Establishing a 'fast track' for low-acuity patients improves efficiency in emergency departments.
Creating a "fast track" process in an emergency department that separates patients with high- and low-acuity conditions significantly reduces length of stay, recent research shows.
Excessive length of stay in emergency departments contributes to ER overcrowding, patients leaving without being seen, and decreased patient satisfaction.
Establishing a fast track capability for patients with low-acuity conditions improves ER efficiency, researchers wrote recently in the Journal of the American Medical Association.
"After the initiation of the Fast Track process in December 2015, and without making any other changes to ED workflow or staffing, there was a 25% decrease in the length of stay of patients with low-acuity conditions (from 190 minutes to <150 minutes) and the rate of patients leaving without being seen decreased from 8% to 4% in just five months. At the same time, patients with moderate- and high-acuity conditions who were discharged had reduced length of stay in the ED and stable or reduced rates of leaving without being seen."
The Fast Track process has five elements:
1. Workflow: The Fast Track care pathway for low-acuity patients features a standardized workflow to manage patients, including specific roles and actions for each staff member such as rooming patients and delivering discharge instructions. Separating low-acuity patients and creating a standardized workflow helps ER staff to estimate the resources needed to meet patient demand.
2. Process management: Standardized staffing processes include adaily team huddle at the beginning of each shift to set expectations such as assigning medical assistants to specific procedures for wound care preparation and nurse practitioner approaches to charting and discharge practices. Department leaders coach standard processes for rooming, documentation, procedures, and discharges.
3.Data drivers: Daily data reports are generated and shared with frontline and executive staff to enable adjustments to new processes.
4.Dedicated work space: Positioning the Fast Track team in a separate area of the emergency department increases the capacity to manage more complex patients in other parts of the ED.
5.Enlisting leaders: Engaging hospital leadership such as the CEO, chief medical officer, and chief quality officer in daily data-driven huddles, weekly planning sessions, and quarterly workshops boosts the ED improvement initiative.
Determining acuity levels
In establishing the Fast Track model, the initiative team took three approaches to determine low-acuity conditions, the lead author of the JAMA article, Mary Mercer, MD, MPH, told HealthLeaders.
Safety parameters were set, including strict exclusion of patients with abnormal vital signs.
The Emergency Severity Index (ESI) nursing triage tool was used to determine which patients would be most likely to be discharged and would be most likely to need the lowest level of resources and tests. This set of patients have low admission rates.
The Fast Track triage process also involves identifying patients who are ESI outliers. For example, patients with chest pain, headache, and abdominal pain, even if initially triaged as an ESI 4 or ESI 5 level, often had much longer lengths of stay than other patients with that triage level because of the risk of a serious condition such as a heart attack or surgical condition.
"We used both aggregate data and direct observation to determine types of patient visits that would be amenable to being safely and efficiently seen in Fast Track," said Mercer, an associate clinical professor in UCSF's Department of Emergency Medicine and EMS base hospital medical director at Zuckerberg San Francisco General Hospital.
Keys to Fast Track success
There are three crucial components to achieving Fast Track success, Mercer said. "What we were trying to highlight in this manuscript were the ingredients needed for implementing sustainable change in a way that used the critical elements of an organizations' culture to align improvement work with the organization's strategic objectives."
Executive leadership: The Fast Track initiative was the first of several improvement efforts to launch a lean management system at Zuckerberg San Francisco General Hospital. The executive team's commitment to embarking on the lean system and seeking to better understand and support frontline initiatives was apparent from the beginning and throughout the process.
Interdisciplinary approach: People of all relevant disciplines in the ED from physicians, nurses, nurse practitioners, clerks, and medical assistants were involved in the design, testing, implementation, and monitoring of the new program. Each staff member's job had to be easy to execute repeatedly and consistently. Interdisciplinary team members helped to coach their peers in an ongoing fashion to ensure consistency of the process.
Daily data reporting and department-wide huddle: Sharing information in real-time is critically important to monitor the performance of Fast Track, elicit ideas for improvement, and update how the executive team and other staff members are supporting the initiative.
An effective hospital discharge process created by Cleveland Clinic is pivotal in the handoff of patients to postacute-care providers.
