PSQH: Patient Safety & Quality Healthcare, May 12, 2021
Can the right tools solve tech-enabled communication challenges?
This article was originally published May 12, 2021 on PSQH by Megan Headley
Clear communication—with patients and colleagues—is a critical component of effective healthcare. Yet the sheer amount of information to communicate, not to mention distractions that derail effective discussions, can make achieving this clarity challenging.
Eliminating the technology that has complicated patient care is not an option, so health systems are searching for strategic technology deployments to address some of the challenges that have emerged. The results aim to bring physicians, nursing staff, and patients back into the realm of more meaningful interaction.
Less note-taking drives stronger patient interactions
Too much screen time has made it more difficult for providers to connect with patients. According to a 2005 evaluation of the impact of exam room computers on communication between clinicians and patients, these computers can monopolize the clinician’s attention, to the detriment of their conversation with the patient.
Rather than removing the exam room computers, Rush University Medical Center invested in a technology solution to combat this problem.
The solution in question, Nuance Communications, Inc.’s Dragon Ambient eXperience™ ambient clinical intelligence, moves Rush closer to a voice-enabled exam room. The advanced scribe captures information from patient-provider discussions and uses it to create contextually rich records.
As a result, “the provider feels like they need to attend less to documenting stuff in the computer while they’re in the room with the patient, and their attention can be focused on their conversation with that patient,” shares Anthony Perry, MD, Rush’s vice president of ambulatory transformation.
Bringing the focus back to the patient is key for everyone to get the most out of the conversation. Research indicates that physicians interrupt patients within the first 12 seconds of speaking, jumping in to speed discussions along. Inattentive listening can derail the speaker and compromise the amount of quality information the physician gains during these encounters.
“This is about trying to enhance the experience in the exam room for both the providers and the patients who are in there,” Perry explains. “Part of what we’re trying to do is preserve the relationship between the provider and the patient when they’re sitting in the room together and allow them to focus on the dialogue that they’re having.”
Perry points out that the ability to document these interactions in real time is its own skill set—one that few providers feel they’ve adequately mastered. “How we contextualize our documentation becomes very individualized,” he says. “Figuring out a way to meet those [documentation] expectations in a consistent fashion is part of the process for us.”
Many physicians now tend to take notes home to complete reports, creating a longer lag time that can cloud recollections of the day’s numerous patient visits. Automating this note-taking process allows physicians to prioritize gaining insight over documenting it, and ultimately better serve their patients. Perry hopes it’s just the beginning.
“There’s a path here where we can start to automate certain things in the examination room. Documenting the notes is certainly a component of that,” Perry says. “But can we start to auto-populate educational materials for patients?”
For example, an exam room discussion around high blood pressure that leads to a prescription could spur the system to note that the patient needs relevant educational materials about the medication to understand its potential side effects. “Those are the things that we really want to explore in the voice-enabled exam room,” Perry shares.
Faster communication means better care
Despite the many technology advances in healthcare, communication tools still lag behind. It is estimated that about 90% of U.S. hospitals continue to use pagers for a host of reasons, while some nursing staff might add a flip phone and computer access to these communication options. However, these older technologies can slow down care and response time.
Kim Barnhardt, MHA, MBA, BS, RN, CPSO, manager of clinical consulting and education with Midmark RTLS, a division of Midmark Corporation, sees the company’s real-time location systems (RTLS) acting as a communication tool for nursing staff.
And Stephanie Bertschy, Midmark’s senior marketing manager, explains, “It is about the location driving the event to help communicate out a need: ‘I need help.’ ‘I need more ID pumps on ICU floor three.’ ‘I need the next staff member to come in and see the patient in exam room two.’ Whatever that need may be, we’re trying to communicate that automatically based on the location of somebody.”
“In a clinic setting we can automate visibility,” Barnhardt adds. With location-enabled support, nursing staff knows, for example, when the medical assistant leaves the patient and it’s time to notify the primary provider. “It keeps everybody much more efficient.”
The flexibility of RTLS tools means this efficiency materializes in a number of ways. Asset tracking platforms let nursing staff instantly visualize where carts are located and what materials are ready at hand. In acute care settings, RTLS tools can interface with the nurse call system, allowing nurses to walk into a room and start providing care rather than taking time to move equipment out of the way and hit the cancel button. All of these small benefits mean attending more quickly to patient needs.
That, according to Bertschy, is how technology should be supporting staff. For her, “Going through the COVID pandemic experience over the last year shed light into how much clinicians are not doing the main job that they’re supposed to be doing, which is caring for the patients and being at the bedside. It brought to life the amount of time that they spend doing other things: searching for the equipment around different departments, trying to find another staff member for a readout of a report or to check on a patient.”
Clinicians, and hospital systems for that matter, are reprioritizing the interactions that matter most. “We’re seeing a lot more interest from hospitals that it’s not just all about the cost savings and operational efficiencies, which are huge with RTLS,” Bertschy says. “It’s also about making the day easier on staff so that they have that joy of coming to work. Burnout is caused by many things, but maybe we could bring joy back to the working environment.”
PSQH: Patient Safety & Quality Healthcare, May 12, 2021
A study on transporting intensive care patients found that 26% had an adverse event, including oxygen desaturation or hemodynamic instability; so how can clinicians work to avoid these situations?
This article was originally published March 12, 2021 on PSQH by Matt Phillion
It happens more than we’d like: Patients require transport from one area to another, be it from their room to an imaging lab or to the ICU, and somewhere along that trek—in a hallway, an elevator—they require emergency intervention. The patient is stabilized and completes their journey, but it’s a stressful situation for patient and provider alike.
A study on transporting intensive care patients found that out of 262 transports, 26% had an adverse event—many of which were serious, including oxygen desaturation or hemodynamic instability. How can clinicians work to avoid these situations? And how can organizations leverage the electronic medical record (EMR) to analyze how and when they happen?
“I think it’s something clinicians know has inherent risk, as part of the day-to-day moving of patients through the hospital,” says Teresa Soman of Capsule, a Philips company. “Patients are on the move, and acute care patients are on the move more than they used to be.”
More movement, more risk
The way healthcare has changed, Soman says, puts sicker patients in the hospital, even in lower-acuity care settings. By extension, this means patients being moved are in a sicker state, which could increase the risk of incidents during transport.
“Clinicians tell me the patients in lower acuity, going to another care area such as radiology or physical therapy, aren’t being monitored when they’re out of the nursing unit,” she says. “Monitoring patients may catch a change in condition sooner if the data is being captured and reviewed when they are not on the nursing unit.”
There’s also the impact of the inherent stress of being moved around as a patient, which can add to the severity of the event. And, of course, very often, the transport staff who are moving the patients are not primary caregivers.
“It’s often a secondary care provider moving the patient who may not know the signs to look for, so by the time they spot those signs, the patient is in a bad state and the caregiver has to go find someone to help,” says Soman. “And they can’t leave the patient to go find that help.”
Data lost in transit
In many cases, patients must be disconnected from monitoring devices for transport. Though this is a necessary step, it means that should an adverse event happen, that data could be lost.
“I’ve seen hospitals try to put transport monitoring on the patient,” says Soman. “You put it on them while moving, but someone is still monitoring that monitor and looking at the data.”
Often the data from those monitors never makes its way back into the EHR or other systems to proactively monitor the patient. But there are ways to avoid these problems.
“What we’ve found was being able to monitor the patient and continue to send patient data with accurate time stamps on it while the patient was on the move, we could monitor that data,” says Soman.
Organizations like Capsule provide wireless transmission of the data to the network, enabling patients to be monitored on the move. “By associating the patient to the device, we can continue to feed the EHR,” she says. This includes alarm systems to notify providers if the patient trends downward. The time stamp enables the organization to have better tracking records to improve their ability to respond to patients in distress.
Barriers to entry
Healthcare can be slow to change, Soman notes, and often driven by regulatory requirements. “[New] changes in care delivery or protocols need to be evidence-based.” Liability feeds into the pace of change as well, requiring all the bases to be covered before any implementation occurs.
“Until policies and procedures are adjusted, everyone will keep doing things the way they did before. Even though implementing new technology is intended to drive efficiency in patient care, it can create a situation where sometimes they do both at the same time—follow the old process and the new,” says Soman.
Staff on the floor are well aware of the stress of moving patients around the facility, though. The patient might have their heart monitor with them on the bed itself, but not transmitting data until they reach their next destination.
“The nurses I talk to call this period of time when moving a patient a marathon race,” says Soman. “You get the patient there as quickly as possible. We’re hoping that with the adoption of technology and monitoring, it creates a more predictable process as the patients are moved around the hospital.”
Better monitoring can help decrease stress on the patient, too. “You’re alleviating stress on the patient on both ends,” says Soman.
The benefits of monitoring, for patient and organization
Soman says that while better monitoring during transport secures better outcomes for the patient, there are monetary incentives as well.
“The old-school me, in my earlier career, would say that having this information helps in case of litigation,” she says. “There won’t be a gap regarding when the patient decompensated. A gap in the record drives attorneys on one side of a lawsuit crazy and excites the lawyers on the other side.”
But there is also evidence that more continued monitoring drives better compensation. “If the organization provides continued monitoring, during transport, this can potentially drive better reimbursement from CMS,” she says.
