Poor integration between primary care and public health is identified as one of the most "egregious" vulnerabilities of the U.S. healthcare system.
During the coronavirus pandemic, the failure to elevate the role of primary care providers on the frontline alongside public health officials has resulted in several missed opportunities to respond to the crisis, a recent study found.
The pandemic has highlighted weaknesses and vulnerabilities in the country's healthcare and public health systems. For example, primary care and public health have been underfunded in the United States, limiting their ability to react to the pandemic. The United States allocates about 6% of national healthcare spending on primary care, which is less than half of the average expenditure on primary care in other high-income countries.
The recent study, which was published by The Johns Hopkins Center for Health Security, is based on 32 semi-structured interviews with subject matter experts and a review of 50 articles.
Weak integration of primary care and public health is a tragic lesson from the pandemic, the study's co-authors wrote. "From its acute onset and throughout its extended duration, the COVID-19 pandemic has illuminated and exploited major vulnerabilities within the U.S. healthcare system, the most egregious of which were deficiencies in communication, collaboration, and coordination between primary care and public health. COVID-19 must be used as a catalyst for change."
This lack of integration limited several key responses to the pandemic, the study's co-authors wrote. "The failure to bring primary care providers into a frontline role as responders, alongside public health, resulted in many missed opportunities to provide better quality care, faster testing, more effective contact tracing, greater acceptance of vaccination, and better communication with patients. Participants in this study further indicated that better integration of primary care, public health, and community-based organizations could have provided greater support for the public health response, thereby easing the burden on overstretched public health personnel; and could have accessed primary care’s reach to amplify public health messaging."
Elements of successful collaboration
The study's literature review identified three primary components of effective collaboration between primary care and public health.
1. Strong relationships with community partners and organizations: "Strong ties with community partners and organizations are necessary to enhance the reach of any public health-primary care collaborative initiative outside of the capabilities of public health and primary care alone. Several articles emphasized the importance of relationships with mental health, social services, and community-based organizations and stakeholders that can leverage their community ties to bring more people into contact with public health and primary care initiatives," the study's co-authors wrote.
2. Established interprofessional relationships at the personal and institutional level between public health and primary care partners: "At the personal level, preexisting working relationships between public health and primary care representatives prior to the inception of the joint program contributed to more effective and regular communication. Previous connections between organizations, but not necessarily between the personnel involved, also provided a stronger foundation upon which the new collaboration could be built," the study's co-authors wrote.
3. Formal arrangements that specify the duties and expectations of public health and primary care partners: "When each partner is clear on their responsibilities and how those responsibilities contribute to the programmatic goals, there is less risk of duplicating efforts or gaps in program delivery. Additionally, identifying common goals and synergizing workplace culture between public health and primary care partners can help streamline collaborative processes and make the program more sustainable in the long term," the study's co-authors wrote.
Recommendations
The study includes four key recommendations:
1. Co-locate primary care and public health servicesto benefit population-level health and support active collaboration.
2. Primary care societies must align their efforts with public health in a unified voiceto drive congressional action to ensure that the disastrous response to the COVID-19 pandemic is not repeated.
3. Craft efforts to support, protect, and sustain the primary care and public health workforcesto drive integration across disciplines.
4. Public health "moves at the speed of trust" and people trust their primary care providers and community-based organizations; therefore, primary care and public health partnerships with strong ties to their community organizations shouldenhance health systems' surge capacity, extend public health disease containment interventions, and position the United States for improved response to future pandemics.
Find out how healthcare supply chain leaders are rising to the most daunting challenges in their field.
Strained supply chains have been a significant concern this year, and HealthLeaders has been following developments in the healthcare system supply chain.
Here are three of the top healthcare supply chain stories published by HealthLeaders in 2021:
The COVID-19 pandemic has been challenging for health systems in many ways. But even supply chain leaders firmly entrenched in their roles learned lessons that will improve their operations for years to come. LeAnn Born, vice president of supply chain at M Health Fairview is one such leader. Born has been at the supply chain helm of this Minneapolis-based health system since 2010, responsible for supply chain at eight hospitals, more than 40 primary care clinics, and outpatient services such as healthcare transportation.
Born says health systems need to identify their best supply chain leaders to foster quick decision-making, focus on standardizing products, engage physicians at the right time and support them with information about supply chain changes, and use data to monitor contract compliance and benchmark pricing.
When David Peck arrived at Houston Methodist in 2018, there was no centralized purchasing. Each entity of the health system purchased its own goods. Peck, vice president of supply chain management, centralized all purchasing at the corporate level, delegating it into pods: The operating room buyers. The laboratory buyers. The general medical-surgical buyers. And so on.
