|CONFERENCE ABSTRACTS AND REPORTS
|Year : 2018 | Volume
| Issue : 2 | Page : 209-243
Selected long abstracts from the St. Luke's University Health Network Quality Awards Program (2017)
|Date of Web Publication||30-Aug-2018|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Selected long abstracts from the St. Luke's University Health Network Quality Awards Program (2017). Int J Acad Med 2018;4:209-43
Diana M. Tarone, Donna Sabol
Department of Quality Resources, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
Address for correspondence: Diana M. Tarone, Quality Resources Department, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, Pennsylvania 18015, USA. E-mail: [email protected]
The St. Luke's Annual Quality Awards Program was created in 2008 to acknowledge innovation and quality improvement throughout the network. The awards ceremony is held annually in conjunction with National Healthcare Quality Week in October. The program is open to all ten campuses in our network and other entities including inpatient and outpatient units, and both clinical and nonclinical areas that contribute to our high-quality care and excellent patient outcomes.
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 Healthsystem Association of Pennsylvania, performance improvement, quality awards, quality improvement, St. Luke's University Health Network
Background Information and Event Highlights: The Annual St. Luke's University Health Network (SLUHN) Quality Awards Program (QAP) was held October 18, 2017, at the SteelStacks Conference Facility/ArtsQuest Center in Bethlehem, Pennsylvania. This special event marked the QAPs 10th year of recognizing network-wide contributions to improve the quality of care provided to our patients and community. Members from the Board of Trustees and Network Administrators participated in the ceremony, along with numerous care providers and other institutional contributors/supporters.
The program recognizes various innovative ideas and contributions made by staff, primarily intended to increase efficiencies, raise standards, and improve care and services provided to our patients and the regional community. The QAP criteria align with SLUHNs mission, unwavering commitment to excellence, and making the patient our highest priority.
This year's program not only received a record number of 46 submissions but also provided a noteworthy look-back at each of the 10 previous year's President's Award Winners. These projects displayed continued sustainability and success well after each respective team received the top recognition. In fact, many of the projects saw significant expansion across the network, institutional investment, and served as foundation for future successful undertakings. The dissemination of quality initiatives throughout the network resulted in numerous innovations, new efficiencies, best practices, improvements in patient care, and better/more effective organizational processes.
Many of the SLUHN quality projects are also submitted to other award programs. 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. There were 91 entries competing in the 2018 program, with 12 winners recognized across four categories. Four of those awards were presented to SLUHN hospitals. The winning teams were recognized at an awards ceremony on May 22, 2018, during HAPs Annual Leadership Summit:
- The “Optimal Operations Award” was presented to St. Luke's Hospital, Quakertown Campus for the project: “Perioperative Services First Case Start Performance Improvement”
- A second “Optimal Operations Award” was presented to St. Luke's Hospital, Allentown Campus for the project: “Improving Sepsis Core Measure Compliance through the Use of a Predictive Analytic Supported Sepsis Alert Protocol”
- The “In Safe Hands Award” was presented to St. Luke's University Hospital, Bethlehem Campus for the project: “Save a Kidney – Orthopedic Total Joint Acute Kidney Injury Reduction”
- The “Excellence in Care Award” was presented to St. Luke's University Health Hospital, Bethlehem Campus for the project: “Don't Just do Something – Stand There! Reducing the Incidence of Pneumothoraces in High Risk Newborns.”
In this issue of the International Journal of Academic Medicine, we will present selected long abstracts from the award years 2016–2017, focusing on the highest quality submissions and QAP winners. Each abstract listing features primary authors while also fully recognizing all scientific contributors and participating quality project team members. As in previous years, each long abstract is uniformly structured and consists of an introductory section, project aim/objective, methods, results, sourced/referenced discussion, and conclusions.
| Abstract Number 1|| |
Integration of Behavioral Health Services into Primary Care Practices
Authors: V. Wagner, J. Holtman, A. Allanson-Dundon, J. Illingworth, M. Abgott, P. Forest, T. Martinez, T. R. Wojda
Scientific contributors (alphabetically): H. Evans, L. Gately, M. Harris, C. Lewis
Departments: St. Luke's Physician's Group, St. Luke's Care Network, Department of Psychiatry, St. Luke's University Health Network, Bethlehem, Pennsylvania, Department of Psychiatry, St. Luke's University Health Network, Phillipsburg, New Jersey, USA
Year of Submission: 2017
Introduction: Behavioral health involves the management of diagnoses associated with mental health, substance abuse, and physical symptoms caused by stress.1 Behavioral health integration synergistically combines primary care and behavioral health clinicians who work in concert with patients and families, using a systematic, cost-effective, patient-centered approach to better match clinical services for the aforementioned issues.1 The importance of behavioral health services/support within primary care is highlighted by the high degree of unmet need, coupled with acute shortage of mental health professionals.2 The magnitude of the problem can be demonstrated by the fact that a significant proportion of patients with common physical complaints have no identifiable organic etiology;3 approximately four out of five of individuals with a behavioral health disorder will visit primary care provider at least once during any calendar year;4 about half of all behavioral health disorders are treated in primary care;5 between 20% and 40% of primary care patients have behavioral health needs;6 and 48% of the appointments for psychotropic agents are with a nonpsychiatric primary care provider.7
Due to these worrisome national statistics and trends, our Behavioral Health Integration Program (BHIP) set out to provide patients access to appropriate resources and improve outcomes for patients with moderate-to-severe emotional distress, while at the same time enhancing provider satisfaction. Before integration, providers at our primary care sites had limited resources for assessing, evaluation, and treatment of patients with mild-to-moderate mental health issues. Consequently, this placed a significant strain on various components of the system. In addition, access to more intensive mental health treatments was challenging, presenting yet another opportunity for improvement.2 When developing the BHIP, we carefully reviewed other similar regional programs.
There were several aims of his project. Among those, we sought to increase initial access to behavioral health services/interventions in the primary care setting, improve patient outcomes, and demonstrate program growth, sustainability, and cost-effectiveness. The strategy used to accomplish our primary goals included increasing behavioral health visits in primary care practices, increasing downstream referrals to our behavioral health centers by 25% over the first 6 months of the program, and standardizing measurement and monitoring of improvement in a patient's mental, emotional, and physical health symptoms through development and implementation of an Integrated Health Assessment Form.
Methods: The project was conducted between August 1, 2015, and August 1, 2016. Centralized data gathering mechanism provided by the network was used to determine which primary care practices had the highest number of mental health diagnoses. As a result, two programs were identified as initial practices with 824 and 460 patients with mental health diagnoses per year, respectively. These sites also had sufficient space to embed a behavioral health specialist (BHS).
Using regularly scheduled integration team meetings, the following measures were identified to monitor program efficacy and growth: patient health questionnaire-9 (PHQ9 to monitor depressive symptoms); reduction in network emergency department (ED) utilization; network medication performance improvement study to track and optimize primary care provider treatment quality for patients with depression; integration program patient volumes; integration network referrals to outpatient behavioral health (including downstream revenues); and provider satisfaction with integration program.
Monthly data were collected and tracked by dedicated information technology staff and an integration clinical coordinator. Aggregate data reviews took place quarterly basis, primarily during integration team meetings. Beginning August 1, 2015, a BHS was embedded into the programs, splitting time between practices Monday through Friday, assisting primary care providers in recognizing, treating and managing behavioral health and psychosocial issues, and acting as a contributing member of the primary care team. The BHSs duties included patient assessments, brief therapy services, and referrals for more intensive behavioral health services for patients in integrated primary care settings.
Increased referrals to the BHS provided support for expanding the program to include a second BHS for the program in June 2016. In addition, to assist with improving care quality during this period, the integration program developed a medication process improvement project under the direction of our lead psychiatrist. The goal of the latter initiative was to optimize and standardize treatment quality for patients with depression across our integrated primary care practices. Thirty random patient charts from the initial four integrated practices were audited to assess the appropriateness of treatment based on the American Psychiatric Association (APA) standards of care regarding appropriate diagnosis, medications prescribed, and laboratory study ordering patterns. After initial audit results, educational seminars were developed and presented to providers at the integrated sites to help discuss various opportunities for improvement. Descriptive statistics using frequencies/percentages were utilized to outline the study results. Because this was a pilot program, no statistical or power analysis was performed. Institutional Review Board approval was obtained before presentation/publication of these results.
Results: During the study period, 700 patients were seen for a total of 1256 visits, and 192 referrals were completed to behavioral health for more intensive outpatient services [Figure 1]. Within 6 months of the program initiation (August 2015), referrals increased by 341% (from 17/month to 75/month). We also noted that 97% of patients seen in the BHIP reported a reduction in symptoms following integration visit. Looking at data from 178 initial and 166 follow-up PHQ9 questionnaires, composite scores indicated a 58% reduction in depressive symptoms following integration visit(s) – this exceeded both the “target performance” (50%) and “high performance” (55%) reduction benchmarks.
During the project duration, average reimbursement per session increased slightly, from $52 to $55. Given the combination of increased referral volume and greater reimbursement per session, the 2016 financial year closed at $40,000 net revenue and was on pace to reach $90,000 during the 2017 financial year. Total investment per clinician for the 2016 financial year was $52,000, which decreased to $38,000 for the 2017 financial year. Two provider satisfaction surveys were completed in integrated primary care settings indicating 97% (July 2015) and 99% (June 2016) provider satisfaction with the BHIP. To demonstrate program efficacy, an Integrated Symptom Assessment/Reduction Survey of 400 integration patients was conducted, showing a 97% reduction in symptoms following an integration visit (note: targeted goal performance was 90%).
In the first two-quarters of the study period, 501 BHIP visits were completed. During the subsequent two quarters, 755 took place [51% increase, [Figure 2]]. We were also able to link integration patients with the appropriate and more intensive psychiatric services through referrals to behavioral health. In the first two quarters, 62 referrals were completed. In the last two quarters, an increase to 130 referrals represented 110% growth. Regarding the medication performance improvement project aimed at improving the management of patients with a diagnosis of depression, an audit was completed following targeted provider education sessions, with 73% of charts meeting APA standards of care for diagnosis, medications prescribed, and laboratory tests ordered – overall a 38% improvement from baseline.
Discussion: It is estimated that approximately 67% of individuals with behavioral health needs do not receive required treatment,5 and that 30%–50% of primary care referrals for behavioral health evaluation and treatment are lost to follow-up.8,9 Furthermore, two-thirds of primary care physicians have limited or no access to outpatient behavioral health for patients due to shortages of mental health-care providers, health plan barriers, and lack of adequate coverage.2,10 One very common mental health diagnosis – depression – goes undetected in as many as half of primary care patients,11 and only 20%–40% of patients improve substantially in 6 months without specialty assistance.12
Taking the above considerations into account, behavioral health initiatives may have significant positive effects on patients participating in personalized programs, such as the BHIP. According to Chiles et al.,13 average savings resulting from implementing mental health interventions were approximately 20%, resulting in estimated savings in the range of $1759–$2205 per episode of care. In another study of diabetic patients, effective treatment of depression was associated with nearly $900 lower total health-care costs over a 24-month period.14 Management of depression in the primary care setting has been shown to result in health-care cost reduction of approximately $3300 over 48 months, translating roughly into a return of $6.50 for every $1 spent.15 Others corroborate these findings in similar settings, with equally sustainable, favorable outcomes.16 Altogether, 75 clinical studies in the area of collaborative care spanning two decades have shown significant improvement in the management of depression and anxiety disorders,17 across a wide variety of settings,18 with better patient engagement and adherence to evidence-based treatment.19 When mental health management is incorporated into a comprehensive treatment program, both chronic physical health and quality of life tend to improve.18,20
Within the parameters of our program, timely (and sometimes immediate) access to behavioral health services in the integrated primary care settings was provided. This was clearly associated with patient volume growth. The BHIP was initially located within two network primary care practices (e.g., August 2015). In December 2015, we expanded to another center, with an additional practice added in January 2016. Following the on-boarding of our second BHS, expansion continued to two more practices by July 2016. When looking at barriers to implementation specific to the BHIP, the level of comfort with, and the understanding of, the program's structure and purpose by providers and patients was a significant issue. Marketing of the effort was also challenging. Both of these barriers were overcome through commitment and persistence in implementing and developing the program. Specific interventions included patient letters, meet-and-greet sessions for patients, as well as dedicated marketing materials available across our integrated practices. Especially useful and effective were rack cards and program description pamphlets. Important to program coordination and harmonization, BHS participation in practice provider/staff meetings, and daily practice huddles with staff were implemented successfully. This mechanism also helped to facilitate daily interactions between staff and providers regarding patient care.
Sustainability of the BHIP is of critical importance and will continue to be monitored through PHQ9 data as well as ED utilization data, both of which are now included on a customized electronic medical record dashboard. The integration team is currently refining, improving, and developing additional quality measures. ED utilization data are being integrated with clinical applications necessary to BHIPs daily functioning. Our initial ED utilization report has reviewed 784 integration patient ED visits at both 6-month pre-integration and 6-month postintegration time points. Corresponding data showed 387 ED visits preintegration and 337 visits postintegration, representing a 13% decrease. This decrease in ED utilization represents cost savings of $161,950.
Moving forward, reduction of inpatient admissions, and better management of medical comorbidities (e.g., diabetes and hypertension) among BHIP patients will be monitored. During the 2017 financial year, approval to develop a 3-year network plan to expand BHIP into all primary care practices was granted. As of late 2017, BHIP has been expanded into ten practices. Throughout the applicable period, referrals remained at a relatively steady level [Figure 3], and patient volumes steadily increased [Figure 4]. This highlights the important role that the BHIP plays across our network's communities.
Given its quasi-experimental design, the current study is subject to inherent biases. The largely descriptive nature of this report, combined with the potential presence of confounding variables, may limit the applicability of our results to other institutions and/or settings. Moreover, despite short-term results showing promise, long-term sustainability of the BHIP and its results remain to be shown. Nonetheless, this report demonstrates the ability of the BHIP to increase patient access to behavioral health services and/or interventions in the primary care setting, with subsequent improvement in patient outcomes and enhanced cost-effectiveness through greater utilization of behavioral health resources across our primary care practices, as well as downstream referrals to behavioral specialty centers.
