The Michigan Value Collaborative

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

Tag: workgroup (page 1 of 2)

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

How MVC workgroups promote collaboration throughout Michigan: Outpatient Heart Failure Clinics

Crystal Loveday

Crystal Loveday is the Heart Failure Nurse Practitioner at Crittenton Hospital Medical Center

MVC recently interviewed Crystal Loveday, a nurse practitioner from Crittenton Hospital Medical Center, which is a ministry of Ascension Michigan. Crystal had participated in the Congestive Heart Failure (CHF) workgroup and is also a current participant in the longitudinal CHF workgroup. During the workgroup meeting, Crystal heard about the CHF heart failure clinic set up at Mid-Michigan and was interested in learning more. Currently, Crittenton is looking at implementing an outpatient Transitional Care Heart Failure Clinic and there was an interest to learn how to set up a clinic as well as its ability to help with patient education and reducing readmissions.  Crystal reached out to Mid-Michigan and was kind enough to report back to MVC the fruits of her visit.

How did your visit to Mid-Michigan help you?

Crystal: I spent time at Mid-Michigan viewing the set up and process within the out-patient clinic. I noticed that it was very organized and beneficial for the patients because the clinic staff spent more 1:1 time with the patient outside of the acute care setting. This gave the patients additional education, reinforcement of HF guidelines, and assisted with HF management. The clinic helped with reducing CHF readmissions to the hospital. It also provided a bridge of care after hospital discharge, assuring further follow-up with the patients, PCP, and cardiologist.  I was able to bring back a lot of information, which I presented and hope to use to initiate a Transitional Care Heart Failure (HF) Clinic here at Crittenton Hospital Medical Center to further strengthen care for these patients in our community.

What does Crittenton Hospital Medical Center do currently for its CHF patients?

Crystal: Currently, Crittenton Hospital Medical Center has a strong inpatient program for Heart Failure patients, providing them with the education and tools they need to manage HF. We assure the patient receives in depth HF education during their hospital stay. We target our acute HF patients and as well as those who have a history of HF or chronic HF. Patients are seen by a nutritionist for additional diet teaching during their stay. Case Management, Home Care, and Social Work combine together as a team to assure patient needs will be met upon discharge. We have a follow-up program that provides follow up phone calls after the patient is discharged. During these calls, we re-educate the patient, review the discharge instructions, and ensure the patient is taking their medications, following a low-sodium diet, measuring their weight daily, and following up with their physician as scheduled. We do a lot of education using teach-back in which we focus on the patient understanding their “signs and symptoms” and their action plan.  We also have a great deal of community involvement such as HF luncheons, guest talks at Rochester’s OPC, as well as partnering with PCP’s to provide additional HF education. Also, throughout Ascension, we have monthly meetings, similar to our MVC meetings. These meetings are nationwide, linking clinicians, pharmacists, and other health care providers to focus on a continuum of a strong heart failure programs throughout all of our ministries.

How do you identify a patient with CHF at Crittenton Hospital Medical Center?

Crystal: As patients are admitted with the diagnosis of Heart Failure, a heart failure nurse practitioner consult is automatically generated. We also review a daily diuretic list from our pharmacy. This identifies additional patients with HF that need to be seen. Additionally, every morning, I meet with case management, nursing managers and the quality team. At these meetings, any patient that has a diagnosis of heart failure or has a history of heart failure is named and reviewed. Then, with the help of case management, we implement a planning process for discharge which includes education about medications, follow-up care. It is sometimes difficult to educate recently admitted patients, as they are often short of breath and have short attention spans. We try to focus on providing HF education just prior to discharge, as this is an optimal time for the patient to learn. I feel this is where the Transitional Clinic will greatly benefit patients.  It can provide additional education, outside of the acute care setting to compliment the inpatient HF program.

What are some initiatives Crittenton Hospital Medical Center is doing right now?

Crystal:  This is an exciting time in treatment options for HF because medicine is developing new advances daily. Currently, Crittenton is using a heart failure monitoring system called Cardiomems. This device is implanted into the pulmonary artery (PA). It transmits the patients PA pressure daily to their cardiologist. This information is reviewed, and if the pressure starts to rise, treatment options such as adjusting medications, referring for an appointment or calling the patient for more information, can easily be done. The PA pressure is more accurate than relying on the patient’s signs and symptoms. I like this because I can show patients actual data about how their daily habits such as medication and diet effect their condition. Typically, if they are not watching their sodium intake or they forget to take their medications, we will see a change in PA pressure immediately. This helps us intervene early to prevent HF from worsening, which can also prevent a hospital admission.  It is also very useful in patients who have other combined conditions such as COPD and renal inefficiencies. There are certain criteria for the patient to be eligible for Cardiomems. Indications include NYHA Class 3 and a hospitalization for HF within the previous year.

Another initiative in place at Crittenton is the use of Entresto, a newer heart failure medication. It is a combination drug (sacubitril/valsartan) that is used in place of an ACE or an ARB, for patients with a reduced ejection fraction. It has been found to reduce the risk of death and hospitalizations, along with providing a better quality of life with less HF symptoms and HF better management.

What is Crittenton’s relationship with skilled nursing facilities (SNF) to help prevent readmissions in CHF patients?

Crystal: I am currently working with Case management and the quality department to identify areas that need to be targeted for readmissions. A number of our readmissions are coming from ECFs/SNFs. I am trying to build relationships with these facilities and currently in the process of setting up educational programs with the staff at these facilities regarding the importance of following a low sodium diet, daily weight monitoring, and fluid restrictions for the patients who reside there. We have also just completed an educational program about HF with the staff at one of our home care companies.

Do you think Crittenton Hospital Medical Center will open an outpatient clinic for your CHF patients?

Crystal: I am very optimistic! Our current program is working quite well, as we have a low rate of readmissions, but a heart failure clinic will help to reduce this rate even further. It will also be useful to provide additional education on an outpatient basis, along with assessing patients to ensure that their HF symptoms are controlled.

On a positive note, Ascension Health does see the value in outpatient clinics and they are in the process of standardizing care across their ministries. Quite a few Ascension ministries have outpatient HF clinics already, so it’s definitely in our future here at Crittenton.

A special thank you to Jennifer Dankers and staff at Mid-Michigan HF clinic, and also to MVC, for providing a way of networking clinicians and health care staff to further optimize care for Heart Failure Patients.

 

 

If you would like to speak further with Crystal or Mid-Michigan regarding heart failure clinics or their experience with MVC workgroups, please contact the Coordinating Center.

 

Questions or comments? We’d love to hear from you. You can comment in this article or fill out the contact form at the bottom of the page.

Older posts