Peck says health systems should standardize products and renegotiate contracts for increased savings, compare the cost to buy equipment such as beds versus renting, and work with local partners to manufacture critical products to decrease sourcing reliance on other countries.
While Hal Mueller worked briefly in healthcare before, the bulk of his corporate life was spent in purchasing at Ford Motor Company. Auto parts aren't healthcare supplies, but there are similarities. He brings that perspective to his work as chief supply chain officer at The Ohio State University Wexner Medical Center. "In some ways, there are parts of the business world where healthcare gets closer and closer to a manufacturing environment," he says. "We talk about variation being the enemy of quality. We like to optimize variation; it's not about minimizing variation."
Mueller says health systems should use the 2-bin Kanban method to understand product cycle time and avoid product expirations, enlist clinical partners to help evaluate and drive supply decisions, and analyze and renegotiate supplies in cycles.
HealthLeaders asked one of the top chief medical officers in the country to gauge trends for clinical care next year.
Workforce shortages will be the most significant clinical care trend in 2022, according to the chief medical and scientific officer of Novant Health.
In addition to serving as chief medical and scientific officer at Novant, Eric Eskioglu, MD, is an executive vice president at the Winston-Salem, North Carolina-based health system. His background also includes practicing as a neurosurgeon and working as a former aerospace engineer at Allied-Signal Aerospace and Boeing.
In a recent interview, HealthLeaders asked Eskioglu about the top clinical care trends for 2022. The following is a lightly edited transcript of his comments.
1. Workforce shortages: The Number One trend in healthcare for 2022 is staffing. We all know about the nursing issues—nursing staffing and the nursing shortage. We are in one crisis with the coronavirus pandemic, but we have also lurched into another crisis in the workforce in healthcare. The workforce crisis is a big challenge for us, and nursing is a top concern.
Health systems are trying to bring in international nurses to address the nurse staffing shortage. First of all, I have a moral issue with this strategy because we are robbing the countries that can barely afford these nurses. So, we are creating a healthcare crisis abroad; and when you talk about COVID-19, it must be a global effort. You cannot just put yourself in isolation in the United States and hope that the pandemic goes away.
By bringing in international nurses, we are robbing Third World countries of a precious resource to fight diseases, including COVID-19. We are accelerating that problem. Secondly, you are going to be seeing some resentment from the nursing staff that is native in this country. As a result, you may see a greater push for unionization.
Medicare has cemented 9.75% cuts for physician pay starting in January 2022. I suspect that the physician workforce is going to go the same way as nursing to the gig economy. We are starting to see that already. You are going to see a lot more physicians moving to locum tenens work. Just like nursing workforce issues came suddenly upon us, I suspect 2022 is the year when we are going to have an even bigger challenge with the physician workforce.
Another workforce issue is the millennial generation. This generation is looking for different experiences. They are on the move. They do not like to be tied down. They like to do things on their own timing and choosing. That is leading to a workforce mentality shift in general. This affects us because we have a lot of millennial physicians coming in. It used to be a Norman Rockwell kind of thought process, where you set down roots in a community, stayed there for 30 years, practiced taking care of patients, then you retired. Those days are gone. The millennial generation is looking for different experiences.
2. Coronavirus variants: A trend is going to be continuing to watch the mutations of COVID-19. As a scientist, with almost 80% certainty I believe the current vaccines that we have, which are based on the original Wuhan strain, are not going to be as effective against the omicron variant when it has 30 different mutations. The antibody that we formed was for the spiked protein that came out of Wuhan. It is an antibody that fits on top of the spiked protein, then your white blood cells come in to destroy the spiked protein.
Right now, our antibodies are probably not going to fit omicron—it is not going to be a good fit. This is going to be like whack-a-mole. Infections by a variant will start to go down, then infections by a new variant are going to start going up. It is going to be a never-ending process.
3. Data technology: Artificial intelligence is going to be accelerated in 2022. It already has taken off. AI is not going to be a choice anymore. It is going to be an imperative. If we do not adopt AI, we stand to lose hundreds of thousands of lives because of the complexity of the medical field.
The medical field is getting very complex, and we have seen this during the pandemic. There have been many discoveries and millions of lives depend on us making the right diagnosis with the right treatment modalities—if we cannot do that with AI, we will start losing more people.
In 2022, AI is going to continue to take off in radiology and pathology.
