Medicine 2011 Annual Report

Clinical Transformation

Medicine is leading the way to improved patient care through our Inpatient Medicine Service Line (IMSL) initiatives and clinical transformation projects. Projects and accomplishments highlighted in this report demonstrate innovation, creativity and flexibility essential to our mission. Some projects have already produced results, while others are poised to improve value in the near future with identifiable, measurable, outcomes.

1. CRTI (Christiana Rapid Transfer Initiative) is improving the process of care for medically critical patients. During FY2011, the CRTI work group initiated the following programs and began Rapid Cycle testing:

MICU Alert Response Team. After assessment in the ED, a MICU based team provides either rapid transfer to the MICU from the ED or a MICU alert nurse to manage the patient in the ED until a MICU bed is available. Early results show a 45 percent decrease in median length of stay (LOS) for MICU patients in the Emergency Department and a 34 percent reduction in overall length of stay in the MICU, while improving or maintaining clinical outcomes.

Procedure Team. A multidisciplinary, medicine-surgery procedure team piloted performance designated procedures at the bedside. Preliminary results show a reduction in time to procedure facilitating decreased LOS and increased patient safety by standardizing processes and providers and reducing complications and unnecessary procedures.

Enhanced 3D (Medicine Stepdown) Care Capabilities. A pilot project to develop a new model of care delivery on the 3D medical step-down unit includes efforts to enhance the partnership between bedside nurses and attendings as well as with the patients and their families. Improved communication, cohesiveness and a goal-directed plan of care enable timely decision making to improve quality, patient safety and care value. Pilot results show physicians and nurses have embraced the new care standards and have expressed satisfaction with ongoing efforts.

2. Unit Based Clinical Leadership models a partnership between the Nurse Manager and a Unit Based Medical Director to promote consistent, visible physician leadership on each unit and physician-nurse collaboration to advance IMSL goals, identify opportunities for improvement and implement change. Using a standardized, analytical approach to problem solving, individual team projects as well as collaborative initiatives are underway. Teams are collaborating to standardize and improve the patient discharge process and to reduce the incidence of hospital acquired infections.

Meet Medicine's team leaders:
5A: James E. Ruether, M.D. & Suzanne Heath, MS, BSN, RN-BC
5B: James A. Piacentine, D.O. & Bonnie Fantini, MS, BSN, RN-BC
5C: Thomas A. Mathew, M.D. & John McMillen, MS, BSN
5D: Surekha Bhamidipati, M.D. & Barbara Marandola, RN
6E: James E. Reuther, M.D. & Connie Jordan, RN-BC
MICU: Badrish J. Patel, M.D. & Carol Ritter, BSN, RN-CCRN
6B Oncology: David D. Biggs, M.D. & Elizabeth Stone, MS, BSN, RN-OCN
4EW: Timothy J. Hennessy, M.D. & Bonnie Osgood, MSN, RN-BC, NE-BC

3. A recently developed IMSL Data Cube incorporates both clinical and financial data for patients discharged from Medicine units. This will allow us to provide feedback to clinicians with the goal of reducing variability in care through emphasis on the use of evidence based protocols where possible.

4. Improving the Discharge Process is part of a comprehensive strategy to improve transitions of care from inpatient to outpatient settings and to decrease readmissions to medicine units. Accomplishments include development of an electronic tool to identify upon admission patients at high risk for readmission and standardizing discharge process interventions.

5. Transformational, condition-specific programs for Medicine patients:

Project Engage, peer counseling for substance abuse patients, resulted in a 41.7 percent referral rate to community based inpatient/outpatient treatment programs and decreased inpatient hospitalizations by 33 percent and ER visits by 38 percent.

MICU Sedation Protocol for ventilated patients, reduced, in six months, the average MICU LOS from 3.93 to 3.71 days and the average hospital LOS by 4.5 days.

Rapid Identification of Risks for Alcohol Withdrawal and DT’s, by working to institute hospital wide screening for alcohol withdrawal risk and a protocol driven assessment for alcohol withdrawal and delirium tremens, improved prevention and decreased transfers to the MICU. Floor to ICU transfers dropped by 2 percent for patients diagnosed with alcohol withdrawal and from a baseline of 21.4 percent in 2009 to 10 percent in 2011 for patients diagnosed with DTs, an important overall patient safety improvement.

Vaccination program on Medicine 5C, a targeted effort of the Patient Care Facilitators on the unit, increased the pneumococcal and influenza vaccination rates to 98 percent.

Anemia Management protocol, developed as a performance improvement initiative in dialysis units, increased appropriate use of an expensive medication (Epogen).

Diabetes Report Card improved patient-physician dialogue and adherence to recommended guidelines for diabetes care in the resident Adult Medicine Office.

6. Multidisciplinary clinical transformation projects designed to reduce harm and improve care value in which Medicine plays a key role:

CUSP - Comprehensive Unit-Based Safety Program focused on health care associated infections (CLABSI, VAP, CAUTI).

Hospital Acquired Venous Thromboembolism prevention protocol.