Apart from the financial aspect, the data captured during patient transport creates a more complete record. That means more ability to analyze outcomes and provide better results for patients, which is the core aspect of any improvement to healthcare.
“Providing more data in real time to doctors and nurses creates a less retrospective tool and offers more real-time value,” says Soman. This expands beyond individual patient data, however, and can help build a bigger picture for overall patient information.
“The other noteworthy technology evolution we’re seeing is organizations are deploying research databases, in combination with artificial intelligence,” says Soman. “We see these initiatives growing as a way to justify change and create evidence-based medicine. Providing the data to a research database, not just the EMR for documentation, could help to improve the whole transport process.”
One potential improvement: identifying the best time to move a patient. Right now, the doctor orders the move, but with the data to support research on patient transport, more predictive care models can emerge—knowing the optimal vital signs that signal a patient is eligible for a move, for example.
“I was talking with a physician who said that with the right data, he could tell within 15 minutes of moving a patient from the OR to the ICU which patients would go septic,” says Soman.
Soman sees a shift where solutions will offer real-time surveillance of the patient, even from an ICU command center rather than an individual nurse on the floor.
“I envision a future with real-time visibility of the patient status, knowing that a patient is ready to move and changing the parameters of what to look for in the vital sign values during the move,” she says. “Surveillance and alarm solutions are key to keeping a better eye on patients.”
This could also feed into improvement in another challenging arena: alarm fatigue. “Device alarms go off all the time, for all reasons,” says Soman. “Knowing which alarms are relevant and need to be prioritized is key.”
It is often difficult for caregivers to know what they are walking into when a patient decompensates and the alarm is sounded for assistance. “My friends who are physicians talk about how they’re walking in blind. They know they’re being called to a code, but if you have some data available up front, you have more insight into what’s going on with the patient instead of going in cold,” she says.
Looking to the future, better surveillance data of patients in transit could even make use of augmented intelligence to help improve outcomes. “These are all smart ways we’re utilizing data to help clinicians take action,” says Soman.
PSQH: Patient Safety & Quality Healthcare, April 27, 2021
A quality improvement project at A & M Healthcare Clinic.
This article was originally published April 26, 2021 on PSQH by Janet M. Pitt, MSN, AGNP-C
Background: Hypertension is one of the most commonly seen issues in primary care. The total yearly economic burden of complications and comorbidities associated with hypertension is in excess of $316 billion, with $51 billion of that attributed specifically to hypertension (Kirkland et al., 2018; Merai et al., 2016). Oklahoma ranks as one of the worst states with regard to hypertension-related mortality. The primary care setting is the perfect venue to examine strategies and employ best practices to reduce rates of hypertension and subsequent disability and death.
Aims: Using the Target: BP framework and the Healthy People 2020 initiative, the aim of this quality improvement project was to reduce the incidence of uncontrolled hypertension by 10% in a given patient population at A & M Healthcare Clinic in Tulsa, Oklahoma, over the course of 12 weeks.
Methods: Patients who chose to participate in the quality improvement project were given an automated upper arm blood pressure device to use at home. Patients were trained in the use of self-measured blood pressure monitoring (SMBP) and were instructed to measure and record their blood pressure on a designated blood pressure log in the morning and evening; this would be done for at least three days per week for a minimum duration of four weeks and a maximum duration of 12 weeks. At enrollment, patients completed the Hill-Bone Medication Adherence Scale (HB-MAS). They repeated the scale every four weeks until their blood pressure was at goal, or until the end of the 12-week project period. At the end of the project period, all blood pressure logs and patient devices were collected, and logs were analyzed for average blood pressures and scores on the HB-MAS.
Results: A total of 21 people participated in the quality improvement project, ranging in age from 30 to 60 years. Final blood pressure readings revealed 50% of patients with a reduction in average systolic and/or diastolic blood pressure of 10 mmHg or more, and 6.3% with normal blood pressure.
Final scores on the HB-MAS showed 23.8% of participants with the same initial and final score, 47.6% of participants with a higher final score indicating increased medication compliance, 4.8% of participants with a lower final score indicating decreased medication compliance, and 23.8% of participants who did not follow up after the initial consultation.
Conclusion: Overall, 57.2% of participants had a reduction in average systolic and/or diastolic blood pressure of 10 mmHg or more, far surpassing the aim of reducing the incidence of uncontrolled hypertension by 10% in a given participant group. These results show that the addition of SMBP was an effective intervention to help reduce rates of uncontrolled hypertension in this participant population.
Hypertension is one of the most prominent issues seen in the primary care setting. The total economic burden of complications and comorbidities associated with hypertension is in excess of $316 billion, with $51 billion of that attributed specifically to hypertension (Kirkland et al., 2018; Merai et al., 2016). More than 100 million people from varying geographic settings and demographic subpopulations have been diagnosed with hypertension, making it one of the most clinically significant issues facing the adult population (American Heart Association [AHA], 2018; Breaux-Shropshire et al., 2015). The prevalence of hypertension increases with age and is more commonly diagnosed in persons over 40 (America’s Health Rankings, 2018; Fryar et al., 2017). Reducing the incidence of hypertension in the clinical setting can significantly reduce the risk of subsequent illness, disability, and mortality (Robert Wood Johnson Foundation, 2019).
Background and significance
Oklahoma ranks higher than the national average for premature death and is the tenth state overall for rates of mortality related to hypertension (Centers for Disease Control and Prevention, 2017). In 2018, among the top 10 causes of death in Oklahoma were heart disease and stroke, conditions that are both strongly linked to uncontrolled hypertension (America’s Health Rankings, 2018). One of the main foci of the Healthy People 2020 objectives is to reduce rates of uncontrolled hypertension (Office of Disease Prevention and Health Promotion [ODPHP], 2020b). The goals stemming from this initiative are slated to be continued for the next 10 years with the Healthy People 2030 initiative, further proving that hypertension is an issue of great concern for the nation overall (ODPHP, 2020a). Rates of hypertension in Oklahoma are consistently 5%–10% higher than the national average (America’s Health Rankings, 2018). The ZIP code in which this project site clinic resides ranks 38 out of 40 across nine quality indicators and has one of Tulsa County’s highest death rates, lowest average life expectancy, and lowest number of primary care providers (Tulsa Health Department, 2018). The project site clinic serves a primarily low-income population ages 18–90, the majority of whom are African American (A. Williams, personal communication, April 7, 2020). African Americans are over 20% more likely to develop hypertension and related comorbidities as compared to persons of white, Hispanic, Asian, and Native American descent (Fryar et al., 2017; Kaiser Permanente, 2018).
Using the Target: BP framework from the AHA, the 2017 American College of Cardiology (ACC)/AHA clinical practice guidelines for hypertension, and the benchmarks from the Healthy People 2020 initiative, this quality improvement project will examine the relationship between SMBP and average blood pressure (Target: BP, 2016; Whelton et al., 2018; ODPHP, 2020b).
The purpose of this project is to implement a standardized method for hypertension diagnosis, treatment, and management, to aid in the early recognition and treatment of hypertension, thereby reducing the number of patients affected and subsequent comorbidities and improving the overall health of the specified patient population. The overarching aim of this project is to reduce the incidence of uncontrolled hypertension by 10% over the course of 12 weeks through early identification, treatment, and patient engagement using the Target: BP framework, the 2017 ACC/AHA hypertension guidelines, and the benchmarks from the Healthy People 2020 initiative (AHA, 2018; Whelton et al., 2018; ODPHP, 2020b).
A large percentage of patients lack knowledge and understanding of their blood pressure goal and of the long-term effects that hypertension has on their health and quality/quantity of life. In addition, they lack adequate education on how pharmacological and non-pharmacological treatments help them achieve their blood pressure goals (Jo et al., 2019). Literature suggests that the use of SMBP in conjunction with typical blood pressure management strategies helps to increase patients’ awareness of their blood pressure goals, and when used appropriately and consistently, can help to decrease overall blood pressure results (Breaux-Shropshire et al., 2015; Fletcher et al., 2016; Qi et al., 2017).
In a study of 7,751 patients, researchers reported that the addition of SMBP increased goal awareness by 24%, increased percentage of patients who achieved their blood pressure goal by 27%, and decreased medication non-adherence by 61% (Jo et al., 2019). SMBP is also reported to be a better predictor of how patients will fare with regard to long-term risk for comorbid conditions and health outcomes than the use of in-office measurements alone (U.S. Preventive Services Task Force, 2020). SMBP monitoring is a cost-effective addition to office measurement and can provide useful information about blood pressure at different times of day. This type of therapy is useful to assist in the accurate and timely diagnosis of hypertension because it eliminates false high readings associated with white-coat hypertension (George & MacDonald, 2015).
Patients between the ages of 30 and 60 with a diagnosis of hypertension had the opportunity to participate in a quality improvement (QI) project to help to determine if SMBP is useful for providers in diagnosing and treating hypertension. Inclusion criteria consisted of patients age 30–60, English speaking, with a diagnosis of hypertension, who consented to participate. Exclusion criteria included patients less than 30 or greater than 60 years of age, patients who did not speak English, women who were pregnant or lactating, and patients with conditions prohibiting blood pressure measurement on the upper portion of the arm. Participants were recruited using an information sheet with details about the project, which was distributed via both the patient portal of the electronic medical record and through face-to-face visits.
