A patient throughput plan at USA Health University Hospital includes addressing patient safety, efficiency, transitions of care, and discharge processes.
An Alabama-based hospital is benefiting from developing a surge plan to manage inpatient bed capacity before the onset of the coronavirus pandemic.
The efficiency of patient throughput—the inpatient processes and transitions of care from admission to discharge—is a concern at all hospitals. For example, inefficient patient throughput can delay hospital admissions from emergency departments, which leads to emergency room crowding and decreased patient satisfaction.
USA Health University Hospital in Mobile, Alabama, started designing its surge plan in late 2018 and implemented the initiative in March 2019.
"The surge plan provides structure and guidance for how to manage bed capacity. We lacked that structure and guidance when we conducted an assessment prior to designing the surge plan. The surge plan tells us what to do when we are at a certain level of bed capacity," says Sheri Salas, MSN, RN, director of nursing at USA Health University Hospital.
The hospital's analysis of pre-surge plan data from March 2018 to February 2019 and post-surge plan data from March 2019 to March 2020 shows several benefits from the bed capacity management initiative:
Partial diversion of patients to other hospitals was reduced from 331 hours in the pre-surge plan period to 202 hours in the post-surge plan period (39% decrease)
Emergency department admissions increased from 553 per month in the pre-surge plan period to 713 per month in the post-surge plan period (29% increase)
Hospital admissions increased from 798 per month in the pre-surge plan period to 916 per month in the post-surge plan period (15% increase)
Hospital referral acceptance rate increased from 61% in the pre-surge plan period to 92% in the post-surge plan period (51% increase)
Hospital discharge orders by 11 a.m. increased from 25% in the pre-surge plan period to 30% in the post-surge plan period (20% increase)
The surge plan initiative has been beneficial during the coronavirus pandemic, Salas says. "Just having a surge plan has helped during the pandemic. If we did not have a plan to begin with, we would have been all over the place. Having a plan with daily guidelines to follow has kept us from having to come up with a plan at the last minute."
Surge plan levels
The surge plan created color-coded levels of inpatient bed capacity, ranging from green, yellow, orange, red, and black.
"Green means we are wide open. Within the green level, we have daily practices that keep us in a mode of constantly monitoring and assessing our bed capacity levels. The policy for the green level includes a check list that we monitor several times a day to monitor bed capacity," Salas says.
The intensity of attention to patient throughput escalates along the color-coded scale, she says. "As we move up the levels of bed capacity, there are reminders and guidelines for what to do such as speeding up the cleaning of rooms so patients can be admitted from the emergency department. There are things that you do not want to assume are being done to keep everyone moving and make patient flow efficient."
Black is the direst bed capacity level in the surge plan.
"The black level is what most hospitals would have if they have a diversion plan. The black level is what we call full diversion. It means that we are at full capacity and are unable to take most new patients. If we are at full diversion, most of the area's hospitals are usually at full diversion as well. There has never been a time when we were absolutely unable to take new patients," Salas says.
Key surge plan elements
The implementation and operation of the hospital's surge plan includes six primary components.
1. Training: The first step in implementing the surge plan was training staff, Salas says. "We educated nursing, clinicians, environmental services, transporters, and patient care assistants. We did 'round robin' sessions, where we talked with staff members in person. We provided cards that were tailored to particular roles that told those staff members what to do to support the surge plan on the various color-coded levels."
2. Leadership: The Patient Throughput Committee has led the hospital's surge plan initiative. The panel, which is chaired by the hospital's CMO and is currently meeting monthly, is interdisciplinary. Members of the committee include hospital administrators, hospitalists, nurses, emergency department leadership, operating room staff, post-anesthesia care unit staff, the environmental services director, and the transport director.
"This team meets to discuss our bed capacity status, gaps, and what we need to do to address patient throughput. The committee looks at data and tackles challenges. One of the roles of the committee is to look at the surge plan and to revise it as needed. Especially since the pandemic began, there is always a new challenge to address," she says.
Focal points for the committee include patient safety, efficiency, transitions of care, and discharge processes.
3. Management team for patient throughput: "The Transfer Center is at the core of patient movement and throughput. It is a referral center. It is where patient bed movement happens. What some hospitals call 'house supervisors' work out of that department. We have staff in the Transfer Center who are nurses and paramedics who handle the referral portion of the Transfer Center," Salas says.
The Transfer Center was launched with a few staff members but has grown to about 19 staff members, she says.
4. Daily huddles: "We have a core group that we call our Surge Team that gets together every morning. They go over key points such as patients who need a bed, patients who are potential discharges, and operating room cases. It is a daily huddle regarding bed capacity status. The Surge Team includes our Transfer Center manager, our emergency department director, our operating room and post-anesthesia care unit teams, clinical nurse leaders, and our environmental services director," Salas says.
