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 Table of Contents  
Year : 2017  |  Volume : 3  |  Issue : 3  |  Page : 176-188

Selected long abstracts from the St. Luke's university health network quality awards program (2015–2016)

Quality Resources Department, St. Luke's University Health Network, Bethlehem, PA, USA

Date of Web Publication21-Apr-2017

Correspondence Address:
Diana M Tarone
Performance Improvement Project Manager, Quality Resources Department, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, Pennsylvania 18015
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJAM.IJAM_46_17

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How to cite this article:
Tarone DM, Sabol DM. Selected long abstracts from the St. Luke's university health network quality awards program (2015–2016). Int J Acad Med 2017;3, Suppl S1:176-88

How to cite this URL:
Tarone DM, Sabol DM. Selected long abstracts from the St. Luke's university health network quality awards program (2015–2016). Int J Acad Med [serial online] 2017 [cited 2022 Dec 8];3, Suppl S1:176-88. Available from: https://www.ijam-web.org/text.asp?2017/3/3/176/204958

Guest Editors

Background Information and Event Highlights: The Annual St. Luke's University Health Network (SLUHN) Quality Awards Program (QAP) was created in 2008 to celebrate quality improvement throughout the Network. The program recognizes the contributions made by staff every day to provide quality health care to our patients and community. This venture has been very successful in encouraging our staff to become involved and to embrace performance improvement (PI) projects. The QAP is open to all seven SLUHN campuses and other entities, including inpatient and outpatient areas, and both clinical and nonclinical staff.

The PI Project Manager is responsible for planning, organizing, and managing the timeline for the event with the assistance of other Quality Resources Department (QRD) members. The QRD also coordinates the organization's PI activities. These activities include network-wide planning, project development, team facilitation, statistical analysis, information retrieval, and the preparation of project data for audio-visual presentations. This team also identifies benchmark data sources, monitors PI requirements of regulatory and accrediting agencies, and educates staff on the appropriate use of PI tools and terminology.

A quality resources member is assigned to each project and serves in consultative/advisory capacity, providing mentorship to participating teams and supporting the application process. Blinded applications are sent to competition judges for review using pre-defined, objective criteria. Scoring evaluates PI methodology, relevance of the project to SLUHN institutional mission and alignment with The Five Points of the Star Leadership Model (quality, service, people, finance, and growth) which defines focus for our organization.

The awards ceremony is held annually during National Healthcare Quality Week in October. There are five first-place winners and five second-place winners. The submissions are grouped according to the above-defined areas of quality, people, service, finance, and growth. From among the first-place winners, The President's Award for Quality is chosen. The President's Award winner is kept confidential until the ceremony. Traditionally, our QAP has served as a springboard to external awards, other programs, as well as publications. We also take the opportunity to use this venue to acknowledge other achievements from around SLUHN.

Each year, The Hospital and Healthsystem Association of Pennsylvania (HAP) honors hospitals and health systems for their innovation, creativity, and commitment to patient care through an annual Achievement Awards program. In 2016, our Network received two HAP Achievement Awards. Dr. Michael Consuelos from AP attended the ceremony and formally presented the following awards to our organization:

  • The “Community Champions Award” was presented to the St. Luke's Hospital, Miners Compus for the project: “Vision for the Future – Connecting Students to Vision Shuttle Care through Community Partnerships in a Rural Setting.”
  • The “In Safe Hands Award” was presented to the St. Luke's University Hospital, Bethlehem for the project: “Intermittent Pneumatic Compression Device Wear Time: Decreasing VTE Rates in major Orthopedic Surgical Cases.”

St. Luke's employees deeply value the QAP, and embrace the recognition and pride it brings to the Network. In addition, the QAP creates a sense of healthy competition within the organization. It is an excellent way to recognize teams that proactively engage in, and demonstrate, performance excellence. In that capacity, the QAP plays a critical role in our journey toward performance excellence as an organization.

The following core competencies are addressed in this article: Interpersonal and communication skills, medical knowledge, patient care, practice-based learning and improvement, professionalism, systems-based practice.

Keywords: Hospital and Health System Association of Pennsylvania, performance improvement, quality awards, quality improvement, St. Luke's University Health Network

  Abstract #1 Top

Intermittent pneumatic compression device wear-time: Decreasing venous thromboembolism rates in major orthopedic surgical cases

Nikki Alderfer, Peter Deringer, Rachel Lukow, Tiziana Jones, Jennifer Grell, Stanislaw Stawicki

Scientific contributors (alphabetically): Janine Beck, William G. Delong, Annette Frederick, Michelle Gormley, Natalie Gould, Kristine Hinds, Vince Lands, Jamie Meckes, Shane McGowan, Leann Rapp, Carolyn Rutkowski, Keri Scholl, April Storm, Kathy Willner

Departments of Nursing, Orthopedics, Occupational Therapy, Physical Therapy, and Research & Innovation, St. Luke's University Health Network, Bethlehem, PA, USA

Year of Submission: 2015; Award: President's Award, SLUHN Quality Awards

Introduction: Pulmonary embolism (PE) and deep vein thrombosis (DVT), collectively known as venous thromboembolism (VTE), are leading causes of morbidity and mortality in hospitalized patients.[1] VTE causes an estimated 200,000–600,000 deaths annually,[2] which places it among the most preventable causes of death in hospitalized or recently hospitalized patients.[3],[4] The average increase in health-care expenditures for a single VTE event is estimated at approximately $22,000.[2] Thus, failure to prevent VTE carries significant consequences for affected patients and substantial financial implications for involved health-care institutions. In early 2013, VTE rates at our institution were considerably higher than the national benchmark of 3.3% with only 63 hospitals out of 2063 performing below this mark.[5] An audit conducted by the network VTE Performance Improvement Team in conjunction with the Quality Resources and Patient Safety Departments determined that intermittent pneumatic compression devices (IPCDs) were not implemented as ordered or in accordance with evidence-based guidelines. The first point-prevalence audit conducted in January of 2013 on a 34-bed Orthopedic Medical Surgical Unit (OMSU) determined that only 20% of patients had IPCDs actively in use during the inspection. A pre-intervention survey of nursing staff from the OMSU revealed that 36% of the staff incorrectly believed IPCDs should be used “only when the patient is in bed.” There was also limited awareness of the recommended IPCD wear-time of at least 18 h/day following major joint replacement surgeries, according to the 2012 American College of Chest Physicians antithrombotic therapy guidelines.[6]