Once several patients opted to participate in the QI project, the direct care staff were trained to train patients on the use of SMBP. Direct care staff received a 30-minute in-service in which they watched a three-minute video from the AHA on how to measure blood pressure at home. They received instruction on the operation and calibration of the automated blood pressure devices. They were instructed on how to choose the appropriate size blood pressure cuff for participants, and they were instructed on how to fill out the blood pressure log and the HB-MAS (Kim et al., 2000). Each direct care staff member performed a return demonstration of these elements before being checked off as a participant trainer.
Training for participants included the same elements: the three-minute video from the AHA describing how to measure blood pressure at home, instructions on how to operate the automated device, instructions on how to record blood pressure readings on the log, and when to return to the clinic for their next follow-up appointment. Patients were able to check out a calibrated blood pressure device from the clinic. They were instructed to measure their blood pressure at least three times a week, measuring it twice in the morning and in the evening. Each measurement was to be taken in succession after a one-minute rest period. Patients were instructed to record all readings on a blood pressure log sheet from the Target: BP toolkit (Target: BP, 2016). The HB-MAS was administered to the patients at week 1 and then every four weeks that they remained as a participant in the project (Kim et al., 2000).
At the end of the participation period, each patient was scheduled to return to the clinic for a final follow-up visit. The participants were instructed to bring the blood pressure device and all blood pressure logs with them. The blood pressure logs for each patient were analyzed for initial blood pressure reading, final blood pressure reading, and average blood pressure readings to see if there was a reduction in blood pressure. The final logs were compiled, and the averages compared across all participants to determine if the goal of reducing the incidence of uncontrolled hypertension in a given participant population by 10% was met.
Data sets for each participant included identification number, age, race, sex, initial and final blood pressure averages, and initial and final results of the HB-MAS. All data sets were input into IBM SPSS® Statistics Data Editor software and analyzed by the project coordinator. Statistical tests performed using this data included frequencies, crosstabs, descriptives, and paired sample T-tests (see Appendix A).
A total of 21 people participated in the quality improvement project. The age of participants ranged from 30 to 60 years with a mean age of 47 and a median age of 49 years. The group included 52.4% males and 47.6% females. Participants identified themselves by race with a composition of 66.7% Black/African American, 19% Caucasian, and 14.3% Hispanic.
Initial blood pressure readings found that 85.7% of patients had Stage 2 hypertension, 9.5% of patients had Stage 1 hypertension, and 4.8% of patients had elevated blood pressure. Final blood pressure readings revealed improvements showing 25% of patients with Stage 2 hypertension, 56.3% of patients with Stage 1 hypertension, 12.5% with elevated blood pressure, and 6.3% with normal blood pressure.
Most participants had a reduction in average systolic and/or diastolic blood pressure of 10 mmHg or more, and 19% of participants had a reduction in average systolic and/or diastolic blood pressure of 0–9 mmHg over the course of the project. Participants who did not follow up after the initial consultation made up 23.8% of the participant group.
Final scores on the HB-MAS showed 23.8% of participants with the same initial and final score, 47.6% of participants with a higher final score indicating increased medication compliance, 4.8% of participants with a lower final score indicating decreased medication compliance, and 23.8% of participants who did not follow up after the initial consultation.
Limitations for this quality improvement project include the small sample size of 21 total participants. Though the demographic composition of the sample size is reflective of the overall population of the project site and the surrounding geographic area, more participants should be included in order to truly generalize the results to a larger population.
Hypertension affects a large percentage of the population and accounts for billions of dollars in healthcare expenditures every year. Reducing the rates of hypertension should in turn reduce the annual economic burden. This QI project aimed to reduce the overall incidence of uncontrolled hypertension and increase the frequency of compliance with prescribed pharmacological therapies. Data analysis revealed that the majority of participants had a reduction in average systolic and/or diastolic blood pressure of 10 mmHg or more, with some participants moving into the normal blood pressure category. Final scores on the HB-MAS indicate that medication compliance increased in over half of the participant population. These findings far surpass the goal of reducing the incidence of uncontrolled hypertension and increasing medication compliance by 10% in a given participant group.
SMBP and the HB-MAS are both tools that serve to increase participant awareness of their condition and give them the opportunity to take a more active role in managing their health. The results of the QI project show that by providing targeted education and support, the addition of SMBP was an effective intervention to help reduce rates of uncontrolled hypertension in this participant population.
To improve this project and garner more participant engagement, this author suggests following up with each participant via telephone on a weekly basis for the first four weeks rather than at monthly intervals. This author believes that this may help participants move toward incorporating SMBP as part of their daily routine and may in turn decrease the number of participants that do not follow up after the initial consult.
This project can be easily implemented at other sites by providing the same recruitment, training, and tools to the clinicians and staff at a chosen site. One barrier to implementation at other sites may be the cost of automated upper arm blood pressure devices. If the clinic in question cannot afford to purchase enough devices for each patient to check out, they can purchase a limited number of devices and rotate small cohorts of patients through the project for a total of four weeks rather than 12 weeks. Alternatively, patients can purchase their own automated upper arm blood pressure device and calibrate their machine. This can be done by comparing the readings from the patient’s automated device with that of a manual blood pressure device.
Overall, this QI project confirms that SMBP is an intervention that helps to reduce the incidence of uncontrolled hypertension, and that it can be implemented across a variety of geographic and demographic settings as a way to improve health outcomes for the given population.
Janet M. Pitt, MSN, AGNP-C, is a doctoral nursing student at the University of South Alabama. She is currently employed as an adult-gerontological nurse practitioner at A & M Healthcare Clinic, LLC in Tulsa, Oklahoma. She holds a bachelor’s degree in nursing from the University of Central Oklahoma, a master’s degree in nursing education from Oklahoma Baptist University, and a master’s degree in adult-gerontological primary care from the University of South Alabama.
Breaux-Shropshire, T., Judd, E., Vucovich, L. A., Shropshire, T. S., & Singh, S. (2015). Does home blood pressure monitoring improve patient outcomes? A systematic review comparing home and ambulatory blood pressure monitoring on blood pressure control and patient outcomes. Integrated Blood Pressure Control, 8, 43–49. https://doi.org/10.2147/IBPC.S49205
Jo, S. H., Kim, S. A., Park, K. H., Kim, H. S., Han, S. J., & Park, W. J. (2019). Self-blood pressure monitoring is associated with improved awareness, adherence, and attainment of target blood pressure goals: Prospective observational study of 7751 patients. Journal of Clinical Hypertension, 21, 1298-1304. https://doi.org/10.1111/jch.13647
Kim, M. T., Hill, M. N., Bone, L. R., & Levine, D. M. (2000). Development and testing of the Hill-Bone Compliance to High Blood Pressure Therapy Scale. Progress in Cardiovascular Nursing, 15(3), 90–96. https://doi.org/10.1111/j.1751-7117.2000.tb00211.x
Kirkland, E. B., Heincelman, M., Bishu, K. G., Schumann, S. O., Schreiner, A., Axon, R. N., Mauldin, P. D., & Moran, W. P. (2018). Trends in healthcare expenditures among US adults with hypertension: National estimates, 2003–2014. Journal of the American Heart Association, 7(11), e008731. https://doi.org/10.1161/JAHA.118.008731
Merai, R., Siegel, C., Rakotz, M., Basch, P., Wright, J., Wong, B., & Thorpe, P. (2016). CDC grand rounds: A public health approach to detect and control hypertension. MMWR Morbidity and Mortality Weekly Report, 65(45), 1261–1264. https://doi.org/10.15585/mmwr.mm6545a3
Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Himmelfarb, C. D., DePalma, S. M., Gidding, S., Jamerson, K. A., Jones, D. W., MacLaughlin, E. J., Muntner, P., Ovbiagele, B., Smith, S. C., Spencer, C. C., Stafford, R. S., Taler, S. J., Thomas, R. J., Williams, K.A., Williamson, J.D., Wright, J. T. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension, 71(6), e13–e115. https://doi.org/10.1161/HYP.0000000000000065
PSQH: Patient Safety & Quality Healthcare, April 26, 2021
Nebraska Medicine's ENFit conversion designed to improve patient safety.
This article was originally published April 26, 2021 on PSQH by Stacie Ethington, MSN, RN-BC
Adverse outcomes caused by enteral tubing misconnections are well documented in The Joint Commission’s Sentinel Event Alert from August 2014 that states “Tubing misconnections continue to cause severe patient injury and death.” To address the issue, in fall 2020 Nebraska Medicine converted legacy enteral tubes and disposables to be compatible with the ISO 80369-3 standard, also known as ENFit®, that is designed to prevent misconnections and disconnections.
ENFit has been on the market for several years worldwide, and conversions to the ISO standard have been completed in the European Union, Australia, and New Zealand and are underway in Japan and Brazil. In the U.S., nearly half of the top 25 hospitals are now using ENFit, including leaders in patient-centric care such as Mayo Clinic, Sharp Memorial, Banner Healthcare, and Kaiser Permanente. However, the U.S. is lagging behind most other developed countries in adopting the safer connectors.
