Pneumonia readmissions on the decline

It appears Shoreline Medical is doing something right, at least when it comes to pneumonia readmission rates. As, compared to the national pneumonia readmission rate of 18%, our hospital had only a 2% readmission rate for the given time period of about a year.

Because of this, I was chosen to give a presentation to a group of respiratory therapy supervisors and managers. This was a unique and exciting opportunity for me, especially considering I was the lowest ranking RT at this meeting. Plus my boss chose me among all my peers to give the presentation.

I worked with the Quality Assurance Analyst for our hospital and created this really nice presentation. Then I spent quality time interviewing, going through charts, and researching all the things we do once a patient is diagnosed with pneumonia, and what we do to keep pneumonia rates down.

I actually learned quite a bit in this process about the administration side of things. What follows here is a summary of my presentation:

A goal at Shoreline Medical is that we all have our priorities in order.

Shoreline Medical is in a small town only a few miles off the shore of Lake Michigan. It's in a small town, a close nit community. And being a close nit community results in a close nit hospital. One of the reasons I chose to work here is because I felt Shoreline was kind of had a down home feel to it. Everyone got along, were good friends, had pot lucks, and stuff like that.

We started the process of getting our ducks in a row by focusing on the CMS Core Measures. To make sure all doctors, nurses and respiratory therapists are always thinking about the core measures, we are all in serviced on this every year by the Quality Assurance Department.

In the chart, before the doctor's orders section, is a bright orange laminated sheet that has all the core measures on it. This way, every time anyone looks at the orders he or she has to flip this page aside. And even if you don't read it, you know what's on it: the core measures. This is one simple reminder to everyone to focus on the core measures when writing and fulfilling orders.

The Core Measures for pneumonia are as follows:

1. Initial Antibiotic Timing (given within 6 hours)
2. Pneumococcal Vaccination if eligible
3. Influenza Vaccination if eligible (October to March)
4. Blood Culture drawn before initial antibiotics
5. Appropriate antibiotic selection
6. Smoking cessation advice and counseling given if indicated (if patient has smoked within the last 12 months)

The most important of the above are the pneumococcal Vaccination, Influenza vaccination and smoking cessation, as studies have linked all three with a reduction in secondary pneumonia. So our major emphasis was on these three.

These core measures are what works according to the most recent best practice evidence to improve patient outcomes and decrease costs for pneumonia patients. The question we had to ask ourselves is: how do we use these core values to get our ducks in a row

Data from our core values back in 2007 showed that Shoreline Medical was about 80% in all of these core measures except for antibiotic timing within 6 hours. In this, we had no data whatsoever, which means we probably didn't even do it.

Yet if you look at data from the first and second quarters of 2010 you can see that we are at or near 100% on nearly every core measure. When it comes to smoking cessation we were at 92%, yet that was basically due to a miscommunication between a doctor and a nurse. So even while we've improved, we still use this data to improve even further, as there is always room for improvement.

So basically back in 2007 we did not have all our priorities in order, and in 2010 we did. So how do we get our priorities in order?

Actually, if you look at pneumonia readmission data other than the above mentioned three month period our hospital at at 16.5%, which is no different than the U.S. National Rate. .

Yet from January to March 2010. During that span we had 52 pneumonia patients, and only one readmission rate.

These improved statistics based on the core measures show we are doing something right. They prove that we have our ducks in a row. The question you are asking is: how did we get our ducks in a row?

The first thing we did was back in 2007 we joined the Keystone Collaborative. We have a champion Internist, a physician from ER, and one from surgery and general practice as our champions. Then we have one nurse from critical care, the general floors, and one from the emergency room.

We also have a representative from lab, x-ray, pharmacy, quality assurance, computer analysis, respiratory therapy (that's me) etc., and we meet every month to analyze data from core measures to create and improve clinical pathways and order sets to improve patient outcomes and reduce costs for our hospital.

The key here is that we review modern wisdom and come up with better practices for our hospital. Anyone can do research, or come up with new ideas, and can share them with any member of the keystone

committee, and then this new wisdom is brought to and reviewed by the committee and changes are made as appropriate.

