Magnitude of Anemia at Discharge Increases 30-Day Hospital Readmissions.

BACKGROUND: Anemia during hospitalization is associated with poor health outcomes. Does anemia at discharge place patients at risk for hospital readmission within 30 days of discharge? Our objectives were to examine the prevalence and magnitude of anemia at hospital discharge and determine whether anemia at discharge was associated with 30-day readmissions among a cohort of hospitalizations in a single health care system. METHODS: From January 1, 2009, to August 31, 2011, there were 152,757 eligible hospitalizations within a single health care system. The endpoint was any hospitalization within 30 days of discharge. The University HealthSystem Consortium's clinical database was used for demographics and comorbidities; hemoglobin values are from the hospitals' electronic medical records, and readmission status was obtained from the University HealthSystem Consortium administrative data systems. Mild anemia was defined as hemoglobin of greater than 11 to less than 12 g/dl in women and greater than 11 to less than 13 g/dl in men; moderate, greater than 9 to less than or equal to 11 g/dl; and severe, less than or equal to 9 g/dl. Logistic regression was used to assess the association of anemia and 30-day readmissions adjusted for demographics, comorbidity, and hospitalization type. RESULTS: Among 152,757 hospitalizations, 72% of patients were discharged with anemia: 31,903 (21%), mild; 52,971 (35%), moderate; and 25,522 (17%), severe. Discharge anemia was associated with severity-dependent increased odds for 30-day hospital readmission compared with those without anemia: for mild anemia, 1.74 (1.65-1.82); moderate anemia, 2.76 (2.64-2.89); and severe anemia, 3.47 (3.30-3.65), P < 0.001. CONCLUSIONS: Anemia at discharge is associated with a severity-dependent increased risk for 30-day readmission. A strategy focusing on anemia treatment care paths during index hospitalization offers an opportunity to influence subsequent readmissions.

From Bad to Worse: Anemia on Admission and Hospital-Acquired Anemia.

BACKGROUND: Anemia at hospitalization is often treated as an accompaniment to an underlying illness, without active investigation, despite its association with morbidity. Development of hospital-acquired anemia (HAA) has also been associated with increased risk for poor outcomes. Together, they may further heighten morbidity risk from bad to worse. OBJECTIVES: The aims of this study were to (1) examine mortality, length of stay, and total charges in patients with present-on-admission (POA) anemia and (2) determine whether these are exacerbated by development of HAA. DESIGN/SETTING/PATIENTS: In this cohort investigation, from January 1, 2009, to August 31, 2011, a total of 44,483 patients with POA anemia were admitted to a single health system compared with a reference group of 48,640 without POA anemia or HAA. MEASUREMENTS: Data sources included the University HealthSystem Consortium database and electronic medical records. Risk-adjustment methods included logistic and linear regression models for mortality, length of stay, and total charges. Present-on-admission anemia was defined by administrative coding. Hospital-acquired anemia was determined by changes in hemoglobin values from the electronic medical record. RESULTS: Approximately one-half of the patients experienced worsening of anemia with development of HAA. Risk for death and resource use increased with increasing severity of HAA. Those who developed severe HAA had 2-fold greater odds for death; that is, mild POA anemia with development of severe HAA resulted in greater mortality (odds ratio, 2.57; 95% confidence interval, 2.08-3.18; P < 0.001), increased length of stay (2.23; 2.16-2.31; P < 0.001), and higher charges (2.09; 2.03-2.15; P < 0.001). CONCLUSIONS: Present-on-admission anemia is associated with increased mortality and resource use. This risk is further increased from bad to worse when patients develop HAA. Efforts to address POA anemia and HAA deserve attention.

Contemporary bloodletting in cardiac surgical care.