The effort has been driven by the Global Enteral Device Supplier Association (GEDSA), a nonprofit organization that promotes patient safety worldwide through the adoption of ISO 80369–compliant small-bore medical connectors. Furthermore, the Institute for Safe Medication Practices (ISMP) promotes use of “an oral syringe or an enteral syringe that meets the [ISO] 80369 standard, such as ENFit” as part of its 2020-2021 Targeted Medication Safety Best Practices for Hospitals.
Nebraska Medicine began its journey toward ENFit conversion in December 2019. An important first step was organizing a project team that included representation from project management, nursing, nutrition, pharmacy, physicians, purchasing, and the supply chain. The project team met with possible vendors over the course of several days. This gave end users the opportunity to get their hands on the products and ask questions related to their areas of expertise. Five vendors were reviewed. The group discussed the pros and cons of each vendor, and those selected were vetted through senior leadership. With their approval, product conversion planning began. The activities that followed included workflow development with the completion of a failure mode and effects analysis, policy revision and creation, physician engagement, education development, and enhancement within the electronic health record (EHR).
Prior to conversion, nursing and pharmacy completed educational modules. The video-based nursing module focused on the ENFit connection, medication preparation, connector cleaning, and documentation within the EHR. The PowerPoint®-based pharmacy module focused on medication preparation. Roaming in-services were completed by the product vendors on the days surrounding conversion. A small group of resource nurses served as the experts for frontline staff to contact with issues or questions. Related nursing policies went live the day of conversion.
Assess compatibility with NICU enteral pumps
A major lesson learned during the project was that the enteral pumps in the neonatal ICU were not compatible with the vendor chosen for disposables. A pump model upgrade would be needed for our enteral pumps to be functional with an ENFit syringe. Luckily, the enteral pumps were due for replacement within the next fiscal year, so the project team was able to get approval from senior leaders for an expedited replacement plan. The new pumps were implemented in tandem with the ENFit conversion. Having two vendors on-site for go-live support was a challenge to coordinate due to visitor restrictions with COVID-19, but the frontline staff appreciated the “at the elbow” on-site support for conversion. If pump compatibility is a potential issue for your organization, consider evaluating not only if ENFit syringes can be run on your pump, but also what size syringes are compatible. The pump manufacturer should have information regarding which ENFit manufacturer’s syringes are approved for use with the device.
Ensure adequate supplies of essential equipment
Three key areas to consider:
60 mL syringe. During conversion, many of the current legacy products were swapped out for the ENFit compatible version of that product. For example, a 10 mL amber oral syringe would be swapped with a 12 mL ENFit syringe. Following educational virtual calls regarding the conversion, units were given a suggested product list with descriptions. Ordering occurred at the unit level, meaning an ICU manager would determine product and parts for their unit, and the same process would occur on other units. One issue that was quickly identified in the days following conversion was that many nursing units did not have 60 mL ENFit syringes available. A deep dive revealed that 60 mL Toomey syringes still had some indications in patient care, so units did not want them converted. This led to a “miss” with realizing the need for adding the 60 mL ENFit syringe.
Each organization must make a decision whether adapters will be used during conversion. Since our organization did a full conversion all at once, adapters were necessary. Similar to the issue above, some nursing units did not order enough adapters for conversion. While the vendors identified the need for the availability of the adapter, the volume needed was not well understood.
Lopez valve. Another supply need that was not appropriately anticipated was the need for an ENFit-compatible Lopez valve. While there are several practice scenarios where these valves were used in relation to enteral tubes, the following section outlines the major need identified.
Coordinate early involvement of the supply chain
Despite involving members of our supply chain early in our planning process, the lift required for a successful conversion was underestimated. When late needs were identified (60 mL syringe, ENFit compatible Lopez valves, need for Legacy tubes for decompression, etc.), it was difficult to quickly resolve the issues. An important factor here is that we went live during a global pandemic. A debrief has occurred in an effort to promote more comprehensive planning for similar future projects.
Understand suction/decompression issues for outpatient use
Patients in the inpatient setting could have their ENFit enteral tubes hooked up to wall suction if needed (e.g., by using an ENFit compatible Lopez valve). However, suction and decompression in the outpatient setting has proven to be a challenge. Some outpatients have had large-bore enteral tubes hooked up to gravity bags to allow for decompression. One scenario occurred where a patient was converted to an ENFit compatible tube, but then had issues at home related to leaking, inability of tube to drain, etc. Due to the smaller inner lumen of the ENFit tube, thicker secretions were unable to drain.
Discussions occurred with our vendors and internal provider experts, and ultimately the decision was made to keep some legacy enteral tubes within the organization specifically for this patient population. These tubes are labeled “**FOR DECOMPRESSION ONLY**” within our EHR to prevent any confusion with ordering. Our organization has hope that this patient need is considered as manufacturing of legacy enteral tubes potentially decreases or ceases.
“Due to running two production lines, innovation of new products for issues such as this was held up,” said GEDSA Executive Director Mike Cusack. “With the promise of phasing out legacy from production lines, this has helped to provide the resources needed to create new products that help patients and those who care for them. We have heard such talk of new devices coming to the market soon.”
Educate community partners
As Nebraska Medicine prepared for go-live, the need for community outreach was evident. Our organization identified that during the transition phase, patients and caregivers might experience variability in enteral access devices requiring ENFit adapters and connectors. ENFit enteral tubes must be accessed with ENFit syringes or tubing sets. Should a patient with an ENFit enteral tube present to an outside organization that does not have ENFit supplies, the caregivers will not be able to access the enteral tube. If a patient with a legacy tube arrives at an organization that has converted to ENFit, an adapter can be placed on the ENFit syringe or tubing set so that the enteral tube can be accessed.
In February 2020, Nebraska Medicine sent out letters to many of our community healthcare partners regarding our intent to convert to ENFit later in the year. Within that letter, resources were shared for those that had not had exposure to the initiative. Unfortunately, post go-live we learned that outside facilities did not always have the supplies needed to care for our patients discharged with ENFit. We coached them if they reached out, and ultimately decided to send out a second letter to the community healthcare partners to let them know our conversion had been completed; we again provided resources within the letter.
As another method to ensure that our patients could safely transition their care, we had discharge orders built within our EHR that prompt the discharging nurse to provide the patient with an appropriate syringe and/or adapter based on the type of enteral tube the patient is being discharged with.
Our nursing staff was positive about the transition. “The extensive planning required for a safe and successful conversion has been well worth it,” one nurse commented. “We have experienced much satisfaction from our nursing staff.” Another nurse commented how ENFit improves patient safety while streamlining workflows. “I love the ENFit adapters because they lock onto the tubing so well that I do not have to worry about the tubing detaching and making a mess,” the nurse said. “It takes one less worry away from my workflow and saves me time with no mess.”
If your organization has not yet converted, there are several resources available. GEDSA’s website has many excellent articles, presentations, and tools, such as a transition checklist. Many of the enteral device suppliers have resources on their websites as well. Another invaluable tool is the ability to network with other organizations that are going through the same process so that lessons learned can be shared.
Stacie Ethington, MSN, RN-BC, is a medication safety nurse specialist at Nebraska Medicine in Omaha.
PSQH: Patient Safety & Quality Healthcare, April 19, 2021
COVID-19 required APIC to staff up, but there were good reasons to develop a pipeline for infection prevention even before the pandemic.
This article was originally published April 19, 2021 on PSQH by Matt Phillion.
The challenges facing infection preventionists (IP) were already immense before the COVID-19 pandemic hit last year. Now the demand for their expertise is higher than ever, says Devin Jopp, EdD, MS, who was recently appointed as CEO of the Association for Professionals in Infection Control and Epidemiology (APIC).
Jopp has identified several crucial goals where APIC can help with current infection prevention challenges and build toward a better future for the industry. The work begins, he says, with creating a pathway into the profession—one that would make it easy for aspiring IP professionals to access education and training.
“There are several problems plaguing the industry when it comes to meeting the expanding demand for infection preventionists,” Jopp says. “They’ve been in high demand, both on the front lines of addressing COVID-19 in our healthcare settings and at the same time, they are being asked to work with other sectors; for example, hospitality and entertainment sectors.”
COVID-19 required APIC to staff up, but there were good reasons to develop a pipeline for infection prevention even before the pandemic. “The second problem we face is an aging workforce,” he says. “Many of our infection preventionists are aging out of the profession. This is not a problem that is just beginning, but one that we have reached a critical point. In essence, the shortage is here. Add in burnout, and that’s creating pressure on availability of IPs.”
The third problem in this equation is that, currently, there’s no straight line into infection prevention. “There’s no way to become an infection preventionist unless you re-career into it,” says Jopp. “That’s a real challenge. Today, you cannot take a straight career path to become an IP and cannot get a degree in infection prevention. This further limits the supply of available IPs.”
The profession is multidisciplinary, drawing upon nurses, lab techs, public health professionals, and a wide array of other career paths, so many skilled professionals could be ready to explore this specialization. Jopp notes that we must take a holistic approach and look at creating programs across the spectrum of higher education—including certificate, undergraduate, and graduate degree programs. “This is a national imperative, and this takes a tremendous amount of effort to stand up, but we have to work fast,” says Jopp.