Basically the point of the Keystone Committee is to do what works and skip doing what's not working.

The following is our pneumonia order set:

Our order set includes the following as options for the doctor to check:

• Code status
• Vitals routine or ___________
• Record input and output, daily weight, pulse oximetry every shift
• EKG on admission
• Chest x-ray on admission and on day 3
• Lab work (if not already done): CBC, CMP, UA, Sputum for gram stain, culture and sensitivity, blood culture prior to administration of antibiotic (this has to be done within three hours of admission)
• AM labs_______________
• Oxygen at _______ lpm or per protocol or _________
• Respiratory treatments: Albuterol 2.5mg with 3cc normal saline Q6 hours, up to ____ hours prn
• Respiratory treatment: Atrovent 0.5 mg in 2.5 ml normal saline QID
• Antibiotic therapy (1st dose to be given in ER) or immediately after blood culture drawn)
• Community Acquired Pneumonia (non CCU): Levaquinn 500 mg IVPB Q24 hours times 3 days, then Levaquin 500 mg PO daily
• Community Acquired Pneumonia (CCU or stepdown patients): Rocephin 1 gm IVPB Q24 hours and Zithromax 500 mg IVPB Q24 hours and Levaquin 750 mg IVPB Q24 hours and Azactam 2 GM IVPB Q12 hours
• Nosocomial Pneumonis (check all that are indicated from list of meds and doses)
• IV Fluid ____________
• Tylenol 650 MG PO Q4 hours prn for pain
• Xanax 0.25 mg PO Q6 prn for anxiety
• Restoril 15 MG PO QHS prn for insomnia
• MOM 30 ML PO BID prn for constipation
• Robitussin 10 ml PO Q4 hours prn for cough

(I left a few things off, but that's basically the gist of it).

This is our pneumonia hymn book. It's all the things that the best practice evidence shows works to help pneumonia patients get well. It's one sheet of paper, which makes it very simple.

As you'll note, some of the things on here are automatically ordered -- the doctor has no choice. For instance, x-ray on admission and in the am times three days, and certain labs on admission and in the am.

The ER nurses are involved right away, because if that patient is in the ER at the five hour mark, they have to make sure a sputum is obtained, and that the patient has been given that initial antibiotic within 6 hours. They have a system to assure this is done, and checks and balances.

As soon as the patient is admitted, the orders are entered into the computer system, and reminders are automatically sent to all the respective departments as to what they have to do and when. In RT department sheets are printed off so we know what our role is for that patient.

For lab and x-ray, what they have to do is printed up on their respective printers, and plus the procedures they have to do are put on the tracker when they are due so they are reminded in that way too.

It's simple. This order sheet is our hymn book: it makes sure we are all singing from the same hymn book.

Then we have our extubation protocol (to see our extubation protocol click here). This order set is part of the ventilator bundle. It works similar to the pneumonia bundle, in that when it comes to intubated patients, it makes sure we are all singing from the same hymn book.

The neat things about our extubation protocol is that when we were in school in 1995 we learned that the cuff pressure should never exceed 20 cwp. Now we are taught to always exceed 20 cwp. The reason is to prevent aspiration , and to prevent ventilator acquired pneumonia.

Another thing to prevent pneumonia is that the circuit not be broken. To do this we use MDIs instead of nebulizers. Also, we do not disconnect the circuit to suction, and use in line suction catheters instead.

Another key is the daily sedation protocol. Every night around 2 a.m. we automatically take all our patients off sedation so that by 6 a.m. we can analyze the patient for readiness to wean.

Here comes another laminated sheet. As part of our ventilator protocol we have a sheet that acts as an algorithm to speed time from intubation to extubation. Actually, the key to a good extubation protocol is that as soon as the patient is intubated we start thinking about extubation.

If the patient can be extubated in 2 hours, now that's possible. Years ago if the attending went on vacation the other doctors didn't extubate because they didn't want to offend the attending. Sometimes we RTs would wonder why the patient was still intubated. Now, that never happens, or rarely happens.

