Long-term ED frequent users use emergency rooms on a chronic basis and have relatively high costs, researchers find.
There are four primary subgroups of emergency department (ED) frequent users, which can help guide hospital treatment of these patients, a recent research article shows.
ED frequent users are associated with a disproportionately large share of emergency room visits and spending on services. Earlier research found that ED frequent users make up about 4.5% to 8% of the ED patient population nationwide but account for 21% to 28% of all ED visits.
The recent research article, which was published in The American Journal of Emergency Medicine, identified four subgroups of ED frequent users: short-term, heart-related, long-term, and minor care. Frequent ED users were defined as making at least four emergency room visits in a year-long period.
"This taxonomy of ED frequent users allows healthcare organizations to tailor interventions to specific subgroups of ED frequent users who can be targeted with tailored interventions. Cost data suggest intervention for long-term ED frequent users offers the greatest cost-avoidance benefit from a hospital perspective," the research article's co-authors wrote.
The researchers collected data from more than 5,731 ED frequent users at a single urban tertiary hospital-based ED in 2014. There was a total of nearly 80,000 ED patients at the hospital in 2014.
ED frequent user subgroups
1. Short-term ED frequent users were unlikely to be admitted as inpatients from an emergency room. The researchers found only 4.26% ED frequent users were likely to be chronic ED users, which were defined as being ED frequent users two years in a row. Short-term ED frequent users were the youngest on average (43 years old), and they did not have one prevalent diagnosis. The average cost of care per patient was $1,196. Short-term ED frequent users were the largest subgroup at 3,383 patients.
"This group may not be a good use of resources [for intervention] as they appear to naturally resolve on their own within one year," the researchers wrote.
2. Heart-related ED frequent users had circulatory disorders as their primary reason for emergency room visits. For this group, a high percentage (66%) of emergency room visits resulted in an inpatient admission. The average cost of care per patient was $5,609. Heart-related ED frequent users were the smallest subgroup at 249 patients.
"Given the small size of the heart-related group (249 patients), effective interventions could lead to relatively fast cost-avoidance benefits. However, given the advanced age and medical complexity of this group, some level of ED and inpatient hospital utilization will likely be unavoidable," the researchers wrote.
3. Long-Term ED frequent users had the highest percentage of chronic ED users (89%), highest percentage of patients insured by Medicaid (50%), and highest percentage of patients who visited the emergency room for mental health disorders (10%). The average cost of care per patient was $2,807. Long-term ED frequent users were the second-largest subgroup at 1,713 patients.
"[The] combination of chronic use and high costs suggests that it would be the optimal subgroup to target with intervention(s)," the researchers wrote.
4. Minor care ED frequent users had the lowest percentage (9%) of inpatient admissions after emergency room visits, had the lowest percentage (39%) of patients insured by Medicaid, and had a low percentage (19%) of chronic ED users. The average cost of care per patient was $922. Minor care ED frequent users were the second-smallest subgroup at 386 patients.
"These patients may not be an optimal group to target with intervention given their relatively low costs and high prevalence of self-resolution in a short period of time," the researchers wrote.
Targeting long-term ED frequent users for interventions
There are several interventions that could benefit long-term ED frequent users and the hospitals that serve them, says Lauren Birmingham, PhD, MA, who is currently working as a senior statistician at General Dynamics Information Technology and served as the lead author of the recently published ED frequent users article while working as a research fellow at Akron, Ohio-based Summa Health.
"We know that frequent users of the ED prefer the ED over other care locations, so it makes it an optimal place to get these patients connected to the right resources," Birmingham recently told HealthLeaders. Some emergency rooms are already staffed with care managers, social workers, and substance abuse counselors that can connect patients with valuable resources, she says.
Earlier research led by Birmingham found that ED frequent users can benefit from navigations services or discussing their health issues with a nurse. "A navigator could help these patients unravel the complexities of the healthcare system and social service system to put together a plan to get the right resources for the patient. There are many resources available to patients, but they often don't know about them and can't figure out how to access them alone," she says.
Connections to community health workers have produced good outcomes in low socioeconomic status, post-discharge populations, and they may be a good strategy for long-term ED frequent users, Birmingham says. "What's great about community health workers or other navigators is that they can learn more about what the patient needs and can further tailor interventions to their needs, which is not often something an ED care provider can do in a busy ED."
