MVC Sepsis Workgroup Review

The Michigan Value Collaborative (MVC) holds bi-monthly virtual workgroups on six different clinical areas of focus. The goals of these workgroups are to help bring collaborative members together to discuss current quality improvement initiatives and/or challenging areas of practice. These six different clinical areas include chronic disease management (CDM), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), diabetes, joint, and sepsis. At the most recent MVC sepsis workgroup, the discussion centered around post-sepsis syndrome and how organizations are identifying and caring for patients that are diagnosed with this condition.

The group learnt that for several organizations, post-sepsis syndrome is not well understood, identified, or diagnosed which prompted some interesting discussion around this topic and the topic of sepsis itself. A number of studies have suggested that due to an aging population with an increased number of comorbidities, frequent use of immunosuppression therapy, expanded use of invasive procedures and medical devices, and multi-drug resistance, the incidence of sepsis has increased. However, the same studies share that in-hospital mortality has decreased. Credit for this decrease in mortality is associated with improved detection, establishing treatment earlier, improvements in critical care, and the implementation of evidence-based guidelines established by the Surviving Sepsis Campaign.

While survivors of sepsis have increased, identification of post-sepsis syndrome is garnering attention as many patients can suffer from a number of serious and long-lasting complications including delusions, debilitating muscle and joint pains, extreme exhaustion, poor concentration, reduced cognitive functioning, as well as mental health issues and concerns. Certain patients, such as the elderly, those with a preexisting condition, or those diagnosed with severe sepsis are more likely to develop post-sepsis syndrome.

Currently, the most effective method of treatment for post sepsis syndrome is to prevent an initial incidence of sepsis. Primary prevention includes hand washing, vaccination uptake, and managing any chronic conditions. Pharmacological strategies for the treatment of sepsis and the prevention of post-sepsis syndrome include:

• Antibiotic stewardship, to improve the use of antibiotics and using prolactin levels to decide when to stop antibiotic use.
• The use of H2-receptor agonists over proton pump inhibitors to prevent stress ulcers.
• Low dosage and short-term use of medications.
• Early mobility to prevent functional decline.

Non-pharmacological strategies for the prevention and treatment of sepsis to avert post-sepsis syndrome include:
• Sepsis treatment and the identification of post-sepsis syndrome education for frontline workers.
• Post-sepsis education for family and caregivers of sepsis survivors along with available resources.
• Vision/Hearing Aids to reduce the risk of delirium, as well as adaptive equipment.
• Referral for rehabilitation post sepsis survival.

MVC collaborative members from multiple facilities including Michigan Medicine, Henry Ford Wyandotte, Sparrow, and Spectrum Health discussed different ways in which they are working to identify sepsis as early as possible within their facilities. Many organizations have instituted a sepsis program, and some are looking to onboard a sepsis navigator. Dr. Jessie King, Program Director, shared information about the Post-Intensive Care Unit (ICU) research and treatment clinic (PULSE) now screening discharged ICU patients for post-sepsis syndrome, and the Michigan Medicine return on investment analysis which helped initiate a sepsis program. You can find the recording of the workgroup here.

The MVC Coordinating Center is interested in hearing how you are treating sepsis and the prevention and treatment of post-sepsis syndrome. We would like more hospitals to share the work they are doing around these important topics so if you would like to present at or attend an upcoming MVC workgroup, please email MVC at the michiganvaluecollaborative@gmail.com


Continuous Glucose Monitoring Has Potential in Inpatient Setting

One of the most prevalent comorbidities in the United States is diabetes; as many as 1 in 10 Americans are diagnosed with this condition, and 90-95% having potentially preventable Type 2 diabetes. It is well documented that unstable blood glucose levels can contribute to increases in morbidity, mortality, and healthcare costs.

In the inpatient setting, the current standard of care for monitoring and testing blood glucose levels in diabetic patients is point-of-care (POC) testing, which combines a specific testing schedule and approved devices to measure blood glucose levels. A recent study involving 110 adults with Type 2 diabetes looked at implementing real-time continuous glucose monitoring (RT-CGM) in order to better manage inpatient glycemic levels. The patients were on a non-intensive care unit (ICU) floor, and received either the standard of care or the RT-CGM with Dexcom G6 monitoring—where a tiny sensor wire is inserted just beneath a person’s skin using an automatic applicator. Data was transmitted from the bedside wirelessly, and monitored by hospital telemetry. The bedside nurses were notified of any abnormal glucose levels or trends and the patients were treated accordingly. The results indicated that patients in the RT-CGM group demonstrated lower mean glucose levels and less time in hyperglycemia.