Our Algorithm goes something like this:

Weaning Screen:

1. FiO2 less than or equal to 40%
2. PEEP less than or equal to 5
3. HR greater than 50 or less than 120
4. Temp. less than 100.5
5. SpO2 greater than 90 unless otherwise directed by physician
6. Systolic BP greater than 90
7. Minimal or no sedation
8. No Vasopressors
9. No signs of respiratory distress
10. Able to follow commands
11. Adequate cough
12. Secretion thin and minimal
13. Plateau pressure less than 30 cwp

If the answer is no, then you stop and reanalyze the next day. If the answer is yes, then you move on to the next step, which is to do a 5 minute spontaneous breathing trial (SBT). (ETT 8.0 or greater use a CPAP of 5 and PSV of 0, ETT 7.5 or smaller use CPAP of 5 and PSV of 5)

Now you do a second weaning screen based on the same criteria as above.

If the patient fails the screen, the SBT is stopped and patient returned to previous settings.
If the patient passes, the following is completed and analyzed:

1. NIF greater than 20
2. VC greater than 10 ml/kg
3. VT greater than 5
4. RR less than 30
5. VE greater than 5 and less than 15
6. RSBI (f/vt) less than 100

If the patient passes this criteria, continue SBT for 30-120 minutes. Then do another weening screen as mentioned above. If patient passes do an ABG and call physician for order to extubate.

So basically we no longer simply do weaning parameters every day, we are actually completely assessing the patient using the common sense, best practice evidence approach. Patients are getting extubated quicker, and VAP is now pretty much nonexistent at our hospital.

Another key is education. As soon as the pnuem order set is initiated the emergency nurse educates the patient about pneumonia. Then the nurse on the floor educates the patient, and then the RT is in the room every six hours, and he or she educates the patient some more.

We make sure not only do our patients learn about pneumonia, they also know about their disease. For example, if they have COPD we make sure they know the early warning signs of an exacerbation so they can nip it in the bud next time and don't have to be readmitted.

We make sure they know if they start to get more short of breath than usual, or have increased cough or sputum production, or change in color of sputum, that they call their doctor or come into the emergency room.

Plus, as soon as pneumonia order set is entered in the computer, an order for RT to do smoking cessation is printed off in the RT department. Several studies show that if when a patient is vulnerable, when he's sick in the hospital, that if someone nudges them to quit they are more likely to quit.

And then when the patient is discharged another paper is printed off that is a pneuminia fact sheet for the patient to take home with them. It is basically a reinforcement of everything they've learned about pneumonia, and is reviewed by the discharge planner.

It's also a reminder to the RN to make sure the patient has had his vaccines while admitted, and to reinforce to the patient that they get their annual pneumonia and flu vaccines.

So basically the pneumonia order set is our hymn book: it gets everyone on the same page from the RT to lab to nurse and x-ray and lab and doctor. We all know exactly what our role is for that patient

Another thing we have an emphasis no is good hand washing. We have signs over every sink that remind of the importance of hand washing. Another sign over every sink describes proper hand washing technique.

We also have hand sanitizer in every room and in various locations, and we encourage or professionals to use this between every patient, and after touching anything in the room, and before touching anything even on their own possession. We also encourage use of hand sanitizers before leaving the room, even if they ultimately wash their hands.

We have some of our nurses are anonymous spies who make note of who they see not washing their hands, or not doing so correctly. We have other pamphlets around the hospital that remind nurses, RTs, and even patients to keep your eyes open, and "It's okay to ask."

So good hand washing is key to preventing the spread of infection.

Another bonus at Shoreline is we are a close nit hospital. This results in really good communication. For example, if I'm in the room and I see something wrong with the patient, I talk to the nurse or sometimes I go right to the doctor.

Instead of the nurses calling the doctor and assuming they know what's wrong with the patient, they often call RT instead so we can use our experience and education to work with the nurse in deciding what needs to be done.

Likewise, many times the doctor calls me up and asks me what I'm thinking is wrong with the patient and what we should do. This is great for morale.


We also have a Rapid Response Team. And another thing is we have good support and encouragement. For example, if an RN calls me to assess a patient, and the patient is fine when I get their, is on the crapper or something, I don't say, "You stupid dummy. Why did you waste my time?"