Conclusion: The BHIP was able to facilitate timely (and sometimes immediate) access to behavioral health services in integrated primary care settings. This was reflected by the growth of patient volumes following the implementation of the program. Moreover, the program was also able to link patients with the appropriate and more intensive psychiatric services through referrals to BHS. Currently, the BHIP team is looking to refine, improve, and develop additional quality measures. Moving forward, we hope to capture quantitative data on inpatient admission reduction and improved management of medical comorbidities (e.g., diabetes and hypertension) for BHIP patients. Given its early success, the program is now undergoing expansion to other primary care sites across our network.
- Peek C; National Integration Academy Council. Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus. National Integration Academy Council; 2013.
- Butryn T, Bryant L, Marchionni C, Sholevar F. The shortage of psychiatrists and other mental health providers: Causes, current state, and potential solutions. Int J Acad Med 2017;3:5.
- Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory care: Incidence, evaluation, therapy, and outcome. Am J Med 1989;86:262-6.
- Hunter CL. Behavioral Health in the Patient Centered Medical Home (PCMH): An Important Part of Meeting the Quadruple Aim and Achieving Level II & III NCQA PCMH Recognition. Tricare Management Activity Falls Church VA; 2011.
- Kessler RC, Demler O, Frank RG, Olfson M, Pincus HA, Walters EE, et al. Prevalence and treatment of mental disorders, 1990 to 2003. N Engl J Med 2005;352:2515-23.
- Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, et al. No health without mental health. Lancet 2007;370:859-77.
- Pincus HA, Tanielian TL, Marcus SC, Olfson M, Zarin DA, Thompson J, et al. Prescribing trends in psychotropic medications: Primary care, psychiatry, and other medical specialties. JAMA 1998;279:526-31.
- Fisher L, Ransom DC. Developing a strategy for managing behavioral health care within the context of primary care. Arch Fam Med 1997;6:324-33.
- Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA 2006;295:1023-32.
- Cunningham PJ. Beyond parity: Primary care physicians' perspectives on access to mental health care. Health Aff (Millwood) 2009;28:w490-501.
- Mitchell AJ, Vaze A, Rao S. Clinical diagnosis of depression in primary care: A meta-analysis. Lancet 2009;374:609-19.
- Coulehan JL, Schulberg HC, Block MR, Madonia MJ, Rodriguez E. Treating depressed primary care patients improves their physical, mental, and social functioning. Arch Intern Med 1997;157:1113-20.
- Chiles JA, Lambert MJ, Hatch AL. The impact of psychological interventions on medical cost offset: A meta-analytic review. Clin Psychol Sci Pract 1999;6:204-20.
- Katon W, Unützer J, Fan MY, Williams JW Jr., Schoenbaum M, Lin EH, et al. Cost-effectiveness and net benefit of enhanced treatment of depression for older adults with diabetes and depression. Diabetes Care 2006;29:265-70.
- Unutzer J, Katon WJ, Fan MY, Schoenbaum MC, Lin EH, Della Penna RD, et al. Long-term cost effects of collaborative care for late-life depression. Am J Manag Care 2008;14:95-100.
- Katon W, Russo J, Lin EH, Schmittdiel J, Ciechanowski P, Ludman E, et al. Cost-effectiveness of a multicondition collaborative care intervention: A randomized controlled trial. Arch Gen Psychiatry 2012;69:506-14.
- Archer J, Bower P, Gilbody S, Lovell K, Richards D, Gask L, et al. Collaborative care for depression and anxiety problems. Cochrane Database Syst Rev 2012;10:CD006525.
- Woltmann E, Grogan-Kaylor A, Perron B, Georges H, Kilbourne AM, Bauer MS, et al. Comparative effectiveness of collaborative chronic care models for mental health conditions across primary, specialty, and behavioral health care settings: Systematic review and meta-analysis. Am J Psychiatry 2012;169:790-804.
- Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression: A cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med 2006;166:2314-21.
- Katon WJ, Lin EH, Von Korff M, Ciechanowski P, Ludman EJ, Young B, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med 2010;363:2611-20.
| Abstract Number 2|| |
Developing an Industry-Leading Vaccine Management Program
Authors: T. Arnold, C. Smoyer, P. Kaur
Scientific contributors (alphabetically): M. Abgott, M. Harris, J. Kahle
Departments: Departments of Analytics and Business Intelligence, Executive Leadership, Finance, Legal Services, Marketing and Public Relations, Medical Leadership, Primary Care, Pediatric Care, Purchasing, Quality and Risk Management, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
Year of Submission: 2017
Introduction/Background: Vaccinations are considered to be among the most important interventions in the history of public health, saving millions of lives every year.1 Because vaccines are biological products, they lose their potency and become inactive over time.2,3,4,5,6,7,8,9 Moreover, temperature-controlled storage is an important requirement, starting with the time of manufacturing through patient administration (cold-chain) of the vaccine, and it is established that proper vaccine storage and handling (VSH) are directly linked to the effective prevention of disease.4 Storage and handling-related errors can reduce vaccine potency and thus lead to the need for avoidable revaccination. This can contribute to loss of public confidence in vaccines which, in turn, may result in decreased vaccination rates and ultimately inadequate control of vaccine-preventable diseases.4
VSH challenges occur around the world, regardless of income status, climate, and other factors.1,5 A recent literature review identified that the incidence of vaccines exposed to temperatures below the required range was similar among high- and low-income countries.5 In addition, the same review identified acute need for better equipment, staff training, stricter supervision, and accountability at various stages in the cold-chain process.5 Effective VSH processes, combined with appropriate staff training, result in timely identification of deficiencies, decrease vaccine wastage and financial loss, reduce potential revaccination(s), and most importantly, improve patient outcomes and enhance disease prevention.4,7
Although VSH deficiencies have been identified as a serious issue contributing to reduced vaccine efficacy, wasting of valuable resources, and financial loss, health-care agencies struggle to implement more reliable processes and systems.5 Health-care professionals have a responsibility to ensure that patients receive vaccines that have not been adversely affected by improper storage.4 The Centers for Disease Control and Prevention (CDC) identified three main elements of an effective cold-chain process: a well-trained staff, reliable storage and temperature monitoring equipment, and accurate vaccine inventory management.4
Equipment malfunctions can lead to breaches in cold chain, even in well-designed and well-managed systems. A 2012 study by the Department of Health and Human Services Office of Inspector General concluded that 76% of the practices participating in the Vaccines for Children Program (VFC) had temperature excursions of at least 5 cumulative hours during a 2-week period.7 Furthermore, the study demonstrated that an average vaccine inventory of 250 vaccines would result in a financial loss of approximately $11,000 for a single storage unit.7
The development of new, more expensive vaccines has further heightened the importance of proper VSH.2 Novel vaccines are anticipated to make up more than 40% of total vaccine costs by 2020.10 Various national immunization stakeholders are actively discussing additional strategies to improve vaccine stability including the manufacturing process, cold-chain labeling of vaccine packaging, and other key elements of the overall vaccination program/system.6
Project Aim/Objective: The aim of this project was to identify root causes of VSH deficiencies in an effort to develop and implement VSH processes that promote vaccine efficacy and reduce vaccine wastage (and thus financial loss) as a result of improperly stored vaccines. The goal of the vaccine management initiative was to eliminate revaccinations related to VSH deficiencies within 1 year of program implementation [Figure 1].
Methods: The study utilized the standard Plan-Do-Check-Act model of continuous process improvement.8 The study design included baseline and postintervention periods. The baseline period was January 1, 2014 to December 31, 2017. The postintervention period was January 1, 2017 to March 31, 2018.
A director of vaccine management was appointed on July 31, 2016. An environmental audit of physician practices that administer vaccines was performed to assess current VSH processes and equipment status. Staff knowledge was assessed using interview techniques. Root cause analysis findings resulted in the development of strategies and action plans to improve staff knowledge, replace suboptimal storage equipment, and cultivate organizational oversight and support.
The project leadership team completed an internal audit of temperature monitoring logs between January 1, 2014, and December 31, 2017. Main audit results are shown in [Figure 2]. The audit included an analytical comparison of documented storage temperatures, patient health records, and vaccine manufacturer storage specifications to determine the need for potential revaccination(s). Final analysis determined the need for 6050 revaccinations, with corresponding clinical campaign initiated in December 2016 and completed by October 31, 2017. Of note, the vast majority of affected patients either received (or declined) recommended revaccination(s), with only a small number of individuals failing to respond to multiple verbal and written communications.
By September 30, 2016, a primary and alternate vaccine coordinator (PAVC) was appointed for practices that administer vaccines, and 1140 employees, including 233 PAVC, received organization-specific VSH education through e-learning modules based on CDC best practices. In addition, 207 PAVCs received hands-on, simulation-based training to improve vaccine temperature excursion management and reporting processes by October 31, 2016. Finally, an equipment replacement schedule was implemented based on individual practice needs and corresponding vaccine volume(s). In December 2016, a capital investment campaign was initiated to replace storage equipment in need of upgrade. By March 31, 2018, a total of 137 storage units were replaced, including 82 refrigerators and 55 freezers.
In accordance with CDC/Pennsylvania VFC regulations, effective January 1, 2018, a total of 133 digital data loggers were installed in 97 practice sites by November 1, 2017. The data loggers selected for deployment have the ability to record and track temperatures continually minute by minute and to notify selected personnel through e-mail/text message/phone call in the event out of range temperatures or power/internet outages are detected.
Results: Following the implementation of postintervention action plans, the leadership team audited 97 practices that administer vaccines. The findings were compared to the 36-month audit period that served as the baseline period for the study. Of the practices audited, there was a 10% reduction in the number of clinical sites with temperature excursions [Table 1]. This was not statistically significant. In addition, the study demonstrated that temperature excursions may occur as a result of power outages, equipment failure, and human error.
Although there was no statistical significance in the number temperature excursions that occurred across clinical locations between the two study periods, there was a statistically significant difference in the percentage of practices requiring revaccinations resulting from temperature excursions. More specifically, during the baseline period, 23% of the practices audited required a total of 6050 revaccinations. The percentage of practices requiring revaccination during the postintervention period dropped to 0%, with no need for revaccinations [Figure 3].
This improvement resulted in avoidance of 2017 revaccinations annually compared to baseline results. In addition, using a weighted average cost per revaccination, the total annual cost avoidance was $166,315. Considering the capital investment for this program, and using a 10-year equipment life expectancy as verified by storage unit manufacturers, the payback period of this program is 2.87 years with a total cost avoidance of $1.19M [Table 2].
Discussion: VSH processes are researched and developed by vaccine manufacturers and the CDC Advisory Committee on Immunization Practices.4 The current study recognized three primary root causes related to VSH deficiencies: knowledge deficit, suboptimal storage equipment, and suboptimal oversight and support.
Effective VSH processes enhance patient outcomes, promote disease prevention, defend vaccine supply, and reduce costs associated with revaccination and vaccine replacement.4 In addition, improper vaccine storage and its consequences can decrease patient confidence in the practice of vaccination, jeopardize provider trust, and negatively impact the overall patient experience within health-care systems.4
Although there has been debate around the development of more thermostable vaccines by the pharmaceutical industry, equally important concerns were raised in relation to escalating costs and varied storage and handling requirements.6 More research is needed before changes to vaccine thermostable characteristics are implemented; therefore, compliance with recommended VSH processes is vital for the efficacy of all vaccines.6
Although VSH processes are well described, implementation can be challenging for health-care systems due to various barriers including knowledge deficits, suboptimal storage equipment, and lack of robust organizational oversight.1,9 To improve VSH processes, staff training should be conducted upon hiring, annually, upon receipt of new vaccines, and upon storage and handling recommendation updates.4
Vaccine coordinators should have advanced training that includes routine, emergency, and vaccine relocation procedures.4 A population-based survey of 221 private physician offices in Georgia revealed that offices utilizing daily monitoring of vaccine storage unit temperatures were 2–3 times more likely to assign those responsibilities to staff with higher levels of training than those who did not implement daily temperature monitoring.2 In addition, an Australian study of 28 general physician offices demonstrated that medical-grade storage equipment is preferred, and essential to, maintaining strict temperature control.11 Furthermore, a 2014 cross-sectional, web-based study of primary care physicians revealed that optimal storage equipment is critical to maintaining strict temperature control, and that practice-based improvement strategies must include the use of medical grade storage equipment, temperature monitoring logs, and temperature monitoring equipment.11
Implementation of effective VSH processes is heavily dependent on the organizational understanding and realization of the impact of improperly stored vaccines on patient outcomes, disease prevention, and vaccine-associated costs.10 Organizational commitment to financial investment, including staff development, equipment procurement, and organizational oversight, is critical to the overall success of VSH process implementation.10,11,12 According to Luzze et al., vaccine management programs for supply chain management were built when immunization programs were neither as complex, nor expensive as today.13 Advancing supply chain management, including current storage and handling processes, requires a commitment to change, coordination of various stakeholders, resources, and funding.10,13
The current project has several important limitations that need to be considered. First, the number of physician practices subjected to an internal audit of temperature logs during the baseline period was limited to locations that had maintained active temperature logs. The number of practices that maintained temperature logs during the postintervention period was greater than during the baseline period. This was largely a result of mandated use of temperature logs and organizational oversight, which could potentially impact the number of temperature excursions and revaccinations identified. Future studies should utilize a comparative study of practices that maintained temperature logs for the same study period. Second, the postintervention period was much shorter than the baseline period due to the need for historical assessment of temperature logs, review of patient health records, and vaccine manufacturer determination of vaccine stability during the baseline period. Although we were unable to show statistical significance for the percent reduction in the number of actual temperature excursions during the postintervention period (e.g., 10% difference), we were able to show statistical significance in terms of reduction in the percentage of revaccinations needed. Finally, the impact of the implementation of “data logger” on the number of temperature excursions and revaccinations was not studied due to the comparatively short 3-month implementation period in relation to study completion. Subsequent studies following an extended “data logger” implementation period should be conducted to determine the impact that “data loggers” have on the rate of temperature excursions and revaccination.
Conclusion: The study identified three leading root causes related to VSH deficiencies: knowledge deficit, suboptimal storage equipment, and lack of oversight and support. Postintervention results demonstrated that detailed evaluation of VSH processes and implementation of effective VSH processes are strongly associated with improved management of temperature excursions, reduced revaccination rates, and decreased costs associated with revaccination and vaccine replacement. In addition, the study revealed that financial investment in staff development, equipment procurement, and leadership, while significant, can be justified and result in improved patient outcomes, increased disease prevention, reduced vaccine wastage and financial loss, and significant organizational cost avoidance in a relatively short payback period.
