Baptist Health System Research Articles

Low Peak Inspiratory Flow Rates are Common Among COPD Inpatients and are Associated with Increased Healthcare Resource Utilization: A Retrospective Cohort Study.

BackgroundPatients with chronic obstructive pulmonary disease (COPD) can have low peak inspiratory flow (PIF), especially after hospitalization for acute exacerbation of COPD (AECOPD).PurposeTo characterize patients hospitalized for AECOPD, and to assess the prevalence of low PIF, changes in PIF after hospitalization, and the association of low PIF with healthcare resource utilization (HRU) outcomes.Patients and MethodsA retrospective cohort study was conducted using electronic health record data of hospitalized COPD patients in the Wake Forest Baptist Health system (01/01/2017 through 06/30/2020). Patients with a first eligible AECOPD hospitalization (index hospitalization) who were discharged before 05/31/2020 were included. PIF was measured using the In-Check DIAL™ at both medium-low resistance (R-2) and high resistance (R-5) during the index hospitalization. For R-2 and R-5, PIF was divided into low PIF (< 60 L/min; < 30 L/min) and high PIF (≥ 60 L/min; ≥ 30 L/min) groups. The primary outcome was the prevalence of low PIF. The stability of PIF after hospitalization was described. Adjusted regression models evaluated associations between low PIF and subsequent 30-day readmissions, 90-day readmissions, and HRU outcomes, including hospitalizations, emergency department visits, inpatient days, and intensive care unit (ICU) days.ResultsIn total, 743 patients with PIF measured at R-2 and R-5 during a AECOPD hospitalization were included. The prevalence of low PIF was 56.9% at R-2 and 14.7% at R-5. PIF values were relatively stable after hospitalization. Adjusted analyses showed significant increases in HRU (all-cause hospitalizations [31%], COPD hospitalizations [33%], COPD inpatient days [46%], and COPD ICU days [24%]) during the follow-up period among patients with low PIF (< 60 L/min) at R-2. The 30- and 90-day readmission risks were similar between patients with low PIF and high PIF.ConclusionLow PIF is common among patients hospitalized for AECOPD, relatively stable after hospital discharge, and associated with increased HRU.

Collaboration Among Providers to Treat COVID-19 Patients at Home Opens Beds for Those with More Serious Illness

In March 2020, COVID-19 cases were beginning to emerge in North Florida and concern over hospital bed capacity started to rise. Baptist Health System in Jacksonville, Florida quickly formed a multidisciplinary team to explore how we could increase hospital bed capacity. Utilizing the resources within our affiliated home healthcare agency, an Enhanced Home Support Model (EHSM) with a COVID-19 protocol was developed. The protocol was implemented by home health nurses and included COVID-19 testing, blood tests, and the ability to start oxygen at home on admission. Patients were provided self-monitoring equipment and information about self-isolating and infection control within the home. After the initial visit, the home health nurse and the primary care physician shared collaborative oversight through virtual visits. This article discusses how we initially approached identification of severity and the methods we used to implement the protocol. The results section offers information about the number of patients utilizing this protocol between April and December 2020; patient and physician satisfaction; and considers strengths and weaknesses of the program. In conclusion, the EHSM protocol allowed patients to receive high quality emergent care at home and increased access to hospital emergency departments and inpatient hospital beds for more seriously ill patients.

Interview With Cathleen Wheatley, DNP, RN, CENP

There are interviews with colleagues that are intriguing. Then there are interviews that raise the level of nursing’s collective consciousness. Cathleen Wheatley, DNP, RN, CENP, does both. As president of Wake Forest Baptist Medical Center and system chief nurse executive of Wake Forest Baptist Health System, her impact and influence not only benefit those in her care, but those nursing professionals aspiring to effect lasting change. She humbly shares her thoughts and ideas about the changing health care milieu, never realizing how relevant they truly are.

The Positive Impact of Establishing an Internal Transfer Center

Health systems are facing greater pressures than ever before, with factors ranging from mergers and acquisitions and changing reimbursement models to capacity challenges and staffing shortages. A transfer center, where with 1 simple call from a referring physician, a decision to accept a critically ill patient can be made, placing them at the most appropriate level of care, the first time. Baptist Health in Jacksonville, Florida, went from an outsourced to an in-house center in 3 months—in the first 28 days alone, patient transfers increased from 900 to 1,500, growing to an average of 1,583 transfers per month.

