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Hospitalist-Led Quality Improvement Projects to Replicate in Your Hospital


 

Hospitalist-Led Quality Improvement Projects to Replicate in Your Hospital

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The largest drivers of healthcare costs are physicians, but these professionals are among the least comfortable discussing healthcare value. According to Leora Horwitz, MD, MHS, director of the Center for Healthcare Innovation and Delivery Science at NYU Langone Medical Center in New York City, physicians prefer to focus on individual patient interactions rather than questions of cost and population management.

Choosing Wisely, a campaign launched in April 2012 by the American Board of Internal Medicine Foundation to encourage conversations between providers and patients, is designed to help patients choose tests, procedures, and care that are necessary, evidence-based, and not harmful or redundant, while allowing physicians to approach the question of value in terms of how to best care for each patient.1 By focusing on very common practices and relying on well-established evidence as the basis of each specialty’s recommendations, Choosing Wisely has garnered widespread support.

Below are five examples of Choosing Wisely programs, initiated by hospitalists around the country. Each is doable, scalable, and reproducible in a variety of inpatient settings.

Mount Sinai Hospital, New York City

“Lose the Tube” was initiated at New York’s Mount Sinai Medical Center to reduce the incidences of catheter-associated urinary tract infection, or CAUTI. The five-month intervention period began April 1, 2014, and lasted through August 31, 2014.

Using electronic health records (EHRs), urinary catheter patients were identified based on nursing documentation and urinary catheter (UC) orders. Once patients were “flagged,” hospitalists would approach each of their providers during interdisciplinary rounds and ask if the patient needed the Foley. Additionally, unit-based metrics of UC and CAUTI were disseminated at weekly meetings to unit medical directors to promote engagement, discussion, and transparency; educational reminders were given monthly in orientations to subinterns, residents, and attending physicians.

“Lose the Tube” proved very successful, reducing rates to 0.2 CAUTI/month from 2.67 CAUTI/month during the intervention period. Total catheter days decreased to 4,318 from 5,610, to 877.0 catheter days/month from 948.5 catheter days/month. CAUTI rate was decreased from to 0.23 CAUTI/1000 catheter days from 2.85 CAUTI/1000 catheter days.

The simplicity of the approach of “Lose the Tube” makes it easily reproducible in other institutions. The intervention uses the existing EHR to readily identify UC in patients; the interaction between the hospitalist and other clinicians is succinct and easily integrated into existing communications. As Hyung Cho, MD, director of quality and patient safety at Mount Sinai, says, “Awareness for Choosing Wisely is definitely there. We just need to figure out ways to integrate these recommendations into our systems.”2

Cincinnati Children’s Hospital Medical Center

The Cincinnati Children’s Hospital initiated a campaign to reduce continuous pulse oximetry use for patients with asthma and bronchiolitis in line with Choosing Wisely recommendations and the hospital’s own guidelines. The objective was to reduce continuous pulse oximetry time after weaning to room air or weaning to every two-hour albuterol treatments from 10.7 hours (baseline) by at least 50% to 5.4 hours.

The initial step was to define goals for discontinuation of pulse oximetry of greater than 90% oxygen saturation on room air or weaning to albuterol treatments every two hours based on existing weaning protocol. These goals were communicated to the unit staff at monthly resident team and nursing meetings. At this point, a decrease was seen in the median time per week to 4.1 hours.

The next intervention changed default settings in the bronchiolitis electronic order set, which allowed the nurse to transition to intermittent pulse oximetry when goals were met and no new clinical concerns arose. A three-item checklist was introduced to identify patients whose goals were met for timely discontinuation during the previous shift, which resulted in a further reduction of more than 70% from baseline, to a median time per week of 3.1 hours.

The straightforward simplicity of interventions, including a paper checklist and changes to order sets, makes them reproducible in a variety of other hospital settings. Another key facilitator was the involvement of the nursing staff. Educating nurses on local guidelines for intermittent oximetry use empowered them to proactively transition patients who met the goals and presented no clinical concerns, which removed the step of calling the resident to change the order.3

Stanford University Hospital

Dr. Shieh

Dr. Shieh

Lisa Shieh, MD, PhD, reports that Stanford began by creating a steering committee of representatives from all hospital departments, which resulted in the development of evidence-based guidelines for necessary transfusions. The hospital’s EHR was programmed to fire a best practice alert (BPA) should a physician order a transfusion in a hemodynamically stable (hemoglobin reading 7 or above) patient; however, the smart BPA did not fire for patients diagnosed with bleeding disorders, hematology and oncology patients, and other special populations. Should a physician choose to transfuse despite the BPA, a reason had to be entered into the EHR.

Prior to the intervention, 50% of transfusions at Stanford were given to patients with a hemoglobin reading of 8 or above. After the intervention, only 30% fell into that category.

“Giving physicians information via the BPA in the moment they are treating the patient really made the difference,” Dr. Shieh says. “The fact that it allows them to explain why they are choosing to transfuse a particular patient allows us to understand appropriate blood usage better.”

“There are patients who really do need blood but exist outside the guidelines.”