Hospital discharge is a complex process involving the primary care team, which can include residents, interns, fellows, nurse practitioners, physician assistants, and other staff members in addition to the attending physician.
Without a thorough discharge summary and completed medication reconciliation, postacute-care teams can be bewildered, and patients can be at risk of costly readmissions. Research has linked readmissions to poor communication and poor care coordination between hospitals and primary care providers.
Amy O'Linn, DO, a hospitalist and physician lead for enterprise readmission reduction at Cleveland Clinic, says an efficient discharge process is about patient safety.
"There can be medication errors, side effects, and confusion after a discharge if we don’t get it right," O'Linn says.
To strengthen the patient handoff process from acute to postacute care, Cleveland Clinic created a new discharge checklist to improve discharge summaries and medication reconciliation. According to the Ohio Hospital Association, the goal of the new process was to "achieve a 100% completion rate on all discharge medication reconciliations and discharge summaries prior to a patient leaving the hospital."
Since the new discharge checklist was established, the completion rate for medication reconciliation at Cleveland Clinic's main campus has increased from about 88.0% to 98.7%, and the completion rate for discharge summaries at Cleveland Clinic's main campus has increased from 58% to 80%.
In March, the Ohio Patient Safety Institute awarded Cleveland Clinic with the Acute Care Best Practice Award for the health system's development of the new discharge checklist.
The Cleveland-based health system's discharge checklist, which was implemented in November 2018, has two components: a medication reconciliation document and a discharge summary.
1. Medication reconciliation
"The discharge medication list has been reconciled with the medications the patient was previously taking at home and the medications the patient was taking in the hospital. The medication discharge list is the final list that the patient receives, [and it] is very valuable. Without a completed, signed-off list, the patient does not know what to take," O'Linn says.
The medication reconciliation document is a mandatory step in Cleveland Clinic's new discharge process, she says. "It's a hard stop. The patient cannot leave the campus until the medication list is signed off by the primary care team."
2. Discharge summary
Although completion of a discharge summary is not absolutely required to discharge a patient, it is a Cleveland Clinic policy and nearly as essential as medication reconciliation, O'Linn says.
Under the health system's discharge summary policy, there are 18 elements in the document, including admission date, discharge date, chief primary complaint when the patient came to the hospital, discharge disposition, and the medication list. Clinicians are also encouraged to include "the story" of the hospital admission, she says.
"What we are encouraging providers to do is answer key questions: What brought the patient to the hospital? What happened during the hospital stay? And what is the plan going forward? The 18 elements that are part of our policy are not as useful in detailing the story of a hospital stay. The story is where the money is—it's what happened and what's going to happen now," O'Linn says.
Crafting the discharge checklist
A multidisciplinary team at Cleveland Clinic developed the discharge checklist, she says.
"We had the information technology people; we had Epic, who had to make the technical hard stop [in our EHR]. We had strong help from the pharmacists because there is nothing more painful for a provider than to have a Band-Aid or piece of gauze on a medication reconciliation—we took out some medicines and other things that don't need to be reconciled like insulin syringes. We had nursing managers and care management. We worked with documentation specialists, who helped get the word out to the providers."
One of the primary barriers to the new discharge checklist effort was fear, O'Linn says.
"People were afraid that if we made a hard stop for the medication reconciliation, then patients would never leave the hospital. After we worked through the process for a couple of months, we came out knowing we could do this. It did not affect the length of stay. The day we launched, we were nibbling our fingernails, but we never got a call. We had all lines open to help people who had trouble, but everything was OK."
Advising other adopters
Incorporating a new discharge list into a health system's electronic health record is a key step, O'Linn says. The EHR flags discharges that do not have medication reconciliations.
"You can work with your electronic medical record to make this happen. Some of our hospitals have tried to use nursing as the people who stop the line for a shaky discharge or an incomplete medication reconciliation, but that takes a lot of nursing strength and can create uncomfortable encounters," she says.
Support from the C-suite is also critically important.
"The culture change needs to come from the top. The administration needs to say, 'We are going to protect the patient.' The whole reason we were able to do this is because our CEO, Dr. Tomislav Mihaljevic, said we had to do it. He said we couldn't let patients leave without a med list. Without his support from the very top, we could not have done this at the grassroots," O'Linn says.
The adoption of an EMR-based screening tool and a sepsis treatment bundle drove down mortality rates markedly over four years.