Impact of a pharmacist-driven intervention on the outpatient dispensing of naloxone

ObjectivesTo determine whether implementation of a pharmacist-driven intervention increased naloxone prescriptions dispensed in outpatient pharmacies within an academic medical center. SettingFive outpatient pharmacies affiliated with the Wake Forest Baptist Health System located in Forsyth, Davie, and Davidson counties in North Carolina. Practice descriptionEvery pharmacy site differs in physical location, customer base, and other provided services. These differences, along with large ranges of prescription volumes and levels of care, provided varying opportunities for naloxone dispensing. Practice innovationPatients at high risk for opioid overdose and who were identified for the pharmacist-driven intervention were provided overdose education and an offer to receive naloxone per North Carolina State Health Director's Standing Order. This quasi-experimental study included a pre-intervention period (3 months), staff education (1 month), and a post-intervention period (3 months). The intervention was the patient-specific education regarding respiratory depression or overdose risk factors and the offering of a prescription for naloxone. The primary endpoint was reported as the change in naloxone prescriptions dispensed. EvaluationThe many factors why patients did and did not receive naloxone were discussed including patient understanding, convenience, and other pharmacy factors including workflow changes. Surprisingly, cost did not seem to play a factor in patient's inability to obtain the medication. ResultsThirty-eight patients were eligible for the intervention. Two prescriptions for naloxone were dispensed during the preimplementation period, and 11 prescriptions for naloxone were dispensed during the postimplementation period (n = 0.0078). ConclusionsThe number of naloxone prescriptions dispensed increased after implementation of a pharmacist-driven intervention. All naloxone prescriptions were filled for patients eligible for study criteria; however, the North Carolina Standing Order allows any patient requesting to receive a naloxone prescription and thus all filled prescriptions were included in the count. Because of pharmacy staff education and overflow from the project into other areas, it is possible that the prescriptions filled for ineligible patients were still due to project efforts.

Cost of Joint Replacement Using Bundled Payment Models

ImportanceMedicare launched the mandatory Comprehensive Care for Joint Replacement bundled payment model in 67 urban areas for approximately 800 hospitals following its experience in the voluntary Acute Care Episodes (ACE) and Bundled Payments for Care Improvement (BPCI) demonstration projects. Little information from ACE and BPCI exists to guide hospitals in redesigning care for mandatory joint replacement bundles.ObjectiveTo analyze changes in quality, internal hospital costs, and postacute care (PAC) spending for lower extremity joint replacement bundled payment episodes encompassing hospitalization and 30 days of PAC.Design, Setting, and ParticipantsThis observational study followed 3942 total patients with lower extremity joint replacement at Baptist Health System (BHS), which participated in ACE and BPCI.ExposuresLower extremity joint replacement surgery under bundled payment at BHS.Main Outcomes and MeasuresAverage Medicare payments per episode, readmissions, emergency department visits, prolonged length of stay, and hospital savings from changes in internal hospital costs and PAC spending.ResultsOverall, 3942 patients (mean [SD] age, 72.4 [8.4] years) from BHS were observed. Between July 2008 and June 2015, average Medicare episode expenditures declined 20.8%, from $26 785 to $21 208 (P < .001) for 3738 episodes of joint replacement without complications. It declined 13.8% from $38 537 to $33 216 (P = .61) for 204 episodes of joint replacement with complications. Readmissions and emergency department visits declined 1.4% (P = .14) and 0.9% (P = .98), respectively, while episodes with prolonged length of stay decreased 67.0% (P < .001). Patient illness severity remained stable. By 2015, 51.2% of overall hospital savings had come from internal cost reductions and 48.8% from PAC spending reductions. Reductions in implant costs, down on average $1920.68 (29%) per case, contributed the greatest proportion of hospital savings. Average PAC spending declined $2443.12 (27%) per case, largely from reductions in inpatient rehabilitation and skilled nursing facility spending but only when bundles included financial responsibility for PAC.Conclusions and RelevanceDuring a period in which Medicare payments for joint replacement episodes increased by 5%, bundled payment for procedures at BHS was associated with substantial hospital savings and reduced Medicare payments. Decreases in PAC spending occurred only when it was included in the bundle.