5. Transitional Care Unit: To reduce emergency department crowding and facilitate inpatient admissions, the hospital has a six-bed Transitional Care Unit. "It is a unit where patients can move from the emergency department until we have discharges throughout the day, then they can move to an inpatient bed. It helps with the patients being more satisfied from moving out of the emergency department," she says.
6. Clinician engagement: The surge plan initiative has boosted clinician engagement, Salas says. "They have been involved in assisting us, giving their input, and working with us on the surge plan and issues related to patient throughput. They are continuing to come to us with new ideas and areas we need to work on."
Before launching interventions to improve interprofessional collaboration in hospitals, leaders should conduct baseline assessments, an expert says.
Hospitalists and nurses working on general medical services have varying perceptions of the quality of interprofessional collaboration, a recent research article indicates.
Earlier research has shown that teamwork and interprofessional collaboration are key elements of providing safe care and boosting patient satisfaction. However, there are several challenges to effective teamwork in the hospital setting such as the large size of medical care teams and physicians working across multiple care units with little opportunity to establish lasting work relationships with nurses and other staff members who are assigned to designated units.
The recent research article, which was published by The Joint Commission Journal on Quality and Patient Safety, is based on data collected from four U.S. hospitals that were participating in the Redesigning Systems to Improve Teamwork and Quality for Hospitalized Patients project. The project is crafted to establish and spread care models that increase interprofessional teamwork and improve outcomes for hospitalized patients.
Nearly 400 medical staff members participated in the study: 193 nurses, 94 nurse assistants, 80 hospitalists, and 13 resident physicians. The research generated two primary results:
63.3% of hospitalists rated the quality of collaboration with nurses as high or very high, but only 48.7% of nurses rated the quality of collaboration with hospitalists as high or very high
Teamwork climate scores varied significantly across the four hospitals in the study
"This study found significant differences in perceptions of teamwork climate across sites and in collaboration across professional categories on general medical services. Given the importance in providing high-quality care, leaders should consider conducting similar assessments to characterize teamwork and collaboration on general medical services within their own hospitals," the research article's co-authors wrote.
Interpreting the data
The lead author of the research article told HealthLeaders that there are likely multiple causes for the perception gap on collaboration between hospitalists and nurses.
"It seems that physicians feel that they have the information they need, while nurses realize that they do not have the information they need. The team members lack a shared mental model of the plan of care. Nurses may be more aware of this lack of a shared mental model because they spend more time with patients and are responsible for administering the treatments such as medications, activity, and diet ordered by physicians," said Kevin O'Leary, MD, MS, professor of medicine at Northwestern University Feinberg School of Medicine and medical director for quality at Northwestern Memorial Hospital in Chicago.
Other underlying causes of the perception gap on collaboration likely include differences in training, experience, and hospital culture, he said. "Teamwork challenges are probably more common in hospitals that continue to have a culture with steep hierarchies."
The research article's finding that there was significant variation in teamwork climate scores at the four hospitals in the study shows the importance of conducting baseline assessments of teamwork and collaboration at hospitals, O'Leary said.
"Baseline assessment of teamwork climate is important for two main reasons. First, it allows hospital leaders to identify whether an opportunity for improvement exists, or assessment may reveal that teamwork is going well. Second, if an opportunity for improvement exists, baseline assessment will serve as an important comparator to post-intervention assessment to determine whether teamwork has improved."
Three complementary interventions can increase teamwork and collaboration between physicians and nurses, he said.
Assigning physicians to work in a minimal number of medical units
Establishing a co-leadership structure in medical units featuring physicians and nurses
Utilizing well-designed interprofessional rounds in medical units
In the first half of 2020, the total number of telemedicine and in-person outpatient visits decreased 9.1%, raising concern about deferred care.
A recent research article gauges the increase in telemedicine patient visits and decrease in outpatient in-person visits in the first half of the year.
Largely to reduce the spread of the novel coronavirus, hospitals and physician practices have increased utilization of telemedicine for patient visits and decreased in-person visits. The increase in telemedicine visits has been colossal. For example, a FAIR Health analysis of commercial insurance claims data found telehealth claims lines increased 3,552% from August 2019 to August 2020.
The recent research article, which was published by JAMA Internal Medicine, is based on information from a national sample of 16.7 million people with commercial or Medicare Advantage health plans. The researchers examined telemedicine and in-person outpatient visits from Jan. 1 to June 16.
