Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions.

Harmony Flows When One Physician Group Manages Multiple Hospital Services

2/15/2017 11:19:59 AM | 2 comments

Good Samaritan Hospital is committed to improving outcomes and patient experience. And with the onset of value-based purchasing, hospital administrators and physicians knew they needed to overhaul their current processes in order to succeed.
 
They wanted to improve operational efficiency, have outstanding clinical quality and service, improve transitions of care, and create better condition-specific clinical pathways.
 
What they needed was closer clinical integration.
 
In today’s post, using Good Samaritan's integrated hip fracture pathway as an example, I'll discuss how administrators and the medical staff approached integration and how CEP America physician leaders helped them create more meaningful integration between service lines.
 

Breaking Down Silos

 
Good Samaritan and CEP America share a long history. The hospital is home to one of CEP's first emergency medicine practices dating back to 1975. As such, we've had the privilege of watching this innovative hospital grow through the years.
 
At Good Samaritan, the push for an integrated hip fracture pathway came from our anesthesia and emergency medicine physicians. They saw the opportunity to better utilize resources, reduce operational costs, improve quality, improve service, and work together more effectively. Their support laid the groundwork for collaboration between the various service lines.
 
So why focus on this population? Well, hip fractures are most common in older people who often have multiple health conditions that make surgery risky. Patients typically arrive via the ED accompanied by their concerned families. And in order to manage pain, ED personnel sometimes rely on narcotics, which can delay surgery and increase the risk of delirium. All of this adds up to an increased complication risk and longer lengths of stay (LOS).
 
To address the issue, several departments (including emergency medicine, anesthesia, surgical services, case management, and rehabilitation) created a multidisciplinary hip fracture committee. Its purpose was to get experts with different backgrounds and training to step back and look at the big picture — at our shared goal of improving patient care.
 
Through discussion, providers set aside their service line-specific goals and challenged ingrained ideas that their departmental processes couldn’t be modified. They took ownership of their role in the big picture of hip fracture care. Agreeing to collaborate meant shifting from isolated practice to shared responsibility for patient outcomes and experiences.
 

Physician Leadership

 
Bringing providers from different practice lines together is, in theory, a great idea. However, oftentimes different goals and incentives of the specialties can create problems moving forward and implementing change.
 
When Good Samaritan's anesthesiology group joined CEP America in 2014, this brought the anesthesia and emergency medicine service lines under the same management umbrella. The newly unified teams were excited to prove the value of integration.
 
To this end, anesthesia and emergency medicine stepped forward to bring leadership and structure to the hip fracture initiative. Their efforts made it much easier for other departments to engage in the process and brought great energy to the project.
 
Together, the teams reviewed the data and discussed strategy to improve hip fracture care. As front line providers, they knew best what was working and what wasn't. With great success, the committee worked collaboratively to codesign a clever, thoughtful, and integrated pathway to improve hip fracture care.
 

Attainable Goals

 
The committee decided to tackle the hip fracture problem by starting with specific, attainable goals. Early efforts were geared toward improving pain management. (After all, patients whose pain is poorly controlled don’t tend to score the ED highly on satisfaction surveys.)
 
The committee started out by asking patients to rate their pain at different points in their care cycle — before surgery, after surgery, and so on. Unfortunately, the replies were inconsistent. It was impossible to account for confounding factors such as pain tolerance. The committee quickly realized that pain would be too difficult to measure.
 
This led to a new focus on LOS. Long hospital stays are costly for all parties involved. They're also dissatisfying to patients, who want to get home and back to their lives as soon as possible.
 

Implementing Goals

 
In designing the new integrated hip fracture pathway, the committee drew on several sources for inspiration.
 
One was the Perioperative Surgical Home (PSH) model promoted by the American Society of Anesthesiologists. In a PSH model, the anesthesiologist works with departments around the hospital to coordinate patient care before, during, and after surgery. As such, they play a key role in facilitating new care pathways.
 
CEP America also made its internal experts available to the committee. A few years ago, CEP personnel had led the creation of a successful hip fracture pathway at John Muir Medical Center in Walnut Creek, Calif. Providers and consultants who had worked on that project freely shared their experience and advice with the Good Samaritan team.
 
Before long, Good Samaritan's hip fracture protocol was up and running.
 
Today when a hip fracture patient arrives at the ED, the emergency physician alerts the anesthesia department. The on-call anesthesiologist consults with the surgeon on pain management options.
 
The anesthesiologist then sees the patient in the ED. In many cases, this allows the patient to receive a nerve block, which is very effective at controlling pain and reduces the need for opioid medication.
 
The anesthesiologist also coordinates communication with the admitting hospitalist, facilitates scheduling with the OR, and orders post-surgical therapies. This allows the patient to move more quickly from the ED to the hospital floor — and ultimately onward through surgery and therapy.
 
Training is an important part of the pathway. The hospital sponsored a regional anesthesia workshop for the anesthesia and EM departments. As a result, some of our emergency physicians are now trained to administer nerve blocks, which could greatly improve our efficiency and bring faster relief to patients.
 

Sharing Results and Celebrating Success

 
The new hip fracture pathway has been quite successful. LOS for this population has dropped from 133 hours in early 2016 to 95 today. Use of opioid medications is down. And anecdotal evidence suggests that our patients and families feel reassured by the camaraderie and teamwork they see.
 
We still have plenty of room for improvement. The committee is currently working to reduce ED to OR time as well as overall turnaround. But the participants have been energized by early victories. The pathway has created believers that an integrated approach can work.
 
Our pathway entered an exciting new phase when Good Samaritan's hospitalist group joined CEP in October 2016. We’re excited to see what gains we can make now that EM, anesthesia, and HM are all Partners in the same organization.
 
Finally, we were excited to learn that our pathway will also be piloted at our sister hospital, Regional Medical Center of San Jose, where CEP America manages the anesthesia, emergency medicine, and hospitalist medicine programs.
 
One thing is for sure: integration is no longer a buzzword at Good Samaritan. We want our hip fracture patients to view us as a single care team from the moment they enter the ED to the moment of discharge. Our CEP departments hold regular joint meetings to discuss how we can improve our collaboration and share responsibility. We look forward to providing some of the fastest, most integrated hip fracture care available anywhere.


Comments
David Carter
What a great example of spanning the differences between groups to arrive at a common goal for the good of the patient and putting the patients (like my grandmother) first. Appreciate all the hard work and leadership that went into this.
2/16/2017 11:35:49 AM

Cyndy Flores
Thanks for your leadership to support these kind of important pathways for our patients!
2/16/2017 8:39:19 AM