Abstract WP379: Mode of Arrival Effects tPA Timeliness: a Retrospective Review

Background: Baptist Health System (BHS) became Primary Stroke Certified in May, 2009. BHS admits approximately 2,000 stroke patients annually. Applying LEAN methodology and the AHA/ASA Target Stroke Best Practice Strategies, BHS initially obtained the Target Stroke Honor Roll status in 2010 and continues to sustain this status. With the addition of Target Stroke Elite and Elite Plus awards, we have re-focused on our Door-to-Needle (D2N) times. The purpose of this review is to evaluate the effectiveness of our D2N initiative of &lt; 60 minutes, whether the patient arrives by EMS or Private Vehicle (PV). Methods: A retrospective review was conducted of AIS patients who received IV tPA between 2008 and 2014 using GWTG data. The intent of the review was to compare annual results of the mode of arrival (EMS versus PV) and the percent of patients who received tPA with a D2N time of &lt; 60 minutes. Results: Between 2008 and 2014, BHS administered tPA to 688 AIS patients. Of these patients, an average of 84% arrived by EMS and 16% by PV annually. Data revealed that prior to stroke certification 31 patients received tPA. Only one (3.2%) of the 31 patients, who arrived by EMS, received tPA &lt; 60 minutes. The year BHS became stroke certified tPA was administered to 63 patients. Of those 63, two patients received tPA &lt; 60 minutes; one arrived by EMS (14.3%) and one arrived by PV (1.8%). Since the implementation of Target Stroke Best Practice Strategies in 2010, tPA administration ranged from 113 - 127 patients the following years. The D2N goal of &lt; 60 minutes was achieved an average of 53.6 % when arriving by EMS and an average of 36.3% when arriving by PV. Although arrival modes did not vary significantly, there was a noted increase in D2N time of &lt; 60 minutes in patients arriving by PV between 2013 at 22.7% and 2014 at 47.4% Conclusion: Patients arriving by EMS have historically had a faster tPA administration time than patients arriving by PV. There is a marked improvement in D2N times in patients arriving by PV with the introduction of the Target Stroke Elite and Target Stroke Elite Plus initiative and a refocus on D2N time in this hospital system.

Abstract WP376: Using the Plan-Do-Study-Act Model to Improve IV TPA Administration Times

Background: Current guidelines for management of acute ischemic stroke include distinct recommendations regarding IV Tissue Plasminogen Activator (TPA) administration times. While 75% of all strokes are ischemic, over 70% of patients are treated after the 3 hour window, placing them at an increased risk for stroke complications. From FY 2014 to FY 2015, Baptist Health System Emergency Departments (ED) had proven that the implementation of the Plan-Do-Study-Act (PDSA) Performance Improvement Model can significantly improve IV TPA Administration Times. Purpose: The purpose of this poster is to describe the use of the Plan-Do-Study-Act Model in improving IV TPA Administration times within Baptist Health System Emergency Departments. Methods: Emergency Departments (Physician Champions, Directors, and Nursing staff) collaborated to standardize processes using lean methodology. Actions taken to improve IV TPA administration times through use of the PDSA include analyzing all TPA fallouts, reporting monthly findings at the regional ED service line (nursing), and submitting findings to the Stroke Coordinator, CNO, and ED Physician Quality Director for follow-up. In addition to the previously used processes of stroke alert notification and evaluating the patient at the door, TPA administration would no longer be held if there was a delay in the telemedicine response. If the ED Physician determined that the patient was a candidate for TPA therapy, the order would be given to administer TPA and the ED Physician would be able to cancel the telemedicine consult if the TPA was administered before reaching the neurologist. The ED Physician would then document the delay in treatment, as appropriate. Results: BHS received the Target Stroke Honor Roll and significantly improved Door to IV TPA therapy within 60 minutes from 53.8% (57/106) in 2013 to 70.5% (62/88) in 2015. Conclusion: In conclusion, BHS showed significant improvement in TPA Administration times through the use of the PDSA Method. Administrative, Physician, Stroke Leadership, and Nursing collaboration with performance improvement items were instrumental in reducing IV TPA administration times in Emergency Departments.

