Transforming Care One Patient at a Time
Eric Loeliger, MD, vice-president, Medical Affairs
HTPP is one of dozens, if not hundreds, of acronyms that make up health reform’s alphabet soup. But Oregon’s Hospital Transformation Performance Program is important in more ways than one.
Not only does it establish quality metrics that will make our patients safer, it allows high-performing hospitals to earn back reimbursements withheld from the state, which helps us deliver better care at a lower cost.
As with other programs promoting patient safety, HTPP aims to reduce adverse drug events, hospital-acquired infections, and readmissions. It also focuses on improving patient satisfaction and ensuring that patients with behavioral health needs or substance abuse problems are screened and properly cared for.
Although only two Asante hospitals—Asante Three Rivers and Asante Rogue Regional medical centers—are large enough to qualify for the program, Asante Ashland Community Hospital is held to the same high performance standards.
To date, all three Asante hospitals have met or exceeded nearly all of HTPP’s benchmarks, which are directed at:
- Reducing health care-associated infections (catheter-associated urinary tract infections and central line-associated bloodstream infections)
- Increasing medication safety
- Improving patient experience
- Reducing all-cause readmissions
- Behavioral health screening and follow-up
- Sharing ED visit information with primary care providers
As you can see from the chart below, Asante Three Rivers had no incidents of excessive anticoagulation with warfarin or hypoglycemia for patients on insulin. The number of opioid oversedations are well under the state’s benchmark. And as part of this program’s measures, our ED is screening for alcohol and drug abuse. (The acronym SBIRT stands for Screening, Brief Intervention, and Referral for Treatment.)
But as good as our record is we all benefit from making it better. If your work has a direct effect on any of these measures—particularly those involving central line infections, hypoglycemia, or opioid oversedation—you play a critical role in ensuring that our patients get the best care at the best cost.
Two Patients With Hypoglycemia, One Culprit
What’s one of the most common causes of severe hypoglycemia in our hospitals? Consider the cases of two patients admitted to our sister hospital, Asante Rogue Regional, this past April.
Elaine is an 80-year-old female with chronic heart failure, kidney disease, and Type 1 diabetes who was admitted with shortness of breath. Her creatinine level was 2.67—higher than her baseline—and she hadn’t been eating well. Even so, her home dose of Lantus (glargine) insulin was continued on admission. After just that one dose, Elaine’s blood glucose level plummeted to 33 mg/dL.
Then there was Susan, a 71-year-old female with cellulitis, COPD, and Type 2 diabetes. During her long hospital stay she was treated with steroid medications, including high-dose Solu-Medrol, which caused hyperglycemia. To counter that, her Lantus insulin was increased to 45 units twice a day. Yet as the steroid was tapered down, Susan’s Lantus dose remained at 45 units, causing her blood glucose levels to drop to 43 mg/dL.
In both cases, severe hypoglycemia was tied to excessive use of basal insulin. Most patients are going to eat less in the hospital than they do at home. Often a patient’s home regimen is “basal-heavy” and that dose can be too much due to hospitalization and changes in eating.
Since hypoglycemia correlates with high mortality in severely ill patients, it’s vital to remember these tips:
- Up-to-Date recommends reducing insulin doses on admission by 25 to 50 percent in anticipation of reduced nutritional intake.
- Be especially cautious if patients are vomiting or fasting for tests or surgery.
- Elderly patients or those with impaired renal function are at a higher risk for hypoglycemia.
- When insulin dosing is increased to address a temporary illness state (such as for steroid treatment or tube feedings) the insulin dosing needs to be readdressed as that condition resolves.
To prevent serious hypoglycemia in our hospitalized patients who have diabetes or are on insulin, Asante’s new protocol requires treating blood glucose levels of 80 mg/dL or less.
This article was submitted by Tim Johnston, MD, chief of medicine, ARRMC, and Tracy Davis, RN, Diabetes Care Center.
Beware the Hidden Risks of Opioid Oversedation
A number of investigations, small studies, and groups have examined the risk factors for opioid oversedation and discovered several common elements. Indeed, when we investigated oversedation at our own hospitals we found many of the same risk factors cited in the literature.
- People who are older or who have renal decline. While renal impairment increases with age, it can also pose an oversedation risk for younger patients.
- Those whose body mass index is over 30. These patients tend to have diagnosed or undiagnosed sleep apnea. Anyone with a breathing disorder is at higher risk, including smokers.
- Patients using benzodiazepine.
- People with cardiac issues. (This risk is mentioned in the literature, but it’s unclear how much a factor cardiac issues have been in oversedations at Asante.)
- Opioid-naïve and opioid-tolerant patients. Even people who take opioids daily can be at risk if they’re prescribed an opioid they haven’t taken before.
- Anyone who has had surgery within 24 hours.