Augmented reality and virtual reality are going to be applied to our psychiatry patients. When they leave the doctor's office, I can see the doctor prescribing them a video from a library of videos with a hololens. The doctor will say, "I want you to put your hololens on once a day and the video is going to stream into your hololens." It is going to be catalogued for bipolar disease, major depression, and obsessive-compulsive disorder. Behavioral health patients will have constant touch points without requiring physicians.
4. Disruptors: There is going to be further push by tech companies into healthcare. I would not be surprised if tech companies took either majority or minority equity interest in some of the for-profit or even not-for-profit healthcare organizations. When I say tech companies, I think it will be Amazon, Microsoft, Apple, and possibly Google. They are going to go deeper into healthcare because their growth has stalled in the environments they are currently in. How many people can sign up for Facebook or Amazon Prime before it plateaus?
Do not forget, healthcare is about 20% of the gross domestic product. So, tech companies are looking at healthcare as a growth avenue. You are going to see speedy, continued integration of tech companies into traditional areas of healthcare that they have not gotten into before.
Companies such as Amazon are going to go after everything. They have gotten licensing for pharmacy in all 50 states. They have one of the best supply chain and distribution operations in the world. They are already in telemedicine with Amazon Care—they are likely to expand to go after the Fortune 500 companies to provide them healthcare.
5. Payers blending with providers: Another trend is that the boundaries between payers and providers are starting to blur. You are going to see more of the payers such as UnitedHealthcare, Blue Cross Blue Shield, Aetna, and Humana getting into the provider space. I read recently that UnitedHealth Group's Optum arm now employs 60,000 physicians, and that is a significant percentage of the U.S. physician workforce. You are going to see a trend where there is more vertical integration from the payers into areas where they traditionally have not been involved.
The payers are going to go after primary care because primary care is the quarterback of the patient. Optum is going to go after more primary care and specialties such as family practice, internal medicine, pediatrics, and possibly obstetrics.
6. Burnout and well-being: The last trend is that physician and nursing burnout is going to accelerate, unfortunately. With each successive wave of the pandemic, morale gets knocked further down. Right now, there is no end in sight. So, you are going to see even further deterioration of physician and nursing morale.
In New Jersey, an increase in in-home deaths for conditions typically requiring hospitalization and a decrease in hospital utilization for several life-threatening conditions indicates delayed care increased excess deaths during the pandemic.
Delayed or deferred care likely contributed to excess deaths in New Jersey during the first year of the coronavirus pandemic, a recent report from the New Jersey Hospital Association's Center for Health Analytics, Research & Transformation (CHART) says.
Health systems, hospitals, and other healthcare organizations have reported significant decreases in service utilization in the early months of the pandemic linked to patient concern over becoming infected with COVID-19 in a healthcare setting. In a September 2020 New Jersey Hospital Association survey of a representative sampling of Garden State adults, 83% of survey respondents reported being concerned about going to a hospital due to fear of contracting COVID-19.
The CHART report includes several key data points on excess deaths based on information collected by the New Jersey State Health Assessment Data system:
In 2020, there were about 95,715 deaths in New Jersey.
In 2020, COVID-19 was the leading or primary cause of death for 16,458 people, leaving 79,257 deaths for other causes.
From 2017 to 2019, total annual deaths in New Jersey did not exceed 76,000. "Therefore, even when separating out deaths due to COVID-19, the total number of non-COVID-19 deaths in New Jersey throughout 2020 was roughly 4.3 percent higher than in previous years," the CHART report says.
Two data trends indicate that delayed or deferred care likely played a role in the number of 2020 non-COVID-19 deaths in New Jersey: an increase in in-home deaths for conditions that typically would require hospitalization and a decrease in hospital admissions for serious conditions such as heart attack and stroke.
In 2020, total in-home deaths in New Jersey were 28% higher than the previous three-year average.
In 2020, in-home heart disease deaths in New Jersey were 24% higher compared to 2019.
In 2020, in-home stroke deaths in New Jersey were 39% higher compared to the average annual total in the prior three years.
In 2020, in-home diabetes deaths in New Jersey were 66% compared to the average annual total in the prior three years.
In 2020, the number of heart attack hospitalizations in New Jersey from April through June was 37% lower than the average over the same months in the previous three years.
In 2020, the number of stroke and other cerebrovascular disease-related hospitalizations in New Jersey from April through June was 25% lower than the average over the same months in the previous three years.
The data sheds light on the uncounted toll of COVID-19 for people who delayed seeking healthcare for life-threatening conditions during the pandemic, Cathy Bennett, president and CEO of the New Jersey Hospital Association, said in a prepared statement. "During COVID's peak in New Jersey in the spring of 2020, EMS teams throughout the state shared anecdotal reports of individuals who waited too long to seek care for life-threatening conditions. Sadly, this data indicates that those reports were not isolated and, in fact, may be counted among COVID's terrible impact on New Jersey residents."