Instead I say, "Hey, that's fine. You were being proactive. That's good. It's better to be safe than sorry. You did great."

Besides, it's better to be proactive than reactive. If you're proactive you are nipping it in the bud. If you're proactive you may stop the problem from occuring, and then you get no credit. But it's better to be proactive and get no credit becasue the problem never occured, than to be reactive. If you're reactive, that means the problem already occured.

It means the patient is already septic, or in failure, or whatever. If you're being reactive, it means the patient is already in need of critical care services, and may need to be in the hospital longer, and cost the hospital more. If your'e proactive, that means improved outcomes and reduced costs.

So it's better to be proactive than reactive.

So starting with the core measures, the keystone collaborative and weekly keystone meetings, to the pneumonia bundle, and then with the small town close nit touch, we have been able to get all of our priorities in order here at Shoreline Medical. That's how we did it.

Thank you. Any questions.

For more information, check out the following resources:

• AHRQ (Agency for Healthcare Research and Quality) http://www.ahrq.gov/
• MHA Keystone Center http://www.mhakeystonecenter.org/
• MPRO http://www.mpro.gov/
• Quality Net http://www.qualitynet.org/
• Blue Cross/Blue Shield www.bcbs.com/innovations

Core Measures

As a medical care professional, whether you're a respiratory therapist or a registered nurse, it's important you understand the behind the scenes politics. Sure you may wonder why you're doing breathing treatments on someone who doesn't need them, yet believe it or not, there is a good method to the madness -- most of the time.

Or if it's not a good method, at least it's a method nonetheless.

Whether or not you think government involvement in the health care system is a good or bad thing, the Centers for Medicare/Medicaid Services (CMS) established what they call "core measures" as a means of improving quality of hospital care and reducing costs. While I don't care for government involvement, I think the idea of "core measures" is a good thing.

Yes, it may result in some overkill, yet sometimes some overkill is needed to meet the ultimate goals of an institution and the overall health care system to the benefit of the patient and to assure cost effectiveness. Bare with me, because by the time this post is complete hopefully you'll have a better overall understanding of what I mean.

So, what are core measures? Please forgive me if I don't get this exactly straight, because I'm learning along with you. Yet after participating in a year's worth of administrative meetings, given presentations, interviewed coworkers and completed a ton of research where I think I have enough information to write about this nearly inexplicable subject.

Core measures are the things the medical staff must do when a patient is admitted under a specific core measure set: acute mycardial infarction, heart failure, pneumonia, and surgical care. Within these four sets there are 27 core measures that are based on scientifically-researched standards of care that have been shown to result in improved clinical outcomes for patients.

Basically, for each particular diagnosis, or diagnosis related group (DRG), the core values are all the things that the latest wisdom has proven work to increase recovery time for that patient.

They have also provided a focus for the development of Clinical Pathways and Standard Orders (post on this coming soon too), both of which assist in the consistent provision of optimal care to patients.

By Clinical Pathways we mean the creation of a system throughout the hospital that makes sure what needs to be ordered is getting ordered, and then completed. One example of this is our hospital has created order sets and protocols for several DRGs.

Now I am of the impression that order sets are bad and protocols are good. This is a topic I will discuss in more detail in an up and coming post.

These order sets and protocols act as a hymn book to make sure every professional taking care of the patient, from the doctor to RT, from the nurse to the lab techs to the x-ray tech, know exactly what their roll is for the patient.

A protocol is a standard order approved by the medical staff that gives the nurses and respiratory therapists the opportunity to do what is best for the patient given the circumstances. If used properly, these work to the benefit of the patient (improved care when needed), the staff members involved (improved morale) and the physician (decreased irritating calls).

An order set is a sheet of paper that the nurse pulls from a cabinet as soon as a patient is, for example, diagnosed with pneumonia. The set is a list of all possible options for that diagnosis. Some of the options that are most essential, such as making sure a sputum is ordered and obtained before the initial antibiotic is given, and giving that first antibiotic within six hours from the time the patient hits the door, are automatically ordered.