Trends in Ideal Cardiovascular Health Metrics Among Employees of a Large Healthcare Organization (from the Baptist Health South Florida Employee Study)

The American Heart Association (AHA)'s 2020 goal is to improve the cardiovascular health (CVH) of people living in the United States (US) by 20% and reduce mortality from cardiovascular diseases and stroke by 20%. Given that 155 million adults are in the US workforce, and >60% have employee-based insurance, workplace studies provide an important opportunity to assess and potentially advance CVH through the use of comprehensive workplace wellness programs. Among a cohort of employees of the Baptist Health System, CVH was assessed annually during voluntary health fairs and health risk assessments (HRA) from 2011 to 2014 using the AHA's 7 CVH metrics: smoking, body mass index (BMI), physical activity, diet, blood pressure, total cholesterol, and blood glucose. Each metric was categorized as ideal, intermediate, or poor according to the AHA criteria. Cochrane-Armitage test was used to detect trends in CVH by year. Ideal CVH, defined as meeting ideal criteria for all 7 metrics, was assessed and compared across years. The overall cohort was 34,746 with 4,895 employees in 2011, 10,724 in 2012, 9,763 in 2013, and 9,364 in 2014. Mean age (SD) was between 43 (±12) and 46 years (±12). Female to male ratio was 3:1. The prevalence of study participants who met the ideal criteria for diet, physical activity, and blood pressure increased significantly from 2011 to 2014 but for BMI, total cholesterol, and blood glucose, a significant decrease was noticed. In addition, the prevalence of study participants in ideal CVH although low, increased significantly over time (0.3% to 0.6%, p <0.0001). In conclusion, this study shows the trends of the AHA's CVH metrics in a large health care organization. The positive findings noted for the metrics of smoking, physical activity, total cholesterol, and blood glucose should be reinforced. However, the metrics of diet, BMI, and blood pressure need more attention.

Mobile Versus Fixed Deployment of Automated External Defibrillators in Rural EMS.

There is no consensus on where automated external defibrillators (AEDs) should be placed in rural communities to maximize impact on survival from cardiac arrest. In the community of Stokes County, North Carolina (USA) the Emergency Medical Services (EMS) system promotes cardiopulmonary resuscitation (CPR) public education and AED use with public access defibrillators (PADs) placed mainly in public schools, churches, and government buildings. This study tested the utilization of AEDs assigned to first responders (FRs) in their private-owned-vehicle (POV) compared to AEDs in fixed locations. The authors performed a prospective, observational study measuring utilization of AEDs carried by FRs in their POV compared to utilization of AEDs in fixed locations. Automated external defibrillator utilization is activation with pads placed on the patient and analysis of heart rhythm to determine if shock/no-shock is indicated. The Institutional Review Board of Wake Forest University Baptist Health System approved the study and written informed consent was waived. The study began on December 01, 2012 at midnight and ended on December 01, 2013 at midnight. During the 12-month study period, 81 community AEDs were in place, 66 in fixed locations and 15 assigned to FRs in their POVs. No utilizations of the 66 fixed location AEDs were reported (0.0 utilizations/AED/year) while 19 utilizations occurred in the FR POV AED study group (1.27 utilizations/AED/year; P<.0001). Odds ratio of using a FR POV located AED was 172 times more likely than using a community fixed-location AED in this rural community. Discussion Placing AEDs in a rural community poses many challenges for optimal utilization in terms of cardiac arrest occurrences. Few studies exist to direct rural community efforts in placing AEDs where they can be most effective, and it has been postulated that placing them directly with FRs may be advantageous. In this rural community, the authors found that placing AED devices with FRs in their POVs resulted in a statistically significant increase in utilizations over AED fixed locations.