The gender pay gap for physicians in 2021 was 28%, with male physicians earning on average about $122,000 more than their female counterparts, Doximity report says.
Average annual compensation for physicians increased 3.8% in 2021, according to a report prepared by Doximity, a digital platform for medical professionals.
Doximity has tracked physician compensation for five years, with data collected from more than 160,000 compensation surveys since 2017. This year's physician compensation report is based on more than 40,000 self-reported compensation surveys.
This year's 3.8% hike in physician compensation is a significant increase compared to last year's 1.5% increase, the Doximity report says. "It's possible this year’s increase reflects a catch-up from last year's relatively flat rate, a tight labor market, or a reflection of rising inflation rates in 2021," the report says.
Despite the growth reported in physician compensation, physician pay has not kept pace with inflation. As measured by the Consumer Price Index, the 2021 inflation rate was 6.2%, the report says.
The report is designed to provide critical information to healthcare industry stakeholders and individual physicians, the report says. "Our overarching goal is to track the data over a multi-year time-frame and help stakeholders understand employment trends taking shape in the healthcare space. We also hope sharing this data will provide individual doctors with information that can help them make important career decisions. As such, we track data at the metro area level, across medical specialties and different employment types."
The Doximity report features several key data points.
The three specialties with the highest average annual compensation were neurosurgery ($773,201), thoracic surgery ($684,663), and orthopedic surgery ($633,620)
The three specialties with the lowest average annual compensation were pediatric infectious disease ($210,844), pediatric rheumatology ($216,969), and pediatric endocrinology ($220,358)
The three specialties with the largest increase in average annual compensation were preventative medicine (12.6%), hematology (12.2%), and nuclear medicine (10.4%)
The metro areas with the highest average annual compensation for physicians were Charlotte, North Carolina, at $462,760, St. Louis, Missouri, at $452,219, and Buffalo, New York, at $426,440
The metro areas with the lowest average annual compensation for physicians were Baltimore, Maryland, at $330,917, Providence, Rhode Island, at 346,092, and San Antonio, Texas, at $355,439
The metro areas with the highest compensation growth rates were Charlotte, North Carolina, at 12.9%, Virginia Beach, Virginia, at 12.1%, and St. Louis, Missouri, at 10.5%
The gender pay gap for physicians in 2021 was 28%, with male physicians earning on average about $122,000 more than their female counterparts
The metro areas with highest compensation for female physicians were Minneapolis, Minnesota, at $347,426, Sacramento, California, at $341,107, and Tampa, Florida, at $339,505
The metro areas with the lowest compensation for female physicians were Baltimore, Maryland, at $262,109, Louisville, Kentucky, at $276,509, and Memphis, Tennessee, at $246,531
The nurse practitioner gender pay gap was 9.6%, with male nurse practitioners earning on average $12,292 more than their female counterparts
The physician assistant gender pay gap was 11.0%, with male physician assistants earning on average $14,646 more than their female counterparts
The three specialties with the largest increase in average annual compensation were preventative medicine (12.6%), hematology (12.2%), and nuclear medicine (10.4%)
The top three annual average compensation practice settings were single specialty group ($442,024), multi-specialty group ($424,312), and solo practice ($415,678)
The growth of urgent care visits before the pandemic continued in 2020 and 2021, an Epic Health Research Network study shows.
The coronavirus pandemic resulted in unprecedented increases in infectious disease testing and immunizations at urgent care clinics, according to a new research article.
Urgent care visits were on an upward trend before the pandemic. The new study shows that upward trend has continued during the pandemic, with the exception of a decrease in visits early in the crisis.
After dropping in the first couple months of the pandemic, urgent care visits rebounded with a dramatic increase in infectious disease testing. "This increase represented a significant change in the distribution of the types of visits seen in urgent care as testing peaked at nearly 40% of urgent care visits in October 2020," the study's co-authors wrote.
Immunizations helped to drive an increase in urgent care visits in 2021. "Immunization visits at urgent care are typically seen at small volumes, peaking at around 3% to 4% of visits in the late fall, likely due to the timing of influenza vaccinations. However, in 2021 immunization visits peaked at nearly 20% of urgent care visits in March of 2021, a five-fold increase from previous peaks," the study's co-authors wrote.
