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Service Delivery Innovation Profile

Alerts, Standing Orders, and Care Pathways Boost Quality of Care for Pneumonia, Heart Attack, and Heart Failure


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Snapshot

Summary

Reid Hospital created a system of alerts, standing orders, and care pathways to eliminate gaps in the care of patients with pneumonia, acute myocardial infarction, and heart failure, and to address surgical complication and infection prevention. Once a patient is diagnosed with one of these conditions, the system automatically generates orders, protocols, nursing measures, etc., that prompt staff to provide recommended medications, tests, treatments, and vaccinations at the appropriate time. As a result, from 2003 to 2005, the hospital improved its performance on 10 original, widely accepted quality measures (from the Hospital Quality Alliance starter set). In many cases, the performance rate rose significantly, from approximately 75 to 85 percent before the program to nearly 100 percent after implementation. In addition, information provided in August 2009 indicates that the hospital now also tracks surgical complications and infection prevention indicators (bringing the total number of indicators tracked to 25); all surgical complication and infection prevention indicators are performing in the top 10 percent of hospitals nationally, at 96 to 100 percent.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key quality measures related to AMI, congestive heart failure, and community-acquired pneumonia.
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Developing Organizations

Reid Hospital and Health Care Services
Richmond, INend do

Date First Implemented

2003

Problem Addressed

Patients with pneumonia, acute myocardial infarction (AMI), and heart failure fare best, and surgical complications and infections are most often prevented, when evidence-based standards for care are followed 100 percent of the time, but frequently they are not.
  • Clear, evidence-based standards: There are clear, evidence-based standards of care for pneumonia, AMI, heart failure, and the prevention of surgical complications and infections. For example, AMI patients should receive aspirin on arrival, daily, and on discharge. Heart failure patients should have an assessment of left ventricular function, and patients with pneumonia should receive the pneumococcal vaccine. These processes have been shown to improve quality of care.1 In 2004, to improve hospital's compliance with evidenced-based protocols, the Center for Medicare & Medicare Services (CMS) began the Hospital Compare program, which provided financial incentives to high-performing hospitals that voluntarily reported compliance with the 10 quality measures related to heart failure, AMI, and pneumonia that were part of the Hospital Quality Alliance starter set.2 In 2008, the hospital adopted activities suggested by the Surgical Care Improvement Project initiative.3
  • Failure to adhere to the standards: Patients with these conditions sometimes fail to receive these and other recommended treatments,1 jeopardizing treatment success and contributing to an increase in readmission rates. At Reid Hospital, before the implementation of the automated system, eligible patients received the recommended tests and treatments only about 75 to 90 percent of the time.

What They Did

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Description of the Innovative Activity

Alerts, standing orders, and care pathways are integrated into the patient's care from admission to discharge. Once a physician diagnoses a patient with pneumonia, AMI, or heart failure, or a patient is admitted for surgery, the nurse or case manger enters the patient's diagnosis into the electronic health record system. The system then automatically generates a series of alerts and treatment instructions based on the diagnosis, as outlined below:
  • Standing orders for pneumonia: Standing orders are a course of treatments and tests that each patient with a given diagnosis receives unless a physician believes there is a compelling reason to change or augment the order. Each instruction requires staff members treating the patient to document what action they took, including any critical thinking. In other words, clinicians cannot simply ignore or easily override the system, yet patient care is individualized. When a patient's pneumonia diagnosis is entered into the system, these steps occur:
    • A computer-generated order prints is printed out that includes oxygenation assessment, antibiotic selection, and blood cultures (to identify infection-causing organisms) before antibiotic administration.
    • For patients meeting the criteria, orders for pneumonia and influenza vaccines automatically print out. Those orders are then faxed to the hospital's pharmacy for immediate processing and doublechecking for allergies and contraindications.
  • Care pathways for AMI and heart failure: Care pathways are similar to standing orders but allow for more flexible courses of treatment and tests, because these conditions are often accompanied by comorbidities and require more complicated types of treatment:
    • AMI pathway: When AMI is diagnosed, a message pops up to alert the nurse to start an AMI care pathway. The system notes, for example, that the patient's left ventricular ejection fraction must be assessed on diagnosis. In addition, it identifies any previous left ventricular ejection fraction records for the patient and posts them automatically to the record for physician review. At discharge, patient care instructions automatically print out with customized discharge orders.
    • Heart failure pathway: Because many heart failure patients have been to the hospital before, the system identifies repeat patients and automatically gathers their records and places them on the screen for the physician or nurse to review. The system reminds the nurse to inquire about the smoking status of the patient and family members, thus ensuring that appropriate patients receive education and counseling (e.g., viewing a smoking cessation video during the stay). The pathway also prompts caregivers to prescribe angiotensin-converting enzyme (ACE) inhibitors and/or angiotensin II receptor blockers, educates patients to weigh themselves daily to measure water retention (a key symptom of heart failure), and gives additional information on smoking cessation programs. At discharge, patient care instructions automatically print out with customized discharge orders.
  • Surgical Care Improvement Project standing order set: Information provided in August 2009 indicates that the hospital adopted a standardized surgical order set to reduce surgical complications and infections; components of the order set, including:
    • Antibiotic administration: Antibiotics are administered within 1 hour of surgical incision; surgical nurses and anesthesiologists begin the antibiotic, and the surgical "timeout" process incorporates a check that the antibiotic has been started. Standard order sets ensure that the appropriate antibiotics are ordered and that clinicians are reminded of appropriate choices for antibiotics when a patient has an allergy to antibiotics. Antibiotics are discontinued within 24 hours of the end of surgery; on the order set, antibiotics are timed to stop at 23 hours, with the pharmacy setting the antibiotic stop time according to the surgery stop time. The original order includes an area to check if antibiotics are to be continued, along with the reasons why.
    • Venous thrombolytic embolism prophylaxis: The surgery order sets include appropriate venous thrombolytic embolism therapy for each type of surgery. The order sets time the therapy to occur within 23 hours of surgery, with check boxes for contraindications.
    • Glucose control: For cardiac surgery, the order sets include specifications for controlled postoperative serum glucose control. Intensive care unit and cardiovascular unit clinicians use strict glucose control order sets.
    • Appropriate hair removal: All razors were discarded, given the infection risk associated with razor hair removal. Clippers are used instead.