A sepsis surveillance and treatment initiative at Frederick Memorial Hospital has slashed the facility's mortality rate for the deadly infection.
On an annual basis, sepsis affects about 1.7 million American adults and the infection is linked to more than 250,000 deaths.
From 2012 to 2016, Frederick Memorial Hospital implemented sepsis surveillance and treatment measures that reduced the infection's mortality rate by 65%.
"In 2012, we recognized that our mortality level was one-and-a-half times what the expected values were based on coding and auditing of charts, and patient comorbidities. So, we started to drill in on the root causes. What we found was that we did not have good bundles or processes that were in place to even identify patients who were at risk of sepsis," says Debra O'Connell, RN, manager of performance improvement at the Frederick, Maryland-based facility.
Screening tool adoption
Frederick Memorial's first step toward addressing its sepsis challenge was developing an EMR-based screening tool.
"There is a screen shot that provides the clinical staff and the nurses with some fundamental questions about the patient's status. It asks about vital signs, it asks about whether there are potential sources of infection, it asks about mental status changes, it asks about white blood cell levels—it asks questions and the nurses fill in the blanks. Then the tool calculates a score, and if patients have a score above a value of 2, it prompts the nurse to get additional orders from the physician because the patient may have sepsis," O'Connell says.
The screening tool underwent a clinical trial at Frederick Memorial, then it was implemented in the emergency department and as an as-needed tool associated with specific chief complaints, she says.
"If a patient came into the emergency department complaining about frequent urination and it could have been a potential urinary tract infection, the nurses could implement our sepsis detection tool. If the tool indicated the patient could be septic, we would implement the appropriate interventions. We would implement the bundle that is now known as the Sepsis Core Measure."
The next step was to make the screening tool available to clinicians and nurses throughout the hospital, O'Connell says. "After we implemented the tool in the emergency room, nurses on the medical floors and the intensive care unit could use it as a screening tool if they were suspicious that a patient could be septic."
In 2017, Frederick Memorial started using the screening tool for active surveillance of all inpatients.
"We recognized there were some opportunities to revise the screening tool and change it from an ED screening tool to more of a sepsis surveillance screening tool, so that all patients who were admitted to the hospital would be screened on admission, then two times per day after admission. That allows us to capture patients who may be hovering with sepsis," she says.
Some members of the nursing staff initially resisted the daily screening of all inpatients, but the reduced mortality rate played a decisive role in achieving widespread adoption of the surveillance effort, O'Connell says.
"We don't want to miss opportunities to capture sepsis because it is a severe disease process. You can go downhill very quickly; and once that process starts to progress, if the appropriate actions are not in place patients can progress into septic shock and die. That is the point of trying to capture sepsis by screening two times a day."
2 keys to success
O'Connell says there were two essential elements in Frederick Memorial's successful sepsis prevention initiative.
Physician champion leadership: "The biggest thing is finding some physician champions who can help drive the processes, the culture change, and education of the entire staff. We had a physician leader in our organization who helped drive this initiative and who helped educate our providers."
Sharing the data: "The other piece is showing the outcomes—being transparent with information. Once we were able to demonstrate that there were benefits from the screening tool, identifying septic patients, and that our treatments were decreasing mortality rates, that made a big difference with our staff."
New research shows how specific impairments can determine the likelihood of increased healthcare services utilization among older cancer patients.
For older cancer patients, geriatric assessments can predict hospitalization rates and long-term care utilization as well as guide interventions, new research indicates.
The country's aging population is having a profound impact on the healthcare sector, according to the American Hospital Association. For example, more than 60% of baby boomers are expected to have multiple chronic conditions after reaching retirement age, more than one-third of boomers are expected to be obese, and about a quarter of boomers are expected to have diabetes.
The recent research, which was published in Journal of Oncology Practice, found that geriatric assessments could be a key component of reducing healthcare utilization by older cancer patients.
"Our findings suggest the importance of a geriatric assessment in predicting adverse healthcare use including the frequency of hospitalizations and long-term care use. Geriatric assessment-focused interventions should be targeted toward high-risk patients to reduce long-term adverse healthcare use in this vulnerable population," the researchers wrote.