Interpreting the data
The decrease in urgent care utilization early in the pandemic mirrors the drop in utilization at other healthcare facilities, a co-author of the study recently told HealthLeaders.
"People were just not going to healthcare facilities at the beginning of the pandemic. In March, April, and May of 2020, people were not seeking healthcare for things that they would have done in the past. Patients were not going to their primary care offices and specialty visits. There was a drop in all access to healthcare during that time. We have seen this reflected in screening tests for mammograms, colonoscopies, and Pap smears—all of those tests decreased in the first three months of the pandemic," said Sam Butler, MD, a clinical informaticist at Epic Systems Corp.
The increase in infectious disease testing at urgent care clinics in the second half of 2020 was unprecedented, he said. "As soon as the COVID-19 test was available, it became a significant portion of urgent care clinics' business. Infectious disease testing went from a small amount of urgent care visits for things such as influenza and strep throat to close to a third of all visits. That was before there were home tests for COVID-19, and urgent care clinics were one of the few places you could get tested."
Similarly, immunization rates at urgent care clinics in 2021 reached levels never seen before, Butler said.
"In general, not just in urgent care, we have not seen an immunization be delivered to so many people in a short period of time, even though we still suffer from not enough people getting vaccinated. We vaccinated hundreds of millions of patients in the United States in a very short period. It was unprecedented to see so many immunizations at urgent care clinics. The increase in visits was not as dramatic as the testing increase, but it was significant. At its peak in 2021, immunizations were about 20% of urgent care visits," he said.
The most interesting part of the study was how urgent care was growing before the pandemic and has continued to grow except for the drop off in early 2020, Butler said. "We think that urgent care has its place, but primary care with a physician that knows you can be better care. So, we have to watch this trend. The care that we provide in urgent care needs to continue, but it does not replace the value of primary care. … Urgent care is well-suited to things such as acute injuries, but it would be less than best care for all of your care to be done at an urgent care clinic."
In 2021, the coronavirus pandemic has exacerbated healthcare worker burnout and the prospects for next year are bleak unless C-suite executives act.
Healthcare worker burnout has reached crisis proportions and urgent action is required to turn the tide, a national burnout expert says.
Bernadette Melnyk, PhD, RN, APRN-CNP, is chief wellness officer of The Ohio State University and dean of the university's College of Nursing. She is a nationally recognized leader on healthcare worker burnout and well-being. Melnyk has published dozens of research articles on healthcare worker burnout and well-being in peer-reviewed journals.
HealthLeaders recently spoke with Melnyk to gauge healthcare worker burnout and well-being in 2021 and the prospects for 2022. The following is a lightly edited transcript of that conversation.
HealthLeaders: Characterize the level of healthcare worker burnout in 2021? How does the level of burnout compare to the pre-pandemic levels?
Bernadette Melnyk: The levels of burnout this year have soared among healthcare professionals. The levels were high prior to the pandemic, but we have several studies that show they definitely have worsened. So, continuing problems with burnout are escalating—compassion fatigue, depression, mental distress are all super high right now.
Prior to the pandemic, you would see burnout rates on average in the range of 30% to 50%. We are seeing levels now that range from 40% to 70%. What is so disturbing about the increase in burnout is not only is it negatively impacting our population of clinicians, but we know when clinicians are burned out, depressed, and suffering from compassion fatigue it negatively impacts healthcare quality and safety.
In the nursing professions specifically, many of the nurses who were planning on working for another five years are retiring now. Younger nurses are leaving the profession—there are turnover rates between 30% and 60% in new graduates. This is creating a healthcare crisis. We do not have enough nurses now—especially in rural areas—to meet the demands. Patient-nurse staffing ratios have gotten worse, which means nurses who are fatigued and burned out are getting higher workloads.
C-suites across the country must fix system issues that we know are causing burnout, or the costs of burnout are going to be horrific.
HL: What are some of the systemic changes that the C-suite should be making?
Melnyk: There are too many tasks. There are staffing ratios that are not appropriate. One nurse taking care of 10 or 12 patients is not an acceptable ratio. Shifts are too long—my research alone in national studies over the past two years has shown that the longer the shift work the poorer the nurse outcomes and the more medical errors that are made. We must stop 12-hour shifts.
We also must do a better job with our electronic health records. It takes up way too much time and it is taking clinicians and nurses away from their patients to the point where it is taking their joy away. Most of us went into the profession to take care of people and to be with people.
These system fixes are critical, in addition to creating wonderful wellness cultures and making available great evidence-based programs to equip clinicians with resiliency skills that they need given the high rates of mental health distress that we are seeing.
