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In a recent Client Outcomes Collaboration Program webinar, Allscripts clients shared how they have used the LACE index to identify patients who are at risk for readmission. Based on what they’ve found, they’ve taken different approaches to intervening with their patient populations.
What is LACE and how does it help prevent readmissions?
The LACE index, designed to identify patients who are at risk for readmission or death within thirty days of discharge, is based on four factors:
L – Length of stay
A – Acuity of admission
C – Co-morbidities
E – Emergency room visits
The higher a patient scores on this index, the higher the risk of returning to the hospital. Hospitals are beginning to use LACE as a tool to stratify patients based on their risk level and work to reduce unnecessary readmissions.
Many healthcare systems are working hard to address the readmission challenge, because more coordinated care benefits patients. They also want to avoid financial penalties associated with these readmissions. While some U.S. regions are beginning to improve readmission rates, it remains a significant challenge for health care.
University Hospital (UH) cuts readmission rate in half with LACE
UH Geneva Medical Center (Geneva, Ohio, U.S.A) started using the LACE index to stratify patients by risk in 2011. It incorporated the LACE tool within Allscripts Sunrise™, enabling nurses to enter data and produce a score. This score is visible on the tracking board and changes to reflect the patient’s current status throughout the hospital stay.
The initiative demonstrated that social factors play a significant role in elevating risk, and that increased patient engagement was key to long-term success. For UH high-risk patients in phase one, a Hospital to Home program helped reduce the readmission rate from 15% to 7.5% over one year.
UH Geneva Medical Center further refined its risk stratification for the second phase of the program, bringing more parameters into the tool. The goal was to focus not just on high-risk patients, but find those patients whose risk levels were rising quickly. Those patients represented 34% of the organization’s total admissions.
By initiating the risk stratification process for all patients, it heightened awareness of the medical teams to begin the process of effective care coordination after discharge. Motivational interviewing techniques with patients were key to addressing behaviors with rising-risk patients who were previously unmoved.
Other emerging approaches to using LACE
A hospital based in Newport Beach, California, U.S.A. launched a pilot program with LACE in the summer of 2015. This organization focused on pharmacists and the important clinical role they can play at discharge. They counsel patients directly to help with medication reconciliation and education.
Another hospital based in New York has used the LACE tool to stratify patients and understand patterns. The goal is to transition patients to the right level of care.
Because each patient population faces different issues, the LACE tool will reveal different things to different organizations. It’s a good way to help establish a baseline for patient populations and gain a deeper understanding of what they need.
To learn more about correlations between LACE scores and readmissions and how different organizations are using this tool, visit our Client Outcomes Collaboration Program website to view more detail.
At one of our client events, Atlantic General Hospital (Berlin, Maryland, U.S.A.) shared its success with Allscripts Sunrise™ Knowledge-Based Medication Administration to reduce adverse drug events.
The effort was all about improving patient safety and is deeply rooted in clinician experiences, such as this one shared by Vice President of Patient Care Colleen Wareing:
“I can remember to this day, standing in an ICU 37 years ago with a 15-year-old patient who had just delivered a baby. And I was mixing meds. I was tired, I was at the end of a 12-hour shift, and I was a very young nurse…As soon as I injected it into the IV, I knew it was wrong and wanted to take it back….It still creates a strong emotion in me 37 years later…Every nurse could tell a story like that….Fortunately the patient was okay, but it was frightening.”
She’s right; every nurse could tell a story like that. Even the most talented, compassionate, thorough caregivers need the right tools to help them deliver medication safely.
Reducing adverse drug events with closed-loop medication delivery
A 62-bed hospital in a resort area just a few miles from the Atlantic Ocean, Atlantic General Hospital launched an initiative to improve medication delivery, featured in a recent case study.
Atlantic General Hospital gathered representatives from various disciplines – including nursing, physicians, pharmacy and information technology – to help reduce adverse drug events, focusing on the errors that touch the patient (National Coordinating Council for Medication Error Reporting and Prevention Categories C and D).
“We went around the country trying to find a compatible vendor that had a similar vision to ours, that had the tools that we need to improve our processes in the pharmacy and reduce our errors,” Director of Pharmacy James McGinnis said. “We selected Allscripts Sunrise, because of its full Knowledge-Based Medication Administration (KBMA), electronic medication reconciliation and CPOE capabilities.”