Many hospitals are incorporating order sets that automatically set in motion certain things that assure core measures are met, because these are scientifically proven to speed recovery and reduce costs. Examples are x-ray on admission and each morning for the next three days, labs on admission and each morning for the next three days, oxygen, IV, etc. These things must be done on all pneumonia patients, and the order set sets this in motion.

Another thing that is automatic is antibiotic selection, although the doctor will have options here. The emergency room nurses have a process in place where they will make sure the patient gets the antibiotic within six hours if the patient is still in the emergency room, and then there is another system in place to make sure this antibiotic is given within six hours if the patient is admitted to the patient floors.

When x-rays and labs are ordered, they pop up on a tracker board automatically through a computerized system both on a board in the emergency room and on similar tracker boards in the lab and x-ray departments. As time elapses, the color of each particular procedure changes from green (you have some time) to red, which means it needs to be done soon or right now or STAT or at least given top priority.

At Shoreline we have a bright orange laminated sheet that is inserted into the patient's chart right before the doctor's orders section, so that every person who looks at the orders is reminded of the importance of core measures.

Sure order sets might result in some overkill, yet all these reminders, all this motion, makes sure the hospital is meeting core measures for this patient. It also assures the hospital is meeting Intensity of Service. For example, on our order set, the options of IV, antibiotic selection, and breathing treatments are on the order set.

Used appropriately, one can see how order sets and protocols, when used together, can result in improved outcomes and reduced costs, improved staff morale, and decreased annoying calls to the physician.

Each individual hospital uses analysis of their own core measures as a means of evaluating performance at their own institution, and as a method of improving this performance.

Here at Shoreline Medical we analyze core measures data at our weekly keystone meetings. An example of the data we look at can be seen in the picture to the right.

The goal is to obtain a 90% rating in each core measure, as indicated by green. If the rating is less than 90%, this would be indicated as red.

The results are reported to the Joint Commission, which records this data on their website so anyone can see where each hospital stands in each area.

The Health and Human Services (HHS) has created a new website so you can check out hospital core measures. The site created is the Agency for Health Research & Quality (ahrq.gov). Another site is HHS's new site hospitalcompare.hhs.gov.

However, as I noted in this Keystone post, "It must be noted, however, that these measures must not be used as a report card to compare hospitals, rather as a tool for hospital improvement. What I mean by this is that if you consider 80-90% a B grade, and 90% or greater an A, you might actually be mislead.

"If you have a small hospital that has only admitted 10 patients with an MI over a span of a month, and a larger hospital has admitted over 100 such patients, and both hospitals forget to
properly chart two patients for whatever reason, the small hospital's stats will show 80% (a B grade) and the larger hospital will show 98% (an A grade). Yet both hospitals made the same amount of errors.

"So, again, these core measures and the percentages that go with them should not be used as a report card to compare hospitals, but as data to assist improvement."

At Shoreline, and other hospitals in Michigan, we get together in a monthly Keystone Meeting to discuss the recent core measures data, and then try to implement a systematic approach to improving our data. For example, back in 2007 there were many core measures where we were in the red, or less than 90%. Our current statistics are mostly green.

Thus, based on these core measures, we have created a a rapid response team, a sepsis protocol, an extubation protocol, a ventilator bundle, a sepsis bundle, a pneumonia bundle, an MI bundle, a heart failure bundle, a surgical bundle, among other successes that have reduced the number of patients being transported to the critical care, and obtaining nosocomial infections. This also includes a reduction in cases ventilator acquired pneumonia (VAP, other nosocomial pneumonia, and sepsis, and has likewise reduced readmission rates (post on this coming Sunday).

We have also created an array of order sets for pneumonia, CHF, sepsis, COPD, asthma, ventilator, ventilator extubation, etc.

So you can see these core measures are a good thing. The only problem I see is our hospital has incorporated all these order sets and no protocols to go with them (with the exception of the ventilator extubation protocol).

This ultimately results in a lot of overkill. For example, every sepsis patient gets ABGs, every pneumonia patient gets breathing treatments, and most patients get EKGs. While these procedures are needed for some patients admitted with said disease, they are not needed for all. Likewise, once breathing treatments are ordered, they are never discharged.