BACKGROUND: Health care providers are seldom aware of the frequency and volume of phlebotomy for laboratory testing, bloodletting that often leads to hospital-acquired anemia. Our objectives were to examine the frequency of laboratory testing in patients undergoing cardiac surgery, calculate cumulative phlebotomy volume from time of initial surgical consultation to hospital discharge, and propose strategies to reduce phlebotomy volume. METHODS: From January 1, 2012 to June 30, 2012, 1,894 patients underwent cardiac surgery at Cleveland Clinic; 1,867 had 1 hospitalization and 27 had 2. Each laboratory test was associated with a test name and blood volume. Phlebotomy volume was estimated separately for the intensive care unit (ICU), hospital floors, and cumulatively. RESULTS: A total of 221,498 laboratory tests were performed, averaging 115 tests per patient. The most frequently performed tests were 88,068 blood gas analyses, 39,535 coagulation tests, 30,421 complete blood counts, and 29,374 metabolic panels. Phlebotomy volume differed between ICU and hospital floors, with median volumes of 332 mL and 118 mL, respectively. Cumulative median volume for the entire hospital stay was 454 mL. More complex procedures were associated with higher overall phlebotomy volume than isolated procedures; eg, combined coronary artery bypass grafting (CABG) and valve procedure median volume was 653 mL (25th/75th percentiles, 428 of 1,065 mL) versus 448 mL (284 of 658 mL) for isolated CABG and 338 mL (237 of 619) for isolated valve procedures. CONCLUSIONS: We were astonished by the extent of bloodletting, with total phlebotomy volumes approaching amounts equivalent to 1 to 2 red blood cell units. Implementation of process improvement initiatives can potentially reduce phlebotomy volumes and resource utilization.

Relationships Between Nurses and Physicians Matter.

Both safety and quality of care patients receive depend upon the quality of the practice environment where care is provided. In this article, the authors review relevant literature, and describe their study that identified how nurses and physicians define respectful behavior; examined perceptions of the relationship between nurses and physicians in clinical settings in which they practice together; and analyzed the impact of nurse-physician relationships on nursing care decisions. Perceptions of nurse-physician relationships were assessed using the Professional Practice Environment Assessment Scale and perceptions of respectful behavior and the effect of physician behavior on nursing practice were assessed with single, forced-choice items. The authors report finding that physicians rated relationships significantly better than did nurses. Additionally, they note that 55% of nurses said that a physician's behavior impacted nursing decisions, and that younger, less experienced nurses were more likely to report being affected by negative physician behaviors than older nurses or nurses with more experience. They discuss how nurses' and physicians' different perceptions of the same environment is not surprising, but is instructive, and conclude that acknowledging differences in values, incentives, and perceptions can provide insights that focus improvement initiatives.

Process improvement in cardiac surgery: development and implementation of a reoperation for bleeding checklist.

OBJECTIVE: High-performing health care organizations differentiate themselves by focusing on continuous process improvement initiatives aimed at enhancing patient outcomes. Reoperation for bleeding is an event associated with considerable morbidity risk. Hence, our primary objective was to develop and implement a formal operative checklist to reduce technical reasons for postoperative bleeding. METHODS: From January 1, 2011, through June 30, 2012, 5812 cardiac surgical procedures were performed at Cleveland Clinic (Cleveland, OH). A multidisciplinary team developed a simple, easy-to-perform hemostasis checklist based on the most common sites of bleeding. An extensive educational in-service was performed before limited, then universal, checklist implementation. Geometric charts were used to track the number of cases between consecutive reoperations for bleeding. We compared these before (phase 0) and after the first limited implementation phase (phase 1) and the universal implementation phase (phase 2) of the checklist. RESULTS: The average number of cases between consecutive reoperations for bleeding increased from 32 in phase 0 to 53 in both phase 1 (P = .002) and phase 2 (P = .01). CONCLUSIONS: A substantial reduction in reoperation for bleeding cases followed implementation of a formalized hemostasis checklist. Our findings underscore the important influence of memory aids that focus attention on surgical techniques to improve patient outcomes in a complex, operative work environment.

Hospital-acquired anemia: prevalence, outcomes, and healthcare implications.