Sunrise helps clinicians improve medication delivery
Atlantic General Hospital has seen improvements in several areas since launching its patient safety initiative to reduce adverse drug events. For example, it reduced medication errors by 86% from 2012 to 2015, exceeding the original target of 75%. That means the average monthly total of 9.2 adverse drug events in 2012 dropped to 0.08 in 2015.
To learn more about Atlantic General Hospital’s success, download a free case study.
We recently worked with a hospital in Newport Beach, California, U.S.A. to maximize Allscripts Sunrise capabilities for better outcomes. We formed an Outcomes Board with leaders from both entities representing clinical, financial and operational disciplines. The Outcomes Board sets goals, identifies anticipated returns on investment and develops metrics for performance improvements.
We’ve had some exciting results, improving early intervention for patients with Clostridium difficile (C. diff) and reducing risk of infection by converting patients from intravenous (IV) to oral (PO) medications.
Faster interventions for patients with C. diff
Physicians note that of all the common hospital-acquired infections in California, all of them are improving except for C.diff. Orange County has one of the highest rates of C. diff infections in the state.
The Outcomes Board targeted C.diff cases, with a goal of identifying patients sooner to help provide faster intervention, prevent transmission and reduce cost per case. Using a Medical Logic Module (MLM) within Sunrise, the hospital created documentation and automatic testing for C. diff when patients met predefined criteria.
The Outcomes Board adjusted cost-per-case measurements using Case Mix Index (CMI), which indicates the severity of cases. Within the first seven months of implementing the project, the organization recognized a 4.65% savings in CMI-adjusted cost per case.
The community is watching this initiative very closely. If this hospital can move the needle on C.diff, these are procedures that other organizations can apply with success, too. The hospital is sharing its progress with the California Department of Public Health collaborative on infectious disease.
Anti-microbial stewardship: IV to PO conversion
The hospital continuously works toward more effective and cost-efficient uses of medications. One consideration is whether clinicians should order intravenous (IV) or oral (PO) antibiotic therapies.
Many hospitalized patients receive IV-administered antibiotics, but they can create clinical challenges. For example, IV therapy increases the risk for catheter-related infections, which can lead to additional time in the hospital, sepsis and other complications. Oral medication alternatives can be just as effective as IV treatments and can reduce these clinical risks. They also reduce costs of IV sets and pumps, nursing and pharmacy personnel time.
According to the hospital’s Medical Director of Infection Prevention and Hospital Epidemiology, research shows 30% to 50% of patients receive unnecessary antibiotics, which contributes to rising bacterial resistance and C. diff rates. Converting medications from IV to PO helps improve patient safety.
The organization designed an MLM to alert clinicians placing IV orders for 15 antibiotics within the stewardship program. If patients also had diet orders, meaning patients are able to eat food, then the alert would recommend an oral medication. Another MLM reminded clinicians to change medications from IV to PO when placing a new diet order.
While the hospital had an IV to PO policy in place, it had very little impact until Sunrise helped make the conversion automatic. Now that the conversion occurs at the time of prescribing, it eliminates manual processes for both the physician and pharmacy.
The project started in spring of 2015, and the Sunrise MLMs triggered alerts for 170 cases during a seven-week period. In 149 of those instances, or 88% of cases, the physician converted the order from IV to PO, moving to a lower cost medication therapy that is equally effective. The estimated annualized cost savings per discharge is about 6.8%, after 4 months of data to date.
The hospital’s Outcomes Board continues to identify new projects with help and input from our Outcomes Collaboration program and onsite team members. Plans are under way to use Sepsis and ICU Delirium pathways, presented earlier this year in our program. Physicians report looking forward to undertaking new initiatives to improve patient safety with Sunrise.
Because with Sunrise, it’s possible to target patient safety initiatives specific to each organization. If you’re interested in learning more about successful workflows in Sunrise, join the conversation in our ClientConnect community today.
Hospital for Special Care (New Britain, Connecticut, U.S.A.) is addressing the healthcare needs of a growing segment of its community, people with Autism Spectrum Disorders (ASD). In Connecticut, ASD affect more than 5,000 children under the age of 21, and current research suggests that number will continue to rise.
The Hospital for Special Care observed that though there are many agencies and groups providing specific services, there was little coordination between health care and other components, such as education, vocation and family support. It created The Autism Center at Hospital for Special Care, an outpatient clinic that provides a variety of diagnostic, assessment and consulting services for children and adolescents with ASD.