Project Aim/Objective: The aim of this project was to decrease the incidence of VTE in the elective total joint arthroplasty population on our OMSU by 50% over a 2-year period by utilizing a multidisciplinary approach and educational program that emphasized the importance of IPCD wear-time compliance. We hypothesized that VTE rates would decrease as a result of a targeted multifaceted intervention aimed at increasing IPCD wear-time.

Methods: After the Institutional Review Board exemption was granted, a retrospective review of our experience during the VTE reduction project (outlined in the introductory section) was performed. A plan-do-check-act performance improvement approach was used to systematically determine root causes, initiate interventions, and measure associated outcomes. Data were collected between January 2012 - December 2015 and categorized in accordance with established definitions of the Agency for Healthcare Research and Quality Patient Safety Indicators.[7] Both fishbone diagramming and a staff knowledge survey helped to identify that the following misconceptions were common among our nursing staff: (a) IPCDs are an “extra” precaution, not an essential component of VTE prophylaxis (in contrast to pharmacologic anticoagulation); (b) IPCDs should be worn only when patient is in bed; (c) limited ambulation by patient in hospital is reason to discontinue IPCD use; and (d) IPCD use when out of bed in chair will lead to increased falls. The following barriers to implementing IPCD orders were concurrently identified as follows: (a) IPCD equipment was difficult to obtain; (b) Sterile Processing Department (SPD) was frequently “out of pumps;” (c) if available in SPD, patient care units had to send someone to pick up IPCD devices or face unacceptable delivery delays; (d) staff members were unaware of 18 h/day wear-time guideline; (e) limited awareness of the importance of engaging patient/family as participants in IPCD therapy; and (f) lack of an established process to address and document active patient refusal of IPCD therapy. As a result of challenges identified, we implemented a plan to help reduce barriers associated with failures to achieve recommended patient wear-times. First, we identified the most appropriate type of bilateral IPCD for orthopedic procedures (i.e., sequential compression device SCD [calf] for total hip surgery and foot pump for knee surgeries). We then developed a patient-specific perioperative process to increase IPCD compliance. The process included IPCD education in the form of preoperative patient classes, followed by direct IPCD application in the preoperative holding area. This was further augmented by providing additional patient education regarding the importance of using the IPCD. We also provided live multidisciplinary education for nursing and physical therapy teams. Of note, we worked with hospital administration and the purchasing department to decentralize IPCD equipment, ensuring an SCD pump device in every room, and a supply of foot pumps on unit. Finally, we conducted weekly audits and biannual point-prevalence determinations for IPCD compliance and shared these results with OMSU nursing staff.

Descriptive statistics were utilized to present basic results and study sample characteristics. Differences between groups were analyzed using Mann–Whitney U-test for nonnormally distributed continuous data and Chi-square test for categorical data. Statistical significance was set at α =0.05.

Results: During the study intervention period, we observed a 72% reduction in VTE incidence on the OMSU, with the greatest drop in measured incidence noted between 2013 (24.6%) and 2014 (9.7%). [Figure 1] shows annual incidence details (P < 0.05). Point prevalence studies examining IPCD utilization were performed over the course of the study and it was noted that the OMSU where interventions were applied showed continued improvement in IPCD utilization, starting at approximately 15% utilization in January 2013 and ending at nearly 85% utilization in December 2014 [Figure 2], P< 0.05]. For our health network, IPCD utilization did rise initially but then plateaued after the 1st year. The initial rise in IPCD utilization on nonorthopedic units was likely associated with increased awareness of the IPCD initiative across our institution. Based on data published by Baser et al., the estimated health-care savings for FY15 on the OMSU were approximately $176,000 according to published VTE costs.[2] In addition, potential treatment expenses for DVT recurrence, readmissions, and the risk for potentially disabling postthrombotic syndrome can also be mitigated by the prevention of the original VTE. Based on previously published financial analyses, it has been estimated that the mean hospital cost per readmission for recurrent DVT was approximately $12,000 and the mean cost of readmission for PE was about $15,000.[8]