The result here is RT and RN burnout trying to get all these things done just so the hospital meets core measures, and the hospital gets reimbursed. It wrongly gives the hospital the impression of caring more for money than for patients.

The ultimate goal, however, I believe, for the government in all of this, is to use these core measures as a means of reimbursing hospitals based on performance rather than for each procedure provided to the patient. Now I'm not sure this is a good thing or not, yet that's the ultimate goal.

Actually, the ultimate goal for the government in all this is to reduce costs, so that when the new health care reform goes into effect, and if the United States eventually adapts a Federalized Healthcare Program such as exists in Britain or Canada, the cost to the government will be minimal.

So, what are the specific core measures? Here are the core measures that are being monitored today:

1. Acute Mycardial Infarction:

• Aspirin at arrival
• Aspirin prescribed at discharge
• Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) for left ventricular systolic dysfunction (LVSD)
• Smoking cessation advice/counseling
• Beta blocker prescribed at discharge
• Time to percutaneous transluminal coronary angioplasty (PTCA)
• Inpatient mortality

2. Heart Failure:

• Aspirin at arrival
• Aspirin prescribed at discharge
• Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) for left ventricular systolic dysfunction (LVSD)
• Smoking cessation advice/counseling
• Beta blocker prescribed at discharge
• Time to percutaneous transluminal coronary angioplasty (PTCA)
• Inpatient mortality

Community Acquired Pneumonia:

• Oxygen assessment within 24 hours of arrival
• Pneumococcal and influenza screening and/or vaccination
• Blood cultures prior to first antibiotic dose
• Smoking cessation advice/counseling
• Arrival time to first antibiotic

Surgical care improvement project: (check out this link)

• Providing a prophylactic antibiotic within 1 hour prior to surgical incision
• Providing a prophylactic antibiotic selection for surgical patients consistent with each type of surgical procedure
• Discontinuing the prophylactic antibiotic within 24 hours after the end of surgery because prolonged use of antibiotics increases the risk of Clostridium difficile infection -- a bacterium that causes diarrhea and more serious intestinal conditions such as colitis -- and the development of pathogens -microorganisms such as bacteria, viruses or parasites that can cause disease -- resistant to antibiotics
• Controlling postoperative serum glucose in cardiac surgery patients because high blood sugar weakens the immune system and increases the risk of infection
• Clipping the hair of surgery patients rather than shaving because skin abrasions increase the risk of infection
• Maintaining immediate postoperative normothermia (normal temperature) in colorectal surgery patients because increased temperatures pose a greater risk of infection, prolonged healing of wounds and longer hospital stays.

Based on these core measures, a major initiative of the Keystone Project was to improve outcomes of the critical care. It is actually the largest statewide collaborative ever: 76 hospitals, and 120 intensive care units. By this accomplishment it has also reduced costs for both the hospital and the government.

Interventions of the project include:

• Implement a unit based safety program
• Eliminate central line associated blood stream infections
• Eliminate Ventilator associated pneumonia (VAP
• Implement daily goal sheets
• Implement sepsis bundles to reduce ICU mortality from severe sepsis and septic shock

So you can see that the overall idea of core values is a good thing to improve quality of patient care and reduce costs -- if done the right way. It's also a method Medicare uses to pay hospitals, and a means of making sure doctors, nurses, RTs, x-ray techs, lab techs, and administrators are on the same page (all singing from the same hymn book) when it comes to taking care of the patient.

Again, though, the bottom line as far as a specific institution is concerned is to make sure we are doing all we need to do to ensure that we will be reimbursed. We have set up order sets so that everything that the most recent evidence shows will benefit those patients is ordered.

The pneumonia order set has bronchodilators every 6 hours. This assures that a bronchodilator is ordered by the attending physician. Now we know full well that pneumonia does not cause bronchoconstriction, yet by ordering bronchodilator treatments the physician is making certain the hospitals foremost experts on the lungs are assessing the patient every six hours during the course of the day."