- Ashok A, Brison M, LeTallec Y. Improving cold chain systems: Challenges and solutions. Vaccine 2017;35:2217-23.
- Bell KN, Hogue CJ, Manning C, Kendal AP. Risk factors for improper vaccine storage and handling in private provider offices. Pediatrics 2001;107:E100.
- Kumru OS, Joshi SB, Smith DE, Middaugh CR, Prusik T, Volkin DB, et al. Vaccine instability in the cold chain: Mechanisms, analysis and formulation strategies. Biologicals 2014;42:237-59.
- Vaccine Storage and Handling Tool Kit. Center for Disease Control and Prevention; 2018.
- Hanson CM, George AM, Sawadogo A, Schreiber B. Is freezing in the vaccine cold chain an ongoing issue? A literature review. Vaccine 2017;35:2127-33.
- Kristensen DD, Lorenson T, Bartholomew K, Villadiego S. Can thermostable vaccines help address cold-chain challenges? Results from stakeholder interviews in six low- and middle-income countries. Vaccine 2016;34:899-904.
- Levinson DR. Vaccines Fir Children Program: Vulnerabilities in Vaccine Management. U.S. Department of Health Services, Office of Inspector General; June, 2012.
- PDCA/PDSA. Available from: https://www.goleansixsigma.com/pdca-pdsa/. [Last accessed on 2018 May 21].
- Lloyd J, Cheyne J. The origins of the vaccine cold chain and a glimpse of the future. Vaccine 2017;35:2115-20.
- Brooks A, Habimana D, Huckerby G. Making the leap into the next generation: A commentary on how Gavi, the vaccine alliance is supporting countries' supply chain transformations in 2016-2020. Vaccine 2017;35:2110-4.
- Page SL, Earnest A, Birden H, Deaker R, Clark C. Improving vaccination cold chain in the general practice setting. Aust Fam Physician 2008;37:892-6.
- Weltermann BM, Markic M, Thielmann A, Gesenhues S, Hermann M. Vaccination management and vaccination errors: A representative online-survey among primary care physicians. PLoS One 2014;9:e105119.
- Luzze H, Badiane O, Mamadou Ndiaye EH, Ndiaye AS, Atuhaire B, Atuhebwe P, et al. Understanding the policy environment for immunization supply chains: Lessons learned from landscape analyses in Uganda and Senegal. Vaccine 2017;35:2141-7.
| Abstract Number 3|| |
The Goldilocks Project: A Newborn Temperature Stabilization Rapid Cycle Quality Improvement Initiative
Authors: M. Harrington, K. Costello, A. Ittoop, D. Hosier, T. R. Wojda
Scientific contributors (alphabetically): S. Bijou, B. Cameline, M. Casey, A. Delillo, J. Donchez, M. Edwards, B. Fox, J. Haas, J. Janco, J. King, A. Matika, A. Nagle, E. Rios, S. Sannoh, M. Toole
Departments: Department of Quality Resources, Department of Neonatal Intensive Care Unit, Obstetrics/Neonatal Intensive Care Unit, St. Luke's Allentown Campus, Respiratory Department, Children's Services Line Department, Department of Pediatrics, New Beginnings Department, Department of Research and Innovation St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
Year of submission: 2017
Introduction: Temperature instability is a serious but potentially preventable outcome for high-risk newborns (HRNs). Poor thermoregulation in HRN is associated with increased mortality and a host of other adverse outcomes.1,2 Admission temperatures below 36°C can be associated with increased mortality and other adverse outcomes such as late-onset sepsis.1 Evidence shows that, for each degree below 36°C upon Neonatal Intensive Care Unit (NICU) admission, there is an increase in infant mortality by up to 28%.3 In addition, hypothermia is associated with hypoglycemia, respiratory distress, and metabolic acidosis.4 Infants <28-week gestation have the highest incidence of hypothermia as the skin temperature of an exposed premature infant can drop at a rate of approximately 0.5°C–1.0°C/min.5
The Vermont Oxford Network (VON) is a nonprofit voluntary collaboration of university-affiliated and nonaffiliated hospital centers with NICUs.6,7,8 The collaborative concentrates on improving quality and safety of medical care for newborn infants and operates a database that collects demographic and clinical outcome data for infants weighing between 401 and 1500 g at birth. Previous trends using VON in clinical practice describing mortality and outcome measures for very low birth weight (VLBW) infants have been described.6,7,8
Our health network uses VON to track and analyze NICUs performance on a quarterly and yearly basis. An analysis of VON statistics for clinical year 2016 demonstrated a need for improvement, specifically regarding outcomes for the VLBW, or micropremature infant population. For this patient group, our baseline temperature readings on NICU admission in the “just right” zone for <1500 g infants were 0% in January 2016. A retrospective analysis of the prior 6-month period (2nd half of clinical year 2015) using VON revealed an average rate of compliance with “temperatures in range” (36.5°C–37.5°C) on NICU admission of only 38.6% cases. At that time, >50% of VON centers had higher admission “temperature recordings within range” compared to our institution. Furthermore, in 2015, our mortality rate in the VLBW population was 10.9%, with the top quartile target rate in Vermont Oxford being 8.7%. After individual case reviews, it was determined that there was a significant opportunity for improvement in the VLBW population by introducing interventions in the areas of improving pneumothorax rates, infection prevention, and temperature management.
The team decided that the first priority to focus on was newborn temperature readings upon admission to the NICU since baseline analysis revealed significant opportunity in terms of our compliance rate in this HRN population. Given that lack of maintenance of newborn temperatures immediately after birth can be linked with other adverse outcomes, the team felt the need to act quickly on improving this critical care quality metric. The team decided the Goldilocks Project, improving NICU admission temperature readings to within range or “just right,” would be the first arm of the current undertaking.
Project Aim/Objective: The aim of this project was to improve NICU admission temperature readings in the <1500 g infant population to the “just right” temperature readings of 36.5°C–37.5°C to a >70% compliance rate by June of 2016. We planned to do this by leveraging our participation in the VON Newborn Improvement Collaborative for Quality (NICQ) Next2 Micro-Preemie Collaborative.
Methods: A communication plan was developed to keep staff informed of upcoming performance improvement (PI) meetings, unit meetings, and other forums in which PI data were distributed and discussed [Figure 1]. Skype meeting invites were extended to staff who could not attend meetings in person. Just in time education was offered, and a checklist of initial newborn stabilization techniques related to temperature management was developed with input from the staff (not shown). Barriers to improvement were also analyzed and a fishbone diagram was developed by the team [Figure 2].
A driver diagram was developed to adequately display the rapid improvement cycles [Table 1]. Primary drivers that would help achieve the Goldilocks Project aim included enlisting the help of the entire multidisciplinary care team to ensure newborn's temperatures are maintained immediately after birth. In addition, a charge to improve from the pediatric leadership team and support to join this initiative from senior leaders helped ensure timely project initiation. Key team members also collaborated with others from around the world on specific areas for improvement, such as jump-starting quality Plan-Do-Check-Act (PDCA) cycles, involving family members in the project, and using VON data for continuous improvement.
Staff had varying levels of knowledge of potentially better practices and evidence-based care and needed to learn more about contributing factors that can lead to hypothermia. Five rapid PI cycles were conducted over the 6-month time frame. During these rapid cycles, key measurement tools were developed, efforts were made to use correct warming supplies, thermostats were regulated in delivery rooms (DRs) and operating rooms, and continuous positive airway pressure delivery was warmed. These cycles enlisted the help of not only the NICU staff but also staff from the respiratory and obstetrics departments. Two additional PDCA cycles were later developed [Figure 1]. Small run charts and bar graphs were initially created to help staff understand the need for change and desired outcomes. Using the Goldilocks analogy, staff quickly understood what temperature range was desired and the benefits of keeping infants within the 36.5°C–37.5°C range. The team was energized by their early and steady success and made ongoing changes to the process steps to accelerate improvement. We used descriptive statistics including frequencies and measures of central tendencies to report study results. Due to lack of comparison groups, no statistical testing was performed.
Results: Following the implementation of this collaborative effort, NICU admission temperature regulation compliance improved from 0% in January to >70% in April. Project-specific “run chart” [Figure 3] with explanatory text boxes demonstrates the seven PDCA cycles implemented. In addition, a statistical control chart [Figure 4] demonstrates reduction in average temperature reading variability over time. The statistical control chart analyzing monthly average newborn temperature readings revealed 12 months of temperatures “in range” since the new practices to improve infant thermoregulation have been put in place.
We have continued the use of the checklist to monitor our admission temperatures. Our recent results, as demonstrated on project-specific run charts, have shown not only much better process control but also a number of slight temperature excursions above our predetermined “just right” range, which accounts for some of the measured noncompliance [Figure 4]. This has led the team to design another PDCA cycle that addresses babies born at 30–32 weeks as perhaps they do not need such aggressive measures to maintain their temperatures. As outlined above, our average admission temperatures were “in range” in more consistent fashion between April 2016 and May 2017.
Discussion: Hypothermia following initial DR stabilization is still common in preterm newborns, despite the use of radiant warmers.3,9,10 Furthermore, studies repeatedly demonstrate an independent association between hypothermia and neonatal mortality.3,9,11,12 The pathophysiologic mechanism placing the immature infant at high risk of net heat loss is due to the relatively high surface area-to-volume ratio and increased evaporative fluid losses from the skin.13 Unfortunately, research that has focused on the prevention of heat loss during neonatal resuscitation through convective, evaporative, and conductive mechanisms has not resulted in sufficient evidence for achieving normothermia on admission of these HRNs.14
The effectiveness of our quality improvement (QI) project in preventing hypothermia is comparable to other contemporary reports on similar populations.5,14,15,16 Nonetheless, our ability to prevent hypothermia did sometimes occur with subsequent hyperthermia. It is important to note that, while no complications occurred because of this, previous studies have demonstrated complications due to these overzealous resuscitative efforts.5,17,18,19 It may be that multimodal measures will be more effective in preventing hypothermia without undue hyperthermic excursions, especially when various interactions (and associated mechanisms) within this complex system become better understood.14
A possible limitation of this study is its generalizability, primarily because stabilization area designs and methods used for thermoregulation vary across centers.20 Some challenges this project faced included educating personnel from various departments (obstetrics, NICU, and respiratory therapy), informing staff about the process, and encouraging them to be leaders of change. Posting our successful results after the various PDCA cycles helped to overcome this challenge. It also helped encourage continued peer education. One key learning point for the team was that rapid cycle improvement can even include smaller tests of change. For example, in Cycle 1, the team actually modified the checklist several times until they achieved the goal of having exactly the type of data required for analysis.
Our pediatric leadership team and hospital Board of Trustees recognized a need for improvement, thus allowing us to join the Vermont Oxford Micro-Premature Infant Collaborative – the NICQ Next 2 Project, in December 2015. This voluntary NICQ brings interdisciplinary teams together for immersion learning through a “homeroom” structure that links hospitals from around the world to share best practices and exchange ideas. Our health network is one of the sixty NICUs from around the world focused on improving medical care for newborn infants and their families through a coordinated program of research, education, and QI projects. By participating in the NICQ Next 2 Micro-Premature Infant Homeroom, our network plans to improve a number of key neonatal outcomes in this high-risk population. The team plans to continue to leverage the expertise and consulting services available through the VON to continue to improve neonatal outcomes at our institution, and to standardize the processes and care in the initial 72 h of a newborn's life. Our overarching aim is to become a top quartile performer in all key VON outcomes' metrics by the end of 2017. We believe this ambitious goal is attainable and will lead not only to improved outcomes for our tiniest NICU babies but also may lead to further national recognition of our improvement efforts.
Conclusion: Our project to improve premature newborn temperatures at our hospital reported a significant improvement in admission temperatures after QI measures were implemented. The project involved education of staff and implementation of several practices in the DR, which occurred during clinical practice. The team did achieve the aim to improve NICU admission temperatures to within range or “just right” in our VLBW infants at least 70% of the time, and they did it ahead of schedule by reaching this goal in May 2016. In addition, the team learned that not only is change possible but also participation in such positive change can be hugely rewarding.
We would like to thank all of our coworkers for their contributions to this initiative, including their participating in the initial conception and implementation of the project, for the overwhelming support in implementing thermoregulation process changes in the DR, and for helping with initial collection, analysis, and reporting of event data. Finally, we would like to thank the entire NICU and DR staff and trainees, whose cooperation and enthusiasm for improvement enabled and sustained this project.
- Russo A, McCready M, Torres L, Theuriere C, Venturini S, Spaight M, et al. Reducing hypothermia in preterm infants following delivery. Pediatrics 2014;133:e1055-62.
- Castrodale V, Rinehart S. The golden hour: Improving the stabilization of the very low birth-weight infant. Adv Neonatal Care 2014;14:9-14.
- Laptook AR, Salhab W, Bhaskar B, Neonatal Research Network. Admission temperature of low birth weight infants: Predictors and associated morbidities. Pediatrics 2007;119:e643-9.
- Nayeri F, Nili F. Hypothermia at birth and its associated com-plications in newborn infants: A follow up study. Iran J Public Health 2006;35:48-52.
- Singh A, Duckett J, Newton T, Watkinson M. Improving neonatal unit admission temperatures in preterm babies: Exothermic mattresses, polythene bags or a traditional approach? J Perinatol 2010;30:45-9.
- Network VO. Vermont-Oxford Network Database Project: Manual of Operations. Burlington, VT: Vermont-Oxford Network; 1993.
- Horbar JD, Badger GJ, Lewit EM, Rogowski J, Shiono PH. Hospital and patient characteristics associated with variation in 28-day mortality rates for very low birth weight infants. Vermont Oxford Network. Pediatrics 1997;99:149-56.
- Horbar JD, Badger GJ, Carpenter JH, Fanaroff AA, Kilpatrick S, LaCorte M, et al. Trends in mortality and morbidity for very low birth weight infants, 1991-1999. Pediatrics 2002;110:143-51.
- Costeloe K, Hennessy E, Gibson AT, Marlow N, Wilkinson AR. The EPICure study: Outcomes to discharge from hospital for infants born at the threshold of viability. Pediatrics 2000;106:659-71.
- Jain A, Fleming P. Project 27/28. An enquiry into the quality of care and its effect on the survival of babies born at 27-28 weeks. Arch Dis Child Fetal Neonatal Ed 2004;89:F14-6.