Discussion: Significant gaps exist in our knowledge regarding practical application of IPCD in the postoperative patient. We are not aware of studies conducted to determine whether increasing IPCD wear-time to recommended levels of 18 h/day of device operation is required to effectively reduce VTE rates. Literature sources support the use of combined mechanical and pharmacologic prophylaxis synergistically in high-risk patients.[6],[9] Similar to other patient care units across the country, our OMSU staff viewed IPCD therapy as a lower care priority. In part, this was due to the fact that the majority of our patients were on pharmacologic prophylaxis treatment, and the IPCD was deemed by some care providers to be of secondary importance. Staff also was not fully aware of the recommendation for wear-time to be 18 h/day and that IPCDs should be actively utilized when patients are out of bed in the chair. Targeted staff education covered these important topics as well as a review of the national incidence, morbidity and mortality rates associated with VTE in hospitalized patients. Education also included a published study to combat the perception that extended IPCD wear-times, especially when out of bed, would increase patient falls.[10] Falls on the OMSU were monitored, with none reported on this unit related to IPCD use during the study period. The education point-prevalence study (August, 2013) showed further opportunity for improvement, leading to the implementation of weekly unit-based audits for IPCD wear-time compliance. These audits resulted in heightened awareness of the importance of IPCD therapy and helped foster multidisciplinary accountability. In terms of equipment availability, beginning in June 2014, SCD pumps were placed in every room, and foot pump devices were kept on the unit to increase accessibility. We also expanded sleeve and foot cover size availability on the unit and published a clinical practice advisory regarding correct sizing of sleeves and foot covers, in accordance to manufacturer recommendations. Correct sizing is important for both the effectiveness of the IPCD treatment and for patient comfort. It also influences overall patient compliance with therapy.[11] New SCD pumps chosen by the network during this study included recommended wear-time compliance meter technology.[6] This technology was utilized by staff to proactively monitor SCD utilization and to increase accountability for compliance on a shift-to-shift basis. Our OMSU was the first in the nation to identify that pump compliance meter was intermittently resetting, resulting in inaccurate wear-time compliance data. A manual process for resetting the meter was developed and implemented to enable continued access to actual patient wear-time. We also worked closely with the pump vendor to determine a software-based remedy. Finally, we formalized a process whereby a patient, after appropriate explanation of risks involved, could formally decline the use of IPCD prophylaxis by signing a “refusal of treatment” form specific to IPCD therapy. We have found that this formal process has resulted in some patients who were refusing the therapy to reconsider their decision and elect to continue using IPCDs. Because of the success of the IPCD wear-time initiative on the OMSU, our study interventions have since been implemented across other SLUHN facilities and units. The subsequent network-wide results of this initiative demonstrated a 51% decrease in VTE events in the total surgical population. In addition, our institution is beginning to document wear-time compliance in the electronic medical record.

Limitations of the study include not collecting data on meter wear-time on a daily basis. In addition, the project did not distinguish between VTE events, i.e., DVT versus PE, and did not stratify data by type of orthopedic surgery, surgical risk, the type of IPCD, or by patient demographics. Finally, the current report represents a retrospective analysis of prospectively collected data. Consequently, our ability to make conclusions is limited.

Conclusion: Improved nursing and patient compliance with 18 h/day of IPCD wear-time alone led to a 72% reduction in VTE in the elective total joint arthroplasty population. PE and DVT are significant threats to patients' lives, both in the hospital and after discharge. The rate of PE and DVT can be directly impacted by the level of compliance with prophylactic measures and the quality of education provided to the patient by the bedside nurse. Educating nursing staff to recognize and reduce barriers to compliance with 18 h/day of IPCD wear-time is essential to patient safety and the reduction of VTE. Based on the statistically significant decrease in VTE incidence and the associated benefits for both our patients and the institution, it is recommended that comparable hospital networks consider adopting a similar approach. Larger scale studies are warranted on this topic.


The authors would like to thank the staff of the Orthopedic Medical Surgical Unit at St. Luke's University Health Network and William Delong MD, Chief of Orthopedics, for their generous support and assistance.

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AHRQ. Agency for Healthcare Research and Quality: Quality Indicators; 2014. Available from: https://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V30/2006-Feb-PatientSafetyIndicators.pdf. [Last accessed on 2017 Feb 18].

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  Abstract #2 Top

Impact of Flinders chronic condition management program on rural health patients' outcomes

James P. Orlando, Thomas R. Wojda, Mark Kender, Greg Dobash, Micah Gursky, William Moyer

Department of Academic Affairs, St. Luke's University Health Network, Bethlehem, St. Luke's Miners Campus Rural Health Clinics, Coaldale, PA, USA

Year of Submission: 2016; Award: SLUHN Quality Award Winner.

Introduction/Background: Health professionals may enhance the lives of those they care for with chronic conditions by working together, fostering trust, and mutual respect between the practitioner and the patient. Various approaches are available to help provide chronic condition self-management support to patients in this growing area of need. As medical innovations lead to increase in longevity in our population, prevention and management of chronic conditions is becoming more and more important. These changes are additionally affected by lifestyle issues such as improved standards of living and concurrent modifications in diet and activity levels. Taken together, the above demographic trends put significant financial pressure on health-care systems, forcing resource-strained facilities to cope with surging demand for medical services.[1] Chronic conditions are expected to consume approximately 80% of health-care costs by 2020.[2],[3] In addition, management of comorbidities consumes 78% of the average “U.S. health care dollar,” yet current and future providers are not trained in many of the evidence-based approaches to chronic disease management. First begun in Australian coordinated care trials during the late 1990's, the Flinders Program has demonstrated a positive influence on the patient-provider relationship.[4] One area of demonstrable benefit to this paradigm includes reduced alcohol utilization and global clinical improvement in war veterans with risky alcohol behaviors and chronic mental health problems.[5] Another area where the program has shown promise is diabetes control, with a clear reduction in average glycated hemoglobin levels among participating patients.[6] Important studies on this topic have been conducted around the world, including Australia, Canada, New Zealand, and the US.[7],[8],[9],[10] However, the applicability of the Flinders method may not be universal, given that important differences across cultures in Australia, Papua New Guinea, and China have been reported.[11] The Flinders Program focuses on patient-centered assessments and organization of care that enables behavioral modification using various instruments designed to encourage patient/provider interaction. The overall paradigm is based on comprehensive, personalized one-to-one evaluation, and care planning using standardized forms and tools. Health professionals must complete a 2-day training course, following which three sample case submissions must be finished. Additional details of the model are shown in [Table 1].[12]

Project Aim/Objective: The aim of this project is to pilot and evaluate the impact of the implementation of Flinders Chronic Disease Management Program (FCDMP) on rural health primary care patients with unusually high emergency department utilization (EDU) or HgA1C levels at St Luke's University Health Network's Miners Campus over a 27-month period (January 2014–March 2016).