Reminders are in the charts for us RTs too. Since best practice evidence shows a speedy extubation reduces ventilator acquired pneunonia, our extubation protocol encourages us to think extubation as soon as the patient is intubated. So we have laminated sheets in the chart to remind everyone who cares for the patient what this protocol is. Another laminated sheet on the chart shows a simple step-by-step algorithm to extubation.

Reminders are everywhere. Some are laminated sheets, some are signs on bulleton boards, some are on the tracker board, some are sheets of paper that print of in respective departments. Likewise, our department supervisors double check our charting to assure we are properly charting. It's the job of your boss to make sure everything is charted properly so core measures and Intensity of Service is met.

Yes, you might think your boss is hounding you at times. You may get lots of notes. Yet this is the job of your boss. His job is to make sure you are doing everything for that patient based on core measures. If core measures are not met, the hospital may not be reimbursed. So if you get the feeling your boss is paying too much attention to your charting and not enough attention to the patient, now you know that's not actually the case.

Yes, there is some overkill. Yes, there will be some needless procedures (such as bronchodilators on all pneumonia patients), yet the ultimate goal is to improve quality and reduce costs (which is the bottom line).

The neat thing about the monthly keystone meetings at Shoreline is that any time any person who cares for the patient has an idea to improve the process, or if new wisdom is learned, this gets reviewed and better clinical pathways are created.

If you're still confused about core measures, don't worry because so are the same people responsible for monitoring them.

Positive Outcome Based Medicine

Perhaps this is just me being unique, but I am suspicious that preventative health care and core values created by Medicare to improve outcomes and reduce hospital costs really don't reduce costs. In fact, I believe they actually make costs go up.

Consider preventative medicine. It was attempted back in the late 1980s. This is where you encourage people to exercise and eat right and quit drinking and smoking, and in this way you prevent people from getting sick. You encourage them to visit their doctor for annual check-ups, and to get annual testing done.

The problem with this theory is that I've seen people who are completely healthy, who eat all the right foods, who don't drink, who never smoked, and exercise daily come into the hospital and get diagnosed with cancer, and have seen patients who eat, smoke, are obese and drink daily live to the age of 90. I've seen it both ways.

So you can see, how you live your life does not prevent you from getting sick. It might help, yet all the preventative procedures you'll be getting every year will more than offset any savings from the people who live longer from living well.

Now I think it's a good idea to eat right and exercise, yet I don't think it's a good idea to force people to do these things. I don't think it's a good idea to force people to undergo tests they don't need. Besides, it's not a good idea to treat everyone the same anyway. If I have no family history of heart disease, I don't think I should undergo the same extensive testing as a person who has both his parents and siblings die from heart attacks.

We have some people chanting that we eat too much salt, and they want to make laws that restaurants should use less of it. Yet then their food will not taste as good, and nobody will want their food.

Look at McDonald's and Burger King. Their food is terrible for you. If you go to those places you will not be getting healthy food. Yet that is the choice of the individual. If you want to eat unhealthy food, you have that right. If people didn't want unhealthy, great tasting food, they shouldn't be going to these places.

The same is true of core values. While I think the idea of analyzing data obtained from a hospital to create better clinical pathways to improve patient outcomes and save money is good in theory, I don't think it will save money. In fact, I don't even think it will save lives.

For example, where I work we have created standing orders for each particular diagnosis (DRG). For every person with pneumonia, for example, we make sure that every one of those patients gets an antibiotic within six hours, smoking cessation offered if needed, a flu vaccine, and the pneumonia vaccine.

Yet, to make sure the patient meets criteria for admission so the hospital is reimbursed, to meet intensity of service, we also make sure the patient gets IV antibiotics and breathing treatments. Of course all of this is beneficial for some pneumonia patients, but most of these things are not necessary for most pneumonia patients. Therefore, there is overkill here. Overkill means wasted procedures being ordered that cost the hospital money.

Yet since most of these procedures and tests and medicines are considered safe, what's it going to hurt giving these to all patients. Basically, if you shoot a duck with ten bullets, maybe at least one will hit the duck. The bullet may not kill the duck, but at least we look like we are trying to kill it.