Within specialties, researchers found wide variation in the distribution of time spent by physicians using EHRs, indicating significant potential for improvement.
A new research article provides details about the time physicians spend working with electronic health records (EHRs) for outpatient encounters.
At most outpatient practices across the country, EHRs have replaced paper-based systems for documenting and retrieving patient data. Among physicians, primary complaints about EHRs include their impact on physician burnout and conversion of clinicians to data entry clerks. Earlier research has found that EHRs are strongly associated with physician job dissatisfaction.
The new research article, which was published today by Annals of Internal Medicine, is a large-scale study. The research features 2018 data collected from nearly 100 million patient encounters with 155,000 physicians.
The research includes several key data points:
On average, physicians in outpatient settings spent 16 minutes 14 seconds per patient encounter using EHRs
Three clinical functions dominated time spent on EHR use: chart review (33% of time using EHRs), documentation (24%), and order writing (17%)
Physicians in the endocrinology, gerontology, internal medicine, and primary care specialties spent the highest mean times using EHRs per patient encounter—ranging from 18 to 22 minutes
Sports medicine (8 minutes) and physical medicine and rehabilitation (10 minutes) spent the lowest mean times per patient encounter
Within specialties, there was substantial variation in the distribution of time spent by physicians using EHRs
"The time spent using EHRs to support care delivery constitutes a large portion of the physicians' day, and wide variation suggests opportunities to optimize systems and processes," the co-authors of the research article wrote.
Interpreting the data
The top two clinical functions that physicians spend time using EHRs—chart review and documentation—have opposing impacts on clinicians, the article' co-authors wrote.
"Despite the effort sometimes required to find the relevant data in the EHR (33% of active EHR time devoted to chart review), physicians generally appreciate the improved availability of data. Documentation, on the other hand, accounts for the second-highest proportion of EHR time (24%) and is often a target of physician concern. Documentation may be easier to delegate than some other tasks," they wrote.
The third highest clinical function that physicians spend time using EHRs—17% of EHR use time writing orders—is a high priority activity that requires clinician attention, the co-authors wrote. "Ordering, particularly medication ordering in the ambulatory setting, is an important provider task because it is a basic tool for recording the specifics of the physician's intent and communicating these specifics to other team members."
Having EHR use times by specialty provides a valuable benchmarking tool for physicians and health system leaders, the co-authors wrote.
"Physicians can compare their own EHR time with the reported times for their subspecialty to understand their performance in the context of other providers. Health system leadership can use the data to gain realistic insight into the effort required by physicians to complete their work, including EHR use, and justify investment in optimizing the physician workflow in the EHR."
The EHR use time by specialty is also valuable for payers and policy makers, they wrote. "Payers can use the data to understand the level of effort required to complete this important part of a physician's work when using an EHR and consider adjusting their expectations for data capture considering the direct costs. Finally, policymakers may incorporate these data into EHR certification processes and data capture expectations."
An editorial accompanying the research article says the scale of the study is impressive. "Others have tackled this same research, but they have studied only a single or small number of sites or specialties. As a result, this study provides perhaps the final word on the question, how much time do outpatient physicians spend using the EHR?"
Researchers find a significant but small decrease in patient experience performance at acquired hospitals.
Hospital mergers and acquisitions (M&A) do not result in quality of care improvement, a recent research article indicates.
Hospitals have been involved in a wave of M&A transactions over the past two decades, with studies documenting a surge of deals since 2010. While several other studies have shown that hospital service pricing increases after M&A transactions, there has been relatively little research on the care-quality impact of the deals.
The recent research article, which was published in the New England Journal of Medicine, examined four measures of quality and concluded there was no evidence of quality improvement.
"Hospital mergers and acquisitions were associated with modest deterioration in patient experiences, small and nonsignificant changes in readmission and mortality rates, and inconclusive effects on performance on clinical-process measures. These findings challenge arguments that hospital consolidation, which is known to increase prices, also improves quality," the research article's co-authors wrote.
Examining the data
The research article focused on hospital M&A from 2009 through 2013. The data features 246 acquired hospitals and nearly 2,000 control hospitals.
The researchers concentrated on four measures of care quality after M&A transactions: patient experience based on five metrics from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey; 30-day readmission rates; 30-day mortality rates; and clinical-process measures that include seven metrics related to cardiac, pneumonia, and perioperative care.
Several key data points were generated on the four measures of care quality:
There was a significant but small decrease in patient experience performance. The decrease was equivalent to dropping from the 50th to the 41st percentile.
