Published in the May 2005 issue of Today’s Hospitalist.
Five years ago, Hackensack University Medical Center got an early taste of how streamlining systems of care could not only improve patient care, but help its bottom line.
At a time when quality improvement wasn’t much more than a buzzword at most U.S. hospitals, the 635-bed teaching hospital in Hackensack, N.J., decided to roll out an ambitious program to change how it cared for patients with community- acquired pneumonia (CAP). A growing body of research had shown that some CAP patients could be safely treated with oral antibiotics instead of IV medications and sent home from the hospital earlier.
Based on that research, the hospital created a list of criteria that physicians could use to identify candidates for oral treatment. After educating physicians about the benefits of oral treatment, Hackensack brought in an advanced practice nurse to work with physicians to make sure that appropriate patients received oral therapy instead of the more traditional IV drugs.
The results were impressive. After only six months, Hackensack’s length of stay for CAP patients dropped an average of 1.34 days; costs for those patients fell by more than $300,000 per year. Just as importantly, the hospital saw no increase in readmission rates for CAP patients.
Reducing costs, however, was only the beginning. Because patients were being discharged earlier, Hackensack was able to free up beds on the wards faster, improving throughput in the emergency department and throughout the hospital. Because payers like Medicare pay the same amount for an episode of care no matter how long the patient is hospitalized, sending CAP patients home earlier helped the hospital generate an additional $320,000 a year in revenues.
The CAP project also helped the hospital meet pneumonia performance measures endorsed by the Joint Commission on Accreditation of Healthcare Organizations and Medicare. Among other things, those measures call for antibiotics to be administered within four hours and for hospitals to screen for and give influenza and pneumococcal vaccines when appropriate.
(More on Hackensack’s CAP program, including details on the hospital’s savings and the extra revenue it generated, is in the July 2004 issue of the
Today, Hackensack has parlayed its early efforts in quality improvement into a reputation as a trendsetter in quality of care. The hospital is taking part in several high-profile projects designed to demonstrate how hospitals can do well by doing good.
One of those efforts is the Pursuing Perfection project, an initiative that is being led by the Institute for Healthcare Improvement and funded by the Robert Wood Johnson Foundation. The project, which began in 2001 and is entering its last phase, has the ambitious goal of helping U.S. health care reinvent itself by designing newer, safer and more efficient systems of care.
Hackensack is also one of nearly 300 hospitals participating in the Premier-Medicare Hospital Quality Incentive Demonstration project. Under this program, the federal government is paying bonuses to facilities that are voluntarily participating in a pay-for-performance pilot.
Hospitals that meet the highest standards of care for patients with conditions like community-acquired pneumonia, heart failure, myocardial infarction, and individuals who undergo hip and knee replacements and heart bypass surgery will receive a bonus of 1 percent to 2 percent of Medicare payments.
Both programs are a natural fit for Hackensack, which has learned some valuable lessons about quality improvement efforts. Peter A. Gross, MD, chairman of internal medicine at Hackensack and project director for the Pursuing Perfection program, says one of those lessons focuses on the value of what he calls “redundant systems.”
He explains that while many quality improvement initiatives focus on changing provider behavior, changing systems is more important than changing the attitudes of individuals. “When you reach a certain level of improvement and want to do more, you need built-in systems of redundancy so you’re not relying on one person to get it all done,” Dr. Gross says.
Instead of relying only on physicians to identify CAP patients who might be good candidates for oral therapy, for example, the hospital used an advanced practice nurse to help get the job done. Hackensack similarly used an advanced practice nurse to work with physicians to successfully reduce the unnecessary use of telemetry services.
When Hackensack began its CAP project, hospital medicine was still in its infancy. Today, however, as hospital medicine solidifies its reputation for leading quality improvement efforts, hospitalists are playing a critical role in the hospital’s quality improvement efforts. Its hospitalists, Dr. Gross says, who provide a very sophisticated level of redundancy in Hackensack’s quality improvement initiatives.
Hospitalists in the ED
Take the role of hospitalists in the emergency department. Dr. Gross says these physicians not only improve clinical care for acute patients, but improve throughput and prevent the emergency room from becoming backed up.
The hospitalists who work in the emergency department perform a variety of jobs, but they focus on caring for acute patients who will be transferred to the floor. Dr. Gross says that hospitalists in the ED will typically work up patients who are going to be admitted to the hospital but remain in the emergency department. That typically occurs when there are no available beds on the wards, or when the patient’s primary care physician, who also sees seeing patients in the hospital, is busy in the outpatient setting.
“The hospitalists can do a history and physical on a newly admitted patient,” Dr. Gross explains. “They can help manage a patient where the private practice doctor wants to do the history and physical but he is in his office, and the patient is a little rocky but can’t go upstairs because there are no beds.”