Another study that evaluated the efficacy of RT-CGM discussed the effect that uncontrolled glycemic levels can have on clinical outcomes and healthcare costs. Currently, hospitals use POC glucose testing in order to monitor and treat hypoglycemia, and it is recommended that POC testing occur four to six times per day. However, this leaves many hours throughout the day where hypoglycemia can go undetected. RT-CGM using a glucose telemetry system (GTS) offers an alternative method to monitor these glucose values. A total of 82 patients participated in this study. Patients in the RT-CGM group experienced 60.4% fewer hypoglycemic events compared to the POC group. Figure 1 below illustrates the number of hypoglycemic events per patient for both the CGM/GTS and the POC.

Figure 1.

RT-CGM has yet to be implemented in inpatient settings for several reasons. The primary reason is the lack of U.S. Food and Drug Administration (FDA) approval. Additionally, institutional challenges may act as a significant barrier. For instance, staff need to be prepared for increased workload and educated on appropriate protocols and procedures. Technological support is required to ensure hardware compatibility and maintain a robust internet network with minimal interference in transmission of results and alerts. Additional factors within the hospital setting include certain medications, procedures, nutrition, acute illness, and any other condition that may affect glucose control. All of these challenges have the potential to impact CGM and its associated workload because of the effect they may have on the patients’ blood glucose levels. Although challenges remain to the implementation of RT-CGM in the inpatient setting, the benefits may outweigh the risks; thus, it is worth considering, especially given the successes in the outpatient arena.

The Michigan Value Collaborative hosts diabetes workgroups where topics such as continuous glucose monitoring are discussed by Collaborative members. If you are interested in attending the next MVC diabetes workgroup, please connect with the MVC Coordinating Center at: michiganvaluecollaborative@gmail.com.


Supporting the Mental Health of Healthcare Workers During COVID-19

Over the last year, the way in which care is delivered has changed and in turn, healthcare workers are faced with potentially high levels of anxiety and depression. These front-line workers, already at risk for high-levels of stress and burnout, are now experiencing even higher levels of stress. Mental Health America recently shared  an article  that discussed a survey distributed to healthcare workers from June-September of 2020. This survey was designed to gain an understanding of the experiences of healthcare workers working during the COVID-19 pandemic and to create better resources moving forward.

Around 93% of the 1,119 healthcare workers surveyed reported feeling stress, with approximately 86% of respondents noting experience of anxiety. The majority of respondents (76%) were worried about exposing loved ones such as children, spouses or even an older family member.  Additionally, emotional and physical exhaustion were common changes reported over the previous three months, with healthcare workers often faced with a lack of emotional support. Despite these results, over half of survey respondents felt they were receiving emotional support from their family and over a third felt supported by their work colleagues.

While emotional and physical exhaustion is taking its toll, anxiety and depression in healthcare workers has also been caused by the uncertainty of how the pandemic will play out. There is a lot of unpredictability regarding the virus as new strains occur, surges continue, and people hesitate or decline vaccination. To help support healthcare workers, the National Academies of Sciences, Engineering and Medicine are responding by putting together a coronavirus resources section that has resources to support healthcare workers. These resources include information and webinars geared towards clinician well-being such as “Supporting Clinician Well-being During COVID-19” and “Taking Action Against Clinician Burnout”.

The Michigan Value Collaborative is committed to supporting collaborative members during the COVID-19 pandemic, and we know hospitals and physician organizations are working diligently to help support their individual staff during this time. To share the ways you are supporting your healthcare workers at your organization, please email us at michiganvaluecollaborative@gmail.com.


