The Michigan Value Collaborative

Helping Michigan hospitals achieve their best possible patient outcomes at the lowest reasonable cost

Category: Spotlight on MI hospitals (page 1 of 4)

Combating Surgical Site Infections in Michigan: Joint Replacement Workgroup Recap and Hospital Initiatives

Deby Evans

Deb Evans is the MVC Site Engagement Manager

The Michigan Value Collaborative (MVC) and the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) held a recent workgroup focused on surgical site infections (SSI) related to joint replacement. Hospitals met to discuss some of the root causes for these infections and initiatives they have implemented to help reduce them.

Below is one of the presented slides that exhibits the proportion of readmissions due to SSI’s for MVC/MARCQI hospitals based on MVC claims data:

Although many of the hospitals have done extensive analysis and in-depth review of pre-, intra- and post-operative joint conditions, few specific root causes for surgical site infections have been identified.  However, major focus areas for hospital-led initiatives that have been identified are:

  • Improving the general health of the patient especially in terms of reducing the body mass index (BMI);
  • Improving hemoglobin A1C for diabetics;
  • Improving albumin levels; and
  • Tobacco cessation

One hospital recently began an initiative aimed at helping patients become healthier and ultimately maintain an optimal weight for joint-replacement surgery. Referrals for the program come from surgeons prior to the surgery. The initiative includes a weight loss clinic and classes, which offers a refund of the cost of the program if the patient is successful in losing weight before surgery.

Most hospitals are following the Joint Commission recommendations from the Surgical Infection project (SIP) and the Surgical Care Improvement Project (SCIP). However, there are some differences in the identification and treatment of staphylococcus aureus carriers with some hospitals universally treating all joint replacement candidates and some only treating those identified as carriers through a nasal swab.  Although this workgroup only focused on SSIs related to elective joint replacement, it was mentioned that some hospitals are treating their trauma cases for staphylococcus aureus as well, while others are looking at this potential.

Other topics that prompted discussion among the group were wound closure and whether different types of closure affected SSI rates along with the type of dressing being used and the length of time the dressing stayed intact over the wound. There was some variety among surgeons and hospitals, however many are using a moisture-impervious silver based dressing that remains on for about seven days. Despite what may be considered a more expensive dressing being used the benefits of keeping the wound covered and out of contact with potentially infectious elements, i.e. pets, clothes, bed linen etc. outweigh these added costs.  In addition, when comparisons were made between these dressings and changing a dressing daily the difference in cost was negligible.

Finally, patient education was a major talking point during the workgroup. All hospitals agreed that having the patient’s cooperation is a significant factor in reducing SSI. Some hospitals have produced videos for patient viewing pre-operatively while others have an educational sheet that they provide to the patient before the surgery. Some discussion focused on the amount of information that the patients are expected to retain and ways hospitals are sharing reminders using booklets, pamphlets, a coach that is known to the patient or being seen by a discharge planner.

The Coordinating Center has put together a pre-, intra and post-operative check list of things to consider to potentially help reduce SSI, as well as a hygiene at home sheet for patients. These can be found in the resource tab on the registry along with information from our other workgroups.

If you have identified any specific root causes or have a new initiative aimed at reducing surgical site infections, then we would love to hear from you. Please contact Deb Evans (debevans@med.umich.edu) or Abeer Yassine (abeery@med.umich.edu) to share your story.  Preference

Michigan Hospital on the Forefront of Reducing Hospital Readmissions

Dino Recchia

Dr. Recchia is Chief of Cardiology at Munson Medical Center

Some goals of the MVC Hospital Engagement team are to help hospitals reduce Heart Failure (HF) readmission rates along with improving patient care and quality in order to have Michigan become a leader in this domain. The Hospital Engagement team has been locating and speaking to hospitals nationwide with the lowest HF-related readmissions. One hospital, Munson Medical Center, falls in the top 1% of hospital readmissions and is located right in Michigan. Munson is on the forefront of using coordination of care to reduce readmissions. The Hospital Engagement team had the opportunity to speak to Dr. Recchia, Sheila Falk, and Anne Bacon about the HF Clinic at Munson Medical Center, which has helped better manage patients and improve readmission outcomes among their sickest patients.