Methods: The study design included pre-/post-intervention clinical, behavioral, and financial measures such as HgA1Cs, body mass index (BMI), Quality of Life scores (e.g., changes in patient self-efficacy), primary care physician (PCP) versus emergency department utilization (EDU), and associated health-care financial aspects. In terms of the pre-/post-intervention time-frames, the “baseline” period was between January and December 2014 and the “postintervention” period was from January 2015 to March 2016. The study included patients who had four or more emergency department visits in a 6-month period, or had an HgA1C level of 9 or higher, were refractory to traditional therapeutic approaches, and named a St. Luke's Miners Rural Health Center (SLM-RHC) provider as their primary care provider (PCP). The FCDMP is a patient/provider-centered approach using motivational interviewing, problem identification, and goal setting techniques to help patients improve their self-management skills. Fifteen SLM-RHC team members received Flinders Certification Training in October 2014. The study team identified patients who met inclusion criteria and tracked them as “Flinders patients” (FP) in the Allscripts (Allscripts, Chicago, Illinois, USA) electronic medical records system (EMRS). RHC providers started enrolling patients into the Flinders program as of January 1, 2015. Study patients were divided into two groups: (a) The interview group (G1) who underwent a Flinders interview; and (b) the non-Flinders group (G2) who did not undergo such interview. In addition, providers drew labs, took vital signs and asked patients to report on their quality of life (QOLS) and self-management skills during the initial and subsequent office visits. The study team created special fields in the EMRS to capture patient data related to the Flinders intervention. The pilot study was approved by the SLUHN's Institutional Review Board. Nonparametric tests (i.e., Mann–Whitney, Wilcoxon signed-rank) were used to analyze and compare HgA1C and vital sign data for the pre-/post-intervention periods. All other analyses were descriptive in nature and reported using graphical or tabular formats.

Results: The study team identified 85 patients who met the study inclusion criteria. For glycated hemoglobin, a Mann–Whitney test indicated that G1 patients were significantly more likely to have reduced HgA1C levels compared to G2 patients [Table 1], P< 0.002]. For BMIs, Mann–Whitney test indicated that BMI significantly increased among G2 patients while remaining constant in G1 patients [Table 2], P< 0.001]. Although there was no statistically significant difference between patients in G1 and G2 groups in terms of QOLS, there was a trend toward G1 patients improving their self-management skills [Figure 1]. Although the difference between G1 and G2 groups was not significant in terms of PCP versus EDU, we noted a trend toward G1 patients utilizing their PCP more often than G2 patients [Figure 2]. At the same time, G2 patients had higher EDU than G1 patients [Figure 3]. PCP utilization among G1 patients increased by 50% while their EDU decreased by 35% during the postintervention period. For G2 patients, the PCP utilization decreased by 23% while their EDU increased by 12% during the same time interval. In terms of hospital resources, the shift in health-care resource utilization associated with the FCDMP positively affected network finances and resulted in reduced costs of care (results not shown).

Discussion: Self-management consists of maximizing QOLS, avoiding unnecessary complications, and optimizing informal and formal support structures, such as community social networks and input from health-care providers.[13] Organizational commitment on all levels is imperative. Dedicated training and education programs facilitate proper evaluation of patients and implementation of planned interventions, but not the support for continued self-management and behavioral adjustment.[14],[15] When viewed cumulatively, the above factors combine to create a compelling argument for a comprehensive preventive health paradigm in the setting of chronic illness.[16],[17] There are numerous barriers to implementing effective programs in the area of self-management.[18],[19],[20] One major barrier is the general perception of such programs being both time and labor intensive. Another potential impediment is the fact that patients may feel as if they are being approached in a confrontational manner about a health issue that is both overwhelming and a direct threat to their well-being. Implementation may also be difficult where existing workflows and established administrative practices, largely based on acute models of care, may not be flexible enough to accommodate required systemic changes. In that context, all actors involved in the process may feel that too much is required of them to participate effectively. Patient-specific barriers to successful participation include cognitive impairment (e.g., dementia) and various socioeconomic factors.[18],[19],[20] Finally, patients who already are effective in the area of health self-management may not find value in organized institutional approaches. For such patients, the greatest utility of an organized program may be the ability to participate in routine health maintenance screening that reinforces positive behaviors and reassures patients that they are “on track.” Practice, monitoring, and mentorship of health professionals to gain proficiency may also be challenging. Finally, many organized self-management models assume that all health professionals will “buy in” to the process.[2],[21],[22]

Conclusions: Overall, this pilot study suggests that successful FCDMP implementation is associated with significant reductions in HgA1C and may prevent increases in BMI. In addition, our data suggest that the Flinders approach increases patients' utilization of their PCP while reducing EDU. Finally, the cumulative effect of the above outcomes may be beneficial to hospital finances.

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Stawicki SP, Kalra S, Jones C, Justiniano CF, Papadimos TJ, Galwankar SC, et al. Comorbidity polypharmacy score and its clinical utility: A pragmatic practitioner's perspective. J Emerg Trauma Shock 2015;8:224-31.

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Battersby MW, Beattie J, Pols RG, Smith DP, Condon J, Blunden S. A randomised controlled trial of the Flinders Program of chronic condition management in Vietnam veterans with co-morbid alcohol misuse, and psychiatric and medical conditions. Aust N Z J Psychiatry 2013;47:451-62.

Lawn SJ. A Behavioural Therapy Approach to Self-Management: The Flinders Program. Diabetes Voice 2009;54:30-2.

Battersby MW, Kit JA, Prideaux C, Harvey PW, Collins JP, Mills PD, et al. Research implementing the flinders model of self-management support with aboriginal people who have diabetes: Findings from a pilot study. Aust J Prim Health 2008;14:66-74.