There was no significant change in readmission rates or mortality rates.
There was a significant but modest increase in clinical-process measure performance. "But this finding is inconclusive because the differential improvement occurred almost entirely during the pretransaction period," the researchers wrote.
The small decrease in patient experience performance was strongly associated with M&A transactions, the researchers wrote. "The modest decline in performance on the patient-experience measure among acquired hospitals was not a continuation of preexisting trends, was not explained by changes in the patient populations at hospitals, and [it] is consistent with expectations that some acquired hospitals face less competition after acquisition."
The data is consistent with other research on hospital M&A transactions, they wrote.
"These findings provide no evidence of quality improvement attributable to changes in ownership. Our findings corroborate and expand on previous research on hospital mergers and acquisitions in the 1990s and early 2000s and are consistent with a recent finding that increased concentration of the hospital market has been associated with worsening patient experiences," the researchers wrote.
Ongoing trends are likely to loom large in the realm of patient safety this year.
A patient safety expert at The Joint Commission says four ongoing trends will dominate the patient safety landscape in 2020.
Patient safety has been a pressing issue in healthcare since 1999, with the publication of the landmark reportTo Err Is Human: Building a Safer Health System. Despite two decades of attention, estimates of annual patient deaths due to medical errors have risen steadily to as many as 440,000 lives, a figure that was reported in the Journal of Patient Safety in 2013.
Anne Marie Benedicto, MPP, MPH, vice president of the Center for Transforming Healthcare at The Joint Commission, recently shared her trend outlook for 2020 with HealthLeaders.
1. Patient advocacy
In 2020, there will be two primary forces at play in patient advocacy, Benedicto says.
"Healthcare providers have become more commercial in how they track patients as 'customers,' and patients are becoming more like consumers and using those skills to help navigate the healthcare system. This means more and more patients feel they have a say in what diagnoses mean for them, how they are treated, and how they engage with their care teams," she says.
With research resources such as WebMD literally at their fingertips, many patients have become savvy healthcare consumers, Benedicto says. "I see it in my personal life, where family members are doing research before they see a physician, or they make sure that they don't go to a doctor visit alone. When you are a patient and a visit is not a routine physical, you want someone else with you to ask clarifying questions because patients can be afraid or preoccupied."
Health systems and hospitals are increasingly embracing patient advocacy, she says.
For example, the Center for Transforming Healthcare is working with a Texas-based health system to boost quality improvement skills in neonatal intensive care units (NICU). The effort initially focused on clinicians, but the health system wanted to achieve quality and safety gains through empowering patients' families, Benedicto says.
"Our biggest surprise has been that the organization not only wanted clinicians trained in improvement skills but also the patient advisory council. We also provided training to parents of babies who were in the NICU for long periods of time. We found that the training gave parents permission to talk about quality issues with clinicians in a way that we had not seen before," she says.
The training for parents has focused on bridging language and skills gaps.
2. Improving the work environment
Ensuring adequate staffing at healthcare organizations is a key element of patient safety, and health systems, hospitals, and physician practices need to step up efforts to care for caregivers, Benedicto says. "This is an ongoing trend because we are already seeing clinician shortages. We are not recruiting and retaining enough medical staff members to meet the demand."
Healthcare organization leaders must shape work environments in ways that ease stress on staff members, she says.
For example, clinicians often struggle to find equipment or supplies such as medication pumps, she says. "They can spend 20 minutes looking for this equipment. It may sound like a simple inconvenience, but it can happen several times daily for a care team. When you put that all together, it can be tremendously wasteful. It also adds frustration and danger to an already stressful day."
She says "the solution to this challenge is to put the proper systems in place such as supply chain management that makes it easier for staff members to do their work."
Another way to improve the work environment at healthcare organizations is to tap into the knowledge and experience of staff members, Benedicto says. "They can not only make their workday better—they can make their patients' day better. If there is no mechanism in an organization to take those ideas and turn them into improvements, then those ideas dry up and stop coming. One of the ways we can retain people in healthcare is to make sure their voices are heard."
3. High reliability
Promoting high reliability at healthcare organizations improves patient safety and reduces wasteful spending, she says. "Going back to the example of a clinician looking for equipment or supplies for 20 minutes—that's 20 minutes of waste. That is time they could spend more cost-effectively on other issues and projects."