- McCall EM, Alderdice FA, Halliday HL, Jenkins JG, Vohra S. Interventions to prevent hypothermia at birth in preterm and/or low birthweight babies. Cochrane Database Syst Rev. 2010;3:CD004210.
- Silverman WA, Fertig JW, Berger AP. The influence of the thermal environment upon the survival of newly born premature infants. Pediatrics 1958;22:876-86.
- Lyon AJ, Freer Y. Goals and options in keeping preterm babies warm. Arch Dis Child Fetal Neonatal Ed 2011;96:F71-4.
- Pinheiro JM, Furdon SA, Boynton S, Dugan R, Reu-Donlon C, Jensen S, et al. Decreasing hypothermia during delivery room stabilization of preterm neonates. Pediatrics 2014;133:e218-26.
- Lee HC, Ho QT, Rhine WD. A quality improvement project to improve admission temperatures in very low birth weight infants. J Perinatol 2008;28:754-8.
- Carroll PD, Nankervis CA, Giannone PJ, Cordero L. Use of polyethylene bags in extremely low birth weight infant resuscitation for the prevention of hypothermia. J Reprod Med 2010;55:9-13.
- Newton T, Watkinson M. Preventing hypothermia at birth in preterm babies: At a cost of overheating some? Arch Dis Child Fetal Neonatal Ed 2003;88:F256.
- L'Herault J, Petroff L, Jeffrey J. The effectiveness of a thermal mattress in stabilizing and maintaining body temperature during the transport of very low-birth weight newborns. Appl Nurs Res 2001;14:210-9.
- Ibrahim CP, Yoxall CW. Use of self-heating gel mattresses eliminates admission hypothermia in infants born below 28 weeks gestation. Eur J Pediatr 2010;169:795-9.
- Leone TA, Rich W, Finer NN. A survey of delivery room resuscitation practices in the United States. Pediatrics 2006;117:e164-75.
| Abstract Number 4|| |
Optimizing Medicare Wellness Visits within Primary Care
Authors: M. Harris, M. Abgott, T. R. Wojda
Scientific contributors (alphabetically): J. Brinker, G. Delmonico, S. Dreyer, D. Fedon, L. Gately, D. Geer, J. Holtman, M. James, V. Klass, D. McGorry, J. O'Neill, M. Owsinski, C. Pogodzinski, I. Sorathia
Departments: St. Luke's Physician's Group, St. Luke's University Health Network, Bethlehem, Pennsylvania, and St. Luke's Warren Hospital, Phillipsburg, New Jersey, USA
Year of Submission: 2017
Introduction: The Centers for Medicare and Medicaid Services promotes annual wellness visits (AWV) for Medicare Fee-for-Service and Medicare Advantage beneficiaries. Wellness visits are distinct from a routine examination or an acute care visit. These comprehensive health risk assessments provide an opportunity for the primary care physician (PCP) to understand a patient's overall health status and to identify preventive and chronic illness health-care needs. The patient has no copay responsibility and a practice can bill a certain amount (approximately $140–150) for the initial wellness visit as well as a predefined amount (approximately $110–120) for each subsequent annual visit. Along with a medical evaluation, wellness visits require a review of the patient's emotional, psychological, and social well-being and include many preventive services that Medicare previously did not cover.1 The AWV includes a review of the patient's medical and family history; measurement of blood pressure and body mass index; screening for cognitive impairment, depression, functional ability, and overall level of safety; establishing a written schedule for recommended screening and preventive services; planning end-of-life care; and education, counseling, and referrals for other personalized preventive services such as colonoscopy.2 Although the overarching goal is to promote wellness, and some of these needs may be partly addressed during nonpreventive visits, physicians may find it difficult to address all recommended preventive care short appointments.3,4 In addition, patients have reported unexpected out-of-pocket costs when AWVs are concurrently billed with problem-based visits.5 Nonetheless, evidence-based preventive services such as discussing aspirin prophylaxis, screening and counseling for tobacco use, cancer screenings, and immunizations have already proven both clinically beneficial and cost-effective.3,4 Accordingly, an AWV, if optimally implemented, should provide value to both the hospital, health-care provider, and most importantly the patient.
Our network's leadership recognizes that the completion of a wellness visit for each Medicare beneficiary represents the best practice for primary care, optimizes value-based reimbursement, and maximizes revenues. Primary care practices were initially hesitant to embrace the AWV due to misconceptions about the purpose and coverage requirements. Specific barriers are found in [Table 1] and have been echoed in previous reports.6
Project Aim/Objective: The goal of the Medicare Wellness initiative was to increase Medicare Wellness visits across St. Luke's Physician Group Primary Care Practices by 40% during the fiscal year 2015 (FY15).
Methods: A small group of key stakeholders, including primary care leaders and staff of various primary care practices, met to conceptualize ideas that may help address various challenges associated with introducing wellness visits, develop an efficient workflow that would engage staff and providers, and meet patient expectations. Key stakeholders acquired a shared understanding of the objectives and developed three workflow options for subsequent pilot implementations [Table 2].
After 3 months, Option 3 demonstrated most favorable results, including an immediate increase in wellness visits, better staff engagement in assisting providers to collect the necessary information for care planning, enhanced provider satisfaction with a process that did not negatively impact compensation, and the near elimination of patient complaints about unplanned copays. Due to the above factors, a decision was made to implement Option 3 for all primary care practices. To assure the AWV process was consistently applied across all primary care practices, a manual was developed that included guidance regarding key components of the visit: workflow, billing, coding, and documentation. Education was provided to practice managers, and regional leadership collaborated with the practices to adopt the new workflow [Figure 1]. Before the provider saw the patient, a medical assistant helped the patient to complete the required health assessment risk questionnaire. Finally, a report was developed in our network's management tracking system to monitor Medicare Wellness visit volumes [Table 3]. Descriptive statistics using frequencies and percentages were utilized to outline study results. Because this was a pilot program, no statistical or power analysis was performed.
Results: From FY15 to FY16, year-over-year (YOY) results showed a 117% increase in wellness visits and a 135% increase in revenue, despite constant staffing/ full-time equivalents during the same period [Figure 2] and [Figure 3]. For FY16–17 (projected), YOY results show sustained improvement, with approximately 22% increase in wellness visits and a corresponding 13% increase in revenues. The practice of AWV is now embedded throughout our family practice and internal medicine clinical environments. To hardwire the process, a template was developed within our electronic health record that would support the efficient and effective capture of the required elements of each AWV. Resulting data are shared monthly with regional leadership. As of FY16, incentives for our providers, staff, and regional leadership were aligned to the AWV goal. Overall, the introduction of Medicare Wellness Visits made a positive contribution to annual provider compensation. Further optimization of the monthly report was completed to include provider level data that will help facilitate optimization and standardization of individual clinical performance metrics.
Discussion: Chronic diseases are costly. The annual direct and indirect costs of the most common chronic diseases are estimated to be $277 billion and $1.2 trillion, respectively.7 However, by 2023, with modest improvement in prevention, 40 million cases of chronic disease could be avoided with a subsequent increase in productivity gains of approximately $905 billion and the corresponding decrease in treatment costs by $218 billion each year.7 Unfortunately, enrollment in AVW is still low, possibly due to lack of awareness.8 One unique area where innovative approaches to AVW could help produce the much needed transformation is the introduction of clinical pharmacists, who as health professionals may be suitable for providing such services.9,10,11 If awareness of the overall process is increased among key stakeholders, and the processes itself improved and optimized, the AWV can be an excellent vehicle for keeping patients healthy by preventing diseases and/or detecting chronic conditions early and thus allowing more effective medical control (and thus fewer downstream complications).
The current quality improvement project demonstrates a substantial increase in visits compared to national trends. Reported trends on AWV from 2011 to 2014 showed increased use from 7.5% (2011) to 15.6% (2014) at the national level.2,12,13 In one study, regional AWV adoption was concentrated among Accountable Care Organizations and certain PCPs, suggesting that the decision to perform an AWV was primarily driven by practice-related factors.5 Moreover, our findings support reports that physicians and health systems that incorporate templates, workflows, or dedicated nonphysician health professionals to complete, document, and bill for AWVs demonstrate enhanced results.6
This study has several limitations. The implementation did not involve a control or comparator group, making it difficult to determine factor-specific attribution of observed beneficial effects of the intervention under evaluation. In addition, patient population specific to our institution may be different from other regional populations, and thus our experiences may not be generalizable to the entire United States. Due to the dearth of research regarding the long-term implications and feasibility of AWV, more investigation is warranted to determine whether AWVs increase the overall use of preventive care and enhance chronic disease management.2,12,13 AWVs were frequently co-billed with problem-based visits, corroborating patient concerns about unexpected costs and emphasizing the need for conversations about potential cost sharing. There may also be as yet undetermined socioeconomic disparities in AWV use.
Conclusion: In FY15, across all primary care practices, our providers performed 8421 Medicare Wellness visits, generating significant additional revenue for the network. In June 2015, a new workflow was developed to incorporate Medicare AWVs into existing follow-up appointments. Without adding additional resources, Medicare AWVs increased by 117% and revenue increased by 135%. Improving the health of each Medicare beneficiary within our network is of critical importance to the wellness of our community and will be of value as our organization takes on risks related to population health within various accountable care arrangements and other alternative payment models.
- Lesser LI, Krist AH, Kamerow DB, Bazemore AW. Comparison between US preventive services task force recommendations and medicare coverage. Ann Fam Med 2011;9:44-9.
- Chung S, Lesser LI, Lauderdale DS, Johns NE, Palaniappan LP, Luft HS, et al. Medicare annual preventive care visits: Use increased among fee-for-service patients, but many do not participate. Health Aff (Millwood) 2015;34:11-20.
- Abbo ED, Zhang Q, Zelder M, Huang ES. The increasing number of clinical items addressed during the time of adult primary care visits. J Gen Intern Med 2008;23:2058-65.
- Baron RJ. What's keeping us so busy in primary care? A snapshot from one practice. N Engl J Med 2010;362:1632-6.
- Ganguli I, Souza J, McWilliams JM, Mehrotra A. Trends in use of the US medicare annual wellness visit, 2011-2014. JAMA 2017;317:2233-5.
- Cuenca AE. Making medicare annual wellness visits work in practice. Fam Pract Manag 2012;19:11-6.
- Heaton PC. Medicare annual wellness visits: Patient need and pharmacist patient care services intersect. J Am Pharm Assoc (2003) 2014;54:336-7.
- Hu J, Jensen GA, Nerenz D, Tarraf W. Medicare's annual wellness visit in a large health care organization: Who is using it? Ann Intern Med 2015;163:567-8.
- Wilson CG, Park I, Sutherland SE, Ray L. Assessing pharmacist-led annual wellness visits: Interventions made and patient and physician satisfaction. J Am Pharm Assoc (2003) 2015;55:449-54.
- Thomas MH, Goode JV. Development and implementation of a pharmacist-delivered medicare annual wellness visit at a family practice office. J Am Pharm Assoc (2003) 2014;54:427-34.
- Park I, Sutherland SE, Ray L, Wilson CG. Financial implications of pharmacist-led medicare annual wellness visits. J Am Pharm Assoc (2003) 2014;54:435-40.
- Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, Gøtzsche PC. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ 2012;345:e7191.
- Jensen GA, Salloum RG, Hu J, Ferdows NB, Tarraf W. A slow start: Use of preventive services among seniors following the affordable care act's enhancement of medicare benefits in the U.S. Prev Med 2015;76:37-42.
| Abstract Number 5|| |
Multidisciplinary Approach to Prevent Neurosurgical Readmissions for Elective Spine and Craniotomy Patients
Authors: C. Belman, H. Moulding, V. Yellapu, J. Rowbotham, S. Kleckner, G. Biundo, A. Ivankovits, L. Naravas
Scientific contributors (alphabetically): M. Cardinale, J. Florkowski, R. Gonzalez, K. Hinds, J. Hosey, L. Machado, D. Norder Jr., K. Smith, R. Wilde-Onia
Departments: Department of Neurosurgery, Quality Resources, Neuroscience, Research and Innovation, Trauma, Acute Rehabilitation, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
Year of submission: 2017
Introduction: An important quality measure that has taken effect since the passage of the Affordable Care Act has been the 30-day readmission rate. Centers for Medicare and Medicaid services (CMS) is empowered to penalize hospitals that have high readmission rates.1 While this creates a strong incentive to prevent readmissions, it also is an opportunity to improve patient care approaches and pathways on a much large scale than previously attempted. While some readmissions are unavoidable, high readmission rates can be reflective of the quality of care and safety provided within a health system.2 In response to the enactment of Hospital Readmission Reduction Program, hospitals have implemented strategies to reduce their readmissions to avoid financial penalties of up to 2%. According to the CMS, roughly $1.4 billion is being incentivized to prevent hospital readmissions.3 Total Medicare penalties assessed on hospitals for readmissions are projected to increase to $560 million in 2018.3
For Medicare, a hospital readmission is defined as an event during which a patient is admitted to a hospital within 30 days from discharge following an index hospitalization. Medicare uses an “all-cause” definition, meaning that the reason for readmission does not need to directly correlate to the initial hospitalization. For this performance improvement (PI) project, readmission performance for all surgical spine and nontrauma craniotomy neurosurgical cases was monitored and benchmarked using the Premier Council of Teaching Hospitals, 400–500 bed hospital dataset (Premier, Inc., Charlotte, North Carolina, USA). Readmission rates were reviewed monthly using Premier comparative data as well as tracked on the neurosurgery score card. The venues for monitoring the PI initiatives were the monthly multidisciplinary neurosurgical PI committee in addition to a small workgroup for ongoing interventions to reduce readmissions.
Project Aim/Objective: The aim of the study was to reduce neurosurgical readmission rate for elective surgical spine and nontrauma craniotomy procedures at St Luke's University Hospital by 25% within a 1-year period.
Methods: It has been shown that a common cause of readmissions is improper documentation of comorbid conditions before surgery.4 Our first step was educating the team, including our medical assistants, on the importance of accurate charting as it relates to surgical outcomes. To ensure consistent compliance, audits were conducted, and errors were reviewed with corresponding team member(s). Preoperative interventions were put in place to optimize high-risk patients for surgery. This included endocrine, weight management, and behavioral health consultations.