Lawn S, Battersby MW, Pols RG, Lawrence J, Parry T, Urukalo M. The mental health expert patient: Findings from a pilot study of a generic chronic condition self-management programme for people with mental illness. Int J Soc Psychiatry 2007;53:63-74.

Regan-Smith M, Hirschmann K, Iobst W, Battersby M. Teaching residents chronic disease management using the Flinders model. J Cancer Educ 2006;21:60-2.

Crotty M, Prendergast J, Battersby MW, Rowett D, Graves SE, Leach G, et al. Self-management and peer support among people with arthritis on a hospital joint replacement waiting list: A randomised controlled trial. Osteoarthritis Cartilage 2009;17:1428-33.

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Fisher EB, Brownson CA, O'Toole ML, Shetty G, Anwuri VV, Glasgow RE. Ecological approaches to self-management: The case of diabetes. Am J Public Health 2005;95:1523-35.

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  Abstract #3 Top

Development of a geriatric trauma clinical management guideline

Rebecca Wilde.Onia, Thomas R. Wojda, Jennifer Grell, William S. Hoff, Alaa.Eldin Mira, Peter G. Thomas, Peter Hlavinka

Scientific contributors (alphabetical): Michael Abgott, Kallie Bashor, Danielle Bennett, Deb Dotterer, Ann Grogan, Bruce Kemmerer, Mary Fran Lipinski, Rob Menak, Christine Simon, Ann Marie Szoke, Gail Wainwright, Holly Weber, Laurie Wilson

Departments of Traumatology, Geriatrics, Advanced Practice, Nursing, Primary Care, Pharmacy, and Clinical Analytics,

St. Luke's University Health Network, Bethlehem, PA, USA

Year of Submission: 2016; Award: 1st Place Winner, SLUHN Quality Awards.

Introduction: The U.S. population is becoming progressively older. As recently as 2010, the United States Census Bureau reported that adults over the age of 65 comprise over 13% of the population.[1] This shift in demographics creates new and unique challenges for traumatologists. It is understood that the aging process alters the physiology of the elderly. Polypharmacy may exacerbate this problem, in addition to modulating patient response to injury.[2],[3] Moreover, advancements and innovation in the treatment of chronic illnesses have led to a more active geriatric population, which may predispose older patients to further injury.[4] Within this context, chronological age continues to be a major predictor of trauma-related mortality.[5] A study of >70,000 patients ages 75 and older using data from the National Trauma Data Bank found that elderly patients with multiple traumatic injuries and/or shock had a low probability of survival.[6] An Injury Severity Score >25 in patients older than 85 years carries a 25% mortality.[7]

Geriatric trauma victims are known to require significant health care resources. In this context, trauma specialists continue to be challenged with the often intricate medical management of geriatric trauma patients. Major challenges include prolonged hospital lengths of stay (HLOS), complications such as delirium, and a broad range of comorbidities present on admission. According to the American Geriatrics Society, various research and screening tools (Beers Criteria, Screening Tool of Older Persons' potentially inappropriate Prescriptions [STOPP]criteria and the Medication Appropriate Index) are valuable in measuring potentially inappropriate medication use patterns in the elderly.[8] The Identification of Seniors at Risk (ISAR) tool was developed by St. Mary's Hospital Center in collaboration with the Sir Mortimer B. Davis Jewish General Hospital, Maisonneuve-Rosemont Hospital, and the Montreal Regional Board for Health and Social Services in Quebec, Canada. This tool is a 6 item screen for identifying elderly patients at risk of adverse outcomes, and may be administered easily by health-care providers with various levels of training.[9] Our institutional trauma registry data show that nearly 40% of patients admitted to the Trauma Service were >75-year-old, substantiating the need for a clinical practice guideline to help manage this growing patient population. A multidisciplinary team consisting of trauma leadership, physicians, advanced practitioners (trauma surgery and geriatric medicine), clinical pharmacists, nurses, and case managers was identified to evaluate and optimize the care of the geriatric trauma patient during the acute hospitalization phase of care. In addition, the team wanted to assure a safe postdischarge disposition and smooth transition back to the care of each patient's primary care physician. After identifying several key areas of opportunity, our team set out to reduce HLOS and decrease the incidence of complications such as delirium in the geriatric trauma population over a 2-year period. To achieve this goal, we developed a clinical management guideline (CMG) specific for geriatric patients.

Project Aim/Objective: The aim of this study is to reduce HLOS and hospital complications such as delirium in the geriatric trauma population from 2013 to 2016 by developing and implementing a CMG.

Methods: Phase I of this project began in September 2012 with in-house clinical pharmacists completing a detailed review of patient's home and inpatient medications, using previously published tools. The recommendations to modify medications were based on the Beers Criteria, STOPP Criteria, and the Medication Appropriate Index. Following this evaluation, an advisory was generated by the pharmacist to help reduce potential medication-related complications. This was then communicated with our team. Because we did not have a dedicated geriatrician at the beginning of the project, the in-house pharmacist was the primary medication safety evaluator for this initiative. A process was put in place to alert the pharmacist of all newly admitted geriatric trauma patients ≥75 years of age. This process included the establishment and implementation of an “e-mail alert” for the in-house pharmacy team to receive new patient notifications and to ensure that each identified patient would receive a prompt and thorough evaluation. All trauma team providers were educated on this process, and the first version of the geriatric CMG was created and implemented. The second phase of the geriatric trauma CMG process added a consultation from an in-house geriatrician. In September 2013, the screening process was enhanced with the addition of the ISAR tool. All geriatric trauma patients ≥75 years of age were to be screened by trauma staff using the ISAR tool. Education was again provided to the entire trauma team, including physicians, advanced practitioners, residents, case managers, and in-patient nursing teams. Additional steps were taken to ensure screening compliance and awareness, such as a direct modification of the trauma daily progress note to include geriatric screening alerts. This established a centralized method of documenting the patient's ISAR score. Finally, laminated ISAR pocket cards were created for our trauma team providers as a resource to assist with screening appropriate patients at the bedside. Data were compiled using McKesson Horizon Performance Manager. Variables examined included geriatric consults, the decrease in specific medications (e.g., lorazepam and diphenhydramine), and hospital lengths of stay. This was completed for calendar years 2013 and 2014. Geriatric consults began in October 2013 and are still ongoing.