Researchers examined data collected from 125 cancer patients who underwent geriatric assessments. They found specific impairments were associated with hospital and long-term care utilization.
"Prefrail/frail status, instrumental activities of daily living impairment, and limitations in climbing stairs were associated with increased hospitalizations. Prefrail/frail status, instrumental activities of daily living impairment, presence of falls, prolonged Timed Up and Go, and limitations in climbing stairs were associated with long-term care use," the researchers wrote.
Deploying interventions
Conducting geriatric assessments in older cancer patients can target areas for intervention, the researchers wrote.
"Our results demonstrate that impairments predominately in the physical function and functional status domains of the geriatric assessment are particularly related to increased healthcare use. This suggests interventions focused on these impairments may be important for improving outcomes. Impairments in instrumental activities of daily living and limitations in climbing stairs or walking short distances are great examples of the types of interventions that occupational therapists and physical therapists treat."
The lead author of the research, Assistant Professor Grant Williams, MD, at the University of Alabama at Birmingham, told HealthLeaders there are several other promising interventions in addition to occupational and physical therapy.
Nutrition
Comorbidity management
Treatment of behavioral health conditions such as anxiety and depression
Social work assistance for older patients with limited social supports
"There are several trials in process that are looking at how geriatric assessment-directed interventions can improve outcomes and we are eagerly awaiting the results," Williams said.
The country's physician burnout epidemic is taking a heavy toll on emergency department clinician trainees.
Three-quarters of emergency department residents are experiencing symptoms of physician burnout, recent research indicates.
Other research has found that nearly half of physicians nationwide are experiencing burnout symptoms, and a study published in October found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction. Burnout also has been linked to negative financial effects at physician practices and other healthcare organizations.
The recent research, which was published in Annals of Emergency Medicine, found that the prevalence of burnout among ED residents was 76.1% in a survey of more than 1,500 of the early-career physicians.
"The majority of U.S. emergency medicine residents responding to this survey reported symptoms consistent with burnout, highlighting that physician burnout in the emergency medicine profession seems to begin as early as residency training," the authors of the research wrote.
The study's data indicate that ED residents have different rates and causes of physician burnout compared to independently practicing ER doctors and clinicians in other specialties.
Nearly three-quarters of the ED residents in the study reported high levels of depersonalization; whereas, earlier research found 38.9% of attending emergency physicians reported high levels of depersonalization. Other earlier research found 34.6% of clinicians in non-emergency medicine specialties reported high levels of depersonalization.
"We hypothesize that this more negative and cynical attitude toward patients results from working more clinical hours in the ED as a resident, having a greater clerical burden, and interacting more with consultants, admitting services, and ancillary staff as a trainee," the Annals of Emergency Medicine researchers wrote.
Daunting challenges for residents
The lead author of the research, Michelle Lin, MD, told HealthLeaders that emergency medicine is a hotbed for physician burnout.
"Because the physician pool is a very heterogenous population, you can't compare our study results—which focus on emergency medicine trainees—and the entire physician population. However, if you slice it by specialty, it is known that emergency medicine has among the highest rates of physician burnout in the 60% to 80% range, depending on which metrics and studies you look at," she said.
The prevalence of physician burnout among ED residents is alarming, said Lin, a professor of emergency medicine at University of California San Francisco and an ER physician at Zuckerberg San Francisco General. "Our study of emergency medicine residents demonstrates that shockingly most are starting their careers already burned out even before they become attending physicians."
Addressing physician burnout
Physicians are inherently resilient, and wellness initiatives that focus on "fixing" clinicians have been shown to have little to no benefit in alleviating burnout, Lin said.
"While education about stress management may be helpful for some physicians, we are advocating for more system-wide, organizational changes. For example, administrative burden such as using cumbersome electronic medical records and inefficient intra-hospital communication systems are straining emergency physicians, who already are in a stressful, time-critical, and task-switching work environment."
Achieving systemic change is particularly important for ED residents, she said.
"For resident physicians, they also have an extra layer of stress, which is to learn the practice of emergency medicine and learn a new hospital system. Although changing the ingrained practices of healthcare will take some time, we suggested the use of ED scribes in the more immediate-term as an example of a way to offload some task-switching burden."