The study has several key data points:
The weekly rate of telemedicine patient visits increased sharply in the early phase of the pandemic—peaking in the week of April 15
From the weeks of Jan. 1 to June 10, the rate of telemedicine visits increased 2,013%, rising from 0.8 to 17.8 visits per 1,000 health plan enrollees
From the weeks of Jan. 1 to June 10, the rate of in-person outpatient visits decreased 30.0%, falling from 102.7 to 76.3 visits per 1,000 health plan enrollees
During the study period, the total number of telemedicine and in-person outpatient visits decreased 9.1%, falling from 103.5 to 94.1 visits per 1,000 health plan enrollees
In the last month of the study period, there was significant geographic variation in the percentage of total visits conducted through telemedicine, ranging from 8.4% in South Dakota to 47.6% in Massachusetts
"Although there was geographic variation in the magnitude of changes, every state experienced a drop in total visits, illustrating the broad scope of deferred care during the first months of COVID-19," the study's co-authors wrote.
Interpreting the data
The nationwide level of deferred care is alarming, one of the study's co-authors told HealthLeaders.
"Deferred care is potentially a very big problem that will disproportionately harm vulnerable populations, further exacerbating all of the racial and social inequity that the pandemic has laid bare. My biggest concerns are worsened chronic disease management—like diabetes—that could take years to reverse and a very big backlog of overdue cancer screening resulting in an increase in preventable cancer deaths," said Michael Barnett, MD, MS, an assistant professor of health policy and management at the Harvard T.H. Chan School of Public Health in Boston.
The level of outpatient in-person visits is likely to ebb and flow with the varying intensity of the coronavirus pandemic, he said.
"Early data is suggesting that outpatient volume is coming back to the pre-COVID baseline in the second half of 2020, but that data is from before the current surge we are all experiencing right now. Outpatient delivery may be riding a bit of a wave up and down as COVID-related restrictions are tightened and loosened over the next several months."
In March, Atrium Health launched a virtual hospital program for mildly and moderately ill COVID-19 patients.
Health systems can expand their inpatient capacity during the coronavirus pandemic and beyond with a virtual hospital at home program, a recent study shows.
As the coronavirus pandemic rages nationwide during its third surge this year, resources are being strained at health systems and hospitals across the country. Virtual hospital at home programs have emerged as a viable option to ease inpatient bed capacity limitations at hospitals.
Charlotte, North Carolina-based Atrium Health features 50 hospitals and other healthcare facilities in three states. The health system launched a virtual hospital at home program for COVID-19 patients in March and recently published a study about the initiative in Annals of Internal Medicine.
Atrium Health's virtual hospital at home program is split into two separately staffed "floors."
"The 'first floor,' or virtual observation unit (VOU), is designed for low-acuity patients who can be managed remotely with daily telemedicine-supported symptom monitoring by RNs. The 'second floor,' or virtual acute care unit (VACU), is designed for patients who would otherwise have been admitted to a traditional brick-and-mortar hospital providing inpatient care, such as oxygen, medical treatments, daily virtual physician rounds, vital sign monitoring, twice-daily nursing assessments, and daily paramedic visits," the study's co-authors wrote.
The study includes several key data points about Atrium Health's hospital at home VOU and VACU:
From March 23 to May 7, 1,477 patients received care through the VOU or the VACU, or both settings
1,293 (88%) patients were admitted to the VOU
40 (3%) of the VOU patients were admitted as inpatients at a conventional hospital
184 (12%) patients were admitted to the VACU
22% of the VACU patients required respiratory inhaler or nebulizer treatments, 22% of the patients required supplemental oxygen, 9% of the patients received antibiotics
24 (13%) of the VACU patients were admitted as inpatients at a conventional hospital
Of the 24 VACU patients admitted at a conventional hospital, 10 (42%) required ICU care, 1 (3%) required mechanical ventilation, and none died during conventional hospitalization
Crucial elements of virtual hospital at home program for COVID-19 patients
The lead author of the Annals of Internal Medicine study recently shared the keys to success of Atrium Health's virtual hospital at home program with HealthLeaders. "Any health system considering developing a virtual hospital program for COVID-19 patients should have an interdisciplinary approach to succeed," said Kranthi Sitammagari, MD, co-medical director for quality at Atrium Health.
There are six primary considerations for this kind of program, he said.
1. Develop an interoperable electronic health record for easy navigation between traditional hospitalization and the virtual hospital
2. Develop a virtual care platform for clinician visits
3. Develop a team of mobile caregivers—paramedics and/or registered nurses—to conduct in-home visits
4. Develop a strong supply chain for home monitoring equipment, including thermometers, blood pressure cuffs, and pulse oximeters
5. Develop evidence-based eligibility criteria, monitoring protocols, and treatment protocols
6. Analyze the costs of the program and allocate the budget accordingly
Atrium Health had a foundational infrastructure that helped the health system build a hub-and-spoke virtual hospital model, Sitammagari said.