An important part of the protocol was the use of referrals designed to help foster coping mechanisms with regard to chronic pain and recovery. Pain management referrals and medical oncology evaluations were also additional avenues considered for preoperative evaluations to reduce postoperative complications, resulting in readmissions. This process was reviewed with the neurosurgeons and physician assistants (PAs) by the Neurosurgery Chief and compliance was monitored by the Neurosurgery PI Subcommittee. Noncompliance to the process was reviewed individually with the provider by the Chief of Neurosurgery and Neuro-oncology Nurse Navigator. The Neuro-oncology Nurse Navigator reviewed complicated cases for medical optimization recommendations. Nurse navigator initiated preoperative telephone calls are made to review preoperative instructions and answer patient questions. The patient's guide to recovery after surgery was created, unique to the surgical location. This was distributed to all surgical patients. This guide serves as a resource for the patient and family setting expectations before and after surgery (e.g., surgical wound healing, pain control, and contact numbers).
A Neurosurgical Pain Committee was formed in collaboration with the acute pain service to standardize pain medication pathways and develop criteria for appropriate preoperative consults to anesthesia. We created these guidelines to assist in managing chronic pain patients starting in the neurosurgery office and preadmission testing. Pocket guides were also created and distributed to surgeons/PAs to improve compliance with the recommended regime created jointly with the acute pain service. A flag was added to EPIC Electronic Medical Record (EMR, EPIC, Verona, WI, USA) to identify patients being treated on the pain pathway and monitor compliance. We established criteria to help our team identify patients at risk for readmission, including the following objectivized item categories:
- The development of “Surgical Site Infection (SSI) Prevention Protocol” to promote consistent screening and clinical practice during pre-, intra-, and post-operative periods. This protocol has been rolled out to the neurosurgery office
- Audits were completed on a bimonthly basis to monitor compliance of HgbA1Cs and methicillin-resistant Staphylococcus aureus orders. Nurse navigators started postoperative discharge calls to review discharge instructions, medication dosages, and follow-up appointments
- LACE scores >50 were identified as high risk for readmission and are called the day after discharge to review discharge instructions and need for ongoing phone monitoring until the 2-week postoperative office follow-up
- Nontrauma craniotomy patients on steroid and anticonvulsant tapers are called by the neuro-oncology nurse navigator to review medication dosages and assess if adjustment is needed
- Patients were given contact number (office or cell phone) to call with any concerns before emergency room (ER) visits. Patients requiring face-to-face evaluation are seen in the office or at home by the navigator
- Office schedules were adjusted to accommodate same-day appointments for patient evaluation. Providers were educated to default to office evaluation before directing the patient to the ER for nonemergent concerns
- On-call evening and weekend providers offered patients next day office appointments and/or phone triage by the nurse navigators
- Patients who had more urgent concerns that required ER evaluation were met in the ER by the hospitalist, PA, and/or neuro-oncology nurse navigator for triage and potential readmission avoidance
- Since non-neurosurgical PAs had limited access to the EMR and lacked familiarity with office protocol, evening and weekend call is now covered by neurosurgical trained PAs.
We implemented the above changes and measured our readmission rates for the next year. We compared readmission rates in neurosurgery patients between the financial years 2016 and 2017.
Results: The average cost of a readmission for any given cause is $11,200.5 The average cost of laminectomy or spinal fusion readmission is $13,400. Readmission average cost for nontrauma craniotomy is $20,296.5 In total, we demonstrated a reduction in seven readmissions for the surgical spine population from fiscal year 2016 (FY16) to FY17 and three readmissions for the nontrauma craniotomy population. Thus, a total reduction of 10 readmissions was observed, with estimated cost savings of approximately $154,688 using the above-referenced average readmission costs. The rate for readmissions in the elective surgical spine procedure population decreased from 5.59% to 0.88%, demonstrating an 84% reduction. An 8% readmission rate reduction for elective nontrauma craniotomies was also observed [Figure 1]. Using data from Premier Council of Teaching Hospitals (400– 500-bed hospital category), we achieved a 41% reduction in the readmission index comparison for FY16 and FY17 (annualized data as of April) for the elective nontrauma craniotomy category [Figure 2]. In addition, we noted an 18% reduction in the readmission index for elective surgical spine procedures [Figure 3]. Moreover, both the elective nontrauma craniotomy and surgical spine procedure readmission indices fell below the peer index. Our goal of a 25% reduction in our readmission rate for surgical spine was achieved successfully. We also experienced a reduction in our rate for nontrauma craniotomy, although we did not achieve our predetermined goal. However, we did achieve an index reduction in the elective nontrauma craniotomy population of 41%. This can also be contributed to enhanced documentation that resulted in improved severity of illness and mortality risk adjustment.
Discussion: Focusing on reducing readmissions within neurosurgery patients is important as the number of patients undergoing spinal surgery is growing.6 With high number of patients presenting with comorbid conditions such as diabetes, which increase the rate of SSIs, it is important to manage these individuals efficiently to prevent readmission, as well as any morbidity secondary to surgery.7,8 It has been shown that rates of readmission range from 4.4% to 6.9% in the neurosurgical patient population, with SSI or other surgical complication accounting for roughly 25%–50% of cases.1,8,9,10,11 Common factors found to be associated with hospital readmissions in neurosurgery are preoperative comorbidities, mental health disorders, tobacco exposure, peripheral vascular disease, chronic renal failure, seizure disorder, coagulopathy and hypercoagulable disorder, increasing age, wound infection, nosocomial infections such as urinary tract infections or pneumonia, refractory postoperative pain, VTEs, falls, and complications from medications either started or withheld during the primary admission.12 The literature did suggest that processes should be set in place to manage patients with multiple comorbidities before, during, and after surgery. These programs can be built into standardized protocols that the neurosurgical providers and staff can readily implement.3,13 Neurosurgical readmission is also a source of significant hospital costs.11,14 We were able to save over $150,000 in a single year by implementing patient safety protocols that improved patient care. This is just one beneficial impact for everyone involved and provides a compelling reason for embracing similar PI measures.
Improving readmission rates is an important part of patient care, and given the enforcement by the CMS, quality measures to prevent readmissions take an ever more prominent role. In our project, we have been able to identify some key reasons (and specific components thereof) for readmission, and after addressing these successfully, will strive to maintain or improve upon this new baseline. As mentioned above, we have been able to create a significant amount of savings as a positive by-product, even with only reducing our readmission rate by ten patients. If the current initiative is expanded to our entire 10 hospital networks, we should be able to see a significant decrease in neurosurgery readmissions and in costs. We expect to further expand on our improvement by including SSI bundle that will be implemented throughout the network. We have discussed our pain pathway and acute pain service protocols with our colleagues in the department of orthopedics and will continue outreach to other surgical services. We also plan to involve nurse navigators more closely within these quality improvement measures as they are vital to this project's success.
Limitations: Some of the limitations we noted within this project include a relatively small number of patients within a short duration period of time. We will continue to monitor key outcome metrics over the next year, hoping to see a continued and sustained decreasing trend. Once we have implemented this project on a larger scale, we should be able to recognize and remedy other barriers that might affect readmission rates within our patient population.
Conclusion: We were able to successfully reduce readmission rates by 84% over the course of a year by implementation of SSI protocols, pain pathways, implementations of nurse navigators in identifying critical patients, and educating all caretakers in preventing readmissions. We hope to continue this effort throughout our network to further reduce readmissions and generate significant cost savings.
- Joynt KE, Jha AK. Thirty-day readmissions – Truth and consequences. N Engl J Med 2012;366:1366-9.
- Tsai TC, Joynt KE, Orav EJ, Gawande AA, Jha AK. Variation in surgical-readmission rates and quality of hospital care. N Engl J Med 2013;369:1134-42.
- CMS Proposals to Improve Quality of Care during Hospital Inpatient Stays; 2014. Available from: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-04-30-2.html. [Last accessed on 2018 Aug 01].
- Amin BY, Tu TH, Schairer WW, Na L, Takemoto S, Berven S, et al. Pitfalls of calculating hospital readmission rates based on nonvalidated administrative data sets: Presented at the 2012 joint spine section meeting: Clinical article. J Neurosurg Spine 2013;18:134-8.
- Qasim MM, Roxanne AM. Post-Surgical Readmission amoung Patients Living in Poorest Communities, Healthcare Cost and Utilization Project; Statistical Brief; 2009. p. 142.
- Deyo RA, Gray DT, Kreuter W, Mirza S, Martin BI. United States trends in lumbar fusion surgery for degenerative conditions. Spine (Phila Pa 1976) 2005;30:1441-5.
- Fang A, Hu SS, Endres N, Bradford DS. Risk factors for infection after spinal surgery. Spine (Phila Pa 1976) 2005;30:1460-5.
- Olsen MA, Mayfield J, Lauryssen C, Polish LB, Jones M, Vest J, et al. Risk factors for surgical site infection in spinal surgery. J Neurosurg 2003;98:149-55.
- Buchanan CC, Hernandez EA, Anderson JM, Dye JA, Leung M, Buxey F, et al. Analysis of 30-day readmissions among neurosurgical patients: Surgical complication avoidance as key to quality improvement. J Neurosurg 2014;121:170-5.
- Moghavem N, Morrison D, Ratliff JK, Hernandez-Boussard T. Cranial neurosurgical 30-day readmissions by clinical indication. J Neurosurg 2015;123:189-97.
- Taylor BE, Youngerman BE, Goldstein H, Kabat DH, Appelboom G, Gold WE, et al. Causes and timing of unplanned early readmission after neurosurgery. Neurosurgery 2016;79:356-69.
- Boccuti C, Casillas G. Aiming for Fewer Hospital U-turns: The Medicare Hospital Readmission Reduction Program. Policy Brief; 2015.
- Shah MN, Stoev IT, Sanford DE, Gao F, Santiago P, Jaques DP, et al. Are readmission rates on a neurosurgical service indicators of quality of care? J Neurosurg 2013;119:1043-9.
- Auerbach AD, Wachter RM, Cheng HQ, Maselli J, McDermott M, Vittinghoff E, et al. Comanagement of surgical patients between neurosurgeons and hospitalists. Arch Intern Med 2010;170:2004-10.
| Abstract Number 6|| |
Geriatric Surgical Program: From Growth to Sustainability
Authors: E. McHugh, A. Carmona, S. P. Stawicki, A. Green
Scientific contributors (alphabetically): A. Buono, M. Dietz, S. Graner, N. Glassic, D. Herman, R. Hodges, D. Luis, M. T. Malaska, C. Markovic, K. Mooney, A. Ng-Pellegrino, T. Pfeiffer, L. P. C. A. Rodriguez, C. Roscher, E. Seibert, M. Shannon, L. Shelly, T. Shine, T. Sipko, B. Stella
Departments: Departments of Preadmission Testing, Quality Resources, Research and Innovation, Anesthesia, Surgical Services– Bethlehem, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
Year of submission: 2017
Introduction: Care of the older surgical patient in the US has been challenged by the continued presence of “clinical silos,” with limited communication between providers.1 At the same time, increasing complexity of the aging population – characterized by the emergence of multimorbidity and polypharmacy as “the norm” – further exacerbated the existing lack of multidisciplinary clinical coordination.2,3 This state of affairs resulted in suboptimal outcomes, lower quality of care, systemic inefficiencies, and increased costs.2 Moreover, solutions to adequately address the above-mentioned challenges have proven difficult to devise.4,5
Following the introduction of the Affordable Care Act and restructuring of the Centers for Medicare and Medicaid (CMS) reimbursement paradigm, the health-care system was forced to adapt by changing the way geriatric surgical care is delivered.6,7 Among best examples of such adaptation was the introduction of the patient-centered medical home (PCMH) – a concept embraced by primary care providers (PCPs).8,9 With the PCP as the central point of coordination, a multidisciplinary team of providers became responsible for the implementation of personalized, patient-centered care plans.10
Several years ago, the American Society of Anesthesiologist (ASA) saw a similar opportunity to streamline the perioperative process for patients undergoing planned operative procedures.11 This led to the implementation of what is called a perioperative surgical home (PSH) approach – similar to that of the PCMH – that centers around the patient with the goal of achieving the “triple aim” of improving patient care, reducing cost, and improving population health.11,12,13 Implementations of PSH involve a multidisciplinary approach with a leader – most often an anesthesiologist – as the coordinating hub and team leader guiding the patient through the perioperative process.13,14,15 The PSH approach has been a prototype for hospitals around the country to improve their surgical processes, and favorable results of early PSH implementations prompted surgical leaders to evaluate its feasibility at our institution.
In 2013, it was identified that our institution was experiencing an unusually high rate of same-day surgery cancellations, primarily due to increasingly complex (and mainly geriatric) patients lacking sufficient preoperative optimization.16 Consequently, we embarked on a journey to transform our preadmission testing (PAT) center into a surgical optimization center (SOC) by adopting the PSH model to streamline our perioperative process and ultimately improve our postoperative patient outcomes.16 This reports focus on our implementation of the Geriatric Surgical Program (GSP) – a unique initiative dedicated to optimizing perioperative of the geriatric surgical patient.
Project Aim/Objective: The aim of this project was to improve surgical outcomes in elderly surgical patient population. Specific aspects of care evaluated included hospital length of stay (LOS), surgical site infections, and readmissions rates. In addition, we sought to reduce surgical case cancellations, focusing specifically on same-day cancellation rates. Finally, we set out to improve pain management among our geriatric surgical patients. We planned to accomplish these goals within 12 months by utilizing a multidisciplinary approach to optimize patients throughout the perioperative process.
Methods: Implementation of the PSH model involved the development of a multidisciplinary team approach that included stakeholders from several departments including anesthesia, PAT, ambulatory surgery center (ASC), and surgical services. Designated team leaders from each department met regularly to discuss ways to implement patient-centered care model for our elective (e.g., scheduled) surgical patients, focusing primarily (but not exclusively) on geriatric patients (e.g., age ≥70 years). We identified a number of clinical issues known to be related to outcomes in the geriatric surgical population [Table 1]. After thorough evaluation of contemporary research on specific benefits of PSH, as well as detailed studies of PSH implementations at other institutions, the process at our institution progressed into the advanced planning phase, with the identification of resources and setting realistic goals before full-scale deployment of the program. Within the global context, we sought to achieve top decile performance in the areas of opportunity outlined above.
