The cost of preventing readmissions: why surgeons should lead the effort.

In accordance with the Affordable Care Act, Medicare has instituted financial penalties for hospitals with 30-day readmission rates that exceed a predetermined value. Currently, this value only considers "excess" readmissions for myocardial infarction, heart failure, and pneumonia with a maximum fine being one per cent of total Medicare reimbursements. In 2015, this penalty will increase to three per cent and encompass more surgical diagnoses. We retrospectively reviewed a database of adult patients undergoing cardiac surgery treated at our institution in 2012 to establish whether patients with readmissions within 30 days of the index operation could have been managed more cost-effectively without readmission. A calculation of cost efficiency was performed to compare the net hospital profit for two scenarios: admitting patients versus hypothetical preventative measures. Of the 576 patients during the study period, a total of 68 (11.8%) patients with unplanned 30-day readmissions were identified. Outpatient management was determined to have been feasible for 18 (26.5%) patients. Whereas the calculated net profit for readmission was $144,000, inclusion of Medicare's penalty resulted in a loss of $11,950. A readmission reduction program with an annual cost exceeding $11,950 would lead to financial loss. The financial implications of Medicare's readmission penalty alone necessitate the development of cost-effective strategies to reduce rehospitalization.

The quality of supportive care among inpatients dying with advanced cancer.

PURPOSE: Managing symptoms and communicating effectively are essential aspects of providing high-quality cancer care, especially among patients with advanced cancer. The purpose of this study is to apply novel quality indicators to measure the quality of supportive care provided to patients with advanced cancer who died in a large university medical center. METHODS: Cancer quality ASSIST is a comprehensive quality indicator (QI) set that includes 92 symptom and care planning indicators, of which we piloted 15 applicable to persons with advanced cancer who died in the hospital setting. We evaluated medical records of all adult terminal hospitalizations with lengths of stay ≥3 days at one university medical center between April 2005 and April 2006. RESULTS: Of 496 decedents, 118 had advanced cancer (mean age 60, 54% male). Forty-five percent received chemotherapy or radiation in the month prior to or during admission. During the hospitalization, 56% of the patients spent time in the ICU (median length of stay 8 days), one in five received first-time hemodialysis, and 23% had a ventilator withdrawn anticipating death. The 118 patients triggered 596 quality indicators of which 476 passed (QI level pass rate 80%, range 50-100%). Pain assessment and management were consistently performed; however, other cancer supportive care needed improvement: 26% of patients not receiving cancer therapy who had nausea and vomiting received inadequate follow-up, more than one quarter of patients with dyspnea had this symptom inadequately addressed, and 29% of patients taking long-acting opioids were not prescribed a bowel regimen. Timely discussion of patient preferences upon admission to the ICU or initiation of mechanical ventilation occurred in 64 and 69% of cases, respectively. CONCLUSIONS: This set of quality indicators can evaluate the quality of supportive and end-of-life care provided to inpatients dying with advanced cancer and identify aspects of care that need improvement.

Predictive combinations of monitor alarms preceding in-hospital code blue events.

Bedside monitors are ubiquitous in acute care units of modern healthcare enterprises. However, they have been criticized for generating an excessive number of false positive alarms causing alarm fatigue among care givers and potentially compromising patient safety. We hypothesize that combinations of regular monitor alarms denoted as SuperAlarm set may be more indicative of ongoing patient deteriorations and hence predictive of in-hospital code blue events. The present work develops and assesses an alarm mining approach based on finding frequent combinations of single alarms that are also specific to code blue events to compose a SuperAlarm set. We use 4-way analysis of variance (ANOVA) to investigate the influence of four algorithm parameters on the performance of the data mining approach. The results are obtained from millions of monitor alarms from a cohort of 223 adult code blue and 1768 control patients using a multiple 10-fold cross-validation experiment setup. Using the optimal setting of parameters determined in the cross-validation experiment, final SuperAlarm sets are mined from the training data and used on an independent test data set to simulate running a SuperAlarm set against live regular monitor alarms. The ANOVA shows that the content of a SuperAlarm set is influenced by a subset of key algorithm parameters. Simulation of the extracted SuperAlarm set shows that it can predict code blue events one hour ahead with sensitivity between 66.7% and 90.9% while producing false SuperAlarms for control patients that account for between 2.2% and 11.2% of regular monitor alarms depending on user-supplied acceptable false positive rate. We conclude that even though the present work is still preliminary due to the usage of a moderately-sized database to test our hypothesis it represents an effort to develop algorithms to alleviate the alarm fatigue issue in a unique way.

Missed opportunities: use of an end-of-life symptom management order protocol among inpatients dying expected deaths.