Falls with injury are a prime example of persistent patient safety problems that are missed high-reliability opportunities, Benedicto says. "Often, an organization will target falls every couple of years, saying that their fall rates are unacceptable. They come up with a solution, put it in place, it lasts for a few months, then the old practices creep back."
There needs to be an understanding that persistent problems in healthcare persist because they are complex, and they require structured and sustained solutions, she says. "The use of highly reliable process tools is necessary to get to zero harm. It's not just a matter of picking the easiest solution and putting it in place. It's a matter of stepping back and figuring out why the problem is happening, finding out why it is persisting, looking at the contributing factors, then developing solutions."
4. Surgery center safety
With the continuing trend of increasing numbers of procedures shifting from the hospital setting to ambulatory surgery centers, improving safety at surgery centers will be a top concern in 2020, Benedicto says.
"Technology is enabling this trend. In addition, if patients can get care in less complicated settings, then those options should be pursued. However, this opportunity comes with a risk. Many surgical centers do not have the same levels of protection that hospitals have. For example, more and more spine surgeries are happening in surgical centers, and those centers may not know what to do when there is a serious complication."
Surgery centers need to adopt patient safety protocols that have become common at hospitals, she says.
"Over the past decade, hospitals have been investing in process improvement and improvement methodologies, so they could make their care as safe as possible. That same type of trend needs to happen in other settings of care such as surgery centers. Achieving zero harm not only requires embracing high reliability as a goal, it means making sure that resources are in place to get to that goal—stronger improvement skills, stronger safety culture, and leadership commitment to zero harm."
In selecting physicians, surveyed adults aged 50 to 80 say that online ratings are nearly as important as information from friends and family members.
A significant number of older Americans are using online reviews to select their physicians, according to a new poll published today.
For clinicians, online reviews should be a primary concern for several reasons: review websites such as HealthGrades and Vitals are collecting information and posting it across the country, online reviews can be a robust marketing tool, and reviews can help hone clinician performance.
The new poll, which was commissioned by the University of Michigan Institute for Healthcare Policy and Innovation with support from AARP and Michigan Medicine, found 43% of Americans aged 50 to 80 had reviewed doctor ratings. In selecting a physician, 20% of those surveyed said online physician ratings were very important compared to 23% who said information from family and friends was important.
“People of all ages are turning to the web to find information, so it is not surprising that older Americans are looking up physician ratings online. But it is a bit of a surprise that these online ratings now carry as much weight as recommendations from family and friends," David Hanauer, MD, MS, an associate professor at the University of Michigan and Institute for Healthcare Policy and Innovation member who worked on the poll, said in a prepared statement.
Key data points
The poll was conducted by Toronto-based Ipsos Public Affairs and features data collected from more than 2,200 adults in a nationally representative household survey. The poll generated several key findings:
Among survey respondents who had viewed physician ratings within the past year, 65% used the reviews for a physician they were considering, 34% used the reviews to find a new physician, and 31% used the reviews for a physician they had already seen.
Nearly three-quarters of survey respondents (71%) said they would pick a physician who had many positive ratings even if there were a few negative reviews.
When selecting a physician with online reviews, the total number of reviews was important to 41% of survey respondents.
Among survey respondents who had viewed online ratings more than once in the past year, 67% chose a physician based on good reviews, 57% said they had not chosen a physician based on poor reviews, and 96% said the reviews matched their experience after visiting the physician.
In selecting a physician, the three most important factors for survey respondents were time to get an appointment (61%), the physician's years of experience (42%), and recommendations from a physician (40%).
Only 7% of survey respondents had posted an online rating or review of a physician. Among these survey respondents, 56% had posted because of a positive experience and 35% had posted because of a bad experience.
"While some may think that choosing a doctor using online ratings is something only younger people may do, this national poll shows that this practice is also common among older adults," the poll's report says.
Cancer is among the deadliest illnesses in the United States, according to the American Cancer Society. In 2017, ACS estimated there were 600,000 cancer deaths. Cancer also is among the costliest illnesses to treat. The Agency for Healthcare Research and Quality estimated total cancer treatment costs in 2015 were $80.2 billion.
The recent research article, which was published in Journal of Oncology Practice, found that patient navigation (PN) in cancer treatment drives significant clinical and financial benefits.
"PN has resulted in improved patient outcomes and patient satisfaction and has important financial benefits for cancer programs in the fee-for-service and the alternative payment model worlds, lending support for more robust staffing of PN programs," the article's co-authors wrote.