Abstract T P337: Outcomes for a Cohort of Patients Not Treated with Thrombolytic Therapy Due to Mild or Rapidly Improving Stroke Symptoms: A Retrospective Review

Background: Symptoms too mild and rapidly improving stroke symptoms (RISS) are relative contraindications for thrombolytic therapy (tPA) in acute ischemic stroke patients (AIS), yet several studies indicate that some of these patients may have a poor outcome. Baptist Health System (BHS) includes five Certified Primary Stroke Center hospitals which admit nearly 2,000 ischemic and hemorrhagic stroke patients a year. Purpose: The purpose of this study is to review the discharge ambulatory status and disposition of the AIS patients that were not treated with tPA because their symptoms were to mild, defined as NIHSS ≤ 5, or with RISS. Methods: A retrospective review was conducted using GWTG data to determine the total number of AIS admitted between 2011 - 2013, the total number of patients who were eligible for tPA with an NIHSS ≤ 5, and the total number of patients who did not receive tPA because of a documented reason of symptoms too mild or RISS. Results: From 2011 to 2013, BHS admitted 3,035 AIS patients, of which 396 patients arrived within 3.5 hours of last known well and had an NIHSS ≤ 5. Of those, 317 (80.05%) patients had an exclusion documented of symptoms too mild or RISS. The discharge disposition of these patients include: Home 59.94% (n=190), Acute Rehab Facility 22.40% (n= 71), Skilled Nursing Facility 14.82% (n- 47), Hospice 1.89% (n=6), Left AMA 0.63% (n=2), and Expired 0.31% (n=1). At discharge, the data reveals 51.74% (n=164) were able to ambulate independently with or without a device, 37.22% (n=118) were unable to ambulate without assistance from another person, 10.73% (n=34) were unable to ambulate and 1 patient died. Conclusions: In conclusion, despite being identified as having a mild and rapidly improving stroke, the patients not treated with IV tPA and an NIHSS ≤ 5 do not necessarily have mild outcomes. The exact reason for these short-term outcomes cannot directly be concluded from this review. This retrospective review of our community cohort shows that there are disabilities and extended care requirements in the context of a mild stroke and more data review, research, evaluation and consideration of the mild stroke patient is indicated.

Abstract T P339: Plan-Do-Study-Act Model Has Positive Impact on Dysphagia Screening in the Emergency Room

Background: Dysphagia is a serious complication of stroke, which can cause aspiration pneumonia leading to increased length of stay or death. Baptist Medical Center (BMC) is one of five Primary Stroke Center Certified hospitals in the Baptist Health System (BHS). In October 2013 it was noted that BMC dysphagia screen measure results had trended downward to be the lowest in the system. Purpose: The purpose of this abstract is to outline actions taken to address the documentation of the dysphagia screen in the emergency room (ER) at BMC. Methods: An analysis of BMC’s dysphagia screen fall outs revealed four contributing factors for this quality measure including: no screen completed (34%), oral intake prior to the screen (38%), a delay in stroke diagnosis 22%) or incomplete documentation (6%). Initially the dysphagia screen was completed on paper while the rest of the ER documentation was completed in the electronic medical record (EMR). In October a performance improvement effort was implemented using a Plan-Do-Study-Act Model (PDSA). Initial changes included placing dysphagia screening forms in each room for easier access, 1:1 teaching with staff for fall outs, and designating a nurse Stroke Champion. Inconsistent improvement was seen so dysphasia documentation was add to the EMR, a patient complaint list was developed and attached to each computer, and any patient with a Head CT order was automatically screened. In April, the directors started assigning a dysphagia screen education module to any staff member with 2 or more fallouts. The PDSA graph and action plan was posted in the ER and discussed during monthly staff meetings. Results: Dysphagia screen documentation in stroke patients in the ER at BMC improved from a low of 73.7% in October 2013 to 100% in May 2014. The drop in April 2014 to 88.5% was attributed to leadership changes and staff turnover. Conclusion: A focus on dysphagia improved the screening of stroke patients in the ER. The commitment to 1:1 teaching and further education emphasized the importance of screening. Dysphagia screening results will continue to be monitored, posted, and discussed monthly.