"At Atrium Health, there was an established transitional services program that had been serving patients discharged from the hospital who were at high risk for readmission, utilizing community paramedics for in-home visits. Also, a robust telemedicine program utilizing a virtual care platform was available to deliver care for virtual in-home visits. A dedicated group of virtual hospital medicine providers and nurses were available to provide 24/7 coverage and monitoring along with other specialties linked as needed for virtual consultations."
Benefits of virtual hospital at home program for COVID-19 patients
Having a virtual hospital at home program for coronavirus patients generates four primary benefits, Sitammagari said.
1. A virtual hospital at home program for COVID-19 patients can limit traditional hospital admissions and increase the bed capacity of traditional hospitals to care for severely ill patients who otherwise cannot be managed outside the hospital setting.
2. Mildly to moderately ill patients can be kept outside traditional hospital settings, which limits the virus exposure of healthcare staff and other patients.
3. A virtual hospital at home program decreases demand for personal protective equipment, which has been in short supply throughout the coronavirus pandemic.
4. A virtual hospital at home program boosts patient satisfaction because they are happier to stay at home with loved ones rather than being isolated in a traditional hospital.
Adrian "Eric" Ramos, MD, discusses physician leadership, quality improvement, and patient safety.
The key to serving as the CMO for multiple hospitals is understanding the culture at all of the facilities, building relationships, and establishing trust, the new CMO of a Tenet Healthcare hospital group says.
Adrian "Eric" Ramos, MD, was recently named as the new CMO of Tenet's Northern California Group and CMO for Doctors Medical Center in Modesto, California. Tenet’s Northern California Group features six hospitals: Doctors Medical Center, Doctors Hospital of Manteca, Emanuel Medical Center in Turlock, San Ramon Regional Medical Center, Sierra Vista Regional Medical Center in San Luis Obispo, and Twin Cities Community Hospital in Templeton.
Before accepting his new roles at Tenet, Ramos served as CMO of Long Beach Medical Center in Los Angeles County. Prior to working at Long Beach Medical Center, he was CMO for HCA Healthcare's Far West Division, which features eight hospitals in California and Nevada.
HealthLeaders recently spoke with Ramos about a range of topics, including physician leadership, quality improvement, and patient safety. The following is a lightly edited transcript of that conversation.
HealthLeaders: What are the primary challenges of serving as the CMO for multiple hospitals?
Adrian "Eric" Ramos: Every hospital has its own culture, and every hospital medical staff has its own culture. So, the challenges are to understand the culture and see how the CMO can engage in the culture as well as the different goals and missions for the hospital staffs and the hospitals themselves.
Part of this challenge is how I look at the two visions of what a hospital administration is driving toward and their pain points, and how I look at the medical staff and what is driving them and their pain points. I try to be a mediator to help improve the understanding of both parties and to help move processes forward.
You must develop relationships with both administrative staff, nursing leadership, and the medical staff—whether it be the chief of staff or the chairs of the various departments. You must establish these relationships rather quickly and develop ongoing trust.
HL: How does rising to these challenges work in practice?
Ramos: It is a lot like being in private practice, which I was for 22 years. You must be able to enter a room, meet a person, put them at ease, develop a trusting relationship, and do an examination. So, it is in my wheelhouse to develop ongoing trusting relationships.
You need to let people know that you really care. When I first started out in a chief medical officer position, one of my friends and patients told me, "People don’t care about what you know. They need to know that you care." I took that to heart. I listen to people, understand what their concerns are, and try to help them address those concerns.
My work of overseeing eight hospitals at HCA Healthcare allowed me to understand how to scale what I learn and how to scale process improvement among a group of hospitals. The way I do that is to look at different initiatives or processes, then bring all groups to the table. Now, I will be working with six facilities to look at an initiative or a process. I want them to decide among themselves the best practices and what their pain points are, then help them address that.
HL: What are the primary elements of successful physician engagement?
Ramos: Each physician has gone into the profession for a reason, and most of the time it is altruism. They are looking to improve the lives of their patients. So, for me, physician engagement is finding out what drives them and what are their core values. What are the things that really move them? Then you connect those values to the initiatives that you bring to the table.
If there are physicians who like to work by themselves, you give them individual things to solve. For physicians who like to work in group settings, you put them in group settings. If physicians are concerned about safety, you put them in patient safety committee meetings. If physicians like changing processes and looking at complex issues, then you put them in those types of roles.
So, you need to understand the core values and drivers of individual physicians, then put them in the right context so that they can be happy and help the organization.
HL: What are the keys to successful quality improvement initiatives?