And that goal isn’t a terrible lift, he says; it just requires getting the right partners together. A number of universities are already interested in collaborating. “Think of it as infection prevention in a box. You’ll be able to create it with these building blocks. The key learning objectives, seminal texts, and knowledge competencies need to all be defined,” he says. “We want to allow universities to be creative with their programming but need to ensure that the core knowledge of the program is consistent.”
Jopp says the APIC team has been pleasantly surprised by the number of universities raising their hands to get involved on the design side, including a Canadian institution. “When we do this, it will not only inspire what we’re doing here in the U.S., but also internationally,” he says.
As a possible bright side to the pandemic, we might see increased interest in this important profession. Building a strong network of IPs is crucial to ensure organizations both inside and outside of healthcare have the expertise to keep communities safe from infection.
“We need to unlock the infection prevention profession and help create a healthy pipeline for the next generation of IPs,” says Jopp. “I believe the demand is there and once we create this new pathway, students will flock to this profession. As an example, one institution participating in the creation of the academic pathway just launched a new certification program and was overwhelmed with student enrollments.”
Beyond education and training for future IPs, there’s also room to make a difference with education and outreach to help frontline workers in many settings, not just healthcare.
While looking to the future, it’s also important to acknowledge and assist with the burnout IPs are experiencing after a year of pandemic lockdowns. “It’s been so hard to see the terrible toll that COVID has had on patients, and recent research suggests that [there are] lingering effects and mental health impacts” that persist beyond the acute phase of the infection, says Jopp. “The impact on providers has also been significant, and we are watching the pandemic take an emotional toll on our IP community.”
APIC is working on a partnership with an Ohio State University research program to measure IP well-being and resiliency. They hope to offer some useful tools and interventions to help their members. “We, as an association, have to help them navigate through this,” he says.
Locally, Jopp urges institutions to continue to create communities of healing and recovery. But burnout was already an issue for healthcare providers, even before the pandemic. “Before I came to APIC, I served as the CEO of the American College Health Association, and we were already working to address provider burnout,” he observes. “Throw in a pandemic and the related stress and pressure, and the anxiety and depression levels build to an entire new level.”
Providers are resilient, but they may also be prone to silent struggling, wherein they may turn to outlets, both healthy and unhealthy, to cope. “We’re really seeing this manifest in organizations,” says Jopp. “Working long hours in difficult situations takes a toll on individuals.”
As CEO of the American College Health Association, Jopp was part of its COVID-19 task force in early 2020. The group spent the bulk of that year developing guidelines for the reopening of higher education. “Before COVID, inside universities, some of the worst public health threats that could happen was an active shooter or a meningitis outbreak,” says Jopp. “Through my work of addressing infections in a college setting, I built an interest in this specific area of focus and jumped at the opportunity to help lead our efforts nationally at APIC.”
Working for APIC during this historic period has been “fast and furious,” Jopp says, and an opportunity to greatly advance the profession and develop collaborations with other industries to involve IPs in new spaces.
“One interesting challenge not many saw coming was others without the requisite expertise entering the space and being asked to serve as experts in infection prevention without adequate backgrounds,” says Jopp. “That’s been a real challenge. We continue to encourage organizations to lean on their IP to help them navigate through this pandemic and frankly, to help guide them through all infection prevention and control issues.”
Infection prevention and long-term care
Jopp is also interested in seeing infection prevention develop a stronger presence in one area that keenly felt the effects of the pandemic: long-term care facilities. “One of the challenges that became quite evident through the pandemic is that infection prevention was not systemically and uniformly present in the long-term care setting in the way that it is with acute care. We saw the tragic outcome of this with COVID-19.”
Many long-term care facilities either don’t have an IP or treat infection prevention as one of many hats a person wears, leaving the discipline underprioritized. “We as a country need to invest in our [long-term care] infection prevention infrastructure,” says Jopp. “We must create a common threshold for IP expertise and practices within these organizations.” The virus spread rapidly in long-term care facilities, something APIC hopes to help prevent in the future.
“The other part of this is we need to do a better job with surveillance,” says Jopp. “We need a national process for reporting infections, like we [have] in acute care settings. We have urged legislative and regulators to require that [long-term care facilities] submit data to the National Healthcare Safety Network (NHSN). We need real-time data so that we can take timely action in the future on trends.”
Right now, Jopp notes, long-term care is paying attention to infection prevention, so there’s an opportunity to take action for lasting improvement. “We have to make sure we don’t lose vigilance on this topic,” he emphasizes. “We also need Congress and the states to ensure that there is proper funding for these added measures and staffing.”
The acute care model for healthcare-associated infections is the gold standard—the long-term care industry needs a similar model that can measure what’s happening and take action. “It’s going to take a lot of resources and follow-through,” says Jopp. “This is an enduring commitment.”
It stands to reason that there will be a new motivating factor for these improvements: After a global pandemic, families and consumers will demand a higher level of infection prevention. “Long-term care facilities are not only going to have to implement higher levels of infection prevention readiness, but they are going to also have to build robust ways to measure these efforts. Families, as consumers, are going to demand that infection prevention be at the forefront as they consider [the choice of] who will help care for their loved ones,” says Jopp.
The world has had close calls with other viruses in recent times, but it took the weight of COVID-19 to capture everyone’s attention. “We had near misses over the years, with H1N1 or Ebola, but none of those previous epidemics truly stuck with us,” says Jopp. “The tremendous death toll and impact on our society makes this different, and I want to believe that we can take this terrible tragedy and help future generations avoid this from happening.”
It’s difficult to make the necessary changes rapidly, of course. “We’re moving systems, and it’s hard to do that overnight. However, we cannot fail in our efforts. We must make the commitment and build infection prevention systems that endure and that we can count on in future emergency crisis situations,” says Jopp.
He concludes, “As a healthcare system, we have to build our capacity to be able to respond to novel pathogens in the future. We must take our lessons learned from COVID-19, remember the terrible costs of this pandemic, and make real and sustainable changes to prevent it from occurring again. Ensuring we have infection preventionist expertise is one of the critical ingredients to enhance our preparedness.”
Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at firstname.lastname@example.org.
PSQH: Patient Safety & Quality Healthcare, April 14, 2021
Doctors, healthcare organizations, and even technology providers have found ways to work with or through the limitations of social distancing, though they’re not happy about it.
This article was originally published April 13, 2021 on PSQH by Matt Phillion.
Healthcare always aims to ensure the best outcomes and the safest care for patients. This often means staying on top of the latest best practices and procedures to ensure organizations are offering the gold standard of care, whether that involves new techniques, innovative technologies, or a combination thereof.
But what happens during a pandemic when surgeons and other clinicians can’t learn about these care advancements in the normal way? Doctors, healthcare organizations, and even technology providers have found ways to work with or through the limitations of social distancing, though they’re not happy about it.
“Things have changed, and we’re hamstrung by not being able to see things in person—that’s the traditional way of doing things,” says Dr. Apurva Thekdi, an ENT specialist with Houston Methodist. “Medicine is a very old-school industry. We don’t tend to adopt technology very quickly, and things need to be tried and true before we accept things.”
Out of necessity, the medical community has made do with remote learning during COVID-19, whether that’s through Zoom®, Webex®, or other online platforms. “It’s phenomenal that we have these options, but it’s not the same,” says Thekdi. “The allure of going to conferences is the spontaneity—meeting people you wouldn’t ordinarily talk to or hearing ideas you wouldn’t ordinarily hear.”
When the gold standard is out there
Dr. Smita De is a urologist with the Cleveland Clinic and has explored techniques on how to make training for holmium laser enucleation of the prostate (HoLEP) more accessible for surgeons when traditional training methods are not available, such as during the COVID-19 pandemic.
“Doing a fellowship, having a mentorship, these seemed to be more successful as far as picking up how to use a holmium laser to perform HoLEP,” says De.
A number of studies examining surgeons trying to teach or learn HoLEP via less extensive options, such as weekend courses, shorter mentorships, or watching simulations, found that while the surgeons may have wanted to introduce HoLEP to their practice, they felt the altered training didn’t leave them comfortable with completing the surgery on their own. That’s a problem, since those who can perform the procedure consider it second to none.
“The notion that HoLEP should be the gold standard has been demonstrated, the outcomes are superior, but not that many people are doing it,” says De. “A lot of my patients are not local, and many HoLEP surgeons find patients are coming from all over because no one is doing it locally on a regular basis.”
Unfortunately, surgeons have traditionally relied on conferences and face-to-face training to learn about new procedures, gain hands-on practice, or talk with peers who are already using a new device or procedure. So what can be done to help more surgeons adopt techniques like HoLEP?
“Develop better simulators,” says De. “Simulation is huge, whether it’s a box trainer or virtual reality simulator or some combination of the two.”
The pandemic has organizations looking at ways of advancing online training as well. “For example, the Endourology Society has held quite a few courses online, talking about topics from straightforward concepts to nitty-gritty details like how do we improve a very specific aspect of prostate surgery,” says De.
While these courses have been highly valuable, De points out that many organizations haven’t yet taken into account that online learning meshes differently with a surgeon’s job responsibilities. A conference enables a surgeon to step away from care duties and focus wholly on learning and improvement. With travel off the table for the past year, surgeons find themselves trying to participate in online courses during or after a day working with patients, which doesn’t set up the best learning environment.
