Appropriate CT cervical spine utilisation in the emergency department.

INTRODUCTION: Over 40 000 CT scans are performed in our emergency department (ED) annually and utilisation is over 80% capacity. Improving medical appropriateness of CT scans may reduce total number of scans, time, cost and radiation exposure. METHODS: Lean Six Sigma methodology was used to improve the process. A National Emergency X-Radiography Utilisation Study (NEXUS)-based PowerForm was implemented in the electronic health record and providers were educated on the criteria. RESULTS: The rate of potentially medically inappropriate CT C-spine scans decreased from 45% (19/42) to 22% (90/403) (two-proportion test, p=0.002). After the intervention, there was no longer a difference between midlevel providers and physicians in the rate of medically inappropriate orders (19% vs 22%) (two-proportion test, p=0.850) compared with that before the intervention (56% vs 31%) (two-proportion test, p<0.01). Overall rates of CT C-spine scans ordered decreased from 69.3 to 62.6/week (t-test, p=0.019). CONCLUSION: A validated clinical decision-making tool implemented into the medical record can improve quality of care. This study lays a foundation for other imaging studies with validated support tools with similar potential improvements.

Using Lean Six Sigma methodologies to reduce risk of warfarin medication omission at hospital discharge.

Unintended omission of warfarin, an anticoagulant used to prevent and treat thromboembolic events, can lead to serious medical complications. These complications include increased medical costs, hospitalisations and significant patient harm, including increased risk of thrombosis and mortality. Chart review of discharged patients at our institution revealed an average of one patient/month with warfarin omitted from the discharge plan despite intention to continue therapy. Lean Six Sigma methodology was used to improve the process. A system alert was implemented in the electronic health record to alert providers of patients who received warfarin during admission, the discharge medication reconciliation was complete, and there was no prescription for warfarin. Date and time of last warfarin dose and international normalised ratio were included in the alert. Providers had the option to return to the chart to update the discharge medication plan and add the warfarin prescription or to choose an appropriate over-ride reason. The number of patients discharged without an intended warfarin prescription following alert implementation was reduced from 10.5% (4/38) to 0% (0/40) (two proportion test, p=0.03). Alert tracking enhanced the ability to identify patients at risk for warfarin omissions. Process sustainability has been achieved by embedding system alerts in the electronic health record to trigger process steps.

Quality improvement of intravenous to oral medication conversion using Lean Six Sigma methodologies.

INTRODUCTION: Lack of medication conversion from intravenous to oral contributes to increased risk of infection, delayed discharges and higher medication costs. At our institution, intravenous to oral medication conversion rate was 76% with missed opportunity for conversion of 37%. The goal of the project was to reduce the percent of missed opportunities for intravenous to oral conversion for applicable medications. METHODS: A pharmacy-driven intravenous to oral policy and procedure was implemented. To identify potential opportunities, a patient worklist of applicable intravenous to oral medications was created for pharmacy review in real time. An intravenous to oral conversion order was implemented in the computerised provider order entry. 'Convert to oral' was added as an option in the electronic medication request and highlighted reminders were added to the electronic medication administration record for eligible medications. RESULTS: After improvements, the missed opportunity rate for intravenous to oral conversion decreased from 37% (19/51) to 21% (24/113) (p=0.04, two-proportion test), a 43% improvement. The trend in intravenous to oral conversion rate increased from 76% (39/51) to 85% (171/201) and severity adjusted length of stay was reduced from 8.1 days to 6.4 days post improvements (p<0.001, t-test).

Improving comprehensive care for patients with diabetes.