Ramos: When we look at process improvement or performance improvement in the quality realm, it is really setting a bar, and not saying, "We are going to be at the median." We want to strive to be the best. So, you need to set the bar high and continue to circle back and make sure that we are moving the ball forward.
You need continuous pressure. You need continuous focus. And you need timeliness in your focus.
For example, there might be initiatives that a hospital is not doing well at. If you do a monthly meeting and you are not moving the needle, then you need to move that meeting to twice a month. If you are still not moving the needle, you need to move that meeting to once a week. I have had initiatives where I have had to do weekly calls, with daily metrics sent to me, so that we could drive change.
I need to have commitment on my behalf to let the team know that an initiative is vital and important to me, and that I am not going to drop the ball or let it go.
HL: Characterize the state of patient safety in U.S. hospitals.
Ramos: Various health systems have attained various parts of patient safety. If you look at a hospital, every hospital has its own culture and its own set of challenges. So, there are some facilities and some health systems that are doing extremely well with patient safety. They are reducing and eliminating patient harm, improving outcomes, and improving metric-driven public data such as door-to-needle times for strokes.
We have made progress in eliminating hospital-acquired infections and hospital-acquired conditions. So, it is very encouraging to see that it has not been just talk. Physicians and physician leaders, nurses and nursing leaders, infection preventionists, pharmacists, and environmental services have come to the table and have helped us address hospital-acquired infections and hospital-acquired conditions.
Until we get to zero harm, we have more work to do. But there are pockets of excellence that are very encouraging.
The Acute Hospital Care At Home program will help health systems and hospitals manage inpatient beds during the coronavirus pandemic and beyond.
The Centers for Medicare and Medicaid Services (CMS) have launched a new program to expand the availability of hospital-at-home care across the country.
Hospital-at-home programs provide inpatient-level care to patients in their homes such as daily supervision by doctors or nurses in-person or virtually via telemedicine. Hospital-at-home programs provide a higher level of care than traditional home health services, which generally focus on skilled nursing and physical therapy.
In an announcement last week, CMS launched the Acute Hospital Care At Home program, which is designed initially to help health systems and hospitals to increase acute care bed capacity during the coronavirus pandemic, CMS Administrator Seema Verma said in the prepared statement.
"We're at a new level of crisis response with COVID-19 and CMS is leveraging the latest innovations and technology to help healthcare systems that are facing significant challenges to increase their capacity to make sure patients get the care they need. With new areas across the country experiencing significant challenges to the capacity of their healthcare systems, our job is to make sure that CMS regulations are not standing in the way of patient care for COVID-19 and beyond," Verma said.
As part of the Acute Hospital Care At Home program, CMS has established an online portal to expedite waivers of the Hospital Conditions of Participation statute. The statute includes several requirements for inpatient-level care, including the 24/7 availability of nursing services on the premises of a hospital-level care setting.
Through the Acute Hospital Care At Home program, Medicare beneficiaries can received home-based care for more than 60 acute medical conditions, including asthma, chronic obstructive pulmonary disease, congestive heart failure, and pneumonia.
As part of last week's CMS announcement, six healthcare organizations were designated as the first participants in the Acute Hospital Care At Home program:
Brigham and Women's Hospital in Boston
Huntsman Cancer Institute in Salt Lake City, Utah
Massachusetts General Hospital in Boston
Mount Sinai Health System in New York City
Albuquerque, New Mexico-based Presbyterian Healthcare Services
West Des Moines, Iowa-based UnityPoint Health
Program requirements
Several requirements were included in last week's Acute Hospital Care At Home program announcement:
Participating healthcare organizations must conduct screening protocols before patients are admitted to a hospital-at-home program. The screening protocols must include assessments of medical and non-medical factors such as home utilities, physical barriers in the home, and domestic violence.
Medicare beneficiaries can only be admitted to a hospital-at-home program from emergency departments and inpatient hospital beds.
A physician must evaluate a patient in-person before hospital-at-home care begins.
A registered nurse must evaluate every hospital-at-home patient daily, either in-person or virtually via telemedicine.
Every hospital-at-home patient must receive two in-person visits daily, either by a registered nurse or by a mobile integrated health paramedic.
Patients cannot be required to participate in a hospital-at-home program.
As long as hospitals have bed capacity, elective orthopedic surgery can continue during the pandemic, a prominent orthopedic surgeon says.
There are steps orthopedic surgery practices and hospital-based orthopedic surgery programs can take to continue performing procedures during coronavirus surges, a Chicago-based orthopedic surgeon says.