With the department of anesthesia at the helm, several “care bundles” were introduced, each featuring a series of standardized, specialty-based interventions, based on best practice recommendations. The GSP was the implemented first.16 This was followed by protocols related to total joint replacement (e.g., major lower extremity Joint pathway) and subsequently the introduction of enhanced recovery after surgery (ERAS) protocols in our neurosurgical patients. We also developed and offered “hands on” educational classes for our surgical patients undergoing various orthopedic, major gynecological, and prostate surgeries. Finally, we began to develop the “Be Your BEST” (breathing, eating/nutrition, stress/sleep regulation, and tracking your steps/exercise) pathway for our “high-risk patients undergoing high-risk surgeries.”
To successfully accommodate the above-mentioned process changes, several key adjustments were necessary. Central to this plan was the hiring of additional staff to the PAT department, with dedicated nurses being designated to become “care navigators” for each specific surgical specialty (e.g., orthopedics, colorectal surgery, and vascular surgery). The implementation of the electronic medical record (EMR) allowed for enhanced communication spanning across the continuum of care, as well as greatly improved workflow between departments. This was especially important for coordinating our outpatient surgical offices, PAT, and the ASC. Equipped with the necessary staff and proper workflow/procedures, our collaborative continued to focus on developing innovative and more efficient methods to attain our goal of standardizing the perioperative processes for our GSP, becoming a regional PSH leader.
Results: Following its implementation, the GSP showed significant promise when comparing baseline (pre-2015) outcome data with early (2015–2016) and late (2016–2017) postimplementation data [Table 1]. In addition to shorter hospital LOS (2.79 vs. 5.98 days), we noted that hospital readmissions decreased from 11.1% to 3.96%; rates of venous thromboembolism decreased from 0.90% to 0.44%; postoperative hemorrhage rate improved from 0.80% to 0%; postoperative pneumonias declined from 2.29% to 0.44%; and the incidence of delirium dropped from 2.29% to 0% in postoperative patients. The rate of acute kidney injury (AKI) also decreased substantially from 6.0% in 2015 to 1.23% in 2017, in parallel with reductions in perioperative hypotension (14.1%–6.3%). Implementation of ERAS protocols helped decrease the utilization of opioids. In 2015, 73.1% of pain medications administered to postoperative patients were opioids, compared to only 26.9% nonopioid pain medication. As of February 2018, there has been a decrease in opioid use to 58.2%, along with an increase in nonopioid pain medication use to 41.8%. One specific area where significant opportunity for improvement continues to exist is the persistence of hospital-acquired conditions (HACs), falls, and trauma, which increased from 0% incidence during the early postimplementation period to baseline levels (0.44% vs. 0.40%).
The implementation of all essential components of the PSH and the GSP, combined with the synergies brought about by the network-wide EMR rollout, we noted a trend toward decrease in same-day surgical cancellations. Overall program results have been sustained at 5% or fewer same-day cancellations, compared to a baseline range between 8% and 12% back in 2015 [Figure 1].
Discussion: We found that adoption of the PSH model – and more specifically the GSP – provided an effective method of addressing major challenges associated with the aging surgical population. As a result of successful GSP implementation, we were able to improve patient outcomes in nearly every area except for of HAC/falls/trauma, where outcomes were unchanged compared to the baseline period.
The implementation of ERAS paradigm was also a success, with introductions of specific care bundles resulting in improvements across a broad range of postoperative parameters, from AKI and delirium to hospital LOS and readmissions. In 2015, we began to implement ERAS protocol designed specifically with neurosurgery patients in mind and have since rolled out additional ERAS protocols to standardize various perioperative processes in other surgical populations. Currently, a total of six other ERAS protocols have been developed and implemented by the anesthesia department throughout the entire Network. This includes initiatives involving thoracic surgery, spine surgery, gynecologic-oncology/major laparoscopic and general surgery, acute and chronic pain management, and complex electrophysiology.
Following successful introduction of the PSH paradigm into our institution's perioperative care matrix, it has become accepted as an effective model of standardizing the care of high-risk surgical patients,17 as well as an excellent conduit for improving the quality of perioperative care.18 Our experience is not unique, with the PSH models now being endorsed by the ASA and the number of successful programmatic implementations growing both in the United States and around the globe. Prominent surgical programs across the country (e.g., University of Alabama, University of Michigan, and Duke University) have instituted various versions of the PSH model into their perioperative processes, effectively transforming the delivery of surgical care. The American Academy of Orthopedic Surgery, ASA, CMS, and other national organizations have instituted a collaborative dedicated to partnering with hospitals and programs across the country for the specific purpose of disseminating the PSH model and making this a standard of care in the United States.15
Conclusion: The rapidly changing landscape of modern health care, with multiple competing priorities, increasing regulatory oversight, and ever-growing consumer expectations, require institutions and providers to adapt and evolve accordingly. Given the acute need for paradigm change in the area of perioperative care – especially as it pertains to the geriatric surgical patient – our institution embraced the PSH model as an innovative and sustainable solution. Within a relatively brief period of time, the implementation of the GSP resulted in significant improvement across a broad range of clinical outcomes and quality metrics, leading to the expansion of the overall effort to other areas within the established institutional PSH paradigm.
As we continue to work on optimizing and standardizing the perioperative process, the evolution and increasing scope of our services led to expansion of our PAT department into a much more comprehensive SOC. In addition, foundations were created for the formation of the high-risk optimization clinic – a specialized center that will focus on addressing unique needs of various high-risk surgical populations, with the ultimate goal of reducing perioperative morbidity and mortality. Other plans intended to further enhance our patients' perioperative and outcomes include “Be Your BEST” program expansion and high-risk patient assessments performed by SOCs Certified Registered Nurse Practitioners. In parallel, we are proactively working to increase staff buy-in and encourage continued interdisciplinary collaboration.
- Challis D. Beyond care management: The logic and promise of vertically integrated systems of care for the frail elderly. In: Kodner DL, editor. Long-Term Care: Matching Resources and Needs. London, UK: Routledge; 2018. p. 115-32.
- Harari D, Hopper A, Dhesi J, Babic-Illman G, Lockwood L, Martin F, et al. Proactive care of older people undergoing surgery ('POPS'): Designing, embedding, evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients. Age Ageing 2007;36:190-6.
- Tolentino JC, Stoltzfus JC, Harris R, Foltz D, Deringer P, Sakran JV, et al. Comorbidity-polypharmacy score predicts readmissions and in-hospital mortality: A six-hospital health network experience. J Basic Clin Pharm 2017;8:98-103.
- Adams WL, McIlvain HE, Lacy NL, Magsi H, Crabtree BF, Yenny SK, et al. Primary care for elderly people: Why do doctors find it so hard? Gerontologist 2002;42:835-42.
- Bettelli G, Ferrari A, Costantini M. Models of care and organizational solutions for geriatric surgery. Perioperative Care of the Elderly: Clinical and Organizational Aspects. Cambridge: Cambridge University Press; 2017. p. 303-8.
- Epstein AM, Jha AK, Orav EJ, Liebman DL, Audet AM, Zezza MA, et al. Analysis of early accountable care organizations defines patient, structural, cost, and quality-of-care characteristics. Health Aff (Millwood) 2014;33:95-102.
- Massie ML. Determinants of Hospital Administrators' Choice of Anesthesia Practice Model. Available from: https://www.scholarscompass.vcu.edu/cgi/viewcontent.cgi?article=6016&context=etd.
- Kogan AC, Wilber K, Mosqueda L. Person-centered care for older adults with chronic conditions and functional impairment: A systematic literature review. J Am Geriatr Soc 2016;64:e1-7.
- Patel NK, Jaén CR, Stange KC, Miller WL, Crabtree BF, Nutting P. Patient centered medical home: A journey not a destination. In: Geriatrics Models of Care. Cham, Switzerland: Springer; 2015. p. 155-62.
- Lee JF. Patient-Centered Medical Home (PCMH) and the care of older adults. In: Primary Care for Older Adults. Cham, Switzerland: Springer; 2018. p. 29-34.
- Vetter TR, Boudreaux AM, Jones KA, Hunter JM Jr., Pittet JF. The perioperative surgical home: How anesthesiology can collaboratively achieve and leverage the triple aim in health care. Anesth Analg 2014;118:1131-6.
- Berwick DM, Nolan TW, Whittington J. The triple aim: Care, health, and cost. Health Aff (Millwood) 2008;27:759-69.
- Criscitelli T. Improving efficiency and patient experiences: The perioperative surgical home model. AORN J 2017;106:249-53.
- Anesthesiologists ASo. Learning Collaborative Overview; 2018. Available from: https://www.asahq.org/psh/learning%20collaborative/an%20overview. [Last accessed on 018 Mar 22].
- Peggy L, Naas M. What are the Benefits of the Perioperative Surgical Home? 2017. Available from: https://www.aaos.org/AAOSNow/2017/Jun/Clinical/clinical03/?ssopc=1. [Last accessed on 2018 Mar 22].
- McHugh E, Wojda TR, Deringer P. The senior surgical services program. Int J Acad Med 2017;3 Suppl S1:176-88.
- Al-Shammari L, Douglas D, Gunaratnam G, Jones C. Perioperative medicine: A new model of care? Br J Hosp Med (Lond) 2017;78:628-32.
- Aronson S, Westover J, Guinn N, Setji T, Wischmeyer P, Gulur P, et al. A perioperative medicine model for population health: An integrated approach for an evolving clinical science. Anesth Analg 2018;126:682-90.
| Abstract Number 7|| |
Immediate-Use Steam Sterilization: How Three Simple Improvements Reduced Patient Risk and Increased Employee Satisfaction
Authors: A. Green, J. Burrell, T. Bennett, S. P. Stawicki, A. Buono
Scientific contributors (alphabetically): D. Batcsics,
S. Benoit, M. Cassidy, J. Gilbert, J. Hinkle, M. LeCoultre, L. Richardson, C. Rosevelt, C. Semmel, T. Shine
Departments: Departments of Research and Innovation, Network Sterile Processing, Trauma, Operating Rooms (Allentown, Anderson, Bethlehem, Miners, Monroe, Quakertown, and Warren), Campus-Specific Sterile Processing (Allentown, Anderson, Bethlehem, Miners, Monroe, Quakertown and Warren), Allentown, Bethlehem, Coaldale, Quakertown, Stroudsburg, Pennsylvania, and Phillipsburg, New Jersey, USA
Year of Submission: 2017
Introduction: Surgical aseptic techniques, including sterilization of surgical instruments, date back to Joseph Lister – a British surgeon, who is credited with the development and implementation of “antiseptic medicine” with intraoperative use of carbolic acid.1,2 The theory behind modern surgical asepsis is based on reducing bacterial contamination of the surgical wound.3,4 Because surgical site infections (SSIs) are multifactorial, numerous techniques and approaches have been established to control for each contributing factor. The mainstay of surgical asepsis is the time-proven concept of equipment sterilization.3
One of the best ways to ensure adequate and effective asepsis of surgical instruments and equipment is the application of steam.3 Steam sterilization is carried out at a specific temperature, and for a specific time, to eradicate all microbes and render instruments sterile. While there are other methods of sterilization (e.g., the use of various chemicals), steam has been proven to be both efficient and effective and remains the preferred method for instrument sterilization today. Proper sterilization techniques involve several key steps including “…cleaning, decontamination, rinsing, and aseptic transfer…”.5 This process can take several hours to properly complete, which in the context of a busy operating room (OR) can affect the availability of necessary equipment, leading to delays and/or cancellations, and translating into increased cost and decreased patient satisfaction. In some instances, instruments may be rendered “unsterile” during an operation and necessitate immediate sterilization. Such instance requires “flash sterilization” – a way of expedited sterilization of a single surgical instrument using an unwrapped tray or pan.5,6
In 2010, “flash sterilization” was retitled “immediate-use steam sterilization” (IUSS) by a national group consisting of the Association for the Advancement of Medical Instrumentation, the Centers for Disease Control and Prevention (CDC), and the Association of periOperative Registered Nurses (AORN).5 Part of the above consensus included the determination of when (and how) IUSS should be used.5 In brief, IUSS use was recommended very selectively, primarily in cases where an instrument is rendered unsterile and needs immediate re-sterilization.6 Thus, IUSS was not to be used for multiple instruments or trays or in the setting of acute instrument shortage (e.g., to accommodate the needs of busy ORs).5,6 The CDC added that there may be an association between IUSS and SSI, and that IUSS should not be used for any implantable devices.5
In early 2016, our network's Sterile Processing Department (SPD) leadership recognized that the IUSS rate was steadily increasing. In January 2016, our six hospitals and one outpatient surgery center reported IUSS rates of 4.2%–5.2%. At that time, it was recognized that an opportunity existed to further reduce IUSS utilization to <3% across our campuses. Through a multidisciplinary collaborative effort involving the Surgical Process Improvement (PI), infection control and SPD, and ORs, we identified three areas for improvement, followed by the development of corresponding action plans.
Project Aim/Objectives: The objective of this project was to decrease the network IUSS rate to 3% or less, over an 18-month time frame. We also sought to achieve at least 6 months of sustained results, at or below the AORN-recommended IUSS levels.
Methods: Through our monthly surgical PI, infection control, OR leadership, and SPD operations, we determined that there were three key areas that required specific action to achieve our objective. These areas included: (a) the process of bringing outside instruments into our facility; (b) deficiencies in our instrument inventory; and (c) communication issues between the OR and SPD.
The process of addressing each of the above opportunities for improvement began with devising a protocol to help regulate the devices brought in by our orthopedic and spine vendors. Through collaboration with our purchasing department, our revised vendor policy set forth more stringent regulations as to how and when vendor trays could be brought into the hospital. UniteOR (UniteOR, Inc, Portland, OR) – a loaner vendor tracking software that integrated with our electronic medical record (EMR), served to streamline the process of requesting the necessary equipment and ensuring that all parties involved were informed of instrumentation needs based on the OR schedule. This software also provided a way for equipment representatives, SPD, and the OR to communicate seamlessly. Finally, improved accountability and compliance were much easier to achieve postimplementation.
The next area for improvement consisted of ensuring adequate instrument inventory across our ORs. After reviewing earlier IUSS data and determining which instruments were most frequently sterilized through IUSS, the SPD was able to make informed recommendations regarding specific instrumentation needs. SPD and OR directors also sought other innovative ways to contain costs while meeting the needs of the health system. This came in the form of a new, Food and Drug Administration-approved rigid container system for terminal sterilization. These containers significantly reduced drying time, thus minimizing our instrument turnaround time (approximately 50% shorter wait).