Results: Phase I: During a five-month period, 91 patients were evaluated, with 86% receiving a medication intervention recommendation. In total, 189 interventions were completed [Table 1]. Phase II: There was a reduction in the use of lorazepam and diphenhydramine and decreased HLOS for study patients between 2013 and 2015. Because of the program's effectiveness, the age for geriatric consults was subsequently reduced to 65 years in March 2015, with the goal of capturing more patients who may benefit from our interventions. Concurrent decreases in documented delirium, from 2.9% to 1.2%, and overall HLOS, from 9.3 days to 6.3 days, were observed [Figure 1] and [Figure 2]. Furthermore, we estimated an approximate $2.2 million in cost savings over 3 years related to the reduction in HLOS alone.

Discussion: The relationship between advanced chronological age and trauma outcomes is well established.[10] Nearly 40% of patients admitted to the Trauma Service at St. Luke's University Hospital are >70-year-old. In this context, the Trauma Program developed a CMG targeted at the geriatric trauma population ≥75 years of age. The overall intent was to optimize the care of geriatric trauma patients during the acute hospitalization, assure safe postdischarge disposition, and smoothly transition their medical oversight to primary care physicians. Because access to board certified geriatricians was limited at the beginning of the study period we utilized a clinical pharmacist during Phase I of the project. The clinical pharmacist reviewed each patient's medications using established risk assessment tools. During a 5-month period, data were measured, and a total of 189 interventions were made on 78 out of 91 (86%) patients evaluated. Our findings supported the need for greater resource availability, including in-patient geriatricians and process-specific support. This also led to Phase II of the CMG implementation. All geriatric trauma patients ≥75 years of age were flagged for screening by trauma staff using the ISAR tool. Geriatric patients who yielded scores ≥2 during this screening received an in-patient geriatric consult. Since October 2013, 418 geriatric trauma patients have undergone CMG-specific evaluations. The implementation of the geriatric consult (Phase II) was associated with a decrease of inpatient delirium diagnosis from 2.9% to 1.2% and a decrease in HLOS from 9.3 days to 6.3 days. Our group continues to review the outcomes and look for further opportunities to positively impact this patient population. Most recently, the internal medicine service also adopted the geriatric consultation model based on the trauma CMG paradigm. Moreover, the Department of Surgery implemented a geriatric surgical program with very favorable early outcomes. As a result of this project, the inpatient geriatric consults expanded throughout the hospital and exceeded established targets for volume. A Network Polypharmacy Committee has also been established to implement a pilot process similar to Phase I of our trauma CMG program, with the goal to have clinical pharmacy recommendations performed on a larger scale across the entire Network. Additional steps are also being taken to develop a working partnership among St. Luke's Physician Group practices and other primary care providers to deliver postdischarge follow-up care and direct feedback to this Network Committee. It is hoped that through this and other similar initiatives, the Committee can have a significant positive impact on all St. Luke's geriatric patients.

Conclusions: In order to provide high quality trauma care for geriatric patients, our Network allocated significant resources specifically toward this goal. A multidisciplinary team was identified to evaluate and optimize the care of the geriatric trauma patient, ensure safe postdischarge disposition, and a seamless return of medical oversight to primary care practitioners. From 2013 to 2015, we found a reduction in the use of lorazepam and diphenhydramine as well as decreased HLOS and lower incidence of delirium among patients treated in accordance to our geriatric trauma CMG. As a result of this success, the CMG target population was expanded in March 2015 to include patients who are 65 years and older. Moreover, we estimate that approximately $2.2 million in cost savings were realized over the 3-year study period, mainly due to documented reduction in HLOS. We continue to review and evaluate HLOS and a number of key inpatient complications, monitor CMG compliance, and will amend our clinical protocols based on these ongoing monitoring and quality improvement efforts.

Bradburn E, Rogers FB, Krasne M, Rogers A, Horst MA, Beelen MJ, et al. High-risk geriatric protocol: Improving mortality in the elderly. J Trauma Acute Care Surg 2012;73:435-40.

McLean AJ, Le Couteur DG. Aging biology and geriatric clinical pharmacology. Pharmacol Rev 2004;56:163-84.

Evans DC, Gerlach AT, Christy JM, Jarvis AM, Lindsey DE, Whitmill ML, et al. Pre-injury polypharmacy as a predictor of outcomes in trauma patients. Int J Crit Illn Inj Sci 2011;1:104-9.

Jacobs DG. Special considerations in geriatric injury. Curr Opin Crit Care 2003;9:535-9.

Taylor MD, Tracy JK, Meyer W, Pasquale M, Napolitano LM. Trauma in the elderly: Intensive Care Unit resource use and outcome. J Trauma Acute Care Surg 2002;53:407-14.

Nirula R, Gentilello LM. Futility of resuscitation criteria for the “young” old and the “old” old trauma patient: A national trauma data bank analysis. J Trauma Acute Care Surg 2004;57:37-41.

DeMaria EJ, Kenney PR, Merriam MA, Casanova LA, Gann DS. Survival after trauma in geriatric patients. Ann Surg 1987;206:738-43.

Campanelli CM. American Geriatrics Society updated beers criteria for potentially inappropriate medication use in older adults: The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. J Am Geriatr Soc 2012;60:616.