Even if hospitals have the bed capacity for orthopedic surgeons to perform elective surgeries such as joint replacements and spine procedures, there are barriers to overcome during coronavirus patient surges. For example, many hospitals and orthopedic practices face financial pressures, and there is a heightened need to achieve infection prevention in the operating room setting.
There are five ways orthopedic surgery practices and hospital-based orthopedic surgery programs can rise to coronavirus surge challenges, says Henry Finn, MD, medical director of the Chicago Center for Orthopedics and Robotic-Assisted Surgery, and a professor of orthopedic surgery at the University of Chicago.
1. Determine surgery demand
Based on assumptions, orthopedic surgeons should try to determine the demand for elective surgery, Finn says.
"In our practice, the demand for surgery now is greater than the fear of the coronavirus. People are fearful of this coronavirus surge and not being able to get surgery. Many patients have satisfied their deductible and want to get their procedure done before the end of the year," he says.
Estimating demand for surgery can be challenging and will vary from practice to practice, Finn says. "We are not seeing a down trend in surgery, but I do have colleagues who have told me they have lower demand for surgery in their practices. It is challenging to predict demand for surgery, but I can say our practice is experiencing increased demand."
Finn gave several examples of evidence-based orthopedic surgery guidelines during the pandemic:
Heightened awareness of OR cleaning and infection prevention measures
Wearing head-to-toe personal protective equipment
Elective surgery patients should be tested within three days of having their procedure, and emergency cases should be tested immediately with rapid COVID-19 tests
When patients are intubated for anesthesia, all OR staff members who are not involved in the procedure should stay out of the room for six to seven minutes after intubation
3. Expedite patient discharge
To mitigate the risk of patients contracting COVID-19 or spreading the coronavirus, they should be discharged as soon as safely possible, Finn says. "We have found that COVID-19 has been the greatest motivator for early discharge to occur—patients want to get out of the hospital. It is kind of shocking that people who may not have been able to get help at home can now get help at home during the pandemic."
Speedy discharge must be balanced against safety concerns, he says. "We find that the majority of patients want to get out of the hospital the next day, but if they have significant comorbidities or they do not have the appropriate resources and help at home, we don't send them home until those factors can be cautiously taken care of."
4. Technology utilization
Using telemedicine and robotic-assisted surgery are helpful during the coronavirus pandemic, Finn says.
"Telemedicine is certainly convenient, and it decreases the contact between the patient and the doctor, which decreases the risk of coronavirus exposure. … Robotic surgery, which I have been involved with for several months, decreases blood loss and post-operative pain. The smaller incisions also help patients to go home earlier."
5. Renegotiate implant contracts
To help address the financial challenges associated with the pandemic and elective orthopedic surgery, hospitals should try to renegotiate vendor contracts for joint implants, he says. "The implant costs that the hospitals pay can be so high that it affects the ability to achieve any profit. The implant costs can be higher than the reimbursement that the hospital receives from Medicare. That is where the big dollars are in the cost of hip and knee replacements."
To renegotiate these contracts, hospitals need to stress the necessity of cost-sharing during the pandemic, Finn says. "Hospitals need to say to the vendors of implants, which have a very high profit margin, 'Look, you are going to have to cost-share if we are going to continue to do joint replacements.'"
Sepsis is a life-threatening immune response to infection that leads to organ dysfunction, which is what happens in seriously ill COVID-19 patients, expert says.
Seriously ill COVID-19 patients are technically afflicted with sepsis, a national sepsis expert says.
Sepsis is the leading cause of death in U.S. hospitals. Sepsis is a costly condition, with costs for acute sepsis hospitalization and skilled nursing estimated at $62 billion annually.
Seriously ill COVID-19 patients have viral sepsis, Steven Simpson, MD, professor of pulmonary and critical care medicine at The University of Kansas in Kansas City and medical adviser for the Sepsis Alliance, recently told HealthLeaders.
"Sepsis is life-threatening organ dysfunction due to a dysregulated host response to an infection. In COVID-19 sepsis, the infection is the virus, and the life-threatening organ dysfunction is all the organs that can dysfunction, including lungs, brain, kidneys, heart, and liver. These are all organs that are classically associated with sepsis. COVID-19 that causes organ dysfunction is viral sepsis," he said.
Sepsis can be caused by bacterial, fungal, and viral infections, and sepsis linked to viral infections is relatively common, Simpson said.
"In addition to the novel coronavirus, there are multiple other viruses that are linked to sepsis. Every year, thousands of people die from influenza sepsis. If you are immunocompromised, there are several herpetic viruses that cause sepsis. For example, if you are undergoing chemotherapy, there are several different viruses that can cause sepsis. We see viral sepsis all the time," he said.