In a fee-for-service payment models, patient loyalty is the primary financial benefit for healthcare providers, the article's co-authors wrote. "PN can generate financial benefits by significantly decreasing the outmigration of patients to other health facilities for their oncology care."
In value-based payment models, healthcare providers can generate more clear-cut financial benefits from PN programs, they wrote. "In evolving bundled payment systems that financially incentivize high-value care and value over volume, the business case for cancer PN is stronger and more direct. In these payment models, practices can recoup avoided costs through performance-based payments rather than relying exclusively on payments made for billable services."
The article features five examples of patient navigation programs that have demonstrated direct and indirect financial gains for healthcare providers.
1. Patient Care Connect
In 2012, the University of Alabama at Birmingham used a federal grant to develop and launch Patient Care Connect, a navigation program at 12 cancer centers. Patient Care Connect featured nonclinical staff in navigation roles, which included routine distress screening to identify barriers to care among patients.
When compared to a control group on a per quarter basis, cancer patients in the Patient Care Connect program experienced higher decreases in emergency department visits (6.0%), hospitalizations (7.9%), and intensive care unit admissions (10.6%). On a quarterly basis, the lower utilization rates helped reduce cost of care per patient in the PN program by nearly $800, which generated a return on investment estimated at 10:1.
2. Levine Cancer Institute
Charlotte, North Carolina-based Atrium Health's Levine Cancer Institute developed a patient navigation program that featured 25 nurse navigators spread across seven locations.
With the exception of melanoma care, an analysis of 970 cancer patients found patients in the navigation program utilized treatment in an acute care setting less often (18% of the time) than patients who did not participate in the program (30% of the time). Another analysis found that patients who did not participate in the PN program were 52% more likely to experience a 30-day all-cause hospital readmission.
3. University of Pennsylvania Health System
At three University of Pennsylvania hospitals, an internal study showed that a PN program staffed with nurse navigators generated fee-for-service financial benefits for the health system.
Compared to cancer patients who did not participate in the PN program, cancer patients in the program were 10% more likely to stay in the University of Pennsylvania network for treatment. Cancer patients in the program also were more likely to receive related treatments in the health system's network, with 27% higher utilization of infusion services and a 17% higher utilization of radiation oncology services.
4. Sarah Cannon Cancer Institute
At Nashville, Tennessee based HCA Healthcare's Sarah Cannon Cancer Institute, a PN program with nurse navigators supports 65 hospitals in seven states. In 2018, the nurse navigators worked with more than 15,000 cancer patients. The PN program includes PatientID, an internal artificial intelligence capability that helps refer patients to nurse navigators.
The cancer institute's PN program has posted patient loyalty gains for the health system:
Between 2017 and 2018, a 59% increase in patients participating in the PN program was associated with increased patient volumes.
When cancer patients participate in the PN program starting early in their treatment, 90% of them stay in network for care. This observation has been particularly strong in breast cancer care, where patients had historically only stayed in network about 50% of the time.
5. Sutter Health
At Sacramento, California-based Sutter Health, internal surveys in 2016 and 2017 found significant variability in the health system's PN services for cancer patients, particularly in how and when clinicians referred patients to nurse navigators.
The health system launched a pilot program to determine the impact of when a referral to a nurse navigator was made, with some patients referred when there was a suspicious oncology finding and others referred 5 to 12 days after notification of a cancer diagnosis. In a significant patient loyalty gain, 35% fewer patients sought care at other health systems if they worked with nurse navigators at the time of a suspicious finding.
Sutter found that retaining cancer patients for treatment generated financial gains for the health system—an analysis found the retention of two patients could cover the cost of one nurse navigator.
Selection criteria for the Top 10 list include whether a story resonated with the HealthLeaders audience.
At HealthLeaders, the top clinical care stories of 2019 covered a range of topics, including patient safety, sepsis detection, maternal mortality, and hospital staffing.
The selection criteria for the following Top 10 list featured whether a story resonated with the HealthLeaders audience and stories that focused on 2019 pressing concerns in clinical care. Click on the links below to see the full text of the stories.
Maternal mortality: The federal Centers for Disease Control and Prevention documented a steady increase in U.S. pregnancy-related deaths from 1987 to 2014. The Team Birth Project is designed to decrease maternal mortality through two primary methods: improving communication between the mother, the family, and the clinical care team; and a pair of decision-making tools.