The clinic was the shared vision of Dr. Recchia and Sheila Falk who began planning the program in 2010.  They identified gaps in the care of many heart failure patients which was resulting in high rates of readmissions and sub-optimal quality of life.  They also saw the growing role of LVADs in the management of end stage heart failure which presented difficulties for LVAD patients in northern Michigan who lived many hours away from an LVAD center.  A similar situation existed for patients with pulmonary hypertension.  They approached the Munson Foundation with a plan to establish a multidisciplinary heart failure program to address the needs of this difficult patient population. With seed monies from the Foundation, the Munson Heart Failure Clinic was established in 2011.

Patient Management

The clinic has grown dramatically over the last 5 years now involving a heart failure cardiologist, special heart failure nurse practitioner, 3 dedicated nurses, and 2 support staff.  90% of the referrals to the program come from Dr. Recchia’s partners and involve cases that are too complex to manage in a general cardiology practice.   Once the patient is referred, care is taken over completely by the Heart Failure clinic with no co-managing between cardiologists. Patients referred to the HF Clinic begin care management the day they are discharged. Inpatients are seen and educated by the nurse prior to discharge as the team found that the time between discharge and their first HF Clinic appointment is a very vulnerable time.  The Munson team has also developed a “shared care” approach for patients with LVADs allowing these patients to be co-managed with their implanting LVAD centers downstate greatly reducing the frequency with which patients and their families have to drive long distances for a routine LVAD follow up appointment.  The same approach is used for co-managing patients with pulmonary hypertension seen in those same institutions.  Another unique feature of the HF Clinic at Munson Medical Center is the phone call strategy they employ.  Instead of suggesting patients call the HF Clinic if something is wrong after a change in their treatment regimen is made, the HF Clinic team arranges a “phone call appointment” at a specific date and time to follow-up on the response to the treatment and facilitating further decision making. These patient management methods at the Munson Medical Center HF Clinic help better coordinate care and consequently improves patient experience and outcomes. Patients reap such benefits from being in the program that they often want to stay in the program even after they have improved enough to no longer need this level of care.  Munson has also had great success integrating hospice care in to their program for those patients that have no further care options resulting in over 60% of the deaths in the program occurring in a hospice setting.

Outcomes and Measurement of Success

Readmission rates can be used as a measurement of success of a program geared towards improving patient care and costs. Munson took less than 2 years to measure the positive outcomes the clinic had on patient care and on readmission rates. Munson’s overall hospital readmission rate for heart failure is 18.6% down from 23% before the HF program was established.  The national average for this metric is 22%.  The patients followed by the HF Clinic are the most difficult heart failure cases with a predicted readmission rate based on clinical parameters of over 25% yet this subgroup had an overall readmission rate of only 12% which is a further testament to the success of the program.  Moreover, Munson has used patient testimonials and resource usage to measure the downstream impact of the HF Clinic and shown benefactors the benefit of investing in a HF clinic.

Advice to Hospitals

Munson was able to provide great advice for hospitals seeking to begin a HF Clinic program. First and foremost, there has to be complete buy-in from the cardiologists where the specialty clinic takes over care for the patient so there is no confusion. Hospitals should structure a multi-disciplinary clinic where each member works to the full potential of their credentials. This ensures coordination of care among services and makes patients feel secure in their decision to use the HF Clinic services. This team is critical to ensuring that patients are receiving timely and quality care.

Dr. Recchia and the HF Clinic team are happy to talk to anyone interested in finding out more about the clinic at Munson. Please contact Deb Evans (debevans@med.umich.edu), Abeer Yassine (abeery@med.umich.edu), or Dr. Recchia (drecchia@mhc.net) for more information.

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