Measuring ED resident burnout
Lin's research team used three measures of physician burnout for ED residents. A restrictive definition of the condition found 18.2% of residents were experiencing burnout, and a more inclusive definition found 80.9% were experiencing burnout.
She stands by the 76.1% burnout rate, which was determined using key elements of the most widely accepted measurement instrument: the Maslach Burnout Inventory (MBI) tool.
"We feel confident about our reporting of a 76% resident burnout rate because we enrolled more than 1,500 emergency medicine residents, applied the validated MBI tool, and scored the responses based on the most common definition," Lin said.
Clostridium difficile infections in the hospital setting have the biggest treatment price tag, researchers say.
Infections linked to multidrug-resistant organisms (MDROs) cause a significant cost burden for U.S. healthcare, recent research shows.
The development of antibiotic-resistant infections is one of the most severe public health problems in the country, according to the Centers for Disease Control and Prevention. About 23,000 Americans die annually from an antibiotic-resistant infection, the CDC says.
The national price tag for treating infections linked to MDROs in the hospital setting is at least $2.39 billion, according to the recent research, which was published in the journal Health Services Research.
The researchers also tallied the treatment cost per inpatient hospital stay for methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile (C. difficile), and other MDROs.
Treatment of infection with MRSA cost about $1,700
Infection with C. difficile cost about $4,600
Infection with another MDRO cost about $2,300
Infection with multiple MDROs cost about $3,500
"We find the highest incremental and total costs for C. difficile and the lowest incremental costs for MRSA, consistent with estimates from previous reports. The higher costs appear to be driven largely by a higher average length of stay, but may also be due to additional testing and increased risk for ICU admission with C. difficile," the researchers wrote.
In 2014, the President's Council of Advisors on Science and Technology made several recommendations to combat antibiotic resistance, including surveillance of MDROs in healthcare settings and the community, anti-microbial stewardship campaigns, precautions to limit exposure, and education of patients and physicians about the dangers of overprescribing antibiotics.
Calculating superbug economics
The lead author of the Health Services Research article, Kenton Johnston, PhD, MPH, told HealthLeaders that determining the cost effectiveness of efforts to reduce MDRO infections is challenging.
"Essentially, you are comparing the costs of MDRO-reduction efforts to the savings generated by those efforts. The costs of MDRO-reduction efforts would be the programmatic costs of interventions. This is tricky because the interventions are wide-ranging throughout society such as hand-washing campaigns. The savings part is also tricky because the savings also accrue throughout society," said Johnston, an assistant professor at the College for Public Health & Social Justice, St. Louis University.
Johnston's research team only examined hospital costs of efforts to combat MDRO infections.
"A systematic review of the literature on just the cost side of this equation found that the cost of measures to combat and eradicate MDROs ranges from $331 to $66,772 per MDRO-positive patient. This is obviously an unacceptably huge range for calculating the cost side of the equation alone. As a result, more research needs to be done," he said.
A new collaborative approach is designed to improve birth outcomes, decrease cesarean section procedures, and increase patient engagement.
Maternal morbidity and mortality continue to be a devastating trend in U.S. healthcare, as reported in The Washington Post last November.
Complications from C-sections such as hemorrhaging are widely considered to be a contributing factor to the country's high maternal mortality rate. The federal Centers for Disease Control and Prevention have been monitoring maternal mortality since 1986. The number of pregnancy-related deaths has risen steadily since the monitoring effort began, from 7.2 deaths per 100,000 live births in 1987 to 18.0 deaths per 100,000 live births in 2014.
In December, the federal government took a step toward addressing maternal mortality with passage of the Preventing Maternal Deaths Act.
To decrease C-sections and improve birth outcomes, Ariadne Labs, a collaborative of Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health in Boston, launched the Team Birth Project in 2018 at a handful of sites across the country to recast the hospital-based birthing process.
The Team Birth Project features two primary elements: efforts to improve communication between the mother, the family, and the clinical care team; and a pair of decision-making tools.
1. Create a labor storyboard and implement team huddles
Under the Team Birth Project model, birth plans are living documents throughout the birth process, says Margie Bridges, DNP, a perinatal clinical nurse specialist at Overlake Medical Center. The Bellevue, Washington, facility is one of the pilot sites for the initiative.