Monitoring Chronic Disease Utilizing Social Media and Sensors

According to the Centers for Disease Control and Prevention, “treating individuals with chronic diseases accounts for 86% of health care costs.” While the number of those living with chronic conditions and the associated costs may be increasing, the Michigan Value Collaborative (MVC) is committed to providing you with current data around providing the right care, at the right time, at the right cost. Technological advances in healthcare are changing how and where chronic disease care is being delivered, how these patients interact with providers, and how organizations exchange information.

Both diabetes and abnormal blood pressure (BP) are extremely common in chronic disease patients and cause various complications, including an increased risk of cardiovascular events. When thinking about the way in which these chronic diseases should be managed moving forward after the COVID-19 pandemic, technological advances offer promising solutions.  Most devices in the healthcare industry have been digitalized. This advancement allows for routine monitoring using various devices that some patients may already own, such as a smart phone or a smart watch. These devices contain sensors that can be used to obtain information that can then be transmitted straight into the electronic health record (EHR). Other devices that can be used to collect patient information include a glucometer sensor, pulse oximeters, temperature sensors, scales, and many more. However, this method is not without its limitations.

The amount of data that is generated from these devices is vast and not all systems are capable of storing and processing it efficiently for precise and real time monitoring. In order to negate this issue, a framework was recently published that can be seen in Figure 1 below. This framework utilizes the cloud environment along with a large analytics engine layer to help store and process the data. The recently published study identifies the importance of utilizing wearable sensors and social networking platforms in collecting patient data, but identifies the challenges that come with this such as issues with data storage and running correct analyses.

Figure 1. Layers in the proposed healthcare monitoring framework

Chronic disease management patients may use social media platforms in order to seek support or learn new ways in which they may be able to reverse certain symptoms. Other ways in which monitoring is done through social networks include patient and provider conversations through application programming interfaces (APIs). Through these APIs, providers can pick up on tone or social connection status. Through this proposed framework of social media and sensor monitoring, providers can closely monitor chronic disease management patients.

MVC hosts chronic disease management workgroups where collaborative members discuss their current initiatives and connect on ways in which they can work together to better the health of Michigan. If you have any questions about upcoming chronic disease management workgroups, please feel free to contact the coordinating center at michiganvaluecollaborative@gmail.com


Reducing Admissions and Readmissions in the COPD Patient Population

At a recent MVC chronic obstructive pulmonary disease (COPD) workgroup, representatives from McLaren Physician Partners presented on their recent quality improvement initiative involving their COPD patient population. McLaren Physician Partners worked to identify areas for improvement within this specific patient population and found some common patient struggles consisted of higher utilization of the emergency department and in-patient settings, as well as higher readmission rates, specifically among their Medicare patients (38%). Five nurse managers were tasked with doing case reviews in order to identify possible areas for improvement. Five to ten patients that had three or more encounters in the last six months were taken from each nurse managers case load. Around 83% of those patients had other significant comorbidities (e.g. Diabetes Mellitus, Congestive Heart Failure, Hypertension.) Additionally, the reason for readmission was most often related to either respiratory insufficiency or a cancer treatment side effect.

Care managers then engaged the patients and went over a questionnaire with them. Approximately 68% of these patients had a misunderstanding of their medication, 26% had environmental barriers, 14% were not compliant with medication, and less than 15% reported an inability to afford medication/devices. Readmissions related to disease progression and inappropriate medication use were the major contributing factor to higher utilization of the in-patient setting and emergency department. Additionally, all admissions and readmissions were related to some form of respiratory insufficiency or a cancer treatment side effect.

Due to the time of implementation, COVID-19 impacted the type of intervention that could be put into place. McLaren Physician Partners opted to adopt a telephonic intervention in order to address education needs and remove barriers. Specific needs related to managing medications and compliance, triggers that led to an exacerbation, and developing a plan of action at the onset of first symptom were addressed. Additionally, the intervention sought to minimize and remove barriers where possible (e.g. cost of medications, transportation issues for visits). Lastly, a consideration was made if a patient was a candidate for palliative care.

Nurse navigators looked into possible ways to engage patients differently in order to hopefully prevent an exacerbation that caused an admission or a readmission. They were aware that what they were doing wasn't working, and needed some sort of upgrade. A toolkit was developed that was sent to the patient prior to a one to two-hour phone call scheduled in order to  help the patient understand this toolkit. The kit requires active participation and helps the patient develop specific goals and actions to take when they see signs of a potential exacerbation.

