Algorithms combine evidence and experience for better care
Patients in adult and pediatric settings nationwide get the right healthcare only half of the time.
This sobering reality is a key driver for standardizing care at Cincinnati Children’s – one of the goals of the 2020 Strategic Plan’s Care pillar.
“Our goal is to always get the best outcome, but we shouldn’t waste time or efforts on providing care that isn’t right for the patient,” says Evie Alessandrini, MD, MSCE, associate chair of outcomes and assistant vice president of Improvement Integration – part of the James M. Anderson Center for Health Systems Excellence at Cincinnati Children’s. “Our aim is to have a system in place that will ensure that patients and families get the right standard of care in an affordable way,” she says.
Achieving this goal required collaboration with frontline clinical and support staff, including Finance and Information Services, as well as the Anderson Center’s Evidence team, analysts and quality improvement consultants. They targeted areas that would have the highest potential impact and developed 37 care algorithms for a variety of conditions, such as asthma, osteomyelitis, sickle cell anemia and more.
The algorithms were based on evidence regarding the best treatment or diagnostic work-up. When evidence was lacking, the algorithm was built by consensus across all clinicians, then tested and tweaked as needed. “Our clinicians are real experts,” says Alessandrini. “We wanted to make it easy for them to make the best decisions based on evidence, experience, consensus and knowing our systems.”
By the end of last fiscal year, 22 of the 37 care algorithms had been reliably implemented (defined as equal to or greater than 80 percent of the time).
“Sometimes standardization gets pushback as being cookbook medicine,” says Alessandrini. “That’s why the goal was reliable implementation 80 percent of the time and not 100 percent. There’s always going to be a kid who falls outside of the standard practice. So, we’ve left 20 percent of the time to address that. One of the benefits of standardization is creating a stable platform for care that frees up the provider’s time to customize care for those who require it.”
Boosting affordability
At a time when reimbursement for healthcare is in flux and families with high deductible plans are comparing prices, standardization is more important than ever.
“Increasingly, standardized care is becoming entrenched in pediatric hospitals,” says Alessandrini. “In the current environment, we can’t keep raising costs. This is part of the work we have to do.”
Standardization also enhances the patient and employee experience, which is why the next challenge is to standardize care across teams. “Children with conditions, like sepsis, can present in multiple places, like the ED, ICU, Gastroenterology or the Cancer and Blood Diseases Institute,” Alessandrini explains. “We want to recognize and effectively treat these conditions the right way, the same way, regardless of where patients are. When we are inconsistent, it’s confusing for families. It’s also confusing for clinical staff who may float from one unit to the next.”
An added goal is to make sure community pediatricians have access to the care algorithms for use in their own practices and to set expectations about what will happen to their patients while they are here. Alessandrini hopes to collaborate with them on creating new algorithms.
“Good use of care algorithms is meant to help us do our work more effectively and efficiently,” says Alessandrini. “They don’t replace good clinical judgment. They don’t override the needs of patients and families. They are simply a guide to help us make the best decisions we can.”
Algorithms in action
Heart Institute lowers costs for patients with syncope
Prior to March 2016, patients with syncope were often referred to the Heart Institute where they would undergo a series of tests that could include an echocardiogram, a stress test, or wearing an event monitor or a Holter monitor.
Under the direction of Jeffrey Anderson, MD, MPH, Heart Institute chief quality officer, and team lead, Christopher Statile, MD, director, Echocardiography Quality Assurance Program, a multidisciplinary group developed a care algorithm to reduce unnecessary testing, which they sent to 42 in-house cardiologists for feedback.
“No one intends to order tests that aren’t needed,” says Statile, “but doctors often do because they want to make sure they’re not missing something – and frankly, sometimes the family expects it. But this algorithm, which is based on evidence, gives doctors something to stand on when deciding how to treat the patient. There are boxes to check regarding family history, patient history, the EKG and the exam. Any of these could raise a red flag, which would send the patient down different paths of the algorithm. Standardizing how it’s done reduces variability and reduces excess patient charges.”
Before the algorithm was implemented, the mean charge for a patient encounter, including testing, was $1,754. Afterward, it decreased to $1,274 – a 27-percent reduction in testing and a savings of $480 per patient.
The next big step is to move the algorithm outside of cardiology to emergency doctors and primary care providers. “Less than 10 percent of patients with dizziness or syncope need to be seen by a cardiologist,” says Statile. “Most can be managed by the primary care provider.”
Cross-divisional collaboration to streamline asthma care
When staff from the ED, Hospital Medicine, General Pediatrics and Pulmonary Medicine put their heads together to lower the cost of a 30-day episode of care for a patient with asthma, they looked at admission rates – the largest cost to insurers. They outlined a multi-step improvement initiative to achieve their goal and reasoned that the best way to start was to help patients take their medications as prescribed when leaving the Emergency Department (ED) or Urgent Care (UC).
“Evidence showed that many patients were not completing the course of prednisone we gave them, which required five doses and a trip to the pharmacy,” says Eileen Murtagh, MD, who led the effort. “So we created an algorithm that calls for prescribing dexamethasone, an equivalent corticosteroid requiring only two doses. We administered the first dose in the ED and gave the family the second dose to take home with them at the time of discharge– no prescription needed and no trip to the pharmacy.”
The team set up their systems so the algorithm was easy to follow across all seven ED and UC sites. They changed the order sets and the way the medication was stocked and packaged so staff could readily hand it to families. The algorithm was implemented in January 2016. The changeover was immediate.
“Before the implementation, only 12 percent of patients received dexamethasone,” says Murtagh. “Now, we have stabilized at 95 percent across all seven sites of care.”
The team continues their work to decrease admissions for patients with asthma but is now focusing on starting care for patients in the ED or UC as soon as possible. The goal of this work is to administer the dexamethasone to patients within the first hour of arrival and standardize the care delivered to all patients with asthma based on the severity of their acute presentation.
They have also re-examined how they administer albuterol. Studies show that a metered dose inhaler (MDI), which can be taken home from the ED or UC at the time of discharge, is as effective as a nebulizer. Previously, about half of patients with mild asthma symptoms received a nebulizer treatment. Now 80 percent of them get an MDI alone. Says Murtagh, “This eliminates one step in the process and only requires one round of patient/family education.”
The team is collaborating with other divisions who care for asthma patients, standardizing approaches and monitoring outpatient clinics to make sure the changes they’ve made aren’t having unintended consequences farther down the line.
“Because asthma patients are a large, diverse population, our algorithm has been segmented into many pieces, and it’s gaining momentum,” says Murtagh. “It’s not a quick change, but it’s an important change. I’m excited to continue this work.”