Abstract W MP1: Leadership + Education = Quality

Background: Baptist Health System (BHS) leadership is invested in “education and training activities that are relevant to the program’s scope of service” as required by Primary Stroke Center Certification. BHS is a five hospital system which reports as one program in five locations. There are 20 stroke-specific nursing departments, with over 700 practitioners and 1,500 stroke admissions annually. This complex system presents unique challenges when developing an education plan to meet Stroke Certification requirements. Purpose: The purpose is to describe a stroke education plan which offers a variety of learning modalities reflecting the complexity of stroke care while meeting the learning needs of nurses in diverse clinical areas. Methods: The BHS Stroke Education Council was developed as a subcommittee of the Regional Stroke Committee and includes representation from all the clinical departments. The education plan was developed based on identified knowledge deficits, leadership feedback and performance outcomes. The education content addresses scope of service, stroke pathophysiology, assessment, diagnostics, treatments, policies and protocols. The content is presented in a variety of learning modalities including self -paced learning, interactive classes with NIHSS skills check off, stroke hymnal, and in-services. As a result of staff evaluations the education plan was restructured to meet the learning needs of the participants. The Stroke Education Council meets monthly and the plan is revised annually to address educational opportunities. Results: The success of this plan is reflected by a 92% practitioner completion rate. In addition, there was a 10% increase in compliance of all required stroke performance measures over a three month period following implementation of the stroke education plan. Conclusion: In conclusion, the results are due to the support of BHS leadership who recognize that staff education drives superior care as reflected in quality data indicators and the overall success of the stroke program. The skills and knowledge of the nursing staff is recognized through the achievement of the AHA/ASA Gold Plus and Target Stroke Honor Roll hospital awards in August 2012 and in August 2013.

SU‐E‐I‐90: Magnetoencephalography (MEG): Quantitative Comparison of Oscillations and Synchronization Differences/similarities in Post‐Surgery/pre‐Irradiation Patients and Control Subjects

Purpose: To evaluate brain synchronization and connectivity differences in post‐surgery/per‐irradiation patients and healthy controls with two different MEG approaches: ECD (equivalent current dipole) and SAM (synthetic aperture magnetometry). Methods: An 8 min resting state scan was collected from 5 post‐surgery/pre‐irradiation patients and 5 sex/age‐matched control subjects. Scans were collected on a CTF MEG 275‐sensors system. All subjects were scanned in upright, open‐eyes position in a magnetically shielded room. MRI whole brain volume was divided into 4mm voxels allowing sensor signal space to be mapped into brain space. Measured signals were filtered into Δ, o/, α and β bandwidths and localized by ECD and SAM. SAM is a type of beamforming, a signal processing technique for sensor array data; the method works like a digital filter by focusing on each voxel while attenuating the majority of signal from all other voxels. Resultant SAM waveforms were evaluated to reject muscle and/or non‐physiological artifacts. The ECD method was applied to the same data and bandwidths to localize sources, its orientations and strengths. Statistical analysis evaluated connectivity and synchronization using dPLI (direct phase lag index) and IC (imaginary coherence). Resultant SAM and ECD maps were compared for differences and similarities. Results: Currently the project is collecting data. The full per‐irradiation data is expected to be completed by June 2013. The study goal is to establish the best method/approach to evaluate resting state MEG data. Conclusion: We expect 3 possible outcomes of the study: no difference, subtle difference, statistically significant difference in resting state analysis between these two methods. The two first outcomes are easy to address by choosing the most time‐efficient method. The last case will require further investigation of both methods to establish the ground of the difference and the most appropriate method analysis for the resting state. Partial support by Radiation Oncology and Neurology Departments at Wake Forest Baptist Health System and by Dalton McMichael Fund in Cancer Research. No conflict of interest is reported.

Abstract TP346: Hospital System Collaborative has Positive Impact on Door to Needle Times