"Historically with birth plans, the patient and the family may have talked to their doctor during an office visit then brought it to labor, when it got tucked into a chart. It wasn't a living document that got changed as conditions changed," she says.
To make sure birth plans are considered during labor, the Team Birth Project calls for clinical care teams to mount a whiteboard in the birthing room that reflects the mother's preferences. At Overlake, 24 x 36-inch whiteboards are affixed to a door facing the mother.
Information on the whiteboard has crucial information such as the birth team, which includes the mother; a plan for the baby such as monitoring; a plan for the mom such as pain management; and a plan for labor progress.
The whiteboard is the "story of the labor," says Lisbeth Jordan, MD, a hospitalist and OB Hospitalist Group site director at Overlake. "It is updated regularly—what's going on with the baby, how the labor is progressing, and next steps with the provider. It's a storyboard to help the family be aware of what they want, how the baby is doing, and how the labor is going."
Birth plan huddles are held at key points during labor, Bridges says. "The huddles get the core team together when decisions are being made. Huddles are held when you would normally consult the doctor, and you include the patient."
The huddles can be held even when the physician is unable to be at the bedside, the nurse specialist says. "We get them on the phone for a conference call in the birthing room. We put the doctor on the speakerphone, and we go over the whiteboard to review changes in preferences, give status reports on the mom and the baby, and raise concerns."
Boosting communication can help avoid C-sections, Bridges says. "Sometimes, it's tricky to understand why a mom has a C-section. There are so many variables and variation. If we look very clearly at the three lanes—mom, baby, and labor progress—and have a plan, we can avoid some cesarean births."
Open communication can be pivotal in avoiding a cesarean birth, Jordan says. "There is a shared understanding of what is going on. So, the story plays out, and the provider checks in with the nurse and the family. The idea is that it is a collaborative, team effort that can reduce unnecessary C-sections because there is shared knowledge about the whole process of labor."
2. Use admission decision and C-section criteria tools
The Team Birth Project has a duo of decision-making tools to help reduce C-sections, Bridges says.
"There is an admission decision aid that helps us decide whether a patient needs to be admitted to the hospital. We know if we admit someone too early—the mother is well and the baby is fine—it starts the clock ticking and increases the rate of cesarean sections. If the patient is hospitalized, we start to intervene."
The second decision-making tool helps determine whether conditions for ordering a C-section are present, she says. "We also have an aid that we can use during the process of labor that focuses on the mom, the baby, and labor progress that tells us whether we have met the minimal criteria to even consider a C-section. It tells us whether it is safe to keep going with a vaginal birth."
Generating results
While the Team Birth Project pilots are in their infancy, the early results are promising.
In February, Boston 25 News (WFXT-25) reported that South Shore Hospital in South Weymouth, Massachusetts, had achieved a 4% reduction in the facility's C-section rate through Team Birth Project implementation. South Shore was the first hospital to launch in the initiative in April 2018.
Patient experience gains are also evident, Jordan says. "The initial motivation of this initiative was to decrease C-section rates and the research outcomes are pending, but we are finding the increased communication has transformed the relationships in the entire team. Communication improves outcomes, so it may be that the most significant outcome is not decreased C-sections but a better experience for the family."
Happier families have also been noted at another pilot organization: Kirkland, Washington-based EvergreenHealth.
"We are seeing amazing things in terms of patient satisfaction—they leave the hospital feeling that they understand what happened to them. They get to write their own birth story. It's an important change in how we deliver care because we are providing care with the patient and not giving care to the patient," says Angela Chien, MD, an obstetrician-gynecologist at EvergreenHealth.
Inappropriate electrocardiographic monitoring results in wasteful spending and decreased quality of care.
Following practice standards through an electronic order set boosts the appropriate use of electrocardiographic monitoring without increasing adverse events, recent research shows.
Earlier research demonstrated that inappropriate use of cardiac telemetry results in significant wasteful spending. Over monitoring has also been associated with quality and safety concerns such as clinician alarm fatigue.
In findings published this month in the American Journal of Critical Care, researchers conclude that ECG monitoring should only be used in situations specified under American Heart Association (AHA) guidelines.
"ECG monitoring should be restricted to patients who might benefit from it and should be discouraged in patients at low risk for arrhythmias that require treatment. ECG monitoring is often not ordered for a specific clinical concern, but instead is used as an extra patient-safety mechanism or as a substitute for frequent monitoring of vital signs," the AJCC researchers wrote.
