ICU-Acquired Delirium and Weakness

The ICU literature recognizes that many ICU survivors  suffer from ICU-acquired delirium and weakness that impacts the quality and quantity of their lives.   While piecemeal efforts to address these problems have been initiated, the authors of this article in the November 2010 issue of Chest make the case for an aggressive ABCDE bundle to improve outcomes for ICU survivors.

ABCDE bundle stands for awakening and breathing coordination, delirium monitoring, and exercise/early mobility.  The authors state “ICU-acquired delirium and weakness are disorders of epidemic proportions and should be viewed as potentially preventable and/or modifiable outcomes for ICU survivors. ”  They also advocate that the bundle be protocolized and all ICU team members be empowered to enact the protocol.

Reducing iatrogenic risks; ICU-acquired delirium and weakness – crossing the quality chasm.  Vasilevskis EE and others.  Chest 2010 Nov;138(5):1224-1233.

AHRQ Effective Health Care Program

The AHRQ Effective Health Care Program “funds individual researchers, research centers, and academic health organizations to work together with the Agency for Healthcare Research and Quality (AHRQ) to produce effectiveness and comparative effectiveness research for clinicians, consumers, and policymakers.”

The Effective Health Care Program produces:

• Research Reviews
• Original Research Reports
• Summary guides (summarize  research review findings on benefits and harms of different treatment options)

The plain language summary guides for clinicians provide a way of integrating comparative effectiveness research into every day practice.   In addition, the plain language consumer guides support  clinicians in their patient counseling concerning the effectiveness, benefits, and harms of different treatment options.  Although there are only a limited number of existing clinician guides, many research reviews and original research reports are in the process of development.   The Effective Health Care Program website invites comments and collaboration.

Example of a Clinician Guide  Treatments for Clinically Localized Prostate Cancer.

AHRQ Effective Health Care Program

Reducing Readmissions of Patients with Heart Failure

In an article in the September issue of Nursing2010 Cheryl Burke,  director of quality at Mercy Hospital in Scranton, PA ,  ” …describes our hospital’s efforts to improve our care of patients with HF and reduce our readmission rates by focusing on patient discharge instructions.”

The Mercy Hospital heart failure performance improvement team used the PDCA cycle to develop a process that resulted a new HF patient education tool, as well as, a discharge sheet that included all elements required by CMS for discharge teaching.  

This HF PI process increased Mercy Hospital’s compliance with the six elements of CMS HF teaching from 30% in July 2006 to 100% in December 2008.

Burke CA.  Reducing readmissions of patients with heart failure.  Nursing 2010 Sep;40(9):12-13.

Lowering the Risk of Readmission for Heart Failure Patients

Decreasing the 30 day readmission rate for Medicare heart failure patients is  the target of both clinical research and quality improvement activities.   This observational analysis examined “…the association between outpatient follow-up within 7 days after discharge from a heart failure hospitalization and readmission within 30 days.”

Their findings support the hypothesis that “patients who are discharged from hospitals that have higher early follow-up rates have a lower risk of 30-day readmission.”   While recognizing the complexity of transitional care that  influences heart failure patient readmissions, this research provides an area for focusing efforts.

Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW,
Peterson ED, Curtis LH. Relationship between early physician follow-up and 30-day
readmission among Medicare beneficiaries hospitalized for heart failure. JAMA.
2010 May 5;303(17):1716-22. PubMed PMID: 20442387.

NEJM Article Explores Medication Adherence

Recent articles on “medication adherence” including this online first article(April 7, 2010) in the New England Journal of Medicine  emphasize the need to address this complex issue in order to improve health outcomes and decrease healthcare costs.

The authors David M. Cutler and Wendy Everett “… suggest that improved adherence will require changes in health care delivery, particularly in the area of primary care, along with continued investment in information-technology system and new health plan designs that focus on achieving improved health outcomes.”

Three examples of current integrated approaches to promoting adherence are briefly described including the Geisinger Health System model which “…has begun implementing multiple programs to address adherence… Geisinger reports that it has achieved a 5 to 7% reduction in costs.”

 Cutler DM, Everett W.  Thinking outside the pillbox — medication adherence as a priority for health care reform.  New England Journal of Medicine.  Online First April 7, 2010.

Does eICU improve intensive care?

The researchers studied why hospitals adopted or did not adopt telemedicine for the ICU.  In addition to trying to find evidence supporting improved quality indicators, the researchers explored financial, return on investment and staffing issues.  They also looked at why some hospitals did not adopt eICU.  The conclusion is “… a lack of hard data to answer the question argues for doing comparative effectiveness research on care delivery.”

Berenson RA, Grossman JM, November EA.  Does Telemonitoring Of Patients–The eICU–Improve Intensive Care?  Health Affairs – Web Exclusive. Aug. 20, 2009.

Assessing Variations in Hospital Resource Use

In healthcare reform discussions many references have been made to the variations in hospital resource use  identified by the Dartmouth end-of-life analysis.    The Dartmouth Atlas analysis includes only individuals who have died.   However, researchers at some California hospitals, that have been identified as high users of resources, looked  at all patients with heart failure.   They discovered:  “when analyzing all patients hospitalized for heart failure, California teaching hospitals that used more resources had lower mortality rates” and “the variation in resource use among California teach hospitals was 27% to 44% less than the variations observed when analyzing only heart failure patients who died.”

This study illustrates the difficulty of finding the excess in health care.

Looking Forward, Looking Back: Assessing Variations in Hospital Resource Use and Outcomes for Elderly Patients With Heart Failure.  Circulation. Cardiovascular Quality and Outcomes 2009;2:548-557.

Failure to Rescue Impacts Surgical Mortality

This study from the Michigan Surgical Collaborative for Outcomes Research and Evaluation used Medicare Provider Analysis and Review (MEDPAR) files from 2005 and 2006 “… to determine whether variations in surgical mortality among Medicare patients are due to differences in incidence of complications or differences in the success of managing complications once they occur, ie, failure to rescue.”

Although the study has limitations, the investigators  suggest “that excess mortality at poorly performing hospitals appears to be attributable to large differences in failure to rescue.”

Complications, Failure to Rescue, and Mortality With Major Inpatient Surgery in Medicare Patients.  Annals of Surgery 2009 Dec;250(6):1029-1034.  19953723

Business Case for Quality

The Institute for Healthcare Improvement recently issued a white paper, Increasing Efficiency and Enhancing Value in Health Care; Ways to Achieve Savings in Operating Costs per Year.  This White Paper presents the business case for quality in terms of waste reduction.

• Section One:  Three Approaches to Improving Value
• Section Two:  Understanding the Opportunity to Decrease Cost by Reducing Waste
• Section Three:  Developing a Portfolio of Waste Reduction Projects to Reach the Goal
• Section Four:  Tools for Tracking “Dark Green Dollars”
• Section Five:  Integrating Waste Reduction into Organizational Strategy

If you cannot download a copy, please contact library via comments.