Background: Target Stroke is a National quality initiative to increase administration of IV rtPA to within 60 minutes from arrival on at least 50% of eligible ischemic stroke patients. Historically, the National statistic was approximately 25%. The Baptist Health System (BHS) benchmark in January 2010 was at 16.9%. This statistic is for a five hospital system with 1,674 licensed beds and one provider number. BHS has one Stroke Medical Director and follows the same standard of care and stroke order sets at all locations. We will describe the process applied across BHS to decrease door to needle times. Methods: One hospital Emergency Department’s (ED) Physician Champion, Director and nursing staff used LEAN methodology to outline present state and streamline the process to eliminate wasted time. Our process already consisted of pre-notification from Emergency Medical Services (EMS) with the estimated time of arrival and a stroke alert page. In our new process, the ED Physician (EDP) and RN1 meet EMS in ambulance bay for a quick assessment. The patient is taken directly to CT scan by RN1 and EMS1. Concurrently, EMS2 reports off to RN2 while assembling the equipment and contacting Specialists On Call (SOC) for the neurology consult. The CT technician notifies the Radiologist of the stroke alert and sends the films to SOC. Upon patient return from CT, the SOC video consultation begins. If a high probability of IV rtPA administration exists per EDP, the rtPA is reconstituted awaiting SOC recommendations. This process was piloted before being duplicated at the other four hospitals. Results: BHS achieved Target Stroke Honor Roll status for third quarter 2010 with 71.4% (n = 20/24) of eligible patients treated with door to needle time of 60 minutes or less. Median time was 48.5 minutes. BHS sustained Target Stroke Honor Roll status for July 2010 through June 2011, at 56.6% (n = 56/99) with a median time of 56 minutes. Conclusion: BHS was the first hospital in Texas to be awarded the Target Stroke Honor Roll. Incorporating LEAN methodology to eliminate waste, develop guidelines, actions, time durations, and collaboration across the hospital system is an effective means to decrease door to needle time.

Abstract WP250: Hospital System Collaborative has Positive Impact on Door to Needle Times

Background: Target Stroke is a National quality initiative to increase administration of IV rtPA to within 60 minutes from arrival on at least 50% of eligible ischemic stroke patients. Historically, the National statistic was approximately 25%. The Baptist Health System (BHS) benchmark in January 2010 was at 16.9%. This statistic is for a five hospital system with 1,674 licensed beds and one provider number. BHS has one Stroke Medical Director and follows the same standard of care and stroke order sets at all locations. We will describe the process applied across BHS to decrease door to needle times. Methods: One hospital Emergency Department’s (ED) Physician Champion, Director and nursing staff used LEAN methodology to outline present state and streamline the process to eliminate wasted time. Our process already consisted of pre-notification from Emergency Medical Services (EMS) with the estimated time of arrival and a stroke alert page. In our new process, the ED Physician (EDP) and RN1 meet EMS in ambulance bay for a quick assessment. The patient is taken directly to CT scan by RN1 and EMS1. Concurrently, EMS2 reports off to RN2 while assembling the equipment and contacting Specialists On Call (SOC) for the neurology consult. The CT technician notifies the Radiologist of the stroke alert and sends the films to SOC. Upon patient return from CT, the SOC video consultation begins. If a high probability of IV rtPA administration exists per EDP, the rtPA is reconstituted awaiting SOC recommendations. This process was piloted before being duplicated at the other four hospitals. Results: BHS achieved Target Stroke Honor Roll status for third quarter 2010 with 71.4% (n = 20/24) of eligible patients treated with door to needle time of 60 minutes or less. Median time was 48.5 minutes. BHS sustained Target Stroke Honor Roll status for July 2010 through June 2011, at 56.6% (n = 56/99) with a median time of 56 minutes. Conclusion: BHS was the first hospital in Texas to be awarded the Target Stroke Honor Roll. Incorporating LEAN methodology to eliminate waste, develop guidelines, actions, time durations, and collaboration across the hospital system is an effective means to decrease door to needle time.

Abstract WP363: Journey of a Five-Hospital System to Primary Stroke Center Certification

Background: In 2008, a city with a population of over one million people had no organized stroke care or Certified Primary Stroke Centers. Patients presenting with stroke symptoms had inconsistent neurology coverage and little or no access to rtPA. The purpose is to describe steps taken for five acute-care hospitals (with one CMS provider number) to become Primary Stroke Certified. Methods: The journey began with administrative support and a commitment to provide the resources for a successful program. To oversee development, a Medical Director and Stroke Coordinator were appointed. To bridge the gap in available specialty physicians, partnerships were formed with a telemedicine group to provide emergency treatment and an academic medical center to augment the neurology and neuro-surgical coverage. Multidisciplinary teams met monthly in each facility. Representatives from each team formed a regional committee and an education council was created to share best practices and assure consistency across the system. Evidenced based order sets were developed using clinical practice guidelines. The Medical Executive Committee at each facility and ultimately the Medical Executive Board endorsed the order sets and mandated their use. Each facility chose the appropriate unit to cohort the stroke patients which encouraged expertise in care. Results: This journey resulted in a high functioning system of care. Baptist Health System became Joint Commission Certified in all five locations (May 2009). We were awarded the Get with the Guidelines Bronze Award (September 2010), the Silver Plus Award (July 2011) and the Gold Plus Award (July 2012). In addition, we were the first in Texas to achieve the Target Stroke Honor Roll (Q3 2011) and have maintained this status for eight consecutive quarters. Conclusion: In conclusion, administrative support is imperative to the success of a stroke program. Leadership, partnerships, committees, councils and staff involvement from the start drove the team to a successful certification process with outstanding outcomes. The stroke committees continue to meet monthly to analyze performance measures, identify opportunities for improvement and execute action plans.