The research was based on data collected from nearly 300 patients hospitalized in medical, surgical, neurological, oncological, and orthopedic care units. Order sets based on the AHA guidelines were placed into the hospital's electronic health record and education about appropriate use of telemetry was offered to hospitalists and medical residents.
The intervention resulted in an increase of appropriate ECG monitoring from 48.0% to 61.2%, with no significant increase in adverse patient events. Medical residents received the most education on appropriate ECG monitoring, and they showed higher adherence to practice standards compared to hospitalists, increasing their appropriate use of telemetry monitoring from 30.8% to 76.5%.
"Use of electronic order sets is an effective and safe way to enhance appropriate electrocardiographic monitoring," the researchers wrote.
The lead author of the AJCC research told HealthLeaders there are five primary considerations when implementing ECG electronic order sets.
1. Gathering the right team
"Involve end-users of the order set, including staff nurses, hospitalists, intensivists, and cardiologists. As the results of our study demonstrated, education is an important component of the practice change, so it's important to have a team member with knowledge and skill in education," said Kristin Sandau, PhD, RN, professor of nursing at Bethel University in St. Paul, Minnesota, and staff nurse, at United Hospital, Allina Health, St. Paul.
"Clinical nurse specialists are a critical part of the team as they bring not only clinical expertise in the content area but also skills and knowledge of practice changes at the nurse and system levels. The experts from our informational technology team included a nurse who is a key member of our EHR staff," she said.
2. Setting baseline metrics
"Allow adequate time to prepare and obtain baseline measures. Preparation time should include pilot-testing at a small site and revising. What are the best feasible ways for you to measure pre- and post-implementation outcomes? This can be challenging because some outcomes are very difficult to measure, such as wait times for an ICU, ED, or telemetry bed," Sandau said.
3. Embedding leadership
"Be sure to have physician and nurse champions who are ready to receive both positive and constructive feedback as the team works to make technology an asset rather than burden to busy clinicians. You should expect that adjustments and tweaks will be ongoing as you face new challenges," she said.
4. Impacting staff members
"It is critical that you consider scope of practice and direct impact on clinicians. Other sites have implemented practice standards in the EHR that require the staff nurse to answer a series of questions about a patient then make a choice to discontinue telemetry based on a set of parameters. We made a dedicated effort at our site to avoid putting the responsibility on the staff nurse," Sandau said.
Sandau's team assigned responsibility for discontinuing ECG monitoring to clinicians. "We've built prompts for nurses and prescribers to share, but we felt it was ultimately the responsibility of the prescriber to discontinue telemetry."
5. Sharing the implementation experience
"By sharing what works and what was not as helpful, we can help smooth implementation for others and shorten the time it takes for research to be integrated into day-to-day practice," she said.
New research helps identify which breast cancer patients are likely to quit going to follow-up visits.
Within the five years following a diagnosis for Stage I or II breast cancer, 21% of patients stop seeing physicians for follow-up care, a recent study says.
Breast cancer is the second most common form of cancer for American women, with about 12% of women developing the condition, according to the American Cancer Society. Breast cancer has a high level of lethality—only lung cancer kills more women annually.
The corresponding author of the recent research, which was published in the Journal of Oncology Practice, told Healthleaders that there are several reasons why follow-up care is crucial for recovery.
"It is important for patients to know that during follow-up appointments they are being evaluated for recurrence, evaluated for early detection of new primary tumors, and to make sure they are up to date with other cancer prevention activities. In addition, information is rapidly changing, so keeping up with the oncologist is important to make sure the care is current," said Dawn Hershman, MD, MS, a professor of medicine and epidemiology at Columbia University Medical Center in New York.
Hershman's research team examined data from more than 30,000 patients who were 65 and older. They found several key points.
In the first year after diagnosis, 85.8% of patients saw a medical oncologist and 71.9% saw a radiation oncologist in addition to a surgeon
Two-thirds of the patients visited all three kinds of providers in the first year after diagnosis
In the five years after diagnosis, 21% of patients stopped follow-up visits
Factors predictive of discontinued follow-up care included older age, single relationship status, patients with low-grade tumors, and patients with hormone receptor-negative breast cancer
Encouraging follow-up care
Surgeons and oncology specialists can take steps to increase follow-up care for breast cancer, the researchers wrote.