COVID-19 sepsis is more deadly than most forms of bacterial sepsis, Simpson said. "One of the problems with this illness is that it is not like a bacterial sepsis; where if you intervene with appropriate antibiotics early in the course of a bacterial sepsis, you can definitely keep it from progressing. We don't have that capability with COVID-19."
COVID-19 sepsis has a high mortality rate, he said. "For COVID-19 patients who require ICU care, by definition, nearly all of them have sepsis. And we know the mortality rate for COVID-19 patients in ICUs is in the range of 30%–40%."
Limited treatment options
COVID-19 sepsis is deadly because there are few available therapies beyond supportive care, Simpson said.
"So far, we have remdesivir, which can shorten the duration of illness but does not save lives as far as we can tell. We have dexamethasone, which is an immunosuppressant. Presumably, what dexamethasone is doing is calming the host response to the coronavirus infection, and that does seem to help save lives. And the FDA recently gave approval to bamlanivimab—a monoclonal antibody to the virus. Bamlanivimab is for people who have mild illness who are not hypoxemic—they do not need oxygen. It looks like this therapy might prevent the need for hospitalization," he said.
Dexamethasone has shown the most promise in combatting COVID-19 sepsis, Simpson said. "Once a COVID-19 patient has developed sepsis, we know that bamlanivimab and remdesivir are not going to be particularly effective at that point. Dexamethasone has been shown to be useful in septic COVID-19 patients—particularly patients who have been placed on mechanical ventilation."
At this point, illness prevention is the best strategy to address COVID-19 sepsis, he said.
"If you want to prevent sepsis from COVID-19, you must prevent COVID-19. Clinicians all understand the utility of wearing masks, washing hands, and distancing ourselves from one another when we can. We need our patients to understand that. This is a definite case where prevention is the key, and it is why we are exploding all over the nation with COVID-19 because many people will not follow these simple recommendations."
Sepsis awareness
A recent Sepsis Alliance survey gauged awareness of sepsis in the United States. The survey collected data from more than 2,000 adult Americans.
The survey has several key findings.
Although sepsis is common in severe cases of COVID-19, only 34% of survey respondents were aware that sepsis is a possible complication.
71% of survey respondents were aware of the term sepsis, which is a six percentage-point increase from the Sepsis Alliance's 2019 survey.
There are stark racial disparities in sepsis awareness. Only 49% of people who identified as black were aware of the term sepsis; 63% of people who identified as Hispanic were aware of the term; and 76% of people who identified as white were aware of the term.
Only 15% of adults could identify the four common signs and symptoms of sepsis, and one-quarter did not know any of the symptoms. The four primary symptoms of sepsis are fever, infection, mental decline, and extreme illness.
There are disparities in sepsis awareness based on income: 79% of people who make an annual income of $75,000 or more are aware of the term, but only 64% of people who make $50,000 or less are aware of the term.
New research shows interprofessional conflicts between female surgeons and nonphysician staff can be addressed at the individual and institutional levels.
There are strategies to address workplace conflicts between female surgeons and nonphysician medical staff members, a recent research article says.
Earlier research has shown female surgeons experience less achievement, more dissatisfaction, and higher levels of burnout compared to male surgeons. Interprofessional conflict has been associated with workplace dissatisfaction and stress, and earlier research indicates women are more likely than men to experience interprofessional conflict.
The recent research article, which was published by JAMA Network Open, is based on data collected in interviews of 30 U.S. female surgeons who were selected to reflect the age range and surgical experience level of female surgeons nationwide. The data generated several key findings.
The primary causes of interprofessional conflicts involving female surgeons were communication breakdowns, performance-related disputes such as staff members failing to provide proper equipment for a surgery, and breaches of institutional policies and protocols such as wearing nail polish.
The female surgeons felt there was a double-standard in interprofessional conflicts favoring male surgeons, an expectation that they should comply with gender norms rather than professional norms, and negative impacts on their well-being and professional reputation.
The female surgeons felt there was the potential for compromised patient safety because of decreased communication following an interprofessional conflict.
Most of the interprofessional conflicts involving female surgeons were with female staff members. In the study's interviews, many female surgeons said these interprofessional conflicts were likely related to actions violating gender stereotypes such as assertive direction from another woman.
"These data support the need for systematic changes to prevent interprofessional workplace conflict and to ensure more equitable adjudication when conflicts arise," the study's coauthors wrote.
At the individual level, female surgeons reported pursuing three primary strategies to address interprofessional conflicts.
1. Relationship management: "Participants discussed aspects such as personal accountability, gauging the emotional responses of others, and recalibrating their actions based on those responses," the study's co-authors wrote. Many of the female surgeons reported that relationship management contributed to the emotional burden of interprofessional conflicts because it was viewed as additional labor.