How to prevent oversedation:
- For older patients, start low and go slow.
- In cases of renal decline, remember that almost all narcotics have some degree of renal elimination. Reduce the dose and increase frequency. Fentanyl and methadone are considered safer, but they do carry many potential interactions.
- Limit benzodiazepine use if possible.
- For patients with breathing disorders, there is little information on whether pulse oximetry monitoring or capnography improves patient outcomes. Nursing should be aware of the risk and monitor these patients more frequently.
One promising area of study is personalized pharmacogenetics—how each individual metabolizes various narcotics. It’s hoped that in the near future we’ll be able to predict which narcotics are safe and effective for an individual’s pain, and which to avoid.
This article was written by Randy Bahm, RPh, a pharmacist at Asante Rogue Regional Medical Center.
Reference: Jarzyna D, Jungquist CR, Pasero C, et al. American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Manag Nurs. 2011;12(3):118-145.e10.
New Chief of Nursing Named
I am pleased to announce that Tiffany Oliver, MSN, MBA, has been named chief nursing officer for Asante. In this new role, Tiffany will have oversight for nursing services across the Asante health system. She will also serve as VP of nursing at Asante Rogue Regional Medical Center.
Tiffany most recently served as the chief nursing officer for St Joseph Health System Sonoma County in Santa Rosa, California. St. Joseph Health Sonoma County includes two acute care inpatient facilities, three large urgent cares, two ambulatory surgery centers, and an outpatient oncology center.
St. Joseph Sonoma County’s operations and facilities serve the entire coastal valleys area, including Sonoma, Napa, Mendocino, and Lake counties as well as coastal Marin County. The scope of Tiffany’s role included oversight of more than 1,100 FTEs within the patient care services departments. Tiffany’s first day at Asante will be June 22. Please join me in welcoming her to Asante!
A Simple Test That May Change Your Antibiotic Rx
Consider this: You suspect your patient has contracted MRSA so you order vancomycin to treat. But what if the infection isn’t methicillin-resistant and can be treated with oxacillin? Or what if it’s not Staphylococcus aureus at all?
In March, Asante began offering a PCR test to detect methicillin-resistant Staphylococcus aureus in positive blood cultures. The test has excellent sensitivity (greater than 99 percent) and its results could alter your patients’ antimicrobial therapy, reducing the risk of further antibiotic resistance.
It is performed on all positive blood cultures that have direct gram stains showing gram-positive cocci resembling Staphylococci. This testing can only be ordered by the laboratory and will not be performed on negative blood cultures, or on positive blood cultures that have organisms in the direct gram stains that don’t resemble Staphylococci. It will be reported in the “Gram Stain” section of the Blood Culture report below the direct gram stain results.
You may see one of these reports:
- Negative for Staph aureus and MRSA by PCR method. This means that the organism seen on the gram stain is not MRSA or MSSA (methicillin-sensitive Staphylococcus aureus). The most likely organism is a coagulase-negative Staphylococcus. Other possibilities include Micrococci, Aerococci, or anaerobic gram-positive cocci.
- Positive for Staph aureus and MRSA by PCR method. This means that the organism seen on the gram stain is MRSA or that both MRSA and MSSA are present.
- Positive for Staph aureus, Negative for MRSA by PCR method. This means that the organism seen on the gram stain is MSSA.
- Positive for Staph aureus, MRSA indeterminate by PCR method. Antimicrobial susceptibility testing pending. This means that Staphylococcus aureus is present, but, probably due to an interfering substance, we are unable to determine if it is MRSA or MSSA.
- Presence or absence of Staph aureus and/or MRSA cannot be determined by PCR method. This means that we are unable to reach any conclusions about whether MSSA or MRSA is present, probably because of an interfering substance. In these cases, the identity of the organism needs to wait for the subculture to grow (18 to 24 hours).
Results will be available within two hours after the direct gram stain is performed. False positive and false negative results can occur, but are uncommon (less than 2 percent of tests performed).
Tom Treger, MD, laboratory medical director at Asante Rogue Regional Medical Center submitted this article.
Amy Watson Leads Asante’s Pharmacy Service Line
On June 8, all pharmacy services at Asante became part of a system-wide Asante Pharmacy Service Line. This included all services within Asante’s three inpatient hospital pharmacies, outpatient pharmacies, and the 340B pharmacy program. As pharmacy service line director, Amy Watson will provide leadership for all entities. All pharmacy managers will maintain a dotted-line reporting relationship to their entity executive.
BBQ: Celebrate Being in the 15 Top!
The Truven honor also comes with a staff barbecue and free T-shirt. Mark your calendars for Monday, June 29, 11 a.m. to 1:30 p.m. or 5:45 to 7:15 p.m. in the Wild Rogue Café Patio.