Patients with diabetes require access to systematic and ongoing care delivered by a team of healthcare providers. Despite national attention and well-accepted best practices, diabetic care, blood pressure and haemoglobin A1c (A1c) levels for patients with diabetes in our primary care setting were highly variable and below the Healthcare Effectiveness Data and Information Set (HEDIS) 75th percentile benchmark. From January 2015 to January 2016, 22% of patients with diabetes in our primary care setting had both blood pressure and A1c levels controlled and 23% had their annual diabetic care bundle completed, which includes A1c and blood pressure measurements, foot examination and nephropathy attention. Lack of standardised care algorithms, electronic health record documentation and education was identified. Lean Six Sigma methodologies were used to re-engineer the care that patients with diabetes receive. Key improvement initiatives focused on standardisation of accepted care practices through electronic templates, education and re-evaluation of patients to make 90-day, rapid cycle changes. Interventions were piloted in one primary care clinic then expanded to eight additional clinics. At the pilot site, the per cent of patients who completed the diabetic care bundle increased from 33% to 71% and the per cent of patients with diabetes with both A1c and blood pressure controlled increased from 31% to 43% (two-proportion test, p<0.01) postintervention. On rollout to eight additional clinics, the per cent of patients who completed the diabetic care bundle increased from 23% to 67% and the per cent of patients with diabetes with both their A1c and their blood pressure controlled increased from 22% to 41% (two-proportion test, p<0.01). After the interventions, nephropathy attention, A1c and blood pressure metrics exceeded HEDIS 75th percentile. Standardisation of accepted care practices for patients with diabetes improved compliance with diabetic care bundle completion and patient outcomes in the primary care setting.

Quality improvement of delirium status communication and documentation for intensive care unit patients during daily multidisciplinary rounds.

Delirium is a key quality metric identified by The Society of Critical Care Medicine for intensive care unit (ICU) patients. If not recognised early, delirium can lead to increased length of stay, hospital and societal costs, ventilator days and risk of mortality. Clinical practice guidelines recommend ICU patients be assessed for delirium at least once per shift. An initial audit at our urban tertiary care hospital in Illinois, USA determined that delirium assessments were only being performed 31% of the time. Nurses completed simulation based education and were trained using delirium screening videos. After the educational sessions, delirium documentation increased from 40% (12/30) to 69% (41/59) (two-proportion test, p<0.01) for dayshift nurses and from 27% (8/30) to 61% (36/59) (two-proportion test, p<0.01) during the nightshift. To further increase the frequency of delirium assessments, the delirium screening tool was standardised and a critical care progress note was implemented that included a section on delirium status, management strategy and discussion on rounds. After the documentation changes were implemented, delirium screening during dayshift increased to 93% (75/81) (two-proportion test, p<0.01). Prior to this project, physicians were not required to document delirium screening. After the standardised critical care note was implemented, documentation by physicians was 95% (106/111). Standardising delirium documentation, communication of delirium status on rounds, in addition to education, improved delirium screening compliance for ICU patients.

See You in 7: improving acute myocardial infarction follow-up care.

Acute myocardial infarction (AMI) follow-up care is a crucial part of the AMI recovery process. The American College of Cardiology's 'See You in 7 Challenge' advocates that all patients discharged with a diagnosis of AMI have a cardiac rehabilitation referral made and outpatient cardiac rehabilitation appointment scheduled to occur within 7 days of hospital discharge. A streamlined AMI cardiac rehabilitation referral and appointment scheduling process was not in place at this urban academic medical centre. To develop the streamlined processes, a Six Sigma project was initiated. Four months before the intervention, 1/38 patients with AMI (2.6%) were scheduled to have the initial outpatient cardiac rehabilitation appointment occur within 7 days of hospital discharge, with an average 18.7 days from hospital discharge to the scheduled initial outpatient cardiac rehabilitation appointment. To reduce the time to this initial appointment, availability of outpatient cardiac rehabilitation appointments was increased, additional staff were trained in appointment scheduling and insurance verification processes and appointments were scheduled prior to hospital discharge. After intervention, the number of patients scheduled to attend an outpatient cardiac rehabilitation appointment within 7 days of hospital discharge improved to 72/79 (91.1%) (two-proportion test, p<0.001). Days from hospital discharge to first scheduled outpatient cardiac rehabilitation appointment were reduced from 18.7 days to 6.3 days (a 66.3% reduction) (Mann-Whitney U test, p<0.01). Initial outpatient cardiac rehabilitation attendance within 7 days of hospital discharge increased from 1/38 (2.6%) to 42/79 (53.2%) (a 50.6% increase) (two-proportion test, p<0.001).