2. Rapport building: Many of the female surgeons reported participating in events for nonphysician staff such as baby showers to forge friendships. "For some, this process was natural and in line with how they would communicate with colleagues, but for others it felt contrived and was viewed as a form of performance needed to make things run smoother," the study's co-authors wrote.
3. Social support: "In the absence of having leadership effectively manage these situations, women surgeons would find other forms of support to alleviate the burden. This support was found in both formal and informal spaces and most often involved commiserating over shared experiences," the co-authors wrote.
Institutional strategies to address interprofessional conflicts involving female surgeons include three approaches, according to the research article.
1. Behavioral standards: Bullying, hostility, incivility, and sarcasm should not be tolerated from any medical staff member, particularly in training programs.
2. Interprofessional team building and training: "Despite the critical nature of teamwork in the operating room, surgeons rarely have significant input in choosing their team members, regular opportunities for performance evaluation, or regular opportunities for team-based training. In this way, the traditional nature of physician and nursing leadership silos may create obstacles to optimal teamwork and accountability," the study's co-authors wrote.
3. Staffing consideration: "Many conflicts reported by the participants occurred early in the tenure of the women surgeons, and relationships often improved after several years, after the staff became more familiar with the women surgeons. Given that many conflicts were related to perceived performance gaps, strategies such as assigning high-performing staff members to new surgeons may reduce interprofessional conflict by reducing the performance-based gaps surgeons may encounter when in a new system," the co-authors wrote.
Difficulties include staffing shortages, lack of personal protective equipment, and an increase in patient health burdens due to delayed or inaccessible care.
Primary care practices are continuing to struggle with the impact of the COVID-19 pandemic, a new survey indicates.
Drops in patient volume and increases in costs for infection control such personal protective equipment (PPE) have hit physician practice bottom lines hard during the pandemic. In the spring, a survey conducted by the Primary Care Collaborative and The Larry A. Green Center found only 33% of primary care clinicians had enough cash on hand to function for four weeks.
The new survey, which was conducted by the Primary Care Collaborative, The Larry A. Green Center, and 3rd Conversation, features information collected from more than 580 primary care clinicians in 47 states, the District of Columbia, and Guam. The survey, which was conducted from Oct. 16 to Oct. 19, has several data points that reflect the status of primary care practices during the fall stage of the pandemic.
60% percent of survey respondents reported seeing a rise in COVID-19 illness in their communities
In a finding consistent with four other Primary Care Collaborative surveys conducted since August, about half of respondents reported the level of strain related to the pandemic as a 4 or 5 on a 5-point scale
56% of respondents reported an increase in health burdens among patients due to delayed or inaccessible care
Only 16% of respondents reported that their practice had added capacity to help patients with mental or behavioral health conditions, despite an increasing burden
Financial difficulties have eased at primary care practices, with only 6% of respondents reporting that they were unable to pay some bills
35% of respondents reported having difficulty hiring staff
27% of respondents reported permanently losing practice members, including to early retirement and illness
44% of respondents reported that it was taking more than two days to receive coronavirus test results
23% of respondents reported that inadequate supply of PPE or the necessity to reuse PPE made them feel unsafe
Interpreting the data
With many primary care practices under severe strain, their ability to play an active frontline role in distributing COVID-19 vaccines is in doubt, the survey authors wrote.
"Successful distribution of a COVID-19 vaccine will require a high functioning primary care platform, yet practices remain weakened by lost revenue, pandemic surges, and deteriorating patient health. It is urgent that public and private payers foster primary care stability by committing to prospective payments and maintenance of telehealth at parity with in-person visits until the vaccine is widely disseminated," they wrote.
Ann Grenier, president and CEO of the Primary Care Collaborative, told HealthLeaders that primary care practices are facing daunting challenges during the fall coronavirus surge. "Many of us are very concerned about how the primary care platform will weather this surge. To date, they have proved resilient and innovative in their response to patient need. But both practices and patients are in a more compromised state as the survey shows."
It is unclear how many primary care practices face existential threats, she said. "Unfortunately, we will know in the rear-view mirror. How many primary care clinicians retire or throw in the towel? How many decide to sell their practice? The primary challenges include lack of capital to weather the volume declines, a fee-for-service payment model that depends upon volume, and a tired and discouraged workforce—many of whom do not have access to basic pandemic supplies like PPE."
There are two primary ways to bolster primary care practices during the fall coronavirus patient surge, Grenier said.
"Public and private payers need to come together and vow that they will not back away from payment parity for virtual and phone patient visits. In the middle of this surge, primary care should not have to worry whether they will be renumerated for doing their job of virtually triaging, managing, and educating patients who are scared. Prospective payments to shore up practices would also be incredibly valuable."