BACKGROUND: When a patient is expected to die, the ideal plan of care focuses on comfort. Prior investigation of application of one institution's end-of-life symptom management order (ESMO) protocol suggested that comfort measures were often instituted too late and sometimes not at all. We studied patient factors associated with missed opportunities for use of an ESMO protocol and protocol adherence in order to identify areas for quality improvement. METHODS: We abstracted the terminal hospitalization medical record for all adult decedents hospitalized for at least 3 days between April 2005 and April 2006 (n = 496) at a university medical center. Detailed information was collected about ESMO use and opiate titration at the end of life. Among patients expected to die, we used multivariate logistic regression to evaluate factors associated with whether patients were placed on the ESMO protocol prior to death. RESULTS: Half of patients who died received ESMO protocol care (n = 248). All had documentation of a do-not-resuscitate (DNR) order (a requirement of the protocol). An opiate drip was used for 95% of patients placed on the ESMO protocol and it was titrated up at least once for 67% of those patients. Patients had a mean of 4 opiate titrations, but for only a mean of 2.2 was a justification documented (symptom documentation is required for each titration per the protocol). In a multivariable regression accounting for other demographic, clinical and provider variables, uninsured patients (risk ratio [RR] 0.25, 95% confidence interval [CI] 0.06-0.62), patients admitted from a nursing home (RR 0.57, 95% CI 0.30-0.99), and patients considered for transplant (RR 0.60, 95% CI 0.40-0.85) were significantly less likely to be placed on the ESMO protocol prior to death. CONCLUSIONS: Evaluation of implementation of a standardized order set can identify areas for quality improvement and missed opportunities for use.

The quality of care provided to hospitalized patients at the end of life.

BACKGROUND: Patients in American hospitals receive intensive medical treatments. However, when lifesaving treatments are unsuccessful, patients often die in the hospital with distressing symptoms while receiving burdensome care. Systematic measurement of the quality of care planning and symptom palliation is needed. METHODS: Medical records were abstracted using 16 Assessing Care of Vulnerable Elders quality indicators within the domains of end-of-life care and pain management designed to measure the quality of the dying experience for adult decedents (n = 496) hospitalized for at least 3 days between April 2005 and April 2006 at a university medical center recognized for providing intensive care for the seriously ill. RESULTS: Over half of the patients (mean age, 62 years; 47% were women) were admitted to the hospital with end-stage disease, and 28% were 75 years or older. One-third of the patients required extubation from mechanical ventilation prior to death, and 15% died while receiving cardiopulmonary resuscitation. Overall, patients received recommended care for 70% of applicable indicators (range, 25%-100%). Goals of care were addressed in a timely fashion for patients admitted to the intensive care unit approximately half of the time, whereas pain assessments (94%) and treatments for pain (95%) and dyspnea (87%) were performed with fidelity. Follow-up for distressing symptoms was performed less well than initial assessment, and 29% of patients extubated in anticipation of death had documented dyspnea assessments. CONCLUSION: A practical, medical chart-based assessment identified discrete deficiencies in care planning and symptom palliation that can be targeted to improve care for patients dying in the hospital.

Assessment of implementation of an order protocol for end-of-life symptom management.

OBJECTIVES: Designing comfort care plans to treat symptoms at the end-of-life in the hospital is challenging. We evaluated the implementation of an inpatient end-of-life symptom management order (ESMO) protocol that guides the use of opiate medications and other modalities to provide palliation. METHODS: Physicians and nurses caring for patients using the ESMO protocol were surveyed about care provided and their experiences. RESULTS: Over 342 days, 127 patients (2.6 per week) were treated using the ESMO protocol and we surveyed a nurse and/or physician for 105 (83%) patients. Most patients were comatose, obtunded/stuperous, or disoriented when the ESMO protocol was initiated and most had a life expectancy of less than 1 day. One fourth of physicians felt that the protocol was instituted too late, principally citing family unwillingness to reorient toward comfort care. Providers reported that opiates were titrated appropriately, although a minority revealed discomfort with end-of-life opiate use. Nearly all clinicians found the ESMO protocol to be valuable. CONCLUSIONS: A standardized protocol is a useful, but not fully sufficient, step toward improving care for dying hospitalized patients.

Improving care after primary cleft palate surgery.

This article reports on the use of a multidisciplinary action plan (MAP) in a tertiary care craniofacial center to evaluate one set of outcomes after primary cleft palate repair (PCPR). Two series of patients undergoing PCPR were studied. The first series of 30 patients was managed by using a set of preprinted order sets developed by plastic surgeons and clinical nurse specialists. The patients were evaluated 90 days after surgery to determine whether they had received the planned postoperative care. Most patients received care from plastic surgeons, and fewer obtained care from otolaryngologists. The second group of patients was managed by using a revised set of preprinted order sets and an MAP developed by both surgical specialty groups. In the second group, the proper postoperative follow-up care was provided by both surgical subspecialists with the revised interdisciplinary order sets and new MAP-directed care.

Case management: an evaluation at Childrens Hospital Los Angeles.

This prospective, quantitative, and qualitative evaluation of the case management program at CHLA clearly demonstrated the value of professional service coordination of care for children with complex, special health needs. Most specifically, the program documented improvement in three discrete areas of evaluation: 1. Financial, with decreased unnecessary expenditures and increased revenue. 2. Patient satisfaction, documented with validated questionnaires. 3. Clinical process improvement, using quantifiable clinical outcomes. At the very least, case management is an extremely valuable service in the present managed health care environment, and may in fact be indispensable.