AT HOSPITAL MEDICINE 16
SAN DIEGO (FRONTLINE MEDICAL NEWS) – Hospitalists looking for ways to reduce costs and make their patients safer might learn strategies from the TV game show “Shark Tank.”
Shark Tank is a reality television show in which aspiring entrepreneurs make business presentations to a panel of “shark” investors, who then choose whether or not to invest. During a session at the annual meeting of the Society of Hospital Medicine, entrepreneurial hospitalists did something similar. They divided themselves into five teams that had 20 minutes to pitch a bright idea to avoid unnecessary care, even if it meant overcoming long traditions and resistance from powerful leadership.
The hospitalist “contestants” faced three “sharks” – all veteran “cost of care–conscious” hospitalists – who each had $100,000 in fake dollars to invest. The sharks emphasized that the idea behind the game was to incentivize hospitalists to think creatively, outside of their routines.
Dr. Christopher Moriates, director of the University of California, San Francisco, Caring Wisely program and of implementation initiatives at Costs of Care, a leader of the session, did not expect that all the “entrepreneurial” ideas presented would work in every setting, but some were likely to be useful as ways to examine hospitalist routines that no longer really make sense. For instance, Dr. Moriates said that, during his residency, “a ritual I wrapped myself in … like stirring milk into my coffee … was, in the morning I’d make my list, I’d look at peoples’ labs, and repeat the potassium like a ninja,” whether it was needed or not.
Dr. Moriates noted that the “Think Twice, Stick Once” program at UCSF to reduce unnecessary phlebotomy draws is one example hospitalist “entrepreneurs” could model. When it was proposed, “It made a lot of doctors in our hospital uncomfortable,” he said. “Most of our colleagues did not really care about saving a CBC. But they did care about their patients, so when we reframed the idea as ‘sticking your patients, the 4 a.m. phlebotomist waking you up,’ that seemed to resonate more.”
Dr. Vineet Arora, director of GME Clinical Learning Environment Innovation at the University of Chicago and educational initiatives at Costs of Care, one of the three “sharks,” said the entrepreneurial teams’ ideas should include processes that are sustainable across nurses and doctors. Can clinicians “walk into a room and see, ‘Oh that Foley is not indicated?’ “ Dr. Arora asked. “It turns out that stopping something is a lot harder than starting something … so you need to train people to think, ‘How do I figure out what to stop.’”
The two other “sharks” were Dr. Reshma Gupta, director of the joint Costs of Care/American Board of Internal Medicine Foundation Teaching Value in Healthcare Learning Network, and September Wallingford, director of operations for Costs of Care and a registered nurse at Brigham & Women’s Hospital in Boston.
In the tank
First up in the conference competition were the “Cheetahs,” led by Dr. Mohamed Morad, a hospitalist at Ball Memorial Hospital in Muncie, Ind. His team said patients are often put on telemetry without indication, and stricter guidelines would reduce that overutilization. “A lot of physicians are not aware or they’re not following guidelines,” he said, and nurses “don’t have a say in deciding who should be on telemetry or not.”
During an interview, Dr. Morad noted telemetry is important for patients suspected of stroke or transient ischemic attack, or who have cardiovascular risks. But others get telemetry unnecessarily. That adds significant costs, ranging from around $400 per patient, but telemetry increases alarms, and thus alarm fatigue. “You have to ask, is it doing a good job, or causing a lot of distraction and not really helping the patient?” Dr. Morad said.
Out of the $300,000 the sharks had to distribute, the Cheetahs received $55,000.
The Top Values team, led by hospitalist Dr. Jason Meadows, assistant attending at Memorial Sloan-Kettering Cancer Center in New York, proposed “X to the O2,” to reduce the number of patients on oxygen. “There’s a lot of evidence showing toxicity with high levels,” Dr. Meadows said. “And patients who are tethered (with a cannula) can have an increase in delirium and falls.”
The Top Values proposed stricter protocols to reduce automatic oxygen “and daily monitoring to make sure the patients still need it.”
“I love this idea,” said “shark” Dr. Arora. “I see this a lot on rounds. … Often on the day of discharge I ask how come this patient is on oxygen? I think there’s a reflex here … to have patients on oxygen even when it’s not ordered.” The Top Values team received $60,000.
The third team, “Value Attack,” named their pitch “Push to the PO,” to reduce unnecessary administration of IV antibiotics when cheaper, safer oral dosage works equally well, said Dr. Amber Moore, a hospitalist at Beth Israel Deaconess Medical Center in Boston.
Often, Dr. Moore explained, ED patients are put on an IV if an infection is suspected. “Then they come up to the floor, and the patent stays on IV antibiotics longer than they need it,” even after infection is ruled out.
IV administration has drawbacks. First it’s expensive, she said. “Levaquin IV is $15, but p.o. is $3. PPI [proton pump inhibitor] is $144 IV but $4 p.o.” And there are other problems such as patients’ pain, having multiple IVs, more nursing care, and more time administering the IV.
The Value Attack’s pitch included enlisting speech and swallowing experts to advise when oral antibiotic doses can substitute. Their idea generated $50,000.
Another team, the “Invaluables,” proposed “Just in time discharge” which would use night hospitalists to discharge patients in the evening, if they’re ready to go home and a ride is available, instead of waiting until morning. Dr. Peter Kaboli, chief of medicine at Iowa City VA Medical Center, said at his hospital, as many as 2 patients of up to 12 discharged a day might be able to go home 15 hours earlier, alleviating boarding in the ED for patients who otherwise wait overnight.
“Our culture is that patients don’t leave after 6 p.m.,” even if they’re ready to go, and a ride is ready, Dr. Kaboli said. He acknowledged the concept is not yet based on evidence, “so we’re kind of sticking our necks out here, but nothing ventured, nothing gained.” The team proposed testing discharges by night shift hospitalists. Their idea was awarded $50,000 by the sharks.
The winning Shark Tank team was the Cost Cutters, who proposed “Standup to Syncope” as their project. Dr. Celene Goetz, a hospitalist at Mount Sinai Medical Center in New York, said all too often, healthy nontrauma patients come into the ED because they fainted, usually because they were dehydrated and called 911, and receive a costly head CT scan and unnecessary radiation exposure.
For many of these patients, taking orthostatic vital signs would rule out CT and reduce admissions, not to mention time in the ED. The problem, she explained in an interview, is that ED physicians don’t do the orthostatic, which requires 5 minutes or more of monitoring the patient’s blood pressure.
“That takes so much of a practitioner’s time, and it’s just easier to order the head CT and put a patient on telemetry,” Dr. Goetz said, noting that ED physicians are often worried about lawsuits from missing a stroke or intracranial hemorrhage.
In a poster presented at the conference, Dr. Goetz reported on 162 patients presenting to the ED with syncope. Of these, 71, or 43.6%, got a head CT, and half of these were inappropriate according to American College of Emergency Physicians’ recommendations. Additionally, “none of the head CTs identified an intracranial bleed or changed management.” Further, “if inappropriate head CTs were not ordered for this group of patients, the hospital could have saved at least $8,680 per year,” Dr. Goetz said.
The “sharks” said this was the best idea, and awarded the winning Cost Cutters $70,000.
