“Accordingly, reducing these inefficiencies and improving coordination across the care continuum are top priorities within healthcare delivery
organizations. Maximize effective, efficient care and eliminate the waste.” —Andrew Masica, MD, MSCI
In March 2013, Rush implemented a two-pronged approach to changing its transfusion culture. The indication of “Other” in the Epic EHR system was removed, and all indications on the checklist were made more specific. Acceptable choices included “hemoglobin <7” or “hemoglobin <8 with symptoms” or “active ischemic or cardiac event.” This change in the order sets also allowed Rush to more precisely track why patients were receiving blood—useful information to build on going forward.
Concurrently, the hospital initiated an intense educational campaign as part of its safety conferences, regularly scheduled meetings for house staff and hospitalists, in which the staff were taught the appropriate indications for blood transfusion and what data exist in the literature to support limiting transfusions, as well as how to transfuse correctly.
Dr. Gupta stresses that educating the physicians made a major impact on the program’s success. “Adding the educational component really helped make the change in how physicians practice,” she says. “When they understand why they are being asked to do things differently, they are more likely to change their behavior.”
Rush successfully lowered the total number of transfusions from 1,491 in the 14 months prior to the intervention to 953 transfusions between May 2013 and June 2014, a decrease of 36%. Transfusions in patients with hemoglobin greater than 8 were tracked during the same time periods, and that amount dropped to 121 post-intervention from 320 pre-intervention, a reduction of over 60%.
Dr. Gupta says that the latter reduction was particularly satisfying, because “not only were we able to reduce the total amount of blood transfused but also to keep the blood that was transfused within the guidelines.”
In Sum
Choosing Wisely addresses the complex relationship between cost and quality in healthcare.
“Fragmented, wasteful systems, particularly where there is duplication of services, produce poor outcomes at higher costs,” says Andrew Masica, MD, MSCI, vice president and chief clinical effectiveness officer at Baylor Scott and White Healthcare of Dallas. “Accordingly, reducing these inefficiencies and improving coordination across the care continuum are top priorities within healthcare delivery organizations. Maximize effective, efficient care and eliminate the waste.”
Maybelle Cowan-Lincoln is a freelance writer in New Jersey.
Residents Choosing Wisely
Dr. Popa
Drs. Popa and Seymann were inspired by their Choosing Wisely project success to actively involve the residents at UCSD in improving healthcare value at their hospital.
Every two weeks, Dr. Popa and Dr. Seymann introduce a new group of students to one or more wasteful healthcare practices, often drawing them from Choosing Wisely recommendations.
“These discussions are eye-opening moments for the students, when they suddenly see there are high-cost practices which really don’t benefit patients,” Dr. Seymann says.
The instructors point the residents toward data from their hospital or literature on the topic and instruct them to educate themselves with this material and return with proposals to decrease the wasteful practices.
“The residents are the front-line workers, doing the day-to-day work on the units,” Dr. Seymann says. “They know what works and what needs fixing.”
Many of their suggestions are creative and practical and have made major contributions to more efficient, less wasteful red blood cell and daily lab protocols, as well as telemetry usage.
References
- American Board of Internal Medicine. About Choosing Wisely. ABIM website. Accessed June 9, 2015.
- Cho H, Khalil S, Wallach F, et al. Lose the tube: preventing catheter-associated urinary tract infections. Meeting abstract. Accessed June 9, 2015.
- Schondelmeyer AC, Simmons JM, Statile AM, et al. Using quality improvement to reduce continuous pulse oximetry use in children with wheezing. Pediatrics. 2015;135(4):e1044-e1051.