Effectiveness of a submassive pulmonary embolism protocol to standardise patient evaluation and treatment.

Treatment recommendations for submassive pulmonary embolus (SMPE), defined as pulmonary embolus (PE) resulting in right ventricular dysfunction and/or myocardial necrosis, vary. The objective of this study was to develop an investigative protocol at our tertiary care hospital to standardise the approach to patients with SMPE and to evaluate the effect of the protocol on process measures including consultation with cardiology and critical care physicians and time to echocardiogram and treatment. Triggered by right ventricle/left ventricle ratios >0.9, the protocol standardised ancillary studies and immediate consultation with critical care and cardiology. Post-protocol implementation, the percent of patients with SMPE evaluated by critical care specialists increased from 26% (19/74) to 93% (41/44) (p<0.001) and cardiology consultations increased from 35% (26/74) to 89% (39/44) (p<0.001). Patient arrival to echocardiogram was reduced from 15 hours to 5 hours post-protocol implementation. In addition, average time to anticoagulation was reduced from greater than 7 hours to 3 hours 27 min post-protocol implementation. The protocol has helped to identify patients with SMPE and standardise the care they receive after diagnosis.

Next day discharge rate has little use as a quality measure for individual physician performance.

INTRODUCTION: Emergency Department (ED) physicians' next day discharge rate (NDDR), the percentage of patients who were admitted from the ED and subsequently discharged within the next calendar day was hypothesized as a potential measure for unnecessary admissions. The objective was to determine if NDDR has validity as a measure for quality of individual ED physician performance. METHODS: Hospital admission data was obtained for thirty-six ED physicians for calendar year 2015. Funnel plots were used to identify NDDR outliers beyond 95% control limits. A mixed model logistic regression was built to investigate factors contributing to NDDR. To determine yearly variation, data from calendar years 2014 and 2016 were analyzed, again by funnel plots and logistic regression. Intraclass correlation coefficient was used to estimate the percent of total variation in NDDR attributable to individual ED physicians. RESULTS: NDDR varied significantly among ED physicians. Individual ED physician outliers in NDDR varied year to year. Individual ED physician contribution to NDDR variation was minimal, accounting for 1%. Years of experience in Emergency Medicine practice was not correlated with NDDR. CONCLUSION: NDDR does not appear to be a reliable independent quality measure for individual ED physician performance. The percent of variance attributable to the ED physician was 1%.

Improving medication reconciliation at hospital admission, discharge and ambulatory care through a transition of care team.

Medication reconciliation is an important component to the care of hospitalised patients and their safe transition to the ambulatory setting. In our Family Medicine Hospitalist Service, patient care is frequently transferred between the various physicians, residents, nurses and eventually to a separate group of providers who provide ambulatory management. Due to frequent transitions of care, there was no clear ownership of the medication reconciliation process. To improve the medication reconciliation process, a Transition of Care Team composed of registered nurses was created to oversee the entire reconciliation process. The team engaged the patient and their family, when needed, contacted patients' pharmacies and their providers, reconciled the patients' hospital medication list with the ambulatory list at hospital admission and within 24 hours of discharge, and attended the hospital follow-up visit to verify medications and provide continuity of care. Implementation of the team allowed for additional investigative resources, redundancy in preventing errors and early recovery should an error occur. The percent of medications with error after implementation of the Transition of Care Team was reduced from 131/386 (33.9%) to 147/787 (18.7%) at hospital admission, 81/354 (22.9%) to 42/834 (5.0%) at discharge and 43/337 (12.8%) to 6/809 (0.7%) at follow-up visit (two proportion tests, p<0.001). In addition, the percent of charts without any errors improved at hospital discharge from 8/31 (25.8%) to 46/70 (65.7%) and at hospital follow-up visit from 16/31 (51.6%) to 64/70 (91.4%) (two-proportion test, p<0.001). Previously viewed as three separate reconciliations occurring at admission, discharge and hospital follow-up, the approach to medication reconciliation was reframed as a continuous process occurring throughout the hospitalisation and hospital follow-up resulting in improved reconciliation accuracy and safer transitions to the ambulatory setting.