BMC Joins the Age-Friendly Health System Community

To better support older adults and improve their health outcomes, health systems must put in place comprehensive, coordinated evidenced-based models that better deliver care to the growing aging population.

In September 2018, BMC joined John A. Hartford Foundation-Institute for Healthcare Improvement’s (IHI) Age-Friendly Health System Community in spreading age-friendly care with the goal of reaching 1,000 US hospitals and 1,000 medical practices by December 2020.

BMC is working towards a comprehensive approach to implementing best practices under the 4Ms (What Matters, Medication, Mentation, and Mobility) for each patient 65+ admitted to the hospital.

BMC is well on its way to becoming an Age-Friendly Health System!

Success of New Hyperglycemia Crisis Management Guideline

In AY2018 the Endocrine Subcommittee of the Pharmacy and Therapeutics Committee rolled out changes to the longstanding BMC Hyperglycemic Crisis Management Guideline, which had been in use for more than a decade.  A QI project done the prior year had shown higher rates of hypoglycemia (blood glucose (BG) <70) in patients after up-titration of the insulin infusion drip, in particular to doses of >0.14 unit/kg/hour of insulin.  These patients had a 3-fold higher rate of hypoglycemia, and in 60% of patients treated at this dose needed to have the drip stopped to prevent hypoglycemia (Figure 1).

Led by Dr. Sara Alexanian the Director of Inpatient Diabetes Program and Quality Leader in the Section of Endocrinology, a multidisciplinary group including en

docrine, pharmacy, nursing and IT came together to create an updated guideline.  The process included reviewing  primary literature supporting current hyperglycemic crisis management, review of national standards as well as protocols at outside institutions.  Based on this review a new guideline was developed.  Major changes included:

1. Removal of default increases in the insulin infusion rate, and
2. An updated insulin titration algorithm based on solid published evidence.

Subsequently there were several months of ED and ICU nursing education, including - in-services by endocrine and pharmacy, as well as a required Health Stream course.   The new guideline was rolled out in September 2019.

Three months after the release of the new guideline, a chart review was done on the 40 patients who were treated with the new algorithm compared to 35 patients on the prior protocol. There was a 60% reduction in hypoglycemia (26% on the prior protocol down to 10% on the new protocol, Table 1).  Furthermore the total episodes of hypoglycemia decreased with the new protocol, as did the number of times the drip needed to be stopped to prevent hypoglycemia.  Further analysis showed that despite the lower rates of hypoglycemia, there was no significant increase in the time to DKA resolution.

The multidisciplinary  workgroup continues to engage with nursing to improve the guideline.  Based on feedback, new changes include making minor adjustments to the insulin titration algorithm and making the transition to dextrose-containing fluids a default in the order set to ease nursing work-flow.  Furthermore, when substantial discrepancies occur between the ED and ICU weights, the nurse will be prompted to adjust the infusion dose appropriately for weight obtained on admission to the ICU. These changes are expected to go live in the fall 2019 with the hope of reducing hypoglycemic events further!

BMC Quality Goals for Fiscal Year 2020 (FY 20)

Reducing Preventable Harm Index (PHI)

PHI is comprised of the 4 major Hospital Acquired Infections (HAIs) with a goal of 1.0 (YTD 0.84):

• Catheter associated urinary tract infection (CAUTI),
• Central Line Associated Bloodstream Infections (CLASBI)
• Hospital acquired Clostridium difficile infections (CDIFF) and
• Methacillin-Resistant Staph aureus bacteremia

The PHI also contains several perioperative/periprocedural complications and “never events” such as falls, pressure ulcers, and iatrogenic pneumothorax. The post-procedural complications followed most closely in internal medicine are venous thromboembolic events, hemorrhage/hematoma and development of acute kidney injury.

This year marks a major change in BMC’s approach to the monitoring and goal setting for HAIs .  We are shifting from rates and standardized infection ratios to simply following counts as we try to “chase zero” with the goal of zero events for each floor team. Following infection counts will allow us to assess and respond more quickly as an organization. Goal counts are in the table below.

If your team is following a patient who develops an HAI, please respond to the nurse manager’s request to meet to assist in the preparation of a preventability analysis.

Reducing Mortality

• BMC’s O/E (Observed to Expected) mortality for FY2019 was 0.79 below the goal of <0.84.
• BMC’s O/E Mortality Goal for FY2020 is 0.77 which places BMC in the top 25th percentile nationally in mortality compared to other academic medical centers.
• What can I do?
• Capture severity of illness by documenting all significant conditions in the H&P.
• Engage Serious Illness Support Services for patients who have been identified as being at high risk of mortality in the next 6 months for discussions on advance care planning.
• Refer BMC patients who are Comfort Measures Only patients for inpatient hospice screening.

BMC Physician Quality Leaders

In July 2016, BMC reorganized the Physician Quality Leaders, funding fewer quality leaders but giving each more responsibility and time to actually get things done.  They report to Dr. James Moses, BMC Chief Quality Officer, and address patient safety events as well as promote hospital quality initiatives.  They are also tasked specifically to work with residents and help mentor resident projects and ideas!!  Faculty and house staff, please reach out to the physician Quality Leader or the Medical Directors in your area of interest.  The current physician Quality Leaders are:

• Chris Andry, PhD — Lab and Pathology
• Willie Baker, MD — Emergency Medicine
• Glenn Barest, MD — Radiology
• Lisa Caruso, MD, MPH — Medicine (including Family Medicine, Neurology, Psychiatry, and all subspecialties)
• Elizabeth Hutton, MD—Pediatrics
• Ron Iverson, MD, MPH — Obstetrics/Gynecology
• David McAneny, MD — Surgery (including all subspecialties)
• James Murphy, MD — Critical Care (MICU, SICU, CCU), Medical Director of Inpatient Quality
• Lauren Nentwich, MD — Emergency Medicine
• Susan O’Horo, MD — Interventional Radiology
• Susannah Rowe, MD, MPH — Ophthalmology