Sepsis detection: A computer-based decision support tool for sepsis at HCA Healthcare hospitals can detect the deadly infection about 18 hours earlier than the best clinicians.
Hospital discharge: Cleveland Clinic has developed a hospital discharge checklist to improve the handoff of patients to postacute care providers. The discharge checklist features two elements: a medication reconciliation document and a discharge summary.
Patient safety: The Leapfrog Group is pushing for widespread adoption of the nonprofit group's expanded Never Event Policy for hospitals. A "never event" is defined as egregious medical errors such as surgery on the wrong patient. Leapfrog's Never Event Policy is intended to hold hospitals accountable and promote high reliability in clinical care.
Millennial healthcare workers: IU Health has developed a four-part strategy to retain millennials at the Indianapolis-based health system—adopting a new dress code, providing opportunities for career advancement, reforming hiring and training practices, and enhancing tuition reimbursement for continuing education.
Behavioral health: New York-based nonprofit FAIR Health research has documented a spike in the behavioral health needs of children and young adults, including increased prevalence of anxiety, depression, and adjustment disorders. The medical director of Pediatric Mental Health Services at Dell Children's Medical Center of Central Texas shares her facility's holistic approach to caring for children and adolescents with mental health disorders.
Rural hospital staffing: An article published in July by the New England Journal of Medicine predicted a worsening shortage of physicians in rural areas of the country—mainly due to an aging workforce. A survey report published by Alpharetta, Georgia–based Jackson Physician Search features four strategies to boost physician recruitment in rural areas such as including family members in recruitment efforts.
Vision-impaired patients: Research published in April by JAMA estimated excess costs in the care of vision-impaired hospitalized patients at more than $500 million annually. Experts from Baltimore-based Johns Hopkins Medicine and the University of Miami Health System's Bascom Palmer Eye Institute share three best practices for the care of vision-impaired patients.
Home health: A executive from CommonSpirit Health shares how the Chicago-based health system is using home health capabilities to help acute care providers manage patient outcomes after hospital discharge.
Telepsychiatry: The medical director at AbleTo, a provider of telepsychiatry services, discusses the best practices for providing behavioral health services through telemedicine.
The lead author of a new report identifies four ways to promote preoperative assessments by anesthesiologists.
The lead author of a new report that found weak preoperative assessments are a primary cause of anesthesiology malpractice claims says anesthesiologists and surgical teams can rise to the challenge.
The report was published by The Doctors Company, a large physician-owned medical malpractice insurer headquartered in Napa, California. Based on review of malpractice claims from 2013 to 2018, improper management of patients under anesthesia was the most common anesthesia allegation, at 32%. Deficiencies in patient assessments were among the top three factors identified in claims, along with patient monitoring and communication among providers.
Productivity pressure plays a key role in limiting preoperative assessments and selecting the safest care setting, the report says.
"A review of cases revealed limited opportunities to conduct pre-op assessments. Older and sicker patients needed closer investigation, but production pressures often limited testing and input from attending or referral physicians. These pressures also limited anesthesia professionals' opportunities to arrange for the safest location for anesthesia care (hospital operating room versus a remote ambulatory surgery center or GI or cardiac labs) or to prepare for complications," the report says.
Promoting preoperative assessments
There are four primary ways to help ensure that thorough preoperative assessments are conducted, the lead author of the report told HealthLeaders this week.
1. Collaborative care teams: "The old 'surgeon is captain of the ship' is not now a viable model for modern preoperative planning," said Susan Palmer, MD, a board-certified practicing anesthesiologist based in Eugene, Oregon.
Collaboration among members of the surgical care team is good for healthcare providers and patients, she said. "What we now know is best for patients is that all physicians and nurses involved in a patient's care should work as a team, and knowledgeable input from anyone on the team should be considered respectfully. Collaborative practice is recognized as important not just for job satisfaction of healthcare providers, but also to provide the safest possible patient care."
2. Taking finances into account: The financial impact of delaying a procedure on the day of surgery cannot be ignore, Palmer said.
Healthcare providers including the surgeon, the anesthesiologist, and the care facility take a financial hit when surgery is postponed for factors that could have been identified in a preoperative assessment, she said, adding that patients can also incur personal and familial costs when a surgery is postponed. "This is why it is critical that anesthesiologists can be able to access the information they need ahead of time to properly plan the anesthesia care and make recommendations about the location for the surgery," Palmer said.