BACKGROUND: Evidence suggests that patients with normal hemoglobin (Hgb) levels on hospital admission who subsequently develop hospital-acquired anemia (HAA) may be at risk for adverse outcomes. Our objectives were to (1) determine the prevalence of HAA and (2) examine whether HAA is associated with increased mortality, length of stay (LOS), and total hospital charges. METHODS: The population consisted of 417,301 adult hospitalizations from January 1, 2009 to August 31, 2011, in an academic medical center and 9 community hospitals. Patients with anemia on admission, and hospitals in the health system without available laboratory data were excluded; 188,447 hospitalizations were included in the analysis. Demographics, comorbidities, and outcomes were retrieved from administrative data; Hgb values were taken from the electronic medical record. Regression modeling was used to examine the association between demographics, comorbidity, hospitalization type, and HAA variables (mild: Hgb >11 and <12 g/dL for women, and >11 and <13 g/dL for men; moderate: Hgb 9.1 to ≤ 11.0 g/dL; severe: Hgb ≤ 9.0 g/dL) on mortality, LOS, and hospital charges. RESULTS: Among 188,447 hospitalizations, 139,807 patients (74%) developed HAA: mild, 40,828 (29%); moderate, 57,184 (41%); and severe, 41,795 (30%). Risk-adjusted odds ratios and 95% confidence intervals for in-hospital mortality with HAA were: mild, 1.0 (0.88-1.17; P = 0.8); moderate, 1.51 (1.33-1.71, P < 0.001); and severe, 3.28 (2.90-3.72, P < 0.001). Risk-adjusted relative mean LOS and hospital charges relative to no HAA were higher with HAA: LOS: mild, 1.08 (1.08-1.10, P < 0.001); moderate, 1.28 (1.26-1.29, P < 0.001); severe, 1.88 (1.86-1.89, P < 0.001). Hospital charges: mild, 1.06 (1.06-1.07, P < 0.001); moderate, 1.18 (1.17-1.19, P < 0.001); severe, 1.80 (1.79-1.82, P < 0.001). CONCLUSIONS: HAA is common and associated with increased mortality and resource utilization. Factors related to its development necessitate further study.

Development and psychometric exploration of the professional practice environment assessment scale.

PURPOSE: Development of the Professional Practice Environment Assessment Scale (PPEAS) was based on the assumptions that a positive professional practice environment is more than and different from the absence of negative, abusive, or disrespectful behaviors by physicians; a positive professional practice environment improves patient outcomes as well as nurse and physician satisfaction; and a positive professional practice environment is characterized by mutual respect, understanding of roles, collaborative decision making, effective communication, and beliefs in the importance of nurse-physician relationships on patient outcomes. The PPEAS is intended as both a research tool and a method of assessing and monitoring changes in an organization's professional practice environment as it relates specifically to the impact the nurse and physician relationship has on the professional practice environment. The purpose of this study was to examine the psychometric properties of the PPEAS and determine if it was a valid and reliable instrument for assessing the positive attributes of the professional practice environment. DESIGN: A large acute care facility in the Midwestern section of the United States provided the setting for this psychometric study. The sample (N= 1,332) consisted of 801 nurses and 531 physicians. METHODS: Psychometric examination, which included principal component analysis with varimax rotation and assessment of internal consistency, was conducted to validate the reliability and validity of the PPEAS. FINDINGS: Analysis identified a four-factor solution. The four factors were classified as positive physician characteristics (five items), positive nurse characteristics (three items), collaborative decision making (two items), and positive beliefs in the value of the nurse-physician relationship (three items). Cronbach's α for the entire scale was .86, with subscales ranging from .73 to .89. CONCLUSIONS: Findings from this analysis support our model and provide evidence of the usefulness of this scale for assessing the presence of a positive professional practice environment. Using the total score, organizations can examine the status of their professional practice environment and examine changes in the environment over time. Subscale analysis can identify specific areas where the organization performs well and those areas in need of improvement. CLINICAL RELEVANCE: The professional practice environment has been implicated as a variable that impacts patient outcomes. The absence of negative physician behaviors is an inadequate measure for assessing the positive attributes of the professional practice environment. Instruments for assessing the professional practice environment typically looked at the presence of negative physician behaviors or examined a single aspect of the nurse-physician relationship. This article provides a theoretical framework that can be used to guide both practice and research. The PPEAS was developed within a theoretical framework that can be adapted to a variety of settings, cultures, and countries. The PPEAS is a valid and reliable instrument that can be used to assess the professional practice environment in a variety of settings.