After implementation of this pilot program, all navigators came together to discuss their findings. Many things were noted, including the fact that patients did not know the difference between their inhalers (long-acting vs. rescue). Additionally, patients often didn't know that by identifying certain triggers, some symptoms may have been preventable. Of the patients who received and engaged in this telephonic intervention, the readmission rate for those who had been recently discharged decreased by more than 20%. Overall, McLaren Physician Partners saw a decrease in their hospitalizations due to the implementation of this program.


Michigan Value Collaborative: Sepsis Reports

In early 2020, the Michigan Value Collaborative (MVC) Coordinating Center created a new sepsis service line with the help of the Michigan Michigan Hospital Medicine Safety Consortium (HMS). Initially the service line began with 215,447 episodes and has since grown to 229,673 episodes. In conjunction with the creation of the sepsis service line, reports customized to each collaborative member hospital were developed. The most recent iteration of these, shared in two volumes, were disseminated to members in February 2021.

Each volume of the sepsis reports serves their own unique purpose. The first volume provides a detailed review into specific components of a sepsis episode with the ability for each member to compare individualized information to regional and statewide averages. These metrics help members garner a better understanding of the sepsis patient population from admission to 90-days post discharge with data on length of stay, causes for readmission, and post-acute care utilization. Figure 1 shares information on length of stay, and this example shows Hospital A’s (a fictional institution) average length of stay to be higher than both the regional and collaborative-wide average. Additionally, metrics such as total episode payment and readmission rates are displayed as trends over time as shown in Figure 2 and Figure 3.

Figure One.

Figure Two.

Figure 3 shows that the individual hospital trend for the 90-day readmission rate is higher than both the regional and MVC averages which mirror each other closely. Initially, the overall hospital trend decreases towards the regional average, but climbs again in 2019. MVC members may wish to use this information to investigate the root causes leading to increased readmissions.

Figure Three.

The second volume of MVC’s sepsis reports provides benchmarking for members to identify how they compare to all other MVC hospitals. Figure 4 shows information on a hospital’s total episode payment compared to the regional and MVC averages. In addition, it shows the range of the average total episode payments across the collaborative. By using previously sent reports, hospitals can compare how the metrics have changed - such as an increase or decrease in collaborative-wide or individualized total episode payments. As these reports are disseminated every six months, when comparing, it is important to take notice of the reporting period covered in each report which can be located in the associated cover letter and footnotes. Members can also access their own sepsis related data on the MVC registry.

Figure Four.

If you have any suggestions on how these reports can be improved or the data made more actionable, we would love to hear from you. We are also seeking feedback on how collaborative members are using this information in their quality improvement projects. Please reach out to the Coordinating Center at michiganvaluecollaborative@gmail.com to share your story. If you have any questions or are interested in custom data for your facility, contact us at the aforementioned email address.

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Henry Ford Health System – Cardiac Rehab

Henry Ford Health System – Cardiac Rehab

At the most recent congestive heart failure MVC workgroup, Dr. Steven Keteyian, Section Head of the Cardiac Rehabilitation/Preventive Cardiology Unit at Henry Ford Medical Group, presented on exercise-based cardiac rehabilitation in patients with heart failure. Dr. Keteyian started out by discussing the importance of cardiac rehabilitation and adhering to a program in order to improve exercise tolerance and disease-specific outcomes. Exercise intolerance is measured and the information gathered can be used to stratify a patient’s future risk. If the measurement improves over time, Dr. Keteyian discussed the potential for a decrease in risk of death and re-hospitalization. This shows a tie to directly improving outcomes and symptoms in cardiac rehabilitation. Also, in the words of Dr. Keteyian, “functionally, the more they don’t do, the less they can do.”

Cardiac rehab is a Class I recommendation from The American College of Cardiology for all of the traditional cardiac disorders. Henry Ford has a 36-visit program that is anchored on exercise training. Between four and fifteen people are in each class and each person receives an individual treatment plan with a focus on bio-behavioral components. Six core components make up the program which include outcome assessments, supervised exercise, dietary/weight management, tobacco abuse, psychological support, and medication adherence. All participants participate in 30-minute behavioral education sessions which cover topics such as nutrition, dining out, proper exercise, medication compliance, and other relevant disease-management self-care activities. These same topics are also available on YouTube and can be found here, all of which are available for use in your cardiac rehab program. Currently, Henry Ford is working on bringing their time to enrollment after hospital discharge to less than 21 days and increasing adherence to the 36-visit program. The goal is to achieve a participation rate of 70% or more in cardiac rehab for Henry Ford’s patient population.