3. Obtaining records: At least a week before surgery is scheduled, patients should provide consent to obtain records from relevant healthcare providers and anesthesiologists should have access to those records, she said.
"Anesthesiology department leaders must work with their hospital administrators to make sure a pathway to obtaining and assembling preoperative medical records before surgery exists and is appropriately supported by medical records and nursing personnel. Anesthesiologists can review those records and order any indicated tests or obtain any necessary consultations. When this kind of system is in place, the cancellation on day of surgery rate goes way down."
4. Working with patients: Also at least a week before surgery, patients should be able to request a consultation with the procedure's anesthesiologist, Palmer said. "This is optimal if either the patient has concerns, questions, or requests about anesthesia care, or if the patient has chronic medical problems that should be optimized before the stresses of anesthesia and surgery."
Pre-anesthesia evaluation
There are several main elements of preoperative assessments by anesthesiologists, Palmer said.
Medical history
Review of current medications and allergies
History and description of any personal or family problems with anesthesia
Evaluation of chronic medical conditions such as hypertension, diabetes, pulmonary disease, renal disease, cardiac disease, neuromuscular disease, and central nervous system problems
Anything that limits a patient's ability to respond to stress should be quantitatively evaluated
Physical examination of the patient's airway anatomy
Evaluation of cardiac rhythms
"The medical evaluation will aid in the planning of anesthetic techniques, the choice of anesthetic medicines, and the planning for post-operative care," Palmer said.
The Sepsis Alliance has created The Sepsis Institute to offer training for healthcare professionals across the continuum of care.
The Sepsis Alliance, which was founded in 2007 to raise awareness about sepsis among the public and healthcare professionals, has launched The Sepsis Institute to provide training for sepsis care best practices.
Sepsis is a deadly infection that is diagnosed in at least 1.7 million adults annually in the United States, according to the Centers for Disease Control and Prevention. About 270,000 Americans die from sepsis every year, and 1 in 3 patients who die in hospitals are diagnosed with sepsis, the CDC says.
The Sepsis Institute (TSI) is designed to build on the sepsis awareness efforts of the Sepsis Alliance, TSI Education Director Peter Broadhead says.
"At TSI, what we aim to achieve is the same level of success that the Sepsis Alliance has accomplished with the public in giving healthcare providers the educational information that they need to achieve excellence in the diagnosis and treatment of sepsis," he says.
The Sepsis Alliance decided to create TSI to meet a pressing need for sepsis education among healthcare professionals, Broadhead says.
"We assessed the healthcare provider community in a survey and found that 3 in 4 nurses said that there was a lack of support services and training on the core concepts of managing sepsis at their facilities. We believe that in making sepsis education interactive, high-quality, and productive for healthcare providers, we can accomplish a great deal in the healthcare community so that fewer people in this country are dying every year," he says.
Educational offerings
TSI was launched in October with funding from the Biomedical Advanced Research and Development Authority, which is part of the federal Department of Health and Human Services.
Training modules, webinars, and other content offered on the TSI website is free and provides opportunities to earn continuing education credits.
TSI's target audience extends to healthcare professionals across the continuum of care, including physicians, nurses, physician assistants, pharmacists, physical therapists, technicians, and social workers. "[The] time from diagnosis to treatment of sepsis is crucial, and any person in a healthcare provider organization ought to know about sepsis. Anyone in the channel of care can be important in the diagnosis of sepsis, and we are aiming to spread this message as far and wide as we can," he says.
All TSI training content is being crafted to fit into the workdays of busy healthcare professionals, Broadhead says. "We have recognized that healthcare providers need convenient opportunities to engage in learning activities. We have found that it is important to meet them in providing small-bite-format learning. For example, they can engage in an activity for 15 minutes, then stop and come back to that activity later."
Building partnerships
Establishing partnerships with professional associations is a key element of TSI's educational strategy.
"We're reaching out to leading healthcare associations and organizations across the continuum of care, recognizing that the different healthcare provider types need different types of educational activities around sepsis," Broadhead says.
Current TSI partners include the Children's Hospital Association, American College of Chest Physicians, and American College of Obstetricians and Gynecologists. The partnerships have generated several training modules such as a home care module produced in collaboration with the National Association for Home Care & Hospice.
Establishing partnerships generates multiple benefits for healthcare professionals who receive TSI training, he says.