HL: In 2021, characterize the impact of the pandemic on healthcare worker well-being and burnout.
Melnyk: We are losing clinicians—that is creating staffing shortages, which is putting more pressure on the ones who are still working. Because of the pandemic, our clinicians have been exposed to a lot of trauma. Many of our clinicians have watched their colleagues die from COVID-19. They have been the sole support for dying patients because of restrictions that were placed on visitation of loved ones. The past 20 months have been traumatic for many of our clinicians.
There is a mental health tsunami that is occurring among healthcare workers. In my latest study with travel nurses, not only did they report high rates of burnout and depression, but the pandemic also impacted their lifestyle behaviors. People have attempted to cope in unhealthy ways. We have seen increases in alcohol use. We have seen increases in unhealthy eating. We have seen declines in physical activity. Downstream, that is going to lead to higher rates of chronic disease, and we must be prepared for that.
HL: What are the prospects for healthcare worker well-being and burnout in 2022?
Melnyk: For the C-suites at health systems throughout the country, if they want to see this improve, they have got to fix their system issues that we know are causing problems. They also must invest in their clinicians' well-being. It is not an expense—that investment will have a huge return on investment and value for the organization.
The C-suite must recognize that unless their clinicians are mentally and physically well, healthcare safety and quality is going to be negatively impacted as well as costs and patient outcomes.
Unless the C-suite acts, healthcare worker burnout and wellness is going to get worse because the pandemic is going to continue to place strain and burden on our already compromised clinicians. They are already suffering. We must treat this urgently. This is an epidemic inside of the COVID-19 pandemic.
Although there have been efforts to raise the visibility of this issue, we have a way to go. We must treat it with urgency, or the future is going to be even more bleak.
HL: In 2022, what can health systems and hospitals do to address healthcare worker well-being and burnout?
Melnyk: First, they need to invest in appointing a chief wellness officer. Somebody must be ultimately charged with improving clinician well-being. They cannot be a title only. A chief wellness officer must be given resources to be able to improve clinicians' health and well-being.
Leaders, managers, and supervisors have got to walk the talk. They must build cultures of well-being that make healthy choices easier for their clinicians to make. Health systems need to offer anonymous screenings for their clinicians for depression and suicidal ideation. The suicide rates for physicians and nurses are higher than they are for the general population. There is still a lot of stigma surrounding mental health, including among clinicians. We must emphasize that recognizing that you need help is not a weakness—it is a strength. There is no shame in seeking help.
HL: How can health systems and hospitals create a culture of wellness?
Melnyk: At Ohio State, we take a multicomponent approach to creating a culture of wellness. We target evidence-based interventions to our top leaders, managers, supervisors, and the grassroots of the organization.
Then you must measure your outcomes. Taking an evidence-based, outcomes-management approach is important.
However, changing culture takes time and patience. In many instances, what happens is leaders do not see an immediate outcome, they get frustrated, and they give up. Culture change is not going to happen in a year or two. It takes time and it takes investment. You must get to the point where the culture is one where people feel supported because perception of wellness culture and support impacts what people feel and what they do. Our research has shown this.
HL: What kind of outcomes do you need to measure?
Melnyk: You need to measure burnout, depression, suicidal ideation, stress, anxiety, engagement, intent to leave the profession, and well-being. We measure all these things. For perceived wellness culture, we have a validated scale that we integrate into our annual personal wellness assessment. Perception of wellness culture impacts what people do and how they feel.
A code response team for agitated patients was modeled on response teams for other acute conditions such as stroke.
A team-based approach to responding to agitated patients in the Emergency Department (ED) setting can result in a significant decrease in the utilization of physical restraints, a recent journal article says.
Agitation is defined as excessive psychomotor activity that causes violent and aggressive behavior. It has been estimated that 1.7 million instances of agitated patients occur in acute care settings every year. Although use of physical restraints for agitated patients is common, earlier research has associated them with several poor outcomes, including psychological harm, physical trauma, respiratory depression, and death.
The recent journal article, which was published by Annals of Emergency Medicine, describes the design and implementation of an agitation code response team at Yale-New Haven Hospital in New Haven, Connecticut.
The agitation code response team was developed in three phases over a five-year period, resulting in a 27.3% decline in the physical restraint rate.
"With the implementation of a structured agitation code response team intervention combined with design and administrative support, a decreased rate of physical restraint use occurred over a five-year period. Results suggest that investment in organizational change along with interprofessional collaboration during the management of agitated patients in the ED can lead to sustained reductions in the use of an invasive and potentially harmful measure on patients," the co-authors of the journal article wrote.