Outcomes of patients with stable heart failure undergoing elective noncardiac surgery.

OBJECTIVE: To evaluate modern surgical outcomes in patients with stable heart failure undergoing elective major noncardiac surgery and to compare the experience of patients with heart failure who have reduced vs preserved left ventricular ejection fraction (EF). PATIENTS AND METHODS: We retrospectively studied 557 consecutive patients with heart failure (192 EF less than or equal to 40% and 365 EF greater than 40%) and 10,583 controls who underwent systematic evaluation by hospitalists in a preoperative clinic before having major elective noncardiac surgery between January 1, 2003, and March 31, 2006. We examined outcomes in the entire cohort and in propensity-matched case-control groups. RESULTS: Unadjusted 1-month postoperative mortality in patients with both types of heart failure vs controls was 1.3% vs 0.4% (P equals .009), but this difference was not significant in propensity-matched groups (P equals .09). Unadjusted differences in mean hospital length of stay among heart failure patients vs controls (5.7 vs 4.3 days; P less than .001) and 1-month readmission (17.8% vs 8.5%; P less than .001) were also markedly attenuated in propensity-matched groups. Crude 1-year hazard ratios for mortality were 1.71 (95% confidence interval [CI], 1.5-2.0) for both types of heart failure, 2.1 (95% CI, 1.7-2.6) in patients with heart failure who had EF less than or equal to 40%, and 1.4 (95% CI, 1.2-1.8) in those who had EF greater than 40% (P less than .01 for all 3 comparisons); however, the differences were not significant in propensity-matched groups (P equals .43). CONCLUSION: Patients with clinically stable heart failure did not have high perioperative mortality rates in association with elective major noncardiac surgery, but they were more likely than patients without heart failure to have longer hospital stays, were more likely to require hospital readmission, and had a substantial long-term mortality rate.

Do weekends or evenings matter in a pediatric intensive care unit?

OBJECTIVE: To assess what independent influence, if any, weekend or evening admission to a pediatric intensive care unit (PICU) staffed 24 hrs/day, 7 days/wk by in-house, board-certified pediatric intensivists might have on mortality. DESIGN AND PATIENTS: A retrospective study of 5,968 consecutive admissions to the PICU from August 1996 to December 2003 for patients aged 0 days to 21 yrs. SETTING: A single, 14-bed, multidisciplinary PICU at an academic medical center. MEASUREMENTS: Standardized mortality ratios of observed-to-predicted mortality were derived with their corresponding p values. Multivariate logistic regression was used to test the independent effect of weekend admission, weekend discharge/death, and evening PICU admission on mortality for the entire sample and, separately, for only emergency admissions, controlling for other significant predictor variables or interaction terms. RESULTS: Overall, crude mortality was significantly higher on the weekend (weekday, 2.2%; weekend, 5.0% [p = .0000]) and in the evening (day, 2.1%; evening, 3.8% [p = .0004]). Assessing the entire sample using multivariate logistic regression, neither weekend admission (p = .146), weekend discharge/death (p = .348), nor evening PICU admission (p = .711) showed a significant relationship with mortality controlling for other significant factors. Limiting the scope to the emergency admissions subset, neither weekend admission (p = .135), weekend discharge/death (p = .278), nor evening PICU admission (p = .867) were significant predictors of mortality. Weekend and evening admissions differed in important ways from weekday and daytime admissions, making simple comparisons of crude mortality rates inappropriate. Weekend and evening admissions were more likely to be emergency, nonoperative patients; have a lower Pediatric Risk of Mortality III score but have a higher overall predicted mortality risk; and differ in the distributions of patients by primary diagnosis. CONCLUSIONS: Using multivariate logistic regression to control for important clinical differences, neither weekend admission, weekend discharge/death, nor evening admission had a significant independent effect on mortality risk in the entire sample or for the emergency patient subset. Our findings are consistent with previous work demonstrating the benefit of intensive care units staffed 24 hrs/day, 7-days/wk by in-house, board-certified intensivists.