"We believe these partnerships are an excellent pathway to subject matter expertise, content creation, distribution, and, in many cases, accreditation. We're working with the American Physical Therapy Association, which is an accredited provider of continuing education credit for physical therapists. By working with accredited organizations, we can jointly provide a credit type that is suitable for particular provider populations."
TSI also will be serving as a clearinghouse for information generated by partner organizations, Broadhead says. "We are aiming to help the provider organizations with distribution of content that they might want to get out to our population of learners—we have learners who have already registered with TSI and many healthcare providers who are part of the Sepsis Alliance family of learners. The benefits of these partnerships feed both ways."
Ambitious goal
TSI's overall vision is a national healthcare system that is well-prepared for sepsis across the continuum of care, he says.
"To get there, we recognize that we need to create, accredit, and deliver expert content for healthcare providers of all types on the prevention, identification, diagnosis, and treatment of sepsis. Ultimately, what TSI is aiming to do in the healthcare provider communities is to enhance the skills, strategies, and performance of healthcare providers."
A crucial component of TSI's approach to sepsis education is focusing on the quality of care rather than mistakes in care settings, Broadhead says.
"Frequently when people talk about sepsis, they think of mistakes or medical errors that were made. What we are trying to do is disentangle that mindset from our educational activities. We want to make our efforts about accomplishing excellence as opposed to fixing errors."
The Leapfrog Group has selected 120 facilities as Top Hospitals in the country based on data from the nonprofit organization's annual hospital survey.
The Leapfrog Group has awarded the 2019 Top Hospital honor to 120 facilities across the country. The list of Top Hospitals can be viewed on the Leapfrog website.
The Top Hospital recognition designates facilities with the highest quality and patient safety ratings as determined from data in the annual Leapfrog Hospital Survey. Quality and patient safety metrics are key elements of value-based care; and patient safety is a top concern in the healthcare industry, with estimates of annual patient deaths due to medical errors as high as 440,000 lives.
Leapfrog, which is a nonprofit organization based in Washington, DC, was founded in 2000 by large employers and other purchasers of healthcare services.
The 120 Top Hospitals of 2019 were selected in four categories: 10 children's hospitals, 37 general hospitals, 18 rural hospitals, and 55 teaching hospitals. Four states had nine or more Top Hospitals: California, Florida, Michigan, and Virginia.
Last year, 118 hospitals earned the top honor. "We don't set a particular number of Top Hospitals—we pick the hospitals that meet the criteria," Erica Mobley, vice president of administration for Leapfrog, told HealthLeaders last week.
Earning Top Hospital designation
There are several primary criteria to earn the Top Hospital honor, Mobley says.
Participation in the Leapfrog Hospital Survey is required to be eligible for consideration. This year, more than 2,000 hospitals completed the survey.
Hospital survey results are put through Leapfrog's value-based purchasing program methodology, and each hospital receives a single composite score. The top 10% of hospitals rated through the value-based purchasing program methodology get considered for the Top Hospital designation.
Then, several other criteria are applied, Mobley says. "In general, we look at hospitals that report on all of the survey measures that are applicable to them, that abide by our Never Events policy, that fully meet most of the measures in our survey including ones such as computerized physician order entry and ICU physician staffing, and that demonstrate overall excellence as a hospital."
Computerized physician order entry (CPOE) is a key metric in the Top Hospital selection process, she says. "We make sure the top hospitals are entering their medications through a computerized system. … CPOE is important because medication errors are the most common errors that happen in hospitals, and CPOE systems are effective in reducing medication errors."
Hospitals are asked to participate in Leapfrog's CPOE simulation tool, Mobley says. "They put several 'dummy' patients into their CPOE system, and we give them a set of medication orders. We look to see whether the CPOE system is putting out the right alerts. For example, is the system alerting to an adult dosage being prescribed to a pediatric patient?"
Leapfrog Hospital Survey helps drive improvement
Hospital leadership teams can use the Leapfrog Hospital Survey as a quality and patient safety improvement tool, she says.
"They need to look at the performance that they have reported and see the areas where they are doing well and the areas where they can improve. Hospitals can see a variety of different types of benchmarking reports by participating in the survey. For example, they can see how they stack up to facilities in their region or other hospitals in their bed size. They should look at their survey results from this year, identify the areas they need to improve for 2020, and keep working toward those improvements."