A multidisciplinary agitation management task force was formed to oversee the design and implementation of the initiative. Members of the task force included emergency medicine physicians, nursing managers, protective services lieutenants, and ad-hoc staff members from administrative leadership, pharmacy, and patient relations.
5-part agitation code response team protocol
The agitation code response team was modeled on response teams for other acute conditions such as stroke. The protocol for the agitation code response team features five elements.
1. Activation: "Any licensed nurse or clinical provider could initiate overhead activation of the code response team if (1) patient agitation required more than one staff member to manage, (2) if there was an immediate safety risk identified related to agitation, or (3) when a notification was received from prehospital services regarding an incoming patient who may be a potential safety risk due to agitation, with approval by a senior nurse on shift," the journal article's co-authors wrote.
2. Roles and responsibilities: There are three essential members of the agitation code response team.
A senior physician or advanced practice provider serves as the team lead. This team member performs the primary patient assessment, attempts de-escalation with the patient, and assesses whether the patient requires chemical sedation and/or physical restraint.
A primary nurse monitors the patient's status, administers care, and documents in the health record.
A lead protective services officer monitors the physical safety of the patient and staff, stabilizes patient extremities if physical restraints are required, and defers to the team lead before any physical maneuvers are made on the patient, unless officers perceive an immediate risk to staff.
3. Process and workflow: "The process and workflow of the code response team provided guidelines for transporting the agitated patient immediately into one of the resuscitation bays if possible and recommendations to attempt initial de-escalation for every patient but apply physical restraints and chemical sedation if immediate danger to self or others was present. It also described processes related to written and verbal handoffs between the code team and staff receiving the patient in other care areas once the initial response ended and it was safe to transition care," the journal article's co-authors wrote.
4. Health record support: The agitation code response team protocol includes "standardized phrases for documenting decision-making and clinical course in the provider notes, nursing flowsheets and narrators, and order sets for sedation and restraint," the journal article's co-authors wrote.
5. Continuous quality improvement: "We standardized a continuous quality improvement process for the intervention with (1) regular audits and observations of responses by task force members, (2) encouragement of clinical debriefs after each response, (3) anonymous feedback from staff members through a [Quick Response] code posted in each resuscitation bay, and (4) monitoring of patient safety incident reports and charge nurse reports related to code team activations and responses. Any potential issues, areas for improvement, and sentinel cases were fed back to the task force to review and make iterative improvements during regular biweekly meetings," the journal article's co-authors wrote.
The leader of the Federation of State Medical Boards calls the increase in misinformation complaints "staggering."
State medical boards are being impacted by the dissemination of false or misleading information about COVID-19, and they are taking action to address the problem, according to the Federation of State Medical Boards (FSMB).
The spreading of misinformation about COVID-19, which has included false or misleading information from some physicians, has been a troubling aspect of the coronavirus pandemic. The misinformation has included erroneous recommendations related to treatments and vaccination.
Last week, the FSMB released data from the organization's 2021 annual survey of member state medical boards. The survey includes three key data points on COVID-19 misinformation and state medical board actions to address it.
67% of survey respondents reported an increase in complaints about licensee dissemination of COVID-19 misinformation
26% of survey respondents reported making statements about the dissemination of misinformation
21% of survey respondents reported taking disciplinary action against a licensee for dissemination of misinformation
The leader of the FSMB says the increase in complaints is alarming, and he hailed the response of state medical boards.
"The staggering number of state medical boards that have seen an increase in COVID-19 disinformation complaints is a sign of how widespread the issue has become. We are encouraged by the number of boards that have already taken action to combat COVID-19 disinformation by disciplining physicians who engage in that behavior and by reminding all physicians that their words and actions matter, and they should think twice before spreading disinformation that may harm patients," FSMB President and CEO Humayun Chaudhry, DO, said in a prepared statement.
In July, the FSMB Board of Directors issued a statement alerting physicians that they could face disciplinary action from state medical boards for disseminating misinformation about COVID-19 vaccination.
"Physicians who generate and spread COVID-19 vaccine misinformation or disinformation are risking disciplinary action by state medical boards, including the suspension or revocation of their medical license. Due to their specialized knowledge and training, licensed physicians possess a high degree of public trust and therefore have a powerful platform in society, whether they recognize it or not. They also have an ethical and professional responsibility to practice medicine in the best interests of their patients and must share information that is factual, scientifically grounded and consensus-driven for the betterment of public health," the board statement says.
The FSMB Ethics and Professionalism Committee is crafting a policy on guidelines and recommendations for state medical boards on the dissemination of misinformation by licensees. The FSMB House of Delegates is expected to vote on adoption of the policy in April 2022.