The same can be said of order sets and bundles where we treat every patient the same. We shoot that illness with everything we've got that we deem safe, and hope something works. At least the patient will be discharged eventually, and the hospital will get paid.

Yet since we are shooting so many bullets, since we are shooting 10 bullets when only one was needed (if one was needed at all), that's at least nine bullets that were wasted. That's nine bullets we had to pay for that weren't needed.

That's the way preventative care and order sheets work. Core values are good, preventative measures and order sheets are terrible. They are nothing but an incentive for doctors to order a bunch of stuff that's not needed, which, to me anyway, is wasteful spending.

I think, instead of preventative care, instead of order sheets, a hospital would be wise to take on a different approach, which I like to call positive outcome based medicine. Basically, this is where you do what works, and don't do what doesn't work. You do what's needed, and you don't do what's not needed. This truly would result improved outcomes and reduced costs.

To do this, I think, you would need to create bundles and protocols. The bundle would initiate all the procedures that might help that patient, and then the bundles would make sure what works is continued, and what's not working is stopped.

For example, since most patients might benefit from an antibiotic given, then give all pneumonia patients an antibiotic. Yet once you learn the patient does not have an infection, stop the antibiotic.

Since a certain percentage of pneumonia patients are also having bronchospasm, give all patients diagnosed with pneumonia a Ventolin breathing treatment. If the treatment works, continue giving them. If it doesn't work, stop giving them. Do what works, don't do what doesn't work.

Basically it goes like this:

• Order sets do not save the hospital money because they treat all patients the same
• Protocols do save the hospital money because they make sure what works is done, and what doesn't work is not done.

When it comes to eating right and exercising, I think it's better that I decide for myself to do those things. I don't think someone should be forced to. If the next guy wants to smoke and drink and eat poorly, that's his God given right.

Likewise, when it comes to treating patients, I think doctors should be encouraged to do what works for that particular patient, and not to treat all patients with a given diagnosis the same.

I think doctors, nurses, and respiratory therapists should be encouraged to use their skills to the benefit of improving patient outcomes and improving costs. I think protocols will do just that.

I also think each hospital should be encouraged to create clinical pathways to improve patient outcomes, yet I think each hospital should be encouraged to find their own clinical pathways. By forcing all of us to do it the same way, you are stifling creativity.

A good example here is the National Recovery Act of 1933. This act encouraged all businesses to set prices, products and to even set wages. The result here is all those in a particular industry were forced to do things the same way.

This Act actually falsely raised wages while productivity and competition were down. FDR did whatever he could to set higher wages. He wanted higher wages to give people who were working more purchasing power so they would buy more goods and services. FDR actually believed this would help end the Great Depression.

If this would have been passed in the early 1920s, and if Henry Ford were forced to produce cars the way every other car company produced cars, then the assembly line never would have been invented.

If in 1980 computer companies had set the price of computers at $1,000, few would have been sold, and the innovation that eventually led to the Internet would have been stymied. People would have to work harder to learn, and that would have led to even fewer innovations, such as no GPSs and iPods and other great inventions. We never would have seen the Internet bubble.

So encouraging everyone to do something the same way discourages innovation, and it does not always result in cost savings.

Yet the way things are designed right now in the medical field, since the government is forcing -- or strongly encouraging via programs that allow Medicade to refuse to reimburse hospitals if Intensity of Service is not met --the hands of the many smart and good people responsible for creating and improving clinical pathways, many hospitals are not "improving" the way that 90-100% success rate might be indicated.

And the difference between we think we see and actual improvements in outcomes and savings can be the difference between an organization (hospital in our case) succeeding or failing. And the difference is essential to you and me, because we want our local hospital to stay in business.

Yet interference by the government is leading many hospitals to failure, as we can see by all the small hospitals closing shop, and even some larger hospitals feeling the pain and plunging into a merger they once though would never be necessary.

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Note: I am going to write several posts between now and February, 2011, about Core Measures, Intensity of Service and reimbursement criteria. Once those posts are published, I will republish this post and hopefully you guys will have a better understanding of what was written here. Perhaps you can use this information to better your institution. Yes I have become privy to such esoteric wisdom, and I will share it will you.