The National Committee for Quality Assurance (NCQA) recently recognized The Autism Center at Hospital for Special Care as the first outpatient clinic of its kind to earn Patient-Centered Specialty Practice (PCSP) designation. The hospital used Allscripts Sunrise™ to meet the six core measures of specialty practice standards, each with multiple weighted elements and factors:
- Track and coordinate referrals
Hospital for Special Care clearly delineated the role of specialty practitioners and primary care providers and set clear expectations for roles and communications. As part of this process, the organization improved processes so it could accommodate urgent visits within 48 hours.
- Provide access and communication
For patients with ASD, communication can be a struggle. It’s important to remove as many barriers as possible. For example, The Hospital for Special Care arranged to have an on-demand video interpreter service available to both parents and caregivers in their language of choice.
- Identify and coordinate patient populations
As part of meeting this measure, Hospital for Special Care worked closely with area labs to better coordinate care. Parents of children with ASD are often reluctant to take them to labs because of their anxiety of unfamiliar surroundings and behavioral challenges. Now, there is a registered nurse who serves as care coordinator for these families to improve the experience and coordinate care.
- Plan and manage care
Hospital for Special Care wanted to improve collaborations with other specialists to assess barriers and reduce redundancy in provision of care. This includes medication reconciliation, which is an important step. Engaging physicians and evaluating medications help caregivers design better care plans.
- Track and coordinate care
For this measure, Hospital for Special Care used Sunrise to track follow-up appointments, tests, referrals, care transitions and hospitalizations. When the risk factor for patients becomes a concern, a psychiatrist can intervene, helping patients avoid unnecessary emergency room visits and hospital readmissions.
- Measure and improve performance
Collecting data through Sunrise helped Hospital for Special Care improve a number of clinical processes and patient experiences. For example, it set a goal that patients would wait no longer than 10 business days between the referral and first appointment. At first, only 18% of appointments met that measure. With information from Sunrise, the organization targeted specific actions to improve that number to 45% in a short period of time.
Congratulations to Hospital for Special Care on its achievement as the first autism center in the United States to achieve the PCSP certification. To learn more about Sunrise, visit our website.
Because every minute counts, healthcare professionals shouldn’t have to reinvent the wheel to achieve great outcomes. Not when Allscripts SunriseTM clients are ready to share best practices with each other to advance health care.
That’s what Allscripts Client Outcomes Collaboration Program (COCP) is all about. Launched earlier this year, this program features ready-to-use tool kits with workflows and clinical performance management (CPM) reports associated with outcomes proven successful by Sunrise clients.
How one client is using the best practices “gold mine”
One of the most active users of the COCP is Sunrise client Appalachian Regional Healthcare System (Boone, North Carolina, U.S.A.). In a recent case study with ARHS team members, we learned more about how they’ve implemented Clinical Performance Management (CPM) reports.
“Finding the COCP was a gold mine for me,” said Systems Administrator Lindsay Grove. “We’ve implemented four of the CPM reports so far for procedures and topics that are globally of interest in health care.”
For example, Health First (Rockledge, Florida, U.S.A.) and Blessing Hospital (Quincy, Illinois, U.S.A.) shared through a COCP monthly webinar how they are using Sunrise to decrease Central Line Associated Blood Stream Infections (CLABSI). Grove helped implement these ready-to-use CPM reports, which are now populating to set a baseline for procedures to reduce CLABSI.
“We’ve been talking with our infection control staff about the CLABSI dashboard,” Grove said. “We found that line removal is not consistently documented, so it’s already helped us identify where we can improve clinically.”
Other CPM reports that the organization has adapted from the COCP include nutrition, medical necessity checking and ICU delirium. Borkowski explained that once the IT team establishes solid baseline reports in each of these areas, they will share the information with clinical and quality team members through the organization’s IT steering committee.
“I’ve been really impressed with COCP, especially the availability and willingness to help from Allscripts…we got to the right experts really quickly,” Grove said.
What’s next for the Client Outcomes Collaboration Program
We’re encouraged by clients like ARHS who have been able to quickly adopt best practices from fellow clients. The CPM reports don’t require extensive programming knowledge, and working closely with ARHS has helped us improve our tool kits to make them even easier and more efficient to adopt.
We continue to offer monthly webinars on timely healthcare topics, such as reducing the incidence of ICU delirium and sepsis. If you’re interested in learning more about successful workflows in Allscripts Sunrise, join the conversation in our ClientConnect community today.
When prescribing medications, physicians base it on the weight of the patient. Pediatricians are constantly scaling doses to fit their patients, increasing the risk of errors.