Clinical event debriefing efforts serve three purposes, linking safety, quality, and staff wellness.
Clinical debriefing efforts can drive several benefits at health systems and hospitals, according to the NYC Health + Hospitals presenters of a session at this week's IHI Forum.
The Agency for Healthcare Research and Quality provides a definition of clinical debriefing: "A dialogue between two or more people whose goals are to discuss the actions and thought processes involved in a particular patient care situation to encourage reflection on those actions and thought processes and incorporate improvement into future performance."
"Three key things stick out to me: dialogue, reflection, and improvement," said Mona Krouse, MD, patient safety officer at NYC Health + Hospitals.
Clinical debriefings are a way to capitalize on information, said Suzanne Bentley, MD, medical director of the Elmhurst Satellite Simulation Center at NYC Health + Hospitals.
"It captures reflections and gets them down with each other and why we are doing things and how we can do them differently. So, it serves to supply information. It allows us to identify knowledge gaps. It offers reflection on local culture, workforce, and team functioning, including identifying issues or struggles when they are present. Above all else, debriefing can serve as a change agent for work toward becoming a culture that has more of these conversations and more sharing so we can all come together to be better," she said.
The purpose of clinical debriefings is trifold, linking safety, quality, and staff wellness, Bentley said, adding that boosting wellness is often underestimated in clinical debriefing efforts.
"Wellness is not a hidden agenda, but it is definitely an unrecognized benefit that comes with debriefing. We should be debriefing with a lens toward wellness and how we are supporting the participants who are filtering in useful information. No one can truly engage in discussions around patient safety and around quality healthcare while they are in distress. There is literature that backs this up. … Additionally, no one can truly heal without having a safe outlet to share their ideas and their suggestions for how things could have gone differently," she said.
Debriefing not only improves patient outcomes but also improves staff outcomes, Krouse said. "Especially now during the COVID-19 pandemic, the crisis hit home for a lot of people in healthcare. Personally speaking, this has been a very tough time, and debriefing offers a space to talk about how you are feeling. In studies, debriefings have been shown to reduce stress and anxiety, improve morale, improve work satisfaction, and decrease burnout."
Overcoming barriers to debriefing
The IHI Forum session also addressed barriers to implementing clinical debriefing efforts.
For example, one of the primary barriers is the perception that it is hard to debrief in the right way, said Komal Bajaj, MD, MS, chief quality officer, Jacobi Medical Center, NYC Health + Hospitals.
"What we have learned over time is that there is not one right way to debrief. There are many published models that all have a few common themes. One is an attention to psychological safety. Two, there is some acknowledgment or solicitation of reactions. Three, there is some discussion about the case itself—what went well and what are the opportunities for improvement. Four, there are takeaways—either takeaways for the individual or takeaways for actions," she said.
Whatever model of debriefing you use, you can craft it to fit your organization, Bajaj said. "It is about picking the tool that meets your needs. As you are thinking about your clinical debriefing program, look at it as a buffet, where you are able to pick and choose formats or questions that seem to make sense for your environment. At the end of the day, we as humans are used to having conversations all the time, with our patients and with each other."
Planning for clinical debriefing programs
Before a clinical event debriefing program is established, key stakeholders and leadership should find answers to a series of questions, Bajaj said.
Who are the stakeholders who need to be engaged? "There are some powerful examples that you can share from the literature as to why debriefing can improve wellness, culture of safety, and quality. Those are powerful examples to share with stakeholders. There is a return on investment for this work," she said.
What debriefing framework works best for your environment? "It depends on what you want to accomplish. There is no one way to debrief," she said.
Who will serve as debriefing champions? "The best examples we have seen are interprofessional. Anyone can serve as a debriefing champion, but there needs to be some discussion about who will serve as a debriefing champion and what training they will need," she said.
How can you foster psychological safety? "We implemented our first debriefing program eight years ago, when debriefing was a dirty word. For the weeks and months leading up to launching our debriefing program, we asked, 'What is debriefing?' It is not meant for individual blame—it is meant for conversations. Our intention was to learn and to be better. The first couple of debriefings we had, there were only two or three people participating. … As people saw that what we talked about got fixed and changed—the idea of closed loop debriefing—debriefing began to be embedded into the culture," she said.
What clinical events should be debriefed? "It is good to start with events that are not the most serious or have the most unfavorable outcomes. You should think about the day-to-day things that can be debriefed, so those muscles are ready when there is a more challenging discussion," she said.