After discussing the program specifics at Henry Ford, Dr. Keteyian discussed the barriers that one may face in relation to participation in cardiac rehab. These barriers include:

  • Demographic
  • Difficulty contacting patient after hospitalization
  • Return to work demands
  • Transportation
  • Co-payment obligations
  • Dependent care responsibilities

Henry Ford is working at a system level in order to increase the percent of patients who gain access to cardiac rehab. This includes increasing the use of electronic medical record (EMR) driven automatic referrals, with an option for users to opt-out if necessary. Additionally, a member of the cardiac rehab team goes to the inpatient setting and talks to patients to establish a touchpoint before they leave the hospital. This five-minute conversation is all some patients need in order to see the importance and benefits of rehab. Lastly, Henry Ford is working to shorten the discharge to start time. Each day after discharge, the chance of getting patients started in rehab decreases by 1% for each day that passes. Henry Ford is working diligently in order to help decrease this risk.

In 2016, Henry Ford launched a hybrid home-based cardiac rehabilitation service. This includes some visits at the clinic and other virtual sessions. Previously being tied to a single visit at a time on their current streaming platform, Henry Ford will roll out a WebEx model in February 2021 that will allow up to six cardiac rehab appointments to occur at one time. This will provide more of a group setting. Currently, a randomized controlled trial is being done on center based cardiac rehab versus hybrid cardiac rehab. Improvements in fitness and the number of sessions attended are being assessed.

If you are interested in watching the entire workgroup, please click here.  If interested in any information about this workgroup, or other MVC workgroups please email michiganvaluecollaborative@gmail.com


Healthcare Burnout and Possible Solutions

More recently than ever, healthcare workers may be faced with the potential for burnout and a decreased quality of life. The Agency for Healthcare Research and Quality defines burnout as “a long-term stress reaction marked by emotional exhaustion, depersonalization, and a lack of sense of personal accomplishment”. From the busy work days, to the intense pace and time sensitive pressures, the healthcare environment places individuals at a high risk. All of this has the potential to impact the delivery of high-quality, compassionate care within an institution. The risk for staff to develop burnout may increase as changes to the work environment result in a poor fit for healthcare workers. :

  • Technological advances
  • Compliance with regulatory measures
  • Difficult electronic medical records (EMRs)
  • Issues with insurance coverage and reimbursement
  • Increased volume and patient acuity

In order to help decrease the risk of burnout, a quality improvement project was put into place in a 37-bed ICU between February and June 2019. Registered nurses, medical assistants, and physician assistants were the targeted population. The Mini-Z Burnout survey was given to those participating in the study to assess for factors contributing to burnout, as well as job related stress and job satisfaction. After completing the survey, interventions were put into place in order to address such risks. These interventions included:

  • Identifying scheduling opportunities (e.g. stacking days when possible)
  • Determining special needs for patients while in the ICU setting
  • Identifying staff backup based on acuity of assignments
  • Staff events to foster a positive team culture and increase collaboration

After three months of applying the above interventions, the Mini-Z Burnout survey was administered again. The findings revealed a higher percentage of staff reporting no burnout after the intervention (57.7% vs. 75%). Additionally, “satisfaction with current job” went from 70.6% pre-intervention to 82.8% post intervention. Finally, open ended questions revealed that stressors that still remained focused heavily on staffing and patient ratios. The sustainability and long-term impact of these interventions on preventing burnout continue to be monitored.

Overall, implementing quality improvement initiatives in order to promote staff wellbeing has the potential to impact the delivery of high quality and compassionate care. The Michigan Value Collaborative (MVC) is committed to helping our collaborative members implement quality improvement projects in order to increase patient and provider satisfaction. If you have any questions or wish to learn more, please reach out to the collaborative at michiganvaluecollaborative@gmail.com