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The largest drivers of healthcare costs are physicians, but these professionals are among the least comfortable discussing healthcare value. According to Leora Horwitz, MD, MHS, director of the Center for Healthcare Innovation and Delivery Science at NYU Langone Medical Center in New York City, physicians prefer to focus on individual patient interactions rather than questions of cost and population management.
Choosing Wisely, a campaign launched in April 2012 by the American Board of Internal Medicine Foundation to encourage conversations between providers and patients, is designed to help patients choose tests, procedures, and care that are necessary, evidence-based, and not harmful or redundant, while allowing physicians to approach the question of value in terms of how to best care for each patient.1 By focusing on very common practices and relying on well-established evidence as the basis of each specialty’s recommendations, Choosing Wisely has garnered widespread support.
Below are five examples of Choosing Wisely programs, initiated by hospitalists around the country. Each is doable, scalable, and reproducible in a variety of inpatient settings.
Mount Sinai Hospital, New York City
“Lose the Tube” was initiated at New York’s Mount Sinai Medical Center to reduce the incidences of catheter-associated urinary tract infection, or CAUTI. The five-month intervention period began April 1, 2014, and lasted through August 31, 2014.
Using electronic health records (EHRs), urinary catheter patients were identified based on nursing documentation and urinary catheter (UC) orders. Once patients were “flagged,” hospitalists would approach each of their providers during interdisciplinary rounds and ask if the patient needed the Foley. Additionally, unit-based metrics of UC and CAUTI were disseminated at weekly meetings to unit medical directors to promote engagement, discussion, and transparency; educational reminders were given monthly in orientations to subinterns, residents, and attending physicians.
“Lose the Tube” proved very successful, reducing rates to 0.2 CAUTI/month from 2.67 CAUTI/month during the intervention period. Total catheter days decreased to 4,318 from 5,610, to 877.0 catheter days/month from 948.5 catheter days/month. CAUTI rate was decreased from to 0.23 CAUTI/1000 catheter days from 2.85 CAUTI/1000 catheter days.
The simplicity of the approach of “Lose the Tube” makes it easily reproducible in other institutions. The intervention uses the existing EHR to readily identify UC in patients; the interaction between the hospitalist and other clinicians is succinct and easily integrated into existing communications. As Hyung Cho, MD, director of quality and patient safety at Mount Sinai, says, “Awareness for Choosing Wisely is definitely there. We just need to figure out ways to integrate these recommendations into our systems.”2
Cincinnati Children’s Hospital Medical Center
The Cincinnati Children’s Hospital initiated a campaign to reduce continuous pulse oximetry use for patients with asthma and bronchiolitis in line with Choosing Wisely recommendations and the hospital’s own guidelines. The objective was to reduce continuous pulse oximetry time after weaning to room air or weaning to every two-hour albuterol treatments from 10.7 hours (baseline) by at least 50% to 5.4 hours.
The initial step was to define goals for discontinuation of pulse oximetry of greater than 90% oxygen saturation on room air or weaning to albuterol treatments every two hours based on existing weaning protocol. These goals were communicated to the unit staff at monthly resident team and nursing meetings. At this point, a decrease was seen in the median time per week to 4.1 hours.
The next intervention changed default settings in the bronchiolitis electronic order set, which allowed the nurse to transition to intermittent pulse oximetry when goals were met and no new clinical concerns arose. A three-item checklist was introduced to identify patients whose goals were met for timely discontinuation during the previous shift, which resulted in a further reduction of more than 70% from baseline, to a median time per week of 3.1 hours.