Dendukuri N, McCusker J, Belzile E. The identification of seniors at risk screening tool: Further evidence of concurrent and predictive validity. J Am Geriatr Soc 2004;52:290-6.

Osler T, Hales K, Baack B, Bear K, Hsi K, Pathak D, et al. Trauma in the elderly. Am J Surg 1988;156:537-43.

  Abstract #4 Top

The senior surgical services program

Ellen McHugh, Thomas R. Wojda, Peter Deringer

Scientific contributors (alphabetical): Heather Alban, Michael Amory, Diane Ankrom, Anita Buono, Aldo Carmona, Jan Concilio, Anne Grogan, Lisa Giovanni, Kelly Glaser, Marc Granson, Andrea Hahn, William Hoff, Andrew Ivankovits, Carol Kuplen, Rob Menak, Velda Mescher, Alaa-Eldin Mira, Barbara Puzzella, Tammy Shine, Virginia Wagner

Departments of Anesthesiology, Pre.Admission Testing, Administration, Educational Services, Geriatrics, Palliative Care and Pain Management, Rehabilitation Services, Surgery and Surgical Services, Medicine, Visiting Nurse Association, Trauma, Pharmacy, Case Management, Behavioral Medicine, Clinical Analytics, Marketing and Public Relations

Year of Submission : 2016; Award : 1st Place Winner, SLUHN Quality Awards.

Introduction/Background: A senior is defined as an individual whose age is 65 years or older. Projections show that 20% of the U.S. population will be aged 65 and over between 2012 and 2050, compared to 13% in 2010 and 9.8% in 1970.[1] In 2050, this population segment is projected to be 83.7 million, nearly twice the estimated senior population of 43.1 million in 2012.[1] Older age is a major risk factor for surgery as seniors tend to have incrementally greater number of comorbidities and higher incidence of polypharmacy.[2],[3] Significant comorbidity burden places the patient at greater risk for postoperative complications. Higher incidences of postoperative morbidity lead to longer postoperative length of stay (LOS), an increase in discharges to skilled nursing facilities, greater frequency of hospital readmissions, and elevated mortality risk. Associated costs to the hospital and the health care system are substantial.

Delirium, an acute decline of cognition and attention, is a severe problem which occurs in 14%–56% of hospitalized patients with associated mortality ranging from 25% to 33%.[4],[5] Delirium is linked to higher morbidity, functional decline, increased hospital costs per day, longer LOS, higher rates of nursing home placement, and increased mortality.[5],[6],[7] Delirium in older hospitalized patients is especially worrying because patients ≥65 years of age currently account for more than 48% of all hospital care days.[7] To address some of the challenges surrounding surgical care of seniors, numerous preventative measures have been described. Harari, et al.[8] demonstrated that older surgical patients who received proactive, targeted care before surgery had significantly lower postoperative rates of pneumonia (20% vs. 4%), delirium (19% vs. 6%), and pressure ulcers (19% vs. 4%). In addition, the authors noted improved pain control as well as significant reduction in hospital LOS by 4.5 days.[8] Cohen et al.[9] conducted a retrospective cohort study to determine if readily collected data in the preoperative phase may be useful in identifying older surgical patients at risk for postoperative complications. Patients with lower Braden Scale score (<18) had significantly higher risk of postoperative complications within the first 30-days, experienced longer LOS and were more likely to be discharged to a nursing or rehabilitation facility versus home.[9] The American College of Surgeons and The American College of Geriatrics have identified ten key assessment areas in the management of the aging surgical population: cognitive, depression, functional performance, gait and mobility, frailty, nutrition, medication/pain management, caregiver burden, falls, and drug/alcohol abuse. These are in addition to the basic cardiac and pulmonary assessments that should be performed before surgery on the geriatric patient.[10]

Project Aim/Objective: The purpose of this project was to assess nursing care of the geriatric surgical patient during their preoperative, surgical intervention, and postoperative phases of treatment. The goal was to demonstrate improved outcomes for older adult surgical patients, guided by the following parameters: decreased average hospital LOS by 1 day, improved readmission rates, and lower complication rates (postoperative venous thromboembolism [VTE], delirium, hemorrhage, pneumonia, and reduction in falls by 25%) over a 1 year period. To facilitate the achievement of our goal, we implemented a Senior Surgical Services Program (SSSP) based on a Geriatric Nurse Navigator (GNN) who provides assessment and guidance to older adult surgical patients throughout the entire surgical experience.

Methods: After examining our baseline surgical outcomes (LOS, readmission and complication rates for patients 70 years and older), reviewing the literature pertaining to the relationship between older age and specific surgical risk factors, and compiling team members' own clinical experiences, a program for older adult surgical patients that provided access to a GNN was developed. The following measures were implemented: (1) A Preoperative Geriatric Assessment Tool (POGAT) was created. The assessment areas included cognitive evaluation (Mini-Cog ), depression screening, functional performance, gait and mobility, nutrition, frailty, medication/pain management and caregiver burden. (2) A GNN position was created to work in conjunction with our Pre-Admission Testing (PAT) Center, Bethlehem Campus. The GNN created educational tools/PowerPoint presentations on SSSP, set up presentations with various surgical and interdisciplinary teams to introduce the program, created a position workflow and patient brochure (not shown), met with geriatric surgery patients, conducted geriatric assessments, developed a patient-specific plan of care (POC), followed through with interventions such as alerting the anesthesia team when patients failed Mini-Cog screening and alerting Ambulatory Surgery Center when a patient was identified as frail, set up home physical therapy (PT) evaluation and treatment for patients who had fallen within the last year, provided nutritional supplements for patients who were either “at risk” or positive for malnutrition, and educated patients on preparing for surgery (including realistic outcome and recovery expectations). The GNN also functioned as a patient advocate, support person who identified postsurgery needs of the patient/primary caregiver, and a communicator with the interdisciplinary care team. (3) The SSSP worked closely with Information Technology teams to build the geriatric note in our outpatient EMR system. (4) Our team coordinated efforts with the Nutrition Department, created created a Pre-Surgery Nutrition Protocol/Verbal order form, and provided patients identified as having high “malnutrition risk” with a case of a liquid nutritional supplement at the time of geriatric assessment with instructions to drink one can, two times per day up until the day of surgery. (5) The SSSP worked closely with Visiting Nurse Association and created a subcommittee for geriatric surgical patients who were identified as having elevated fall risk. The SSSP also applied for and received United Way Aging Grant to provide preoperative home physical therapy evaluations to assess for equipment and safety needs in high risk patients. Of note, this evaluation was not covered by third party payers. Finally, we followed patients at 30 days, 6 months, and 12 months postoperatively to assess for further falls.