The final area addressed was that of communication between the OR and SPD. Previously, this important notification pathway was insufficiently utilized, and to help address this opportunity, staff from SPD started attending daily OR “huddles” to better assess surgical instrumentation needs for the subsequent day's operative schedule. It also provided an opportunity for the OR to indicate which instruments would need a quicker turnaround time, which then allowed SPD to more efficiently allocate/plan staffing levels. These small changes helped facilitate better interdepartmental communication and coordination, significantly improving (and streamlining) bilateral processes.
Results: Structured program addressing our three key objectives was introduced in 2016. This program included the development and implementation of goal-specific action plans, as well as the deployment of dedicated teams. As a result, the Network IUSS rate decreased by 50% in the first 15 months [Figure 1]. More specifically, we recorded a total of 1204 IUSS uses throughout the network in 2016. During the following calendar year (2017), total IUSS events were reduced to 669 – a decrease of 44%, and overall cost savings of $165,850 for our network. For 11 out of 12 months in 2017, the network IUSS rate remained under the industry (AORN) expected threshold of 3% [Figure 1].
Discussion: Surgical aseptic technique has evolved significantly since the initial descriptions of carbolic acid use.1,2 Currently, primary methods of surgical instrument sterilization include steam sterilization and IUSS. Strict control of IUSS utilization as a percentage of total sterilization procedures is an important consideration for institutions. The AORN and CDC published strict guidelines on IUSS use and as an organization our goal was to meet or exceed that standard.7,8 To achieve this objective, we successfully addressed three key areas of opportunity and were successful in implementing the integrated program that ultimately reduced our IUSS rates from as high as 5.2% to well below 3% [Figure 1].
The first element of our three-pronged approach was establishing better control and standardization of entry points for externally introduced surgical equipment. After key stakeholders from each involved area/department were identified, we worked to better understand our current process with regard to third-party vendors. We identified and prioritized critical issues that were contributing to our high IUSS rates. We then streamlined our process by utilizing the UniteOR software and hiring a dedicated team member to oversee the new process and to perform routine/daily maintenance of the system. Consistent with our findings, others also noted that implementation of EMR has been shown to improve process efficiency.9 We found that synergies generated by the integration of new technology into our overall process enabled us to improve both the efficiency and level of coordination among our various departments, contractors and other vendors.
Optimization of the surgical instrument inventory was the next area of opportunity addressed by the project team. This process started with an in-depth examination of existing inventories and the careful estimation of additional equipment that may be required to minimize and/or optimize our overall sterilization process efficiency. Due to our primary goal being the reduction in IUSS utilization, we focused our analysis on instrument type(s) that underwent IUSS most frequently. Utilizing targeted strategy, we were able to accomplish our stated goal not only by purchased additional instrumentation within each category of need but also by acquiring new type(s) of rigid containers to increase our speed and efficiency with regard to instruments turnover throughout the day. Synergistically, these interventions served to substantially enhance the availability of needed instrumentation for each case.
Our final preidentified opportunity centered on improving communication between the OR and SPD. Good team communication is critical in any work environment, especially the OR environment.10 At the same time, it can be challenging at times to coordinate and facilitate sustained, high-quality communication between departments, especially considering the high-paced and dynamic character of both OR and SPD. We solved this issue by integrating SPD representatives into OR team meetings. This provided a more granular insight into specific OR supply needs, well ahead of the following day's planned surgical cases. We found this approach especially helpful in instances where planned back-to-back cases required the same instrument sets. The combined interdepartmental team was able to subjective achieve better moment-by-moment communication, with greater openness and fewer barriers to voicing questions and/or concerns.
There were several limitations to our study, including the potential presence of temporal bias. Due to the project's design using the Plan-Do-Check-Act model, the primary goal was to show a change, as opposed to demonstrating statistical significance. Furthermore, this was a single health network experience, which may not be generalizable to other institutions. Consequently, our approach to reducing IUSS may not be relevant or readily applicable to unique circumstances and/or workflows at other organizations.
Conclusion: With the implementation of a vendor-tracking system to address third-party loaner instrument trays, improving communication between key stakeholder departments, and strategically increasing our inventories while cutting down our turnover time, we were able to decrease our IUSS rates to <3% and have sustained that change for over a year now. We have also purchased additional rigid containers which should further decrease the usage of IUSS to decontaminate instruments.
- Sunavala A, Singhal T, Soman R. Pioneers in infection prevention – Part 2. J Assoc Physicians India 2015;63:90-1.
- Green VW. Surgery, sterilization and sterility. J Healthc Mater Manage 1993;11:46, 48-52.
- Baines S. Surgical asepsis: Principles and protocols. Practice (London) 1996;18:23-33.
- Owens CD, Stoessel K. Surgical site infections: Epidemiology, microbiology and prevention. J Hosp Infect 2008;70 Suppl 2:3-10.
- Seavey R. Immediate use steam sterilization: Moving beyond current policy. Am J Infect Control 2013;41:S46-8.
- Instrumentation AftAoM. Comprehensive Guide to Steam Sterilization and Sterility Assurance in Healthcare Facilities. Arlington, VA: Instrumentation AftAoM; 2010.
- Bingman CA. Effectively reducing flash sterilization in a rural community hospital surgical suite. Am J Infect Control 2014;42:S45.
- Foster S, Sullivan SC, Brandt J, Brockway T, Jackson R, Griffin D, et al. Code flash: How an interdisciplinary team eradicated immediate-use steam sterilization: Previous presentations: This information was presented at the Arkansas Nurses Association with preliminary data in October of 2012. Infect Control Hospital Epidemiol 2015;36:112-3.
- Bates DW. The quality case for information technology in healthcare. BMC Med Inform Decis Mak 2002;2:7.
- Stawicki SP, Cook CH, Anderson HL 3rd, Chowayou L, Cipolla J, Ahmed HM, et al. Natural history of retained surgical items supports the need for team training, early recognition, and prompt retrieval. Am J Surg 2014;208:65-72.
| Abstract Number 8|| |
Do not Just Do Something – Stand There: Reducing the Incidence of Pneumothoraxes in High-Risk Infants
Authors: K. Costello, A. Zacharia, M. Harrington, K. Nunemacher, P. Kaur, V. Yellapu
Scientific contributors (alphabetically): P. Bates, S. Bijou, B. Cameline, A. Delillo, J. Donchez, M. Edwards, D. Hosier, D. Paul, S. Sannoh
Departments: Departments of Neonatal Intensive Care Unit, Quality Resources, Respiratory, Research and Innovation, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
Year of Submission: 2017
Introduction/Background: Premature infants (preterm infants, PTIs) face intense challenges after birth due to underdevelopment of key organ systems. This, in turn, can increase the complexity of physiologic stabilization following the birth. Preterm birth is a leading cause of neonatal mortality and is responsible for a significant percentage of all birth-related short- and long-term morbidities.1,2,3,4 The immature lung with surfactant deficiency, undeveloped alveoli, immature nervous system with impaired respiratory drive, and feeble chest muscles all predispose the lung to alveolar collapse and difficulty with gas exchange. Pneumothorax (PTX) is among the most common air leak syndromes, and its connection with underlying primary lung disorder is well known.3,4,5 Research has shown that mortality and morbidity related to PTX is higher in early PTI, or those born before 32 weeks of gestation.6 Increased mortality, chronic lung disease, intraventricular hemorrhage, and PTX all tend to be more common in very low birth weight (VLBW) neonates, resulting in longer hospital stays and deaths.7
Besides immaturity, risk factors for PTX also include respiratory distress syndrome (RDS), meconium aspiration, pneumonia, as well as invasive and noninvasive respiratory support. PTX can also be a complication of overzealous neonatal resuscitation.7 A higher incidence of PTX has been seen with mechanical ventilation in various studies. The mild increase in incidence among infants receiving continuous positive airway pressure has also been reported.5 In one study, about 40% of newborns were intubated before the diagnosis of PTX, and in most cases, endotracheal tube was aspirated.8 An increase in clinical interventions (e.g., suction procedures, chest radiography, reintubation, and chest compressions) has also been reported in these infants.5
The earlier a PTX is evacuated, the less physiologic damage will occur from hypoxia, hypercarbia, or venous arterial changes. It is vital to adjust respiratory support and to extubate efficiently to limit any lung damage.9 Thus, identifying risk factors for PTX in ventilated neonates may reduce the mortality, prevent the subsequent air leak, and improve the long-term outcome among survivors. Although there are existing protocols for the “golden hour,”10 the best practices for avoiding both short- and long-term outcomes vary considerably among different centers.
St. Luke's University Health Network (SLUHN) uses the Vermont Oxford Network (VON) database to analyze its Neonatal Intensive Care Unit (NICU) performance. Nearly 1000 NICUs from around the globe participate in VON database. An analysis of VON data for clinical year 2016 showed a need for improvement specifically with outcomes for VLBW or micropremature infant population. A review of 2014 Annual Report revealed the mortality rate in the VLBW population placed SLUHN in a higher percentile as compared to other VON-participating centers. After individual case reviews, it was determined that there was a significant opportunity for improvement in the VLBW population, with efforts that would also be applicable to the entire NICU population.
Project Aim/Objective: The aim of this project was to reduce incidences of PTX in high-risk infants and to the VON top quartile of rate of 0.0% in the VLBW population. Moreover, we sought to achieve <1.7% PTX rate in the expanded population by July 2017. The project involved sequential “Plan-Do-Check-Act” (PDCA) improvement cycles.
Methods: Initial tests-of-change began with SLUHN joining the VON NICQ Next2 Collaborative. An analysis of our VON 2014 annual report revealed the need for improvement in the following areas: mortality rates, NICU admission temperatures within range (36.5°C–37.5°C), PTX rates, and retinopathy of prematurity rates. To address these issues, we established a dedicated multidisciplinary care team by February 2016. Once we identified all of our barriers, we created a fishbone diagram [Figure 1] to delineate all the steps, we had to take during the project implementation stage.
Based on the preliminary analyses, an overarching aim statement was developed along with a hierarchy of aims to plan an organized approach toward stated improvement goals over the next 2 years. The first (thermoregulation) arm of the project was initiated in January 2016. In June 2016, given the success of the thermoregulation arm of the project, and a review of our VON 2015 annual report, the attention shifted to the second arm of the project, which focuses on reducing our PTX rates.
With ongoing team education, interventions using the PDCA quality improvement paradigm, we implemented the following measures to improve PTX rates:
- PDCA Cycle 1: Volume-targeted ventilators (VTVs) control the amount of air entering the lungs with each breath. Evidence shows that infants treated with VTVs were less likely to experience a PTX, more likely to survive free from lung damage and used ventilator assistance for shorter periods of time.11 Three VTVs were purchased to make a substantive change before the focus could shift away from the thermoregulation project
- PDCA Cycle 2: With the focus on this arm of the project, new extubation criteria were developed based on utilizing lung-protective strategies when providing respiratory support [Table 1]
- PDCA Cycle 3: We switched to a porcine-derived lung surfactant for infants weighing <1500 g. A Cochrane review comparing types of surfactants concluded that animal-derived surfactants are successful in treating RDS in PTIs and exhibit benefits over first-generation synthetic surfactants.12 Due to the higher cost of this surfactant, it was initially approved only for VLBW infants
- PDCA Cycle 4: While hosting the Micro-Preemie Onsite Conference in April 2017, it was discovered that other hospitals were using the porcine-derived lung surfactant for all infants. It was stated that they usually only used 1–2 doses, as opposed to, 3–4 doses of the synthetic surfactant, which helped to mitigate the cost. With that knowledge and considering that two of the three cases of PTX this year were in infants that received the synthetic surfactant, we began using the porcine-derived surfactant for all infants.
Results: We collected retrospective data on quarterly basis, with graphs made for monthly outcome analysis with corresponding counts and rates. To better direct our efforts, control charts were created [Figure 2] and [Figure 3] which showed improvement over time with the continued implementation of interventions. Analyzing rates of improvement was another way to determine our progress. Comparing our rates of PTX between Q3 2016 and Q3 2017, we noted a 62% improvement in our expanded population and a 33% improvement in our VLBW population. Of note, we have been able to achieve our target goal of 0% PTX in VLBW infants. In our expanded population, we reached a low of 1.6% (4Q 2016) incidence, which places us within the top VON quartile.
Discussion: Based on our four-stage PDCA cycle implementation, we were able to achieve a significant reduction in PTX incidence. Our PDCA methodology involved a stepwise rollout, allowing us to establish a well-controlled environment with clearly set improvement milestones. It also allowed us to create pertinent in-house guidelines for the management of PTX in infants. Given that VLBW infants are at higher risk of developing PTX due to decreased amount of surfactant and increased lung pressures, it was vital that we addressed both these problems.6 A Cochrane review showed that infants using VTV had decreased mortality and morbidity from respiratory complications.11 Using the VTV significantly decreased our rates of PTX. As previously outlined, other forms of ventilation in premature and VLBW infants may increase the risk of PTX.11 It has been shown that there has been a drastic decrease in infant mortality due to low birth weight compared to 20 years ago.6,13 It is perhaps due to developments such as the introduction of VTV and improvements in synthetic surfactants.
It is well known that decreased surfactant production in PTI and VLBW infants can lead to RDS.14,15 It is, therefore, vital to prevent RDS and other respiratory complications in infants deemed to be at risk.16 Although we have had success with the standard therapy (Exosurf, colfosceril palmitate, Glaxo Wellcome), recent guidelines from the American Academy of Pediatrics indicated that there might be benefits to using animal-derived surfactant (e.g., Curosurf, poractant alfa, Chiesi USA) over the standard surfactant.16 It is unclear why this benefit exists, but other institutions reported better outcomes as well.17 Consequently, we decided to proceed with Curosurf implementation. Of note, Curosurf was more expensive than the synthetic surfactant; therefore, initial approval was only given for its use in infants weighing <1500 g. After seeing clinical improvement in our VLBW population, a request was made to expand Curosurf administration to all infants requiring surfactant.