“Adding the educational component really helped make the change in how physicians practice. When they understand why they are being asked to do things differently, they are more likely to change their behavior.” —Manya Gupta, MD

University of California, San Diego

Dr. Seymann

Dr. Seymann

Remus Popa, MD, and Gregory Seymann, MD, SFHM, instituted a program at the University of California at San Diego hospital to reduce the number of patients in a telemetry bed who receive no benefit from cardiac monitoring. When physicians entered telemetry orders into a patient’s EHR, they were prompted to choose a diagnosis from the list of accepted indications programmed into the system. They were also able to choose a diagnosis of “Other” for patients who existed outside the guidelines and then explain their reasoning for ordering cardiac monitoring.

“This system is not attempting to limit the physician’s autonomy,” Dr. Popa explains. “Choosing ‘Other’ allows the clinician to order telemetry for patients with special situations, maybe not entirely addressed by the guidelines, and entering a reason can help tweak the telemetry order set going forward.”

The intervention successfully reduced the use of telemetry to a post-intervention rate of 20% from a baseline of 44%. An additional benefit was the 1.2-hour reduction in time elapsed from presentation at the ED to being placed in the telemetry bed. Because fewer of these beds were in use at any time, patients who could benefit from cardiac monitoring were in place faster.

Rush University Hospital, Chicago

Hospitalist Manya Gupta, MD, an assistant professor in the department of internal medicine, and her team at Rush embarked on a program to decrease the number of blood transfusions performed per year to be more in line with new data demonstrating that more restrictive transfusions result in better patient outcomes. The hospital had originally tried to reduce the number of transfusions by amending the blood transfusion order set in the EHR system, requiring physicians to select the indication for the transfusion from a checklist. If the desired indication was not found on the checklist, they could check “Other” and proceed with the transfusion, even if the patient did not require a transfusion. This system did not result in a meaningful decrease in transfusion.

“Accordingly, reducing these inefficiencies and improving coordination across the care continuum are top priorities within healthcare delivery

organizations. Maximize effective, efficient care and eliminate the waste.” —Andrew Masica, MD, MSCI

In March 2013, Rush implemented a two-pronged approach to changing its transfusion culture. The indication of “Other” in the Epic EHR system was removed, and all indications on the checklist were made more specific. Acceptable choices included “hemoglobin <7” or “hemoglobin <8 with symptoms” or “active ischemic or cardiac event.” This change in the order sets also allowed Rush to more precisely track why patients were receiving blood—useful information to build on going forward.

Concurrently, the hospital initiated an intense educational campaign as part of its safety conferences, regularly scheduled meetings for house staff and hospitalists, in which the staff were taught the appropriate indications for blood transfusion and what data exist in the literature to support limiting transfusions, as well as how to transfuse correctly.

Dr. Gupta stresses that educating the physicians made a major impact on the program’s success. “Adding the educational component really helped make the change in how physicians practice,” she says. “When they understand why they are being asked to do things differently, they are more likely to change their behavior.”

Rush successfully lowered the total number of transfusions from 1,491 in the 14 months prior to the intervention to 953 transfusions between May 2013 and June 2014, a decrease of 36%. Transfusions in patients with hemoglobin greater than 8 were tracked during the same time periods, and that amount dropped to 121 post-intervention from 320 pre-intervention, a reduction of over 60%.

Dr. Gupta says that the latter reduction was particularly satisfying, because “not only were we able to reduce the total amount of blood transfused but also to keep the blood that was transfused within the guidelines.”

In Sum

Choosing Wisely addresses the complex relationship between cost and quality in healthcare.

“Fragmented, wasteful systems, particularly where there is duplication of services, produce poor outcomes at higher costs,” says Andrew Masica, MD, MSCI, vice president and chief clinical effectiveness officer at Baylor Scott and White Healthcare of Dallas. “Accordingly, reducing these inefficiencies and improving coordination across the care continuum are top priorities within healthcare delivery organizations. Maximize effective, efficient care and eliminate the waste.”


Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

Residents Choosing Wisely

Dr. Popa

Dr. Popa

Drs. Popa and Seymann were inspired by their Choosing Wisely project success to actively involve the residents at UCSD in improving healthcare value at their hospital.

Every two weeks, Dr. Popa and Dr. Seymann introduce a new group of students to one or more wasteful healthcare practices, often drawing them from Choosing Wisely recommendations.

“These discussions are eye-opening moments for the students, when they suddenly see there are high-cost practices which really don’t benefit patients,” Dr. Seymann says.

The instructors point the residents toward data from their hospital or literature on the topic and instruct them to educate themselves with this material and return with proposals to decrease the wasteful practices.

“The residents are the front-line workers, doing the day-to-day work on the units,” Dr. Seymann says. “They know what works and what needs fixing.”

Many of their suggestions are creative and practical and have made major contributions to more efficient, less wasteful red blood cell and daily lab protocols, as well as telemetry usage.

References

  1. American Board of Internal Medicine. About Choosing Wisely. ABIM website. Accessed June 9, 2015.
  2. Cho H, Khalil S, Wallach F, et al. Lose the tube: preventing catheter-associated urinary tract infections. Meeting abstract. Accessed June 9, 2015.
  3. Schondelmeyer AC, Simmons JM, Statile AM, et al. Using quality improvement to reduce continuous pulse oximetry use in children with wheezing. Pediatrics. 2015;135(4):e1044-e1051.

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