"Coordination of follow-up care between oncology specialists and other providers may reduce discontinuation rates as well as the redundancy of visits, thereby increasing clinical efficiency. Identifying patients who are at risk for early discontinuation of follow-up will eventually allow for the promotion of public health initiatives to improve access to care," they wrote.
Hormone therapy should be a focal point of public health efforts, Hershman told HealthLeaders. "The most important thing we do during follow-up is to make sure women on hormone therapy stay on their hormone therapy. Making sure these treatments are available to everyone is an important public health initiative."
Educating breast cancer patients about the seriousness of follow-up care is essential, she said. "As a provider, it is hard to know when patients stop following up. Sometimes, patients move or change providers. Patients need to be active in making sure they follow with at least one provider."
Engaging patients and family members is crucial when there are documents specifying physician directives for life-threatening conditions.
For clinicians, there are a handful of approaches to working with physician orders for life-sustaining treatment (POLST) documents in the emergency department setting, according to a recent article in the Annals of Emergency Medicine.
POLST forms are available across the country. Compared to living wills and durable power of attorney documents, POLST forms have been associated with significantly higher decreased odds of resuscitation attempts in the field and increased odds of out-of-hospital death for patients with "comfort measures only" directives.
"POLST forms are more useful than CPR directives in that they describe important broader end-of-life treatment choices than just whether to receive CPR attempts. For example, some patients may not want to go to the ICU; they may not want intubation," the author of the Annals of Emergency Medicine article, Jean Abbott, MD, MH, wrote.
Clinicians should take five approaches to working with POLST forms in the emergency department setting, according to Abbott, who is a professor emerita at the Center for Bioethics and Humanities, Department of Emergency Medicine, University of Colorado, Aurora.
1. Supporting emergency medical service workers
Abbott recently told HealthLeaders that EMS personnel are obligated to honor POLST documents but emergency departments are better equipped to interpret the forms as well as the care preferences of patients and family members. "When a family is overwhelmed enough to call 911, EMS should respond and bring the patient to the hospital. The ED is the place to sort out how to best honor a patient's wishes," she said.
The goal for EMS and ED staff should be to narrow the gap between the care that is provided and the patient's care preferences, Abbott said. "I have done a significant amount of training both with EMS and the ED to get them to a better place than, 'Well, I'll just do everything and if the patient survives, they can just figure out what to do upstairs.'"
2. Honoring POLST orders for CPR and airway management
Even in crisis conditions, ED clinicians should check the "yes" and "no" orders at the top of POLST documents for CPR and intubation, Abbott said. "Though not usually part of the ED situation, there are starting to be lawsuits when clear advance directives—usually in the form of the orders associated with POLST rather than more vague wishes expressed in other advance directives—are ignored."
3. Using POLST information to engage the patient and family members
After the initial crisis has been stabilized, ED clinicians should use POLST forms to engage patients and family members in a discussion about care preferences, Abbott said.
"There is no substitute for a conversation with patients and families to discern the meaning behind various choices—would they want antibiotics for an episode of presumed sepsis, would they want vasopressors for low blood pressure, etc. Much of those choices depend on where the patient is in the arc of their life—do they want a robust attempt to restore them to their pre-crisis state, or was their life already very difficult and they would lean more toward gentle interventions."
4. Considering disposition strategies that align with patient wishes
Based in information in POLST forms, ED clinicians can help patients or their surrogates to establish an action plan for hospital-based care, Abbott wrote in her Annals of Emergency Medicine article.
"Broaching the concept of, for instance, a time-limited trial or of revisiting interventions started in the ED may help the admitting team to later suggest stopping interventions that are not successful in restoring the patient to an acceptable quality of living," she wrote.
5. Preparing patients and families for difficult intervention questions
ED clinicians are well-suited for laying the foundation for discussions about intervention dilemmas, Abbott wrote.
"The ED role includes good documentation and robust communication with admitting teams. The electronic health record note should include topics broached, who was present, and what wishes and intent might have been clarified by the ED team. Palliative care consultation can and should be initiated when appropriate from the ED," she wrote.