Optimization of Patient Progression in a New Era: A Comprehensive Framework.

PURPOSE/OBJECTIVES: The onset of the coronavirus disease 2019 pandemic increased the demand for inpatient services and led to widespread staffing shortages in the acute and post-acute setting, contributing to delayed inpatient throughput and leading to capacity crises. Novel strategies are needed to facilitate the efficient progression of hospitalized patients when medically ready for lower levels of care. The authors have developed a foundational strategic framework for patient progression to ensure capture of patient progression data, enhance efficiency, and optimal utilization of post-acute resources in increasingly complex and resource-constrained acute and post-acute environments. PRIMARY PRACTICE SETTINGS: Interventions were implemented, and metrics of success tracked as part of an overarching framework to test new models of care or optimize existing assets related to barriers to patient progression. Brigham and Women's Hospital (BWH) and Brigham and Women's Faulkner Hospital (BWFH) comprise an academic medical center and a community hospital, respectively, that are affiliated with Massachusetts General Brigham (MGB), a nonprofit health care system in Massachusetts. Key interventions include (1) screening to prioritize patients needing case management services through a modified early screening for discharge planning tool and process; (2) communicating, documenting, identifying patient progression status, barriers to discharge and post-acute needs through interdisciplinary care optimization rounds, a novel tool in the electronic health record, and an associated dashboard; (3) managing active high-risk patients through a novel complex care team and post-acute strategy development; (4) developing novel transportation and hospice pathways; and (5) establishing community hospital repatriation and a physical therapy "Why Not Home" campaign. FINDINGS: Key metrics of success were (1) modified discharge planning tool resulting in screening out low-risk patients (53%) and impacting length of stay (0.55-day reduction, p = .083) during a 3-month intervention versus control study; (2) documentation adherence in more than 98% of patients 10 months postimplementation; (3) complex care team achieving a 2.5% reduction in Case Mix Index-adjusted length of stay 6 months postimplementation; (4) use of care van offsetting ambulance/chair car in 10% of cases, and earlier discharge time/length of stay in 21% of cases 3 months postimplementation; and (5) implementation of community repatriation impacting delay days to discharge (10-month pilot, 40 patients accounting for 1,000 delay days). CONCLUSIONS: Implementation of a novel comprehensive framework focusing on optimizing patient progression resulted in increased operational efficiency and positively impacted length of stay at our academic and community hospitals. Additional study is actively ongoing to understand long-term benefit of the innovations that the authors have developed. Further interventions are needed to wholly mitigate evolving capacity challenges in the acute and post-acute settings. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: The authors' implementation of the Brigham framework for progression demonstrates that innovative approaches to case management can help address the evolving challenges in care transitions planning. Notable opportunities include approaches that empower case managers as multidisciplinary team leaders, improve workflow, utilize patient progression data, prioritize patients with complex care needs support key patient populations, and promote post-acute collaboration.

A Nurse Anesthesiology Mentorship Program: An Evidence-Based Project for Implementation.

Transitioning from the role of student to the professional certified registered nurse anesthetist (CRNA), as well as a CRNA transitioning to a new job can be very difficult because of uncertainty in the new environment when compounded by a lack of social support. A formal mentorship program was developed and organized by CRNA leadership to help retain and engage new employees and ensure that they assimilate to the new culture while effectively gaining institutional knowledge and clinical skills. The mentorship program consisted of structured meetings that included the newly hired cohort of CRNAs, matched mentors, and CRNA leadership at regular intervals to foster a sense of community and professional growth. The working definition of the mentorship process for this project was described as the following: a mentor, defined as an experienced CRNA, not a direct manager, meets with the mentee, a newly hired CRNA, on a regular basis following a predetermined timeline to assess and meet the mentee's goals, to provide resources, including networking, and to provide guidance for the mentee to make the best decisions for their professional and personal growth. The purpose of this project was to explain the potential benefits of implementing a formal mentorship program for recruiting, on-boarding, and retaining CRNAs.

Creating KidneyPal: A Specialty-Aligned Palliative Care Service for People with Kidney Disease.

BACKGROUND: Patients with kidney disease have notable unmet palliative care needs and represent an underserved population for specialty palliative care teams. INTERVENTION: We designed a specialty-aligned interprofessional palliative care service called KidneyPal that is aimed at improving delivery of palliative care to patients with kidney disease through focus groups and iterative improvement cycles. MEASURES: We iteratively measured the development of KidneyPal through clinical process metrics: percent of the inpatient nephrology census followed by KidneyPal, patient demographics, consult origin, clinician feedback, and self-reported team interventions. OUTCOMES: KidneyPal saw 314 unique patients from January 2019 to January 2021. The majority of consultations came from nephrology services though the source of consultation changed over time. We consulted on an average of 13.5% of the entire inpatient nephrology patient hospital census with highest involvement with patients on the inpatient nephrology hemodialysis service (mean of 29.9%). KidneyPal was rated highly by surveyed nephrology clinicians and provided high rates of psychosocial support and goals of care interventions. LESSONS LEARNED: The creation of KidneyPal led to us to serve a new cohort of patients with specialty palliative care. We grew over time to serve the full range of patients with kidney disease as defined by our nephrology service lines. We succeeded in doing so by embedding in nephrology and building relationships with those caring for people with kidney disease while tailoring our service and interventions over time.

Specialty-Aligned Palliative Care: Responding to the Needs of a Tertiary Care Health System.

