth rate of 28% and is forecasted to be $7.7 billion worldwide by 2020."
The researchers identified several constraints that could slow growth in the genetic testing market:
While it has fallen markedly over the past decade, the cost of sequencing is still relatively highly at about $1,000 for a whole genome sequencing test
Some payers are providing coverage for multigene tests, but some are not
Out-of-pocket costs for patients
Balancing the clinical utility of genetic tests with introducing them practically in a clinical setting
Fragmentation in the clinical lab industry
Uncertainty about how the clinical lab industry is evolving appears to be decreasing, the researchers wrote. "There is some evidence that the market is becoming bifurcated, with the less numerous specialized tests performed by labs within organizations, while high-volume centralized labs perform the large-scale tests."
The researchers found not only an increase in genetic test volume but also spending. The highest levels of spending were on prenataltests, hereditary cancer tests, and a relatively new class of tests that measure multiple genes.
From 2014 to 2016, the researchers found that spending was highest on prenatal tests, ranging from 33% to 43%. Hereditary cancer tests were the second-highest spending category at about 30%. All other categories accounted for much smaller fractions of total spending.
Safety is one of the driving factors for growth of genetic prenatal tests, the researchers wrote. "These tests meet a clinical need by being an alternative to prenatal screening methods that incur a risk of miscarriage (such as amniocentesis)."
The researchers examined 13 categories of genetic tests:
For emergency room patients, a Maryland hospital's new observation unit has lowered length of stay and reduced admission of patients to inpatient care.
A new observation unit at Carroll Hospital in Westminster, Maryland, designed to treat patients for stays less than 48 hours has reduced its length of stay by more than eight hours and lowered the rate of patients transferring to inpatient care from 33.9% to 12.3%.
In 2016, the observation unit was given a wing in the 168-bed hospital. Three factors contributed to the unit's development: a well-designed set of inclusion and exclusion admissions criteria, dedicated staffing, and a tight working relationship with ancillary services.
"We didn't want to randomly select people for observation status; we wanted to have evidence-based criteria. We established the criteria based on certain diseases and certain conditions that we knew were typically short stays," says Kim Baker, PA-C, director of hospitalist and ICU services.
In August 2016, gaining the designation as a closed unit helped ensure that patients were appropriately placed in the observation unit. "Once we closed the unit and put the inclusion and exclusion criteria in place, we decreased our inpatient conversion rate from about 33% before we closed the unit to around 12%," Baker says.
Admissions decisions for the observation unit are made by the attending emergency room physician, a hospitalist from the observation unit, and a case management staffer.
"It should be a closed unit because you can control your metrics better. It's more than outcomes metrics. With the inclusion and exclusion criteria, you have dedicated people in the observation unit who understand exactly what is going on in the unit and understand how it needs to be run," she says.
Although hospitalists rotate through the observation unit, most of the staff are dedicated nurses and physician assistants. The nursing staff has been an essential component in the development of the observation unit, Baker says.
"We needed to have dedicated observation nurses. We needed nurses who understood the process of moving patients through quickly, getting testing done quickly, and discharging quickly. It's a totally different mindset than inpatient status," she says.
The 22-bed unit operates seven days per week, with full staffing from 7 a.m. to 7 p.m. There is hospitalist and nursing coverage overnight rounding every 4 hours. Average full staffing includes:
1.5 clinicians
Two case managers
Patient-to-nurse ratio of 6:1 or 5:1
Developing strong relationships with ancillary services—particularly laboratory testing—has been a key factor in the efficient operation of the observation unit, Baker says.
"Short of the emergency department or an emergency test, our unit gets testing priority over everything else in the hospital. The goal is that testing and reporting gets done quickly, so we can either order more testing or be ready to discharge the patient," she says.
Shortening stay
Moving quickly and sound decision-making are primary factors that shorten a patient's length of stay in the observation unit, Baker says.
"The way we keep length of stay down is by seeing the patient quickly, ordering appropriate and prioritized testing, and making decisions with swiftness based on testing or whether the patient needs treatment," she says.
Timeliness is essential for the clinicians working in the observation unit, she says. "You have to monitor your time: rounding frequently, engaging the nurses to be more proactive, and making sure you are communicating well with the ancillary staff and case managers."