“We want to get educated on state-of-the-art equipment and advances,” says De. “But asking people to do that on their own time is hard when before you could jam it into a four-day conference. The requirements of the job have not changed.” There’s also a concern that, after a year or more without travel, organizations may view traveling to conferences as unnecessary and discourage doing so even after travel restrictions are lifted.
Not just the courses, but the content
One factor that came up in De’s research was the effectiveness of online learning, which could vary based on presentation. Ideally, a remote learning session wouldn’t just display slides for a physician, but it would get into “Here’s the surgery, and here’s how you do it,” says De.
And when it comes to demonstrations, sometimes it’s best to not pick the perfect take. “It’s really rare to find online training videos in which something goes wrong,” says De.
Understandably, demonstrations often aim to present a flawless recording—an ideal patient, a surgery without hiccups. But De says, “I don’t need another perfect video. What I need to see is when something goes wrong, what should I do, how does one handle it. I think that’s most useful. It is important to know that not everyone will do it perfectly every time, and you have the ability to get out of it safely if something goes wrong.”
In a time when in-person learning is a challenge, this is particularly useful because sometimes the nearest trained expert on a gold-standard procedure is in another state. “We often have someone we consider a ‘phone-a-friend,’ someone who you can call on for help, but with HoLEP, my phone-a-friend was in Tennessee! There was only so much she could do for me from there,” says De. “Even with a very safe procedure, it’s important to have more people trained who can back you up, to help assess a situation.”
How other physicians work
De talks about the potential for live mentoring through video rather than a recorded demonstration of a case. “When you’re presenting to thousands, you’ll want to pick the perfect case, have everything perfectly orchestrated, and be very careful what they see,” she says. “But if it’s a one-on-one scenario, [the live video mentoring will] be more relaxed and the surgeon can treat it more like how it would be on a daily basis.”
This would allow the mentor to consider how they teach a trainee, particularly when the procedure is a single-person job with one scope, one instrument, and one place to sit. That doesn’t make for an ideal in-person teaching situation, but a live video scenario could provide a better option.
“Right now if I’m training someone in person, I place my hand on top of the trainee’s hand to guide them, which can be awkward,” says De. “But listening to how someone else teaches this, what words they use, which steps they let the trainee do versus what’s an advanced level—I love to see that. It provides a different perspective than how I learned.”
And even experienced surgeons can learn from a live video scenario, De says. She explains how she recently watched a fellow surgeon trialing the new Moses™ 2.0 laser, which was still in the testing phase at the time.
“I got to see how she trains her fellow, but also I could see her equipment and setup,” De says. She even noted that there was a particular way the other surgeon set herself up physically that improved the experience not just for the patient, but also for the surgeon. “There are little things that can be hugely disruptive, and I got to see her entire operating room setup, not just how she used the laser, and that’s something you get from being there or having an opportunity to watch live.”
That particular learning experience was a fluke, arising out of an invite from a colleague, but any opportunity to watch someone or hear about their experiences can be a chance to improve, De says. “Sometimes it’s luck, sometimes it’s seeking out opportunities, but I tell my fellows: ‘I’m trying to teach you everything I can, everything I’ve learned, and every mistake I have made, but be open to every opportunity and take advantage of it.’ ”
Mobile training on the road
Some medical technology companies have taken their training on the road, literally. Thekdi has connected with Lumenis, which sponsors a countrywide road trip with the LuMobile RV to give talks and lectures outside. It’s a chance to capture some of the spontaneity of medical conferences without travel or other pandemic challenges.
“People really enjoy getting together again, even if it’s socially distanced and outside,” says Thekdi. “It makes a huge difference the kinds of conversations you can have when you’re in person.”
The company also brings lasers and tech support staff from research companies or labs to offer training, which gives surgeons the chance to see things with their own eyes. “One of the first things we’re taught is to doubt: don’t take everything at face value,” says Thekdi. “It’s hard to adopt a new technology when you can’t question and get responses. We also want tactile feedback, the chance to do or see something for ourselves.”
Even the best Zoom call doesn’t offer that kind of interaction, Thekdi notes. And while on-the-road sessions obviously can’t offer live patient procedures to truly see the technology in action, Thekdi participated in the hands-on course at one outdoor event and says even this modified approach still beats out Zoom courses. “We make do and learn [with remote training], but there’s a benefit to making it more accessible.”
The impact of COVID-19 on advancement
With travel at a minimum and adoption of gold-standard procedures held back, has medical technology been slower to advance during the pandemic?
“For sure there’s been stagnation,” says Thekdi. “There’s a density of ideas that occurs when you can bounce things off each other, a chance for more rich, innovative ideas.”
The pandemic has also seen a slow in funding for research that’s not related to COVID-19. “This was understandable—[COVID-19] was on the forefront of everyone’s mind in our day-to-day, minute-to-minute existence,” says Thekdi. “And it’s not like we’re falling behind other countries or communities, but compared to our normal pace of innovation, we’ve slowed the past year.”
Between the inability to travel and get face-to-face training and the limited contact with organizations developing technologies or procedures due to social distancing, medical advancement is only now starting to ramp up again.
“We’re going to see a rebound in conference and travel, but it’s not going to happen all of a sudden,” says Thekdi. “It’ll ramp up slowly. But I would anticipate that [eventually,] things are going to be back to pre-pandemic levels, maybe even a little rebound in attendance—as people are going to be itching to get back, learn new skills, brush up on old skills, and learn new techniques.”
As we begin to see social interaction return, will online training avenues remain? “I think they’re here to stay,” says Thekdi. “They add value. There’s a preference to meet in person, but conferences do take physicians away from their practice and family. With hybrid options, if you can’t make it to an in-person event, the opportunity will still be available.”
PSQH: Patient Safety & Quality Healthcare, April 14, 2021
How physicians can support better technology development.
This article was originally published April 13, 2021 on PSQH by Megan Headley.
Healthcare technology innovation is moving faster than ever as technology companies push tremendous disruptions into this critical sector. However, these disruptions often fail to acknowledge existing workflows and how best to support clinicians. As every physician who has bemoaned the time demand of entering data into EMR systems knows, when technology solutions address a given need, they often create other challenges.
Often the blame goes to a lack of interoperability—the ability of information technology systems and software applications to communicate, exchange data, and put this exchanged information to use. Ideally, data exchange standards would allow data to be shared across clinicians, labs, and facilities, regardless of the application or software vendor.
“We see this phenomenon [of interoperability challenges] all the time, and the root cause is lack of communication,” says Dr. Jeffrey Zavaleta, a board-certified anesthesiologist at Cook Children’s and chief medical officer at Graphium Health, a software provider for anesthesia practices.
From Zavaleta’s perspective, a lack of communication is often due to siloed departments. While physicians, administrators, and IT professionals may be looking at the same problem, they are likely interpreting solutions through different lenses.
Interfaces (the languages and codes that programs use to communicate with one another and their hardware) are fraught with examples of incomplete communication, Zavaleta says. “Interfaces, in general, are real solutions to system integration, but interfaces alone make the job more difficult. There has to be operational infrastructure, processes, and human resources to support interfaces.”
While it is easy to point the finger at technologists, clinicians can play a critical role in helping tech companies develop solutions that take their operational processes into account. Effective relationships and collaborations between technologists and clinical practitioners demand two factors, Zavaleta says: respect and shared interest in data.
“Too many times either physicians lack respect for the real technical obstacles (while ironically being unable to remember their usernames), or technologists lack respect for real clinical nuances that impact workflows,” he says. Yet, “where there is mutual respect between technologists and clinical practitioners, and where there is a shared interest in turning data into actionable information, collaboration between these two parties tends to thrive.”
Once clinicians have the right mindset in place, Zavaleta offers a few additional tips to help them maximize the usefulness of any technology collaboration. First, he suggests that physicians take time to not only describe their typical workflow in detail, but also dig into why the work is done that way. These details will identify areas for improvement and pinpoint aspects of the workflow that should not be adjusted. If there are gaps in knowledge about why things flow a certain way, that’s important to highlight as well.
Zavaleta also suggests that if physicians have a basic understanding of coding, they’ll know better which details to communicate to technologists. “From personal experience, I think it helps by orders of magnitude for the physician to have some knowledge of coding and what software can do,” he says. “While anything is possible, any development comes down to cost: cost to develop, cost to support, and ability to sell.”
That is the last critical factor to consider in the development of new tech solutions. You can shoot for the moon with features, but any solution must provide a solid balance of value and cost-effectiveness.
“Many times, a given feature request for interoperability may not necessarily create value for the paying party,” Zavaleta points out. “A great example in our industry is anesthesiologists requesting vital sign integration with anesthesia machines. While it may make life a bit easier in the OR for documentation, it comes at significant expense to the hospital. It is then important to confirm if this interoperability feature is worth building and supporting.”
Another challenge he is working to address, Zavaleta elaborates, is building user interface features to help anesthesia providers correctly document their individual care times. “The problem seems simple on the surface, but as you dig and find nuance, you realize making a simple and intuitive solution is quite difficult,” he explains. “The goal is to build a user interface that presents a true time error correctly and offers a suggestion to fix it. This makes the billing team more efficient, reduces rejected claims, and reduces fraud.”