Quality improvement for stroke management at the Cleveland Clinic Health System.

BACKGROUND: The Cleveland Clinic Health System established a stroke quality improvement (QI) initiative across its nine hospitals. IMPLEMENTING THE STROKE QI INITIATIVE: A stroke QI team took a three-pronged approach to QI: professional education, public education, and hospital process improvements. Its activities and subsequent data analysis needs were divided into four cycles (1999-2003). All data were provided to the stroke QI team and then to the Medical Operations Council to review results, consider data integrity issues, and plan dissemination. The dissemination of performance results permitted broad organizational responses to facilitate improvement. Improvement activities included professional education, public awareness, process improvement, focused data collection with routine feedback, protocol refinement, and coordination of clinical personnel within and between hospitals. RESULTS: The frequency of brain hemorrhagic complications decreased by more than half, from 13.4% to 6.4%; the rate of intravenous tissue plasminogen activator use increased from 1.5% to 3.9% of all stroke patients; and protocol deviations were reduced from 33% to 17%. DISCUSSION: The keys to this initiative's success were the health system's leadership's support, physicians' engagement via multidisciplinary project committees at the health system and hospital levels, and flexibility in implementing locally tailored process interventions.

Utilization of intravenous tissue plasminogen activator for acute ischemic stroke.

BACKGROUND: Intravenous tissue plasminogen activator (tPA) is the only approved therapy for acute ischemic stroke, although only 2% of patients with stroke receive intravenous tPA nationally. OBJECTIVE: To determine the rate of tPA use for stroke in the Cleveland, Ohio, community and the reasons why patients were excluded from thrombolysis treatment. DESIGN: Retrospective cohort study. SETTING: Community. Subjects Patients admitted because of stroke to the 9 Cleveland Clinic Health System hospitals from June 15, 1999, to June 15, 2000. MAIN OUTCOME MEASURES: Utilization of intravenous tPA and reasons for ineligibility. RESULTS: There were 1923 admissions for ischemic stroke in the 1-year period. Of these, 288 (15.0%) arrived within the 3-hour time window, and approximately 6.9% were considered eligible for tPA. The most common reasons for exclusion among patients arriving within 3 hours were mild neurologic impairment and rapidly improving symptoms. The overall rate of tPA use among patients presenting within 3 hours was 19.4%, and the rate of use among eligible patients was 43.4% (n = 56). The use of tPA did not differ significantly according to race or sex. CONCLUSIONS: Only 15% of patients arrived within the 3-hour time window for intravenous tPA, making delay in presentation the most common reason patients were ineligible for i.v. thrombolysis. Neurologic criteria were the second most common group of exclusions. Overall tPA use was low, but it was used in nearly half of all patients with no documented contraindications. Intravenous tPA use in a community setting can compare favorably with the rate of use seen in academic medical settings.

Quality improvement and tissue-type plasminogen activator for acute ischemic stroke: a Cleveland update.

BACKGROUND AND PURPOSE: A systematic audit of intravenous tissue-type plasminogen activator (tPA) use and stroke outcomes in Cleveland, Ohio, during 1997-1998 demonstrated higher rates of symptomatic intracranial hemorrhage (ICH) than reported in the National Institute of Neurological Disorders and Stroke (NINDS) trial. We now report updated results of intravenous tPA use in the Cleveland Clinic Health System (CCHS). METHODS: A stroke quality improvement program was initiated in the 9-hospital CCHS in 1999. A retrospective chart review for all stroke patients with primary International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes 434 and 436 admitted to the 9 hospitals from June 1999 to June 2000 was used to determine outcomes of patients treated with intravenous tPA. RESULTS: Intravenous tPA was given to 18.8% of patients arriving within 3 hours of symptom onset. Protocol deviations occurred in 19.1% of patients given intravenous tPA. The symptomatic ICH rate was 6.4%. CONCLUSIONS: Since 1997, intravenous tPA use has increased, while the rates of symptomatic ICH and protocol deviations have decreased in the CCHS. The CCHS symptomatic ICH rate is now similar to that reported in the NINDS trial. These improvements occurred after initiation of a stroke quality improvement program.