Context of the Innovation

Reid Hospital, a 237-bed, not-for-profit community hospital in Richmond, IN, serves as a regional referral medical center, covering east-central Indiana and west-central Ohio. The hospital had 12,774 inpatient admissions and about 50,000 emergency department visits in 2004. Reid's effort to improve its performance on 10 standard quality measures for treating community-acquired pneumonia, AMI, and congestive heart failure occurred in response to the CMS's 2004 movement toward tying levels of Medicare and Medicaid reimbursement to how well hospitals meet these standards. Reid participated in CMS's voluntary hospital reporting program as part of the Hospital Compare program. In the fall of 2008, Reid moved from a 100-year-old facility to a new, state-of-the-art facility. In 2008, Reid served 11,000 inpatients and more than 140,000 outpatients and emergency department patients.

Did It Work?

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Results

The alerts, standing orders, and care pathways helped Reid Hospital significantly improve its performance on the vast majority of standard measures used to judge the quality of AMI, heart failure, and pneumonia care and initiate the same types of processes for surgical complication and infection prevention indicators.
  • Significant improvement on 24 of 25 public indicators: Before implementation of the program in the third quarter of 2003, Reid's performance was between 85 and 88 percent on five common measures, with rates as low as 74 percent for one measure (use of ACE inhibitors for heart failure patients). By the first quarter of 2004, Reid had achieved 100 percent performance on 9 of the 10 measures. This level of performance was largely sustained (ranging between 96 and 100 percent) in subsequent quarters. By the fourth quarter of 2009, Reid had achieved and sustained 100 percent performance on 10 of the 25 measures, and above 90 percent on all other measures. As of June 2009, all surgical complication and infection prevention indicators are performing in the top 10 percent of hospitals nationally, at 96 percent to 100 percent.
  • External recognition for quality care: Based on an analysis of the 3,558 hospitals that participated in the Hospital Compare program, Reid Hospital was identified as one of the top nine performing hospitals with the highest composite scores across the original 10 quality measures related to AMI, heart failure, and pneumonia. Information provided in August 2009 indicates that the hospital has won national recognition for its performance, as follows:
    • VHA Awards: The hospital received a Leadership Award for clinical excellence in the treatment of AMI in 2005 from VHA Inc., a national health care alliance. Additional VHA Leadership Awards were earned in 2006 (AMI, heart failure, and surgical infection prevention), 2007 (AMI, surgical infection prevention, pneumonia, and rapid response teams), 2008 (pneumonia), and 2009 (a Leadership Award for clinical excellence, clinical quality, and superior system performance and a VHA Central PEAK Award for Performance Excellence for AMI, heart failure, pneumonia, and the Surgical Care Improvement Project initiative).
    • Hospital & Health Networks recognition: Reid was also named one of the "most wired" small health care institutions in the country by Hospital & Health Networks magazine in 2004, 2006, 2007, and 2008; "most wired" hospitals show better outcomes in four key areas: mortality rates, patient safety measures from the Agency for Healthcare Research and Quality (AHRQ), core measures from the CMS Hospital Compare Web site (http://www.hospitalcompare.hhs.gov) and average length of stay.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key quality measures related to AMI, congestive heart failure, and community-acquired pneumonia.