Another key to lowering length of stay is judicious use of specialist consults. "That keeps your length of stay down because the consultants are not always in the hospital during the day. Even if they are trying to prioritize your patients, they often can't because they are usually seeing their outpatient-practice patients," she says.
Limiting consultations and lab testing is done without compromising quality, Baker says. "We make sure we are practicing based on best practices. We are not over-testing and we are not under-testing just because we are worried about length of stay."
From August 2016 to February 2018, length of stay in the observation unit has fallen from 29.0 hours to 20.7 hours.
Cost control
The observation unit is generating a positive return on investment, including helping the LifeBridge Health hospital avoid readmissions penalties, Baker says. "Making sure the patients are being treated appropriately and not coming back to the hospital has huge return on investment," she says.
Personnel has been the highest cost in operating the observation unit, but staffing with a relatively high number of physician assistants and nurse practitioners has helped curb spending, she says. "To keep costs down, physician assistants and nurse practitioners are fabulous."
Researchers find that hospitals are most likely to be responsible for readmissions within a week of discharge, but outpatient clinics and homecare givers are most likely responsible for later readmissions.
Hospital readmissions are not monolithic, and Medicare should change its readmissions penalty program time frame from 30 days to seven days, researchers say.
The researchers, whose study was published this week in the Annals of Internal Medicine, say Medicare's Hospital Readmissions Reduction Program (HRRP) often penalizes hospitals for patient outcomes that are out of their control.
"We found that readmissions within the first 7 days after hospital discharge were more likely to be preventable than those within a late period of 8 to 30 days," the researchers wrote. "Early readmissions were more likely to be amenable to interventions within the hospital and to be caused by factors for which the hospital is directly accountable, such as problems with physician decision making."
Outpatient facilities and home caregivers were more likely to be accountable for readmissions from eight to 30 days, the researchers wrote.
"Late readmissions were more likely to be amenable to interventions outside the hospital and to be caused by factors over which the hospital has less direct control, such as appropriate monitoring and managing of symptoms after discharge by the primary care team."
The study, which covered 10 academic medical centers from April 2012 through March 2013, included 822 adult patients:
301 patients (36.6%) were readmitted within seven days after discharge
521 (63.4%) were readmitted eight to 30 days after discharge
36.2% of early readmissions vs. 23.0% of late readmissions were deemed preventable
The researchers found that faulty physician decision making was the number one cause of early readmissions, associated with 28.9% of the cases.
Three primary variants of errant decision making were identified:
Difficulty monitoring and managing symptoms was the number one cause of late readmissions, associated with 33.2% of cases. The researchers identified three primary variants of monitoring and managing difficulties:
Lack of disease monitoring in 12.7% of cases
Overly long wait times for follow-up appointments, 10.0%
Inability to make follow-up appointments, 10.9%
The researchers say their data indicate several reasons why the HRRP timeframe should be switched from 30 days to seven days.
First, they found a significant difference in the preventability of early and late readmissions in the 30-day timeframe after discharge. "Early readmissions were associated with double the odds of preventability compared with late readmissions," the researchers wrote.
Second, a pair of physician adjudicators who reviewed the readmissions cases found hospitals were the best site to intervene and prevent early readmissions. The physician educators found outpatient clinics and home were the best settings to prevent late readmissions.
Third, the researchers found that erroneous physician decision making and premature discharge were leading causes of early readmissions.
"Taken together, these findings suggest that readmissions in the week after discharge are more preventable and more likely to be caused by factors over which the hospital has direct control than those later in the 30-day window," the researchers wrote.
Beyond narrowing HRRP's 30-day readmissions window to seven days, the researchers also offer five recommendations to promote readmissions prevention:
Hospitals should try to decrease cognitive errors that impact diagnosis and treatment
The impact of hospital efforts to increase throughput on premature discharge should be examined
Outpatient facilities should boost multidisciplinary care management for post-discharge monitoring of patients after discharge
Access to primary care clinicians should be expanded
Accountability for readmissions 30 days after discharge should be shared between outpatient and inpatient facilities
"Shared accountability over the 30 days, possibly with weighted penalties by readmission timing, would engage outpatient practices in readmission reduction efforts and reduce unfair financial penalties on hospitals."