BACKGROUND: Expanding specialty palliative care within complex health systems involves consideration of patients' unmet needs, clinicians' perceptions of palliative care, and the availability of palliative care resources. Prior to this quality improvement (QI) project, palliative care services in our health system primarily served oncology patients. INTERVENTION: We undertook a prospective strategic planning process that included executive sponsorship and engagement of institutional leaders and clinicians to help define which palliative care services were most needed by the health system. MEASURES: We interviewed and surveyed a broad range of clinicians including physicians, nurse practitioners, and social workers. OUTCOMES: The two most prominent themes that emerged from the stakeholder engagement process were clinicians' wish for specialty-aligned interprofessional palliative care teams and for expansion of nononcology palliative care access. CONCLUSION: Careful needs assessment and stakeholder engagement can result in goal-directed and data-driven expansion of palliative care services within tertiary health care systems.

A Health System-Wide Initiative to Decrease Opioid-Related Morbidity and Mortality.

BACKGROUND: The opioid overdose crisis now claims more than 40,000 lives in the United States every year, and many hospitals and health systems are responding with opioid-related initiatives, but how best to coordinate hospital or health system-wide strategy and approach remains a challenge. METHODS: An organizational opioid stewardship program (OSP) was created to reduce opioid-related morbidity and mortality in order to provide an efficient, comprehensive, multidisciplinary approach to address the epidemic in one health system. An executive committee of hospital leaders was convened to empower and launch the program. To measure progress, metrics related to care of patients on opioids and those with opioid use disorder (OUD) were evaluated. RESULTS: The OSP created a holistic, health system-wide program that addressed opioid prescribing, treatment of OUD, education, and information technology tools. After implementation, the number of opioid prescriptions decreased (-73.5/month; p < 0.001), mean morphine milligram equivalents (MME) per prescription decreased (-0.4/month; p < 0.001), the number of unique patients receiving an opioid decreased (-52.6/month; p < 0.001), and the number of prescriptions ≥ 90 MME decreased (-48.1/month; p < 0.001). Prescriptions and providers for buprenorphine increased (+6.0 prescriptions/month and +0.4 providers/month; both p < 0.001). Visits for opioid overdose did not change (-0.2 overdoses/month; p = 0.29). CONCLUSION: This paper describes a framework for a new health system-wide OSP. Successful implementation required strong executive sponsorship, ensuring that the program is not housed in any one clinical department in the health system, creating an environment that empowers cross-disciplinary collaboration and inclusion, as well as the development of measures to guide efforts.

Medical staff guidelines for periviability pregnancy counseling and medical treatment of extremely premature infants.

OBJECTIVES: The goal of this report is to describe the collaborative formation of rational, practical, medical staff guidelines for the counseling and subsequent care of extremely early-gestation pregnancies and premature infants between 22 and 26 weeks. The purposes of the guidelines were to improve knowledge regarding neonatal outcomes, to provide consistency in periviability counseling, and to promote informed, supportive, responsible choices. METHODS: To formulate the guidelines, a 5-step process was conducted; it began with a series of multidisciplinary meetings among maternal-fetal medicine specialists (MFMs), obstetricians, neonatologists, neonatal nurse practitioners, and nurses from both the labor and delivery unit and the NICU at Providence St Vincent Medical Center (Portland, OR). First, our discussions reviewed mortality rates, morbidity rates, and long-term neurodevelopmental outcomes for extremely premature infants. Second, we explored the variations in counseling that pregnant women received, based on providers' individual beliefs and disparate knowledge of neonatal outcomes. Third, we asked participants to complete a survey that focused on the theoretical impending delivery of a premature infant, presenting at each week between 22 and 26 weeks of gestation. Participants indicated their recommendations for NICU care at each gestational age by using a numeric scale. Fourth, the survey results were tabulated and used as a basis for the formation of guidelines related to the recommended obstetric and neonatal care at each week of gestation. MFMs and neonatologists were urged to use these specific guidelines as a framework for counseling pregnant women between 22 and 26 weeks of gestation. Fifth, we surveyed women approximately 3 days after they were counseled by their MFM and neonatologist, to assess comprehension, utility, consistency, and comfort with the periviability counseling. RESULTS: Twenty pregnant women with the possibility of delivery between 22 and 26 weeks of gestation (mean: 24 weeks) received periviability counseling with our consensus medical staff guidelines. The respondents rated the counseling process as highly understandable (80%), useful (95%), consistent (89%), and performed in a comfortable manner (100%). All (100%) of the pregnant women thought they were given enough information to make critical decisions related to the potential level of care of their infant. CONCLUSIONS: Informative, supportive, clear, medical staff guidelines developed to assist in the counseling of women delivering extremely premature infants have been designed and implemented successfully at our hospital. These guidelines form the basis of periviability counseling, which is appreciated by our at-risk pregnant patients. We recommend that all hospitals that provide high-risk obstetric and neonatal intensive care develop similar consensus guidelines based on published outcomes and local provider experience.

Nurses' work environment perceptions when employed in states with and without mandatory staffing ratios and/or mandatory staffing plans.

Multiple stakeholders have sought regulatory and nonregulatory strategies to address nursing workforce and patient safety concerns. This study examines differences in nurses' work environment perceptions. Approximately 4,000 nurses employed in 10 states provided their perceptions of key characteristics of their work environment using the Individual Workload Perception Scale. Univariate statistics were used to characterize mean values of the nurses' work environment perceptions by state of employment and whether these perceptions changed if employed in states with versus without mandatory staffing ratios and/or mandatory staffing plans. This study provides preliminary evidence that mandatory staffing plan legislation may be linked with the most positive nurse work environment perceptions when compared with implementation of mandatory staffing ratios or no workforce regulation. Based on this preliminary observation, further analysis comparing the relative benefits and costs of workforce regulation may be warranted.