Striking the proper balance during product development—a balance between time-saving features and low cost—is the key to business success, Zavaleta advises. “It absolutely requires clinicians and technologists to have some shared vocabulary and, as mentioned above, a mutual respect for the challenges facing each party.”
PSQH: Patient Safety & Quality Healthcare, March 23, 2021
If patients aren't equipped to navigate the complexities of the healthcare system, they may struggle to get the help they need, adhere to medications, or deal with other complications that can reduce their quality of care.
This article was originally published March 22, 2021 on PSQH by Matt Phillion
When considering social determinants of health (SDOH), we often look at core needs that impact a person’s ability to remain healthy, like food, medicine, education, and transportation. But recent surveys have found there’s also a “digital divide” that stands between patients and better care.
Data exists that can help patients achieve better healthcare, but the industry itself must ensure that this data is available, accessible, and understood. Organizations and providers often have access to some of the data in question; the key, though, is connecting healthcare stakeholders and patients to complete information that enables informed decisions, which the industry has not yet perfected.
Often, payer care management systems are built for transactions rather than coordinated care, and thus there are several places where coordination can break down, including disparate, unstructured, or undigitized data, or a lack of patient consent. If patients aren’t equipped to navigate the complexities of the healthcare system, they may struggle to get the help they need, adhere to medications, or deal with other complications that can reduce their quality of care.
All this being factored in, where can hospitals and healthcare organizations work to connect patients with this data?
Viewing behind the scenes
“When you think about traditional healthcare delivery and networks, what tends to be the case is a lot of care management coordination activities are obfuscated from the patient,” says Lynn Carroll, COO of HSBlox, the maker of a digital health platform that enables SDOH risk stratification, care coordination, and permissioned data sharing. “The patients don’t have a lot of view behind the scenes.”
Carroll explains that empowering the patient means giving them the tools, information, and education they need to take better care of their own health.
The healthcare environment can be a fragmented place, which complicates the task of keeping patients informed. It’s challenging to bring the array of players into alignment when they include community-based organizations, social service agencies, and home care providers, as well as medical professionals. Stakeholders who are part of a patient’s care team have bits and pieces of information about that patient, but they don’t have all of the information—and neither does the patient.
“If I want to bring the patient traditional care delivery systems and these neighborhood or social contracts into play, how do I orchestrate that?” asks Carroll. “That’s one of the things we’re focused on here. How do you go to the intersection of the digital and physical worlds and enable that empowerment, not only for the patient but also for the care team, and effectively manage the patient’s needs?”
The obvious places to start are areas like chronic conditions or disease management where there are many data points to parse, but the focus can be beneficial across the healthcare spectrum.
What patients don’t know about themselves
Often, patients don’t know what they don’t know—and their lack of data can have a negative impact on their outcomes. Specifically, with SDOH, they may be unaware of a local organization that offers needed assistance, such as with transportation. Other examples are behavioral approaches that can help them address chronic conditions.
“There’s a patient awareness aspect,” says Carroll. “What are the patient’s medical needs, and what are their social needs? There’s been a lot of dialogue recently about the need for social interaction, particularly for the elderly, and there are organizations focusing on this.”
These organizations do, in their own way, gather important data on their patients. It’s not tracked in the traditional healthcare sense, but it’s out there—and it has the potential to help.
“There’s structured data, the kind that ends up being in the electronic medical record,” says Carroll. “But there is also unstructured data: clinical notes and things of that nature. Trying to understand a more holistic approach to the medical and social components is a challenge, and part of that challenge is this unstructured data.”
For example, even in interacting with healthcare practitioners, items indicative of social care may be buried in the notes of a patient’s records. “How do we bring unstructured data into structured?” says Carroll.
A basic step is to bring it into the billing data so you have a more holistic record of the patient’s care. “If you need to align medical resources, you need information on what each of those resources knows and be able to communicate effectively about how these resources can be utilized,” says Carroll.
Carroll and his colleagues look at traditional and social components and apply this structured and unstructured data to achieve a holistic view. This enables organizations to stratify populations and target areas for specific interventions, like chronic disease management scenarios or indicators of acute events.
“We focus on the orchestration component,” says Carroll. “The patient becomes more integrated into the process. Our belief is that if the patient is empowered with more information, alongside these other tools, we can better orchestrate their involvement in the continuum of care.”
The impact of unstructured data
Unstructured data is an untapped goldmine of patient information. It involves touch points with the patient that are more frequent than, say, scheduled quarterly visits to a specialist. These points of contact provide an opportunity to proactively understand changes in a patient’s medical condition or social contract. “That’s a part of the secret sauce” of orchestrating better outcomes, says Carroll.
The other component is that, in contrast to traditional integrated networks like hospitals and specialty groups that rely on more sophisticated technology, the system grows less sophisticated as you move down the line of care providers—some caregivers in community organizations manage their information through things like spreadsheets or manila envelopes.
“We need more connectivity with the digital world at the street level,” says Carroll. “The hidden gems can be lifted out of that unstructured data and structured alongside traditional data.”
Optimization through data
The data analysis component is used part and parcel with more traditional health methods, explains Carroll. But the difference here is that care is targeted with data from individual experiences.
“You might have a health score, but also a social score,” says Carroll. “You might have a combined score. It helps us focus our efforts to stratify and identify the particular social needs unmet for a given patient.”
An example of one of those needs is English as a Second Language (ESL). Does the platform the patient is engaged with support the appropriate languages? If there is a caregiver at home, such as a spouse or an adult child, there might be a language barrier. ESL support becomes part of the street-level contract with the patient to ensure proper delivery of services.
“From our point of view, we want to keep the patient happy and healthy, and empower them to be able to stay at home and be healthy as much as possible,” says Carroll.
Many patient needs go beyond healthcare but are still pivotal to health: employment security, housing, food security, social interaction, and transportation, for example. The patient needs to be able to interact with the healthcare system and the outside resources the system draws upon, and there may not be readily available coordination with patients for some of these resources.
The impact on providers
With a better understanding of who is providing care in the home, how do we bring that information back into the medical world and the medical record so that practitioners can take action?
Part of the answer, Carroll notes, is collecting the information in a timely fashion. A primary care physician or specialist may not be able to be regularly in the home. More current or real-time status information is an untapped resource for these professionals.
“How often is someone participating in the continuum of contact with the patient so you can have as much up-to-date information as possible to properly digest?” says Carroll.
This goes beyond human interaction, as well. It’s possible to utilize mobile device integration, remote monitoring, and even the internet of things to provide information on a more real-time basis.
“Part of the approach is to ultimately personalize medicine,” says Carroll. “To empower patients to understand what’s available. But it’s also addressing, from a healthcare equity standpoint, where we can create more opportunity for a diverse population to participate in things like clinical trials. If we’re relying solely on a practitioner seeing the patient or a claim being generated, we’ve got a big blind spot.”
The other question is what technology is needed to make all of this happen. Fortunately, healthcare doesn’t have to reinvent the wheel. There are already examples of this kind of orchestration working in other professional settings, like the supply chain or financial services industries.
This orchestration looks at components that are event driven, have multiple stakeholders, and require a coordination of activity in real time or near real time—components that are common in these other industries that healthcare can benefit from.
“The endgame is to empower patients to be healthy and to empower their caregivers in the process,” says Carroll. “The ‘what’ for us is integrating the patient, the ‘how’ is the digital platform at the edge of the physical and digital worlds, and the ‘why’ is for patient empowerment.”
Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at email@example.com.
PSQH: Patient Safety & Quality Healthcare, March 23, 2021
Advance care planning is an underrecognized issue, but its status has been elevated during the COVID-19 pandemic.
This article was originally published March 22, 2021 on PSQH by Matt Phillion
It’s something many healthcare professionals and organizations are well aware of: Advance care planning and end-of-life preferences are an oft-overlooked part of patient care to be improved upon.
But it isn’t just about being aware of patient preferences. Ensuring every patient’s end-of-life care preferences are documented and accessible also works to reduce harm and improve patient outcomes.
A year living through a pandemic has made this issue even more abundant—older patients, and those with chronic conditions, have been among those most at risk for severe, life-threatening conditions, including those attached to COVID-19. And what happens when one of these patients is placed on a ventilator, unable to voice their wants in terms of treatment?
To avoid these scenarios, the industry needs to ensure providers, caregivers, patients, and families are engaged in advance care planning discussions.
“Providing goal-concordant care to individuals at end of life is absolutely a patient safety issue,” says Ryan Van Wert, MD, an intensive care physician, a part-time clinical assistant professor at Stanford University, and co-founder and CEO of Vynca, an advance care planning solution organization. “It absolutely fits into quality measures and value-based paradigms.”
Advance care planning is an underrecognized issue, but its status has been elevated during the COVID-19 pandemic, Van Wert notes. It rose to the forefront at the outset of the pandemic, making sure everyone’s voice was heard, he adds. “Certain demographics were at the highest risk, but I think the message was that nobody was really safe. Everyone had the potential to get seriously ill, and that brought it home to a lot of people.”
Our time with COVID-19 has forced many patients, families, and providers to reflect on what would happen if the unthinkable does occur. Do you have a mechanism through which your wishes could be honored?