Results: A reduction in hospital LOS by 2.37 days and a 58.9% improvement in the readmission rate postoperatively were seen following the implementation of the SSSP. In addition, a 100% improvement in postoperative falls, 51.7% improvement in postoperative VTE, 49.6% improvement in postoperative delirium, 27.5% improvement in postoperative pneumonia, and a 27.5% improvement in postoperative bleeding were noted [Table 1] and [Figure 1]. Patients in the SSSP had an average LOS of 3.66 days (down from 6.03 days). The total number of patients in the SSSP at the last data collection point was 306 (November 30, 2015). When examining the LOS reduction, estimated cost savings to the hospital for the SSSP pilot population (306 patients) were approximately $853,000. Extrapolating to the entire targeted population of elective surgical patients 70 years and older at our University Campus (Bethlehem) over a 1-year period (using the baseline of 887 patients), annual savings of approximately $2,475,000 would be realized.

In addition, when examining just one of the complications measured - VTE - with estimated added expense of $10,000-$20,000 per occurrence, the associated cost savings in the pilot population alone were between $20,000–$40,000. When extrapolating this figure to the entire target population, an annual cost savings of $60,000–$120,000 would be realized at the University Hospital Campus alone.


: Beginning in Financial Year 2015, the Hospital-Acquired Condition (HAC) Reduction Program, mandated by the Affordable Care Act, required the Center for Medicare and Medicaid to reduce hospital payments by 1% for facilities that rank among the lowest-preforming 25% with regard to HACs. VTE, hemorrhage, pneumonia and falls are all considered in the HAC Reduction Program. Therefore, the anticipated financial benefit related to the process improvement demonstrated by our project has the potential to be very significant over time.

Because of the favorable SSSP outcomes described herein, the program continues to expand, including the potential addition of further GNNs. This will allow the SSSP to capture additional older patients undergoing elective surgery and eventually expand the services to any “high-risk patient” regardless of age. Additional resources will allow our team to provide post-surgery rounding capabilities on the inpatient units to assess all program patients postoperatively and ensure that the SSSP Plans of Care are appropriately and consistently implemented. Finally, we would like to expand the SSSP to other campuses within the network. It must be noted that this is a unique program, with very few similar ventures currently in existence.


: The Senior Surgical Services Program was developed to meet the unique needs of older adults undergoing elective surgery. Led by the Geriatric Nurse Navigator, the program provides comprehensive assessment, planning and communication throughout the patient's surgical experience. Because of the very favorable outcome profile achieved, the SSSP warrants expansion to identify and assist all older patients undergoing elective surgery, as well as any high-risk patient regardless of age.

Kahn SR, Morrison DR, Cohen JM, Emed J, Tagalakis V, Roussin A, et al. Interventions for implementation of thromboprophylaxis in hospitalized medical and surgical patients at risk for venous thromboembolism. Cochrane Libr 2013; [Last accessed on 2013 Jan 01].

Baser O, Sengupta N, Dysinger A, Wang L. Thromboembolism prophylaxis in medical inpatients: Effect on outcomes and costs. Am J Manag Care 2012;18:294-302.

Blum CA, McCaffrey RG, Bishop M, Singh R, Swan A, Neese R, et al. Educating nurses about veno-thrombolytic events (VTE). J Nurses Prof Dev 2012;28:173-6.

Stawicki SP, Grossman MD, Cipolla J, Hoff WS, Hoey BA, Wainwright G, et al. Deep venous thrombosis and pulmonary embolism in trauma patients: An overstatement of the problem? Am Surg 2005;71:387-91.

Hospital Compare; 2014. Available from: http://www.medicare.gov/hospitalcompare/search.html. [Last accessed on 2017 Feb 18].

Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ; American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141 2 Suppl: 7S-47S.

AHRQ. Agency for Healthcare Research and Quality: Quality Indicators; 2014. Available from: https://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V30/2006-Feb-PatientSafetyIndicators.pdf. [Last accessed on 2017 Feb 18].

Spyropoulos AC, Lin J. Direct medical costs of venous thromboembolism and subsequent hospital readmission rates: An administrative claims analysis from 30 managed care organizations. J Manag Care Pharm 2007;13:475-86.

Kakkos SK, Caprini JA, Geroulakos G, Nicolaides AN, Stansby G, Reddy DJ, et al. Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism. Cochrane Libr 2016; [Last accessed on 2013 Jan 01].

Boelig MM, Streiff MB, Hobson DB, Kraus PS, Pronovost PJ, Haut ER. Are sequential compression devices commonly associated with in-hospital falls? A myth-busters review using the patient safety net database. J Patient Saf 2011;7:77-9.

Moore C. Enhancing patient outcomes with sequential compression device therapy; 2014. Available from: https://www.americannursetoday.com/enhancing-patient-outcomes-with-sequential-compression-device-therapy. [Last accessed on 2017 Mar 12].


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