To ensure patient safety, Phoenix Children’s Hospital (Phoenix, Arizona, U.S.A.) wanted to find an enhanced solution to Dose Range Checking (DRC) to help its clinicians during order entry. Phoenix Children’s Hospital Chief Medical Information Officer, Dr. Vinay Vaidya, M.D., shared more information in a recent Client Outcomes Collaboration Program webinar. The positive results were also published in an article in the Journal of Patient Safety.
Phoenix Children’s had three goals for this project. First, given the importance of pediatric patient safety, it wanted to move quickly. Second, it wanted to take a phased approach, addressing high-risk, high-frequency medications first. And third, it was striving for zero prescribing errors.
Unfortunately, there weren’t any commercially available, pediatric-specific, plug-and-play DRC applications. But because Phoenix Children’s has Allscripts SunriseTM, which is an Open platform, it could rapidly change its configuration with a medical logic module (MLM).
How a single MLM simplified complex configurations
Phoenix Children’s recognized the complexity of configuring hard and soft limits for hundreds of drugs. The traditional approach is to configure one limit at a time. But Phoenix Children’s took a more efficient approach and created one single DRC reference table and a single MLM.
In just four months, this MLM brought 604 dosing rules to the system – far more than the 75 rules previously available. Those rules will trigger alerts if a physician prescribes a dose that falls outside a standard range. Physicians who receive the alerts have the opportunity to review the order and either change or override it, depending on the best interests of the patient.
The system has been in place for more than three years. It triggers about 30 alerts every day – or 3% of the drug orders at Phoenix Children’s. Of the 330 hard stops each month, 90% resulted in modified orders. Another benefit of the MLM was that it reduced “alert fatigue” when it decreased daily dose range alerts from 20% to 3%.
Allscripts Sunrise clients can find more detail about Phoenix Children’s DRC MLM in a solution guide and webinar presentation. To learn about the next webinar, visit the Client Outcomes Collaboration Program site on ClientConnect.
Central Line Associated Blood Stream Infection (CLABSI)* is one of the most deadly hospital-acquired infections in the U.S. with a mortality rate of 12% – 25%. CLABSI can add up to 20 days to a patient’s hospital stay and carry additional healthcare costs estimated at $16,550 per case.
Proven prevention techniques can reduce CLABSI incidence by 65% – 70%. Health First (Rockledge, Florida, U.S.A.) and Blessing Hospital (Quincy, Illinois, U.S.A.) shared in a recent client webinar how they are using Allscripts SunriseTM and best practices to decrease CLABSI.
Blessing Intensive Care Unit (ICU) has had zero CLABSI cases in 3 years
Blessing ICU Nurse Manager Kim Buck, RN, described how her organization uses Sunrise to guide clinicians through best-practice central line protocols. “Monitoring and charting patients through Allscripts Sunrise has contributed to our ability to have zero infections,” she said.
Four key process steps to ensure best practices include:
1. Present on Admission Documentation – This step enables clinicians to document an infection if it’s present upon arrival or triage.
2. Insertion/Removal Documentation – Requires adding a date, time and reasons for insertion and removal. If an indication field is missing, the clinician will receive an alert when he tries to save the flowsheet.
3. Protocol Adherence – Reminds clinicians to follow evidence-based guidelines, proven to reduce incidence of CLABSI, including hand hygiene, appropriate insertion site and a required request for line discontinuation after seven days.
4. Reporting – Dashboards help clinicians view patient information in multiple ways, which can help clinicians quickly address any variations from standard protocols.
According to Health First Director of Infection Control Paul Yates, “Across our Integrated Delivery Network including four-hospitals, we want to leverage the EHR [electronic health record] with every patient, every central line, every day.” He notes that while better outcomes for patients is Health First’s top priority however, there are also financial aspects to consider. Payments can be denied when CLABSIs are billed as a complication.
CLABSI cases are decreasing across the country, and I believe improved technology workflows are playing a role in that achievement. Thanks to both Health First and Blessing Hospital for sharing their best practices through our Client Outcomes Collaboration Program.
If you’re interested in learning more about successful workflows in Allscripts Sunrise, join the conversation in our ClientConnect community today. Our next webinar on Pediatric Dose Range Checking featuring Phoenix Children’s Hospital will occur on May 27 at noon ET. Click here to join.
* Source for all CLABSI statistics: US Centers for Disease Control and Prevention. Vital signs: Central line–associated blood stream infections—United States, 2001, 2008, and 2009. MMWR Morb Mortal Wkly Rep. 2011 Mar 4; 60 (8):243–248.