Evidence-Based Practice

Northwest Hospital moves from traditional QI program to disease-specific initiatives 

Seattle-based Northwest Hospital (NWH) is a 250-bed private, not-for-profit community hospital that has a In-year history of using pathways and guidelines to support its clinical duality improvement (01) initiatives. Until recently, however, the process hasn't been as effective in improving practice as they'd anticipated considering the amount of effort that was being dedicated to developing and implementing the guidelines and pathways. At best, they were used 50% of the time to manage patient care.

 "In the past 18 months we've completely reorganized our clinical programs, says Gregory P Schroedl, MD~ vice president, medical quality and information. "Our primary focus now is to measure just a few key, evidence-based indicators for specific disease states.

He adds.' Historically, we attempted to measure too many indicators, many of which were based on opinion. As a result, our success in holding clinicians accountable for the outcomes was somewhat limited.

WORKING SMARTER

 NWH's new disease-specific 01 programs include three components--the evidence-based key indicators (three to lour for each initiative), outcomes measurement (mortality and complications), and resource utilization (length-of-stay charges).

Three clinical practice improvement projects are fully operational-management of acute myocardial infraction (.4Ml), ischemic stroke, and total joint replacement surgery...The key indicators for each initiative were selected based on our Institution specific performance in meeting the evidence-based practice standards says Schroedl. Two additional projects congestive heart failure and community acquired pneumonia--will be launched later this year.

In large part, NWH's new QI attitude is being fostered by the use of the Evidence-Based Forecaster (EBF), a Web-based tool developed by Zynx Health, Inc., a subsidiary of the Cedars-Sinai Health System, Beverly Hills, CA.

Using hospital-specific data, the EBF calculates the absolute risk and relative risk reduction for mortality and associated morbidities as they relate to level o~ Use of key aspects of care proven in the literature to be efficacious (see figure I). Key aspects of cost can be calculated as well.

Similarly. a companion tool, the Clinical Pathway Constructor (CPC), provides evidence-based content for organizations to create customizable inpatient pathways that are compatible with the key aspects of care identified for each improvement initiative Information is available on the 23 diseases and conditions that represent a majority of all hospital admissions in the United States.

PHYSICIAN BUY-IN MADE EASIER

NWH uses the EBF to quickly execute the most critical activity of any 01 initiative-gaining physician buy-in. An example of how NWH has been able to use the EBF to effect measurable improvements in clinical practice relates to the prescription of aspirin (ASA) for patients with acute myocardial infarction (AMI).

At the outset of the AMI initiative, the rate Of aspirin use was 85%. a relatively high percentage considering the national averages. But.after running Its AMI population data through the EBP AMI module· NWH determined that improving ASA usage to 95% would result in one less death per year.

 "The risk reduction data painted a compelling picture for the cardiologists to want to make that 10"/, improvement." says Schroedl.  "and It also made it much simpler to get them to agree on a system that would ensure that every appropriate AMI patient gets aspirin."

NWH has since modified a typical procedure for the use of "standing'. orders. Instead of having a physician check a box to order ASA, the admission AMI orders include ASA as a default order unless the physician indicates that it's contraindicated. An electronic pharmacy ordering system provides secondary verification that the ASA isn't contraindicated.

STAYING FOCUSED AND KEEPING PACE

 The NWH 01 program was also designed to concur with the performance improvement standards established by the Joint Commission on Accreditation of Healthcare Organizations and the Health Care Financing Administration's Sixth Scope of Work.

The task was made much simpier because the core measures for JCAHO and HCFA are incorporated in each of the EBF and CPC modules--inpatient care of patients with heart failure, community acquired pneumonia, adult asthma, and ischemic stroke; and preventive care for mammography and diabetes screening Additionaily… because the evidence that supports the EBF and the CPF modules is continually updated, the most current information is always available to its users.

"We're using a grid of the lCAHO and HCFA standards to compare our current and future QI initiatives to determine what areas still need to be addressed,” says Schroedl.

THE COST OF QUALITY

For a small community hospital such as NWH, the investment in the evidence-based practice tools offered by Zynx Health is visionary. The annual subscription fee, which is based on hospital size, starts at $8.000 for a single product And. while NWH hasn't done a cost analysis to determine if use of the tools has reduced the administrative costs for its QI program. Schroedl is confident that they've resulted in improved productivity.

He notes that "The teams are spending significantly less time hunting down the current evidence related to care processes, the overall data collection process is much more focused and efficient, and the staff time spent creating and revising pathways has been minimized.. The tools are also compatible with NWH's existing databases.

Cost savings associated with the delivery of evidence-based care are demonstrable. For example, treatment costs for patients with community-based pneumonia can be appropriately reduced by eliminating the use of chest physiotherapy (PT) for patients with simple primary pneumonia, because it isn't an efficacious intervention. With an average cost of $37 per treatment (and five total treatments), the approximate cost savings per year is $4.800, if chest PT is avoided in IO patients among every 275 admitted.

The bottom line is that any intervention or strategy that quickly gains and maintains physician support for evidence-based practices proven to enhance patient outcomes is in the words of those credit card commercials--priceless.

For more information about Zynx Health, visit hllp:www.zynx.com, or cal 310-247-7700
Editor's note: Scott Weingarten, MD~ presidenl/CEO of Zynx, Inc., is a member of the COR Clinical Excellence Editorial Advisory Board. ML

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