Provider Alignment Is Integral to Future Success

The healthcare industry is undergoing dramatic changes, and the Patient Protection and Affordable Care Act (U.S. Congress 2010) is accelerating these changes. The way healthcare is currently paid for in the United States, especially in the traditional, fee-for-service (FFS) Medicare program, does not support coordinated care and the establishment of a delivery system with the appropriate capacity and utilization (Devers and Berenson 2009). The days of FFS are likely to soon end, in part because of the inherently inflationary nature of volume-based reimbursement. Health policy-and, in particular, reimbursement policy-has made a decided shift toward pay-for-performance, value-based purchasing, bundled pricing, and other forms of reimbursement that shift the burden of risk back to the providers and reward them for producing value. Whether FFS completely goes away is anyone's guess, but most will concede that the days of FFS as the predominant form of reimbursement are drawing to a close. Byrnes and Fifer's assertion that, due to these sweeping policy changes, organizations must quickly prepare thoughtful, effective responses to ensure their financial stability could not be more resoundingly evident. Developing a strategy to form an integrated delivery system that can position an organization to operate in this new reimbursement environment is critical to maintaining a strong future and delivering on mission. Vanguard Health System's Baptist Health System (BHS) in San Antonio, Texas is a five-hospital system serving a market of more than 2 million residents in the 22 counties of South Texas. BHS is similar to other large multihospital systems in competitive markets around the country. The system has been and continues to be progressive and innovative. So much so, in fact, that BHS has established itself as a market leader for quality care, satisfaction, and engagement among its physicians and staff and for bringing new services to the market (i.e., the Brain and Stroke Network). San Antonio has four major healthcare systems, a multitude of independent hospitals and physicianowned hospitals, a large teaching hospital, and the country's largest concentration of military medicine providers. Hence, San Antonio can be characterized as a highly fragmented provider market with most physicians splitting loyalties among systems and a city with an overabundance of service offerings among all providers (e.g., 13 open heart programs). In December 2008, BHS was selected to participate in CMS's Acute Care Episode (ACE) demonstration project to study the effects of bundled pricing, gain sharing, competitive bidding, and beneficiary incentives for 28 cardiac and 9 orthopedic DRGs. The demonstration sought to explore whether improvements in quality of care can result from alignment of financial incentives between hospitals and physicians in such a way that they must coordinate care on a case-by-case basis. The ACE program was launched at BHS on June 1, 2009, with approximately 150 physicians, predominantly in the cardiology and orthopedic specialties. In the first year, more than 1,400 patients recieved care under the ACE demonstration program. The early results have been significant, and they provide a glimpse of what can be accomplished through an integrated and coordinated system approach. BHS viewed the ACE demonstration program as a means to quickly advance toward an integrated approach that creates greater alignment with our physicians, facilitates improvement in the quality of care, reduces the cost ofthat care, and further distinguishes the system with a competitive advantage in the effort to deliver care under an alternative payment approach (bundled payment). We learned that the task of transforming our existing delivery platform to one able to accommodate the delivery of coordinated care under the ACE program required significant time and resources. The resulting benefits were impressive and realized sooner than anticipated. …

Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency Care

Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency Care

Interview with James G. Springfield, FACHE, president and chief executive officer, Valley Baptist Health System, Harlingen, Texas

Interview with James G. Springfield, FACHE, president and chief executive officer, Valley Baptist Health System, Harlingen, Texas