With the implementation of both the VTV and Curosurf, we have been able to substantially reduce our rates of PTX in infants. We have achieved our goal PTX rate of 0% in the VLBW population and have sustained this rate for 6 months. This is on par with the top quartile of the VON database. We have also noticed improvement in our expanded population, with a decrease in PTX from 5.2% to as low as 1.6%. This has placed us in the top quartile of VON for both infant groups. We continue to improve neonatal outcomes by standardizing the processes and care in the initial 72 h of a newborn's life.
Limitations: While we were able to achieve excellent clinical results, our study had some limitations. Given that we are not a primary NICU center, we do not have a large population of patients in the primary group under study. In addition, although our interventions were implemented in stages, it is difficult to determine the attribution of each consecutive intervention to the overall (final) outcomes. Moving forward, we will continue to implement additional changes to help further reduce PTX incidence; however, it will be difficult to say how effective our methods would be in a larger NICU with greater patient volume.
Conclusion: Our aim of reducing PTX incidence to 0.0% in the VLBW population and 1.7% in the expanded population by July 2017 was met using our outlined PDCA multicycle implementation. We believe that our systematic and evidence-based approach was instrumental in achieving our goal. The team plans to continue to take advantage of the expertise and resources provided by VON participation and continue to implement changes that will improve care in the initial 72 h of a newborn's life.
- Castrodale V, Rinehart S. The golden hour: Improving the stabilization of the very low birth-weight infant. Adv Neonatal Care 2014;14:9-14.
- Simmons LE, Rubens CE, Darmstadt GL, Gravett MG. Preventing preterm birth and neonatal mortality: Exploring the epidemiology, causes, and interventions. Semin Perinatol 2010;34:408-15.
- Schindler T, Koller-Smith L, Lui K, Bajuk B, Bolisetty S; New South Wales and Australian Capital Territory Neonatal Intensive Care Units' Data Collection, et al. Causes of death in very preterm infants cared for in neonatal Intensive Care Units: A population-based retrospective cohort study. BMC Pediatr 2017;17:59.
- Terzic S, Heljic S, Panic J, Sadikovic M, Maksic H. Pneumothorax in premature infants with respiratory distress syndrome: Focus on risk factors. J Pediatr Neonatal Individ Med 2016;5:e050124.
- Bhat Yellanthoor R, Ramdas V. Frequency and intensive care related risk factors of pneumothorax in ventilated neonates. Pulm Med 2014;2014:727323.
- Duong HH, Mirea L, Shah PS, Yang J, Lee SK, Sankaran K, et al. Pneumothorax in neonates: Trends, predictors and outcomes. J Neonatal Perinatal Med 2014;7:29-38.
- Ngerncham S, Kittiratsatcha P, Pacharn P. Risk factors of pneumothorax during the first 24 hours of life. J Med Assoc Thai 2005;88 Suppl 8:S135-41.
- McIntosh N, Becher JC, Cunningham S, Stenson B, Laing IA, Lyon AJ, et al. Clinical diagnosis of pneumothorax is late: Use of trend data and decision support might allow preclinical detection. Pediatr Res 2000;48:408-15.
- Stola A, Schulman J, Perlman J. Initiating delivery room stabilization/resuscitation in very low birth weight (VLBW) infants with an fiO(2) less than 100% is feasible. J Perinatol 2009;29:548-52.
- Sharma D. Golden hour of neonatal life: Need of the hour. Matern Health Neonatol Perinatol 2017;3:16.
- Wheeler K, Klingenberg C, McCallion N, Morley CJ, Davis PG. Volume-targeted versus pressure-limited ventilation in the neonate. Cochrane Database Syst Rev 2010;11:CD003666.
- Singh N, Halliday HL, Stevens TP, Suresh G, Soll R, Rojas-Reyes MX, et al. Comparison of animal-derived surfactants for the prevention and treatment of respiratory distress syndrome in preterm infants. Cochrane Database Syst Rev 2015;12:CD010249.
- Horbar JD, Badger GJ, Carpenter JH, Fanaroff AA, Kilpatrick S, LaCorte M, et al. Trends in mortality and morbidity for very low birth weight infants, 1991-1999. Pediatrics 2002;110:143-51.
- Eichenwald EC, Stark AR. Management and outcomes of very low birth weight. N Engl J Med 2008;358:1700-11.
- Hack M, Horbar JD, Malloy MH, Tyson JE, Wright E, Wright L, et al. Very low birth weight outcomes of the national institute of child health and human development neonatal network. Pediatrics 1991;87:587-97.
- Polin RA, Carlo WA; Committee on Fetus and Newborn, American Academy of Pediatrics. Surfactant replacement therapy for preterm and term neonates with respiratory distress. Pediatrics 2014;133:156-63.
- Curstedt T, Halliday HL, Speer CP. A unique story in neonatal research: The development of a porcine surfactant. Neonatology 2015;107:321-9.
| Abstract Number 9|| |
i-STAT Troponin Migration to Laboratory Troponin in the Emergency Department
Authors: J. Marine, V. Lazansky, V. Yellapu, G. Korszniak, S. Brown, S. Wasykowski
Departments: Departments of Clinical Laboratory, Emergency Medicine, Quakertown, and Research and Innovation, Bethlehem, Pennsylvania, USA
Year of Submission: 2017
Introduction: Troponin (TN) is a commonly used diagnostic test that is typically ordered in the Emergency Department (ED) for any patient that is seen for chest pain.1,2,3 This consists of approximately 10% of patients who are evaluated in the ED.4 It is also an important laboratory marker in the diagnosis and management of acute myocardial infarction. The vast majority of patients who present to the ED with a chief complaint of shortness of breath, chest pain, or chest discomfort receive a TN blood draw. Many critical decisions are made based on the result of TN studies.5,6 Therefore, it is vital that these blood studies are completed quickly and their results are accurate.
There are two common types of TN laboratory draws, i-STAT and laboratory TN. Point-of-care i-STAT TN testing is routinely used in the ED. Until recently, it was thought that i-STAT TN was inferior in terms of diagnostic sensitivity.7,8 However, there have been studies to suggest that point-of-care TN (POC-TN) is now just as sensitive and faster than laboratory TN test.1,9
At St. Luke's University Health Network – Quakertown Campus, we noticed that the use of i-STAT TN testing was not only higher in comparison laboratory TN but was also being performed nonselectively. With assistance from the finance/billing department, we determined that the cost difference between i-STAT TN testing and laboratory TN testing was $9.28 per single use, which could result in significant savings with appropriate and successful implementation of selective testing initiative. After the implementation of EPIC electronic medical record (EMR) in January 2016, the ability to collect department-specific test data allowed us to determine that 68% of all TN tests performed in our ED were i-STAT TNs.
Project Aim/Overview: The primary aim of this project was to decrease the number of i-STAT TNs being utilized within our ED by half over the course of a year. By achieving this aim, we estimated that it would reduce associated laboratory costs by at least $1127 per month.
Methods: Using the EPIC EMR (EPIC Systems, Verona, WI, USA), we conducted retrospective reviews of ED patients who received TN testing. We identified the number of laboratory-processed TNs and the number of i-STAT TNs [Figure 1]. ED patients with TN testing between January and March 2016 were used as preintervention data points. Once we determined that our ED population that had high usage of i-STAT TN, the ED and laboratory leadership made a coordinated effort to outline criteria for ordering i-STAT versus laboratory TN testing. These criteria were then disseminated throughout the department.
It was determined that the workup for patients with normal (nondiagnostic) EKGs did not need to include i-STAT TN. I-STAT TN was to be used for workup of patients with acute, time-sensitive issues and/or those with EKG changes (i.e., STEMI). All ED providers were instructed to consider laboratory TN testing for patients requiring a routine nontime sensitive workup for chest pain with a normal EKG. Information regarding the cost difference between i-STAT and laboratory testing was also communicated to all stakeholders. Both the ED staff and the laboratory staff were invested in the success of this project. It was vital that everyone in both departments understood the new implementation process and were able to follow through with the intervention. The laboratory was trained in running reports to identify patients receiving TN orders utilizing our EMR. Each month we used these reports to compare the costs accrued by using i-STAT and laboratory TN.
Results: Within the first 4 months of implementing the new diagnostic criteria, we saw a decrease of 6% in i-STAT testing. Monthly data continued to be collected and shared with ED management and providers. By our 6-month mark, we noted an average 22% decrease in utilization of i-STAT TN. This corresponded with the timing of laboratory-facilitated reporting on monthly ED turnaround times showing an average time of 22 min for laboratory TN testing. By 7th month of implementation (January 2017), we were able to achieve a 71% decrease in i-STAT TNs. Moreover, between February and May of 2017, the average monthly decrease of i-STAT TN was 81%. Significant monthly cost savings were appreciated as ISTAT TN orders reduced. There were no specific quality-of-care concerns identified in this patient population because of the change.
In January of 2017, we achieved our aim of decreasing the use of ISTAT TN testing by >50% and realized a monthly cost savings of >$1100 that initially expected. These results have been sustained and have far exceeded the goal. After a slow but steady average 15% decrease in i-STAT TNs for the first 7 months of project implementation (June 2016–December 2016), there was an average 71% decrease in i-STAT TN utilization in the subsequent 5 months (January–May 2017) [Figure 2]. This created an average monthly savings of >$2300. If we are able to continue this effort and further optimize the utilization of TN testing, we could expect annualized savings of >$27,600.
Discussion: TN testing is a common and important component of cardiac diagnostics in the ED. As with any diagnostic tests, it is crucial to optimize the way we use various available clinical tools. Multiple studies that show that laboratory TN has been able to identify more patients with cardiac ischemia than POC-TN tests.10,11,12,13 The most important factor for using POC-TN is the immediate availability of the results. If result generation from traditional laboratory TN assessment can be expedited, this fundamental difference becomes less relevant. There have been other studies that support our method of laboratory TN testing versus i-STAT in terms of result timing.9
Throughout the current quality improvement (QI) project, our team was able to create added value within a short period of time by facilitating more efficient utilization of laboratory resources – an increasingly important consideration given our growing patient volumes. Because TN assessment is one of the most common ED-ordered tests, creating an effective guideline for more efficient utilization has allowed us to significantly reduce costs. An important part of the overall process was the discovery (and subsequent action based on this evidence) that providers and staff were not aware of the cost difference between – i-STAT testing and laboratory TN testing. This, in turn, led to suboptimal utilization of available TN tests.
Equipment and technology played a key role in the current QI initiative. During the last 6 months of 2015, our laboratory installed new chemistry analyzers. This allowed for the implementation of a new TN assay which featured shorter specimen analysis time. In addition, autoverification and release of results “within normal range” was instituted. These upgrades efficiently reduced laboratory specimen processing times to <30 min after the receipt of specimen in laboratory.
TN testing represents a suitable area for introducing efficiency and cost reduction into the health system. Given the high volume of patient with potentially time critical diagnoses, we need to be aware of how best to identify and test patients. During the past few years high, value-based care modules have increasingly been implemented, resulting in provider awareness that goes beyond the direct health impact of ordering diagnostic tests but also highlights various economic and sustainability aspects of care. In this project, we have demonstrated that, through targeted education and creation of guidelines, we were able to streamline TN testing for ED patients. Further studies are underway to allow us to identify other areas of opportunity for streamlining within the realm of high-volume diagnostics.
Limitations: There are important limitations of this study. First, the project was carried out at a relatively small hospital/campus, with TN testing being ordered approximately 430 times per month. Consequently, our results may not be translatable to higher volume facilities. Second, the implementation of our guidelines may have been simpler than compared to larger institutions, primarily because of smaller project teams, lean administrative structure, and a clinical environment that was overall more amenable to quasi-experimental control. Finally, there may have been temporal (and other) biases that could have influenced both quantitative and qualitative aspects of our study.
Conclusion: The current QI project exceeded our predetermined goals and expectations in terms of both TN diagnostic guideline compliance and cost savings. We will continue to encourage changes that were implemented during this undertaking, with a goal of expanding the scope of our project into other diagnostics tests and other hospital network locations.
- Apple FS, Ler R, Chung AY, Berger MJ, Murakami MM. Point-of-care i-STAT cardiac troponin I for assessment of patients with symptoms suggestive of acute coronary syndrome. Clin Chem 2006;52:322-5.
- Daubert MA, Jeremias A. The utility of troponin measurement to detect myocardial infarction: Review of the current findings. Vasc Health Risk Manag 2010;6:691-9.
- Collinson PO. Troponin T or troponin I or CK-MB (or none?). Eur Heart J 1998;19 Suppl N:N16-24.
- Bhuiya FA, Pitts SR, McCaig LF. Emergency department visits for chest pain and abdominal pain: United States, 1999-2008. NCHS Data Brief 2010;43:1-8.
- Hamm CW, Goldmann BU, Heeschen C, Kreymann G, Berger J, Meinertz T, et al. Emergency room triage of patients with acute chest pain by means of rapid testing for cardiac troponin T or troponin I. N Engl J Med 1997;337:1648-53.
- Apple FS, Wu AH. Myocardial infarction redefined: Role of cardiac troponin testing. Clin Chem 2001;47:377-9.
- Jossi S, Gordon SL, Legge MA, Armstrong GP. All troponins are not created equal. Internal Med J 2006;36:325-7.
- Venge P, Ohberg C, Flodin M, Lindahl B. Early and late outcome prediction of death in the emergency room setting by point-of-care and laboratory assays of cardiac troponin I. Am Heart J 2010;160:835-41.
- Bingisser R, Cairns C, Christ M, Hausfater P, Lindahl B, Mair J, et al. Cardiac troponin: A critical review of the case for point-of-care testing in the ED. Am J Emerg Med 2012;30:1639-49.
- Bock JL, Singer AJ, Thode HC Jr. Comparison of emergency department patient classification by point-of-care and central laboratory methods for cardiac troponin I. Am J Clin Pathol 2008;130:132-5.
- Loewenstein D, Stake C, Cichon M. Assessment of using fingerstick blood sample with i-STAT point-of-care device for cardiac troponin I assay. Am J Emerg Med 2013;31:1236-9.
- Jossi S, Gordon SL, Legge MA, Armstrong GP. All troponins are not created equal. Intern Med J 2006;36:325-7.
- Lee-Lewandrowski E, Januzzi JL Jr., Grisson R, Mohammed AA, Lewandrowski G, Lewandrowski K, et al. Evaluation of first-draw whole blood, point-of-care cardiac markers in the context of the universal definition of myocardial infarction: A comparison of a multimarker panel to troponin alone and to testing in the central laboratory. Arch Pathol Lab Med 2011;135:459-63.