“The challenge with advance care planning is in reality, it’s a very complex process to implement and scale in a high-quality, consistent way,” says Van Wert.
Unique challenges to implementation
To start, advance care planning isn’t something that should be done on the fly, Van Wert notes.
“These are difficult decisions. They take time,” he says. “And providers are often not trained for it. There’s often a default in healthcare that you do everything to save the patient until you’re instructed otherwise. It’s an aggressiveness of care.”
Physicians and other care providers, without the proper guidance of advance care planning, can only do what they believe is the right thing. And yet patients don’t often ensure their wishes are clearly documented.
“We know from the data that advance care planning for populations 65-plus is often in the single-digit percentages,” says Van Wert.
Hospitals and other healthcare organizations can step in to improve that number, though. Organizations like Vynca can work with hospitals by providing analytics to identify populations in need, offering providers the education they require to conduct the difficult conversations around advance care planning, and locating patients who need to have these conversations before they end up in an emergency situation.
Organizations need to realize that advance care planning—or the lack thereof—is a patient safety issue like any other, Van Wert notes.
“We look at issues like central line infections or wrong-site surgeries and address them by implementing standardized processes and protocols,” he says. “This applies to other areas of medicine, including delicate topics like advance care planning.”
The logical, scientific processes used to prevent other patient safety issues or medical error risks—workflow redesigns, custom messaging, change management, and business intelligence—can also come into play when tackling advance care planning, helping to implement change and measure success.
“It’s a way of looking at organizational change: Normalize dialogue and look at natural points to have these conversations,” says Van Wert.
Finding the right time
Clearly, a patient in distress is not in the best situation to consider their advance care preferences. A better opportunity to bring this topic up, Van Wert notes, is during Medicare wellness visits, when the patient and provider can have a frank conversation without the pressure of an emergent situation.
“It’s a matter of finding a natural point in the patient’s care when these conversations are appropriate and can have an impact on individuals,” he says.
It’s hard to determine exactly why these conversations don’t always happen. In some cases, patients may be uncomfortable outlining their wishes to their loved ones. In others, patients who are approached by a provider on the subject may feel like the provider is giving up, which is not the case either.
“It’s a multifaceted problem, and that’s why it’s been historically difficult to solve,” says Van Wert. “Our goal is, at an organizational level, to unpack those reasons and make it OK—to normalize it.”
There’s also the matter of time itself. There’s only so much time in the day, and often advance care planning is not considered pivotal enough to take it up. However, this is changing on the reimbursement side, signaling a greater understanding of advance care planning’s importance. CPT® codes and other payment structures now recognize the time it takes for providers to have these conversations.
“Advance care planning is a quality measure, and payers like CMS and others have recognized that,” says Van Wert.
If these conversations and their documentation are tied to financial performance, this means organizations can look at them from a strategic point of view. “Beyond quality of care, and knowing it’s the right thing to do, there are measures and payments that recognize the time involved,” says Van Wert.
Organizations are also starting to look more at who has those conversations. Often, the best person to sit down with the patient is not the physician, but rather another member of the interdisciplinary team. It might make sense, for example, for a nurse practitioner to have specific training in this area, identify patients coming into the office who need to have an advance care planning conversation, and build that conversation into a regular appointment.
“It’s important to make sure they’re equipped with the right tools and ensure their time is protected to have these conversations,” says Van Wert. “There are multiple ways to solve the problem of lack of time, and it comes down to how we make sure there’s a strategic reason to focus on this area, and then looking at the workflow, accountability, team formation, and ancillary services to make sure it’s done in a quality, consistent way.”
We also know through numerous studies, Van Wert notes, that a number of patients would see the value of palliative care if offered.
Understanding that patient preferences are a part of care quality is key to successful advance care planning. This means accepting the necessity of honoring patients’ wishes. It also means that failing to clarify or document an individual’s wishes is in fact a medical error, and medical errors predispose patients to an adverse event—in this case, over- or undertreatment.
Aligning the organization to these facts can help prioritize advance care planning as a program or initiative, which can prompt greater success as well as sustainability.
“It’s an enormous patient safety issue that’s been historically difficult to develop a business case to support, because of competing priorities,” says Van Wert.
The starting point for the benefits of advance care planning should always begin with a better patient experience, but on paper, there are a number of risks a proper focus on the issue can help alleviate.
Hospitals spend millions of dollars trying to optimize their mortality rates. “How do we make sure fewer people die in the hospital?” says Van Wert. With an advance care plan on file, the odds of dying in the hospital are 79% lower, and fewer readmissions are seen as well.
“The way to reduce a lot of these events is to make sure people who would prefer not be in the hospital are not,” says Van Wert. “Enable them to go into hospice or palliative care.”
Another trend to look out for: a rise in wrongful life cases. As mentioned earlier, healthcare organizations often default to sustaining life as a supposedly lower-risk decision. But more and more legal cases are being brought against organizations because a patient’s advance care planning documentation was not accessible or honored.
“A lot of organizations have underinvested in comprehensive advance care planning,” says Van Wert. “There’s a misalignment between the patient, the family, and the caregiver. If those conversations have been had but the documentation is not clear or accessible, that’s a medical error. It’s not just a problem of what happens in the ER—it’s if the organization has recognized the importance of this issue and recognized that the patient’s voice must be heard.”
Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at firstname.lastname@example.org.
PSQH: Patient Safety & Quality Healthcare, March 23, 2021
Transparency is needed to connect more patients with critical services.
This article was originally published March 22, 2021 on PSQH by Megan Headley.
In addition to a direct death toll of more than 400,000, it’s becoming clear that COVID-19 is also having a significant indirect toll.
A July 2020 survey from the Kaiser Family Foundation found four in 10 U.S. adults reporting symptoms of anxiety or depressive disorder, up from one in 10 adults who reported these symptoms at the same time in 2019.
In December 2020, the CDC reported that the 12-month period ending May 2020 had the highest recorded number of drug overdose deaths in the United States, more than 81,000.
These figures hint at the fact that while overdose deaths were increasing in the months preceding the COVID-19 pandemic, they have dramatically accelerated since the pandemic’s onset, the CDC noted in a news release.
Yet, at the same time, Americans are finding it even more difficult to access behavioral health services.
The National Council for Behavioral Health found that 52% of community behavioral health organizations it surveyed have seen an increase in demand for services, while 65% have had to cancel programs, reschedule, or turn patients away due to lack of revenue or pandemic-related restrictions. Nearly 40% of these organizations predict they may not last six months due to this loss in funding.
“This is at a time when demand for their services hasn’t been higher,” points out Dr. Nishi Rawat, critical care physician and cofounder of the addiction treatment connection service OpenBeds. “So how do we go about ensuring that these behavioral health organizations can continue to offer their vital services?”
While funding is no doubt a critical part of the solution, fragmented care remains a major stumbling block when connecting people with behavioral health services. Through her organization, Rawat is seeking to create greater transparency between behavioral health and medical care providers to address the fragmentation in data and care.
OpenBeds does this work through connected provider- and public-facing platforms. On the provider side, OpenBeds offers visibility into outpatient and inpatient treatment capacity as well as decision support tools that help clinicians choose the right level of treatment for their patient. Clinicians can also use the systems to speed communication, with digital referrals and feedback as to whether the client has been accepted into treatment and whether they show up for that treatment. These frequent touch points provide a tremendous amount of data.
“We set up the two-sided network in a given region with a health system, a payer, or a state government as the convener of that network,” Rawat explains. “We provide data analytics, both at the organizational and local level as well as at the regional level, to identify gaps in care delivery as well as what’s working.”
This granular data around capacity or utilization might include the current proportion of inpatient or residential treatment beds that are available, as well as the demographics of the patients who aren’t getting treatment. States and health systems can use this rich data to drive investments around the most appropriate behavioral health solutions, based on a wide range of factors.
For the public, the platform supports a state-deployed Treatment Connection that connects people seeking mental health and substance use disorder (SUD) treatment for themselves or loved ones through a HIPAA-compliant platform. “We’re agnostic as to organizations,” Rawat says, “but we have a decision support tool that we built that helps people figure out the right type and level of treatment based on their needs.”
The platform is currently available in nine states, giving Rawat some insight into areas where there is still a need for improved care coordination between behavioral health and medical providers.
“For example,” she notes, “if you are an EMT provider, unless your patient tells you, you may not know that they actually overdosed last week and were seen at a local emergency department. So how do we go about sharing data across different types of providers in order to get better care for the patients?”
While these questions remain to be answered, targeted solutions will be critical to maximize the usefulness of available resources.
Rawat is encouraged by the state and federal government-led initiatives beginning to arise in response to the COVID-19 crisis. Paving the way for this support is $4.25 billion in funding allocated for the Substance Abuse & Mental Health Services Administration by the December 2020 COVID relief package.
This includes $1.65 billion for the community mental health block grant; $600 million for Certified Community Behavioral Health Centers; and $50 million for Project AWARE, a school-based mental health program.
“Many say that that is not enough money,” Rawat says, “but in any event, we see states using the money that they’ve been given to date to expand treatment capacity specifically for medication treatment, to build out the necessary SUD and mental health workforce, and to create the necessary data collection infrastructure to identify gaps in care.”