Hospitalists in the emergency department also help make sure that patient care meets Medicare performance measures for conditions like myocardial infarction, heart failure and community-acquired pneumonia. It’s much easier to give CAP patients the correct antibiotic within four hours “the time frame set out by Medicare’s performance measure “if a physician can administer it before the patient is transferred to the wards.
Finally, the hospitalists who work in the ED also see patients who may not need to be admitted to the hospital but do need some kind of medical evaluation.
“They may need a stress test to determine if they should go home,” Dr. Gross explains. “Hospitalists can do that while the patient is still in the ER.”
Rapid response teams/multidisciplinary rounds
Hackensack is using hospitalists in other areas of the hospital to help improve patient care and reduce mortality and length of stay. Hospitalists work with advanced practice nurses on rapid response teams to intervene before patients code and require a trip to the ICU.
“The advanced practice nurse will be called to the floor of a nursing unit when the local nurse senses that something is wrong with the patient,” Dr. Gross explains. “It can either be a sixth sense that something is wrong, or it can be that the vital signs have changed, the blood pressure has dropped, the patient has spiked a high fever, the oxygenation is not as good, or the patient is breathing faster.”
The advanced practice nurse comes to the patient’s bed and decides whether to call the rapid response team, which is headed by a hospitalist. Dr. Gross says a primary goal of the team is to reduce admissions to the ICU by intervening in deteriorating patients before they need attention from critical care doctors. But he notes that it also has the overall effect of reducing mortality in the hospital.
(For more on rapid response teams, see the November 2004 issue of Today’s Hospitalist online.)
Dr. Gross explains that hospitalists on rapid response teams also work in other areas of the hospital when they’re not busy intervening with deteriorating patients. If a heart failure patient needs some attention but isn’t crashing and the primary care physician can’t leave her office, he says, a hospitalist from the rapid response team can step in.
Hackensack also uses what Dr. Gross likens to “part-time hospitalists” for multidisciplinary rounds. Physicians from private practice or another service in the hospital like infectious diseases work five days a week for an hour or two a day. Working with the nursing staff, social services representatives and health care providers, they round on individual units, reviewing all the patients on the floor and looking at factors like resource utilization and compliance with quality measures.
“Let’s say a patient comes into the hospital,” Dr. Gross explains. “One thing we do as part of our redundant systems is screen all positive troponins.” Hospitalists conducting multidisciplinary rounds, he says, can talk to the patient’s attending physician to discuss the patient’s elevated troponin level. “We’ll try to get an opinion as to whether the patient had a heart attack,” Dr. Gross adds.
Physicians conducting multidisciplinary rounds similarly examine BNP levels on a routine basis to help identify patients that might have heart failure.
Adjusting to oversight
Dr. Gross acknowledges that in the above roles, hospitalists at Hackensack are being asked to review the actions of other physicians and health care providers who work at the hospital, particularly primary care physicians who provide inpatient care for their hospitalized patients.
While Dr. Gross says this oversight role has on occasion produced some tension between hospitalists and outpatient doctors, most primary care physicians have adapted. “It’s a delicate balance, but it’s the direction we’re moving in,” he explains. “Everybody knows the direction we’re heading, and they know it’s irreversible.”
That’s not to say that hospitalists don’t try to be sensitive to outpatient physicians and not step on their toes. If a hospitalist manages a hospitalized patient of an outpatient physician who wants to manage the patient but is stuck at the office, the hospitalist will try to keep in close touch with the private practice doctor.
“When a patient comes into the ED with one of the diseases we’re focusing on,” Dr. Gross says, “we have order sheets that are supposed to be completed. If the order sheet is not completed by a private attending, the hospitalist has orders from me to make sure the appropriate orders are completed. If there are questions, the hospitalist is told to call the doctor and get the answer to complete the order sheet.”
While some primary care physicians have had a hard time coping with Hackensack’s system, Dr. Gross points out that most primary care physicians “really get it.” These physicians are not afraid to stand up at meetings and say they are delighted that the hospital staff are calling them and reminding them to give their pneumonia patients antibiotics within four hours or screen for a pneumococcal vaccine.
While Dr. Gross admits that many physicians may accept this kind of help grudgingly, he predicts that way of thinking will soon change. While many pay-for-performance programs currently focus on hospitals, it’s only a matter of time before individual doctors are paid according to how well they meet performance measures.
And hospitals like Hackensack, after all, help primary care physicians perform at their best by ensuring appropriate patients have received a pneumococcal vaccine or other care listed in the growing list of performance measures.
“When payers start measuring individual physician practices for their compliance with performance measures,” Dr. Gross says, “it’s going to sharpen physicians’ interest.”
Edward Doyle is Editor of Today’s Hospitalist.