How They Did It

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Planning and Development Process

Key elements in the planning and development process included:
  • Winning buy-in from physicians and frontline staff: Senior hospital management, including the hospital's president/chief executive officer (CEO), strongly supported the new system and emphasized its importance at all relevant meetings and functions.
  • Quality improvement teams to review procedures: Reid's senior management team formed quality improvement teams to review the hospital's treatment protocols for pneumonia, AMI, heart failure, and surgical complication and infection prevention. The teams included staff from administration, information technology (IT), nursing, medicine, surgery, emergency care, cardiac care, patient resources, infection control, clinical resource utilization, and pharmacy and a physician champion. Recommendations coming from this process were presented to Reid's Medical Executive Committee and the hospital board. After their review, specific quality improvement tactics were selected and adopted.
  • Collaboration with peer institutions: Reid received guidance and support for quality improvement through its voluntary participation in VHA's CEO Clinical Excellence Workgroup, a group of 20 institutions that share quality data, discuss best practices, and work collaboratively to attain high performance.
  • Addition of clinical documentation system: Reid plans to launch Soarian, a new Windows-based clinical documentation system by Siemens. The system will be built to include all key quality “alerts” that have thus far been successful in helping Reid provide superior care.
  • Addition of the Surgical Care Improvement Project workgroup: A dedicated workgroup, including a physician champion and representatives from surgery, nursing, pharmacy, information services, quality improvement, and administration, was created in 2008. The workgroup implemented the Surgical Care Improvement Project activities and meets monthly to review surgical complications and infections and develop additional preventive activities.

Resources Used and Skills Needed

  • Staffing and training: The new system did not require the hiring of any additional personnel, because it is integrated into ongoing medical care. IT staff made the system as user friendly as possible, so separate training sessions were not needed. Changes in staff procedures were reviewed as part of regular staff meetings and/or covered in memos.
  • Equipment: Reid utilized their current Siemens Invision system and adapted it to meet its needs.
  • Costs: Data on costs are not available.
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Funding Sources

Reid Hospital and Health Care Services
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Tools and Other Resources

The quality measures included in the Hospital Quality Alliance starter set used by Reid Hospital are available at: http://www.cms.hhs.gov/hospitalqualityInits/downloads/hospitalStarterSet200512.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

Adoption Considerations

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Getting Started with This Innovation

  • Seek top-level support: High-level support helps ensure that employees at all levels realize they need to work to make the system a success. If all the new quality tools at Reid had been championed only by the director of quality improvement (without senior management support), they would not have gained traction as quickly and might have failed.
  • Involve physicians: Identify physician champions to help promote changes. Provide physicians with their individual results to encourage behavior change, and promote successes. Make it easy for physicians, but don’t waste their time; call them into meetings only when their presence and participation are critical.
  • Be persistent: Early on, staff working to adapt the systems to meet the hospital's needs may express skepticism ("we can't do that," "it won't work," etc.). To overcome this, hospital leaders should be patient but persistent in explaining that failure is not an option and that it is worth the time and effort it takes to devise solutions.

Sustaining This Innovation

  • Emphasize effect on patient care: Some staff members may perceive an effort to meet quality standards as meaningless bureaucracy. Dispel such perceptions by sharing research showing that meeting the standards has a direct effect on improving patient care. Communicate results continuously throughout the organization, particularly with medical staff and medical staff leaders.
  • Promote teamwork and collaboration with IT staff: Integrating a new alert system into patient care requires nursing, medical, and IT staff to work together closely, because getting the system to work properly often requires tweaking. Hospital administrators need to work hard to cultivate good team relationships and instill a “good for the whole” mentality.

More Information

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Contact the Innovator

Jennifer Ehlers
Vice President/Chief Quality Control Officer
Reid Hospital and Health Care Services
1100 Reid Parkway
Richmond, IN 47374
Phone: (765) 983-3426
E-mail: jennifer.ehlers@reidhospital.org

Innovator Disclosures

Ms. Ehlers has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Case study: achieving high-quality care at Reid Hospital and Health Care Services. The Commonwealth Fund Web site, January 24, 2006. Available at: http://www.commonwealthfund.org/innovations/innovations_show.htm?doc_id=342968.

Footnotes

1 The Center for Medicare & Medicaid Services. 2007. Quality Measures Compendium V.2.0: Medicaid and SCHIP Quality Improvement Compiled by the Division of Quality Evaluation and Health Outcomes, Family and Children's Health Programs Group. 
2 Case study: achieving high-quality care at Reid Hospital and Health Care Services. The Commonwealth Fund Web site, January 24, 2006. Available at: http://www.commonwealthfund.org/innovations/innovations_show.htm?doc_id=342968.
3 The Joint Commission. Surgical Care Improvement Project Core Measure Set. November 2008. Available at: http://www.jointcommission.org/assets/1/6/Surgical%20Care%20Improvement%20Project.pdf.
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: May 26, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: September 25, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: August 30, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.