Ambulatory Safety Nets: Catching Cancer Diagnoses

10/1/19

For this post, we asked one of our Department of Quality and Safety medical directors, Sonali Desai, MD, MPH to discuss a safety improvement initiative related to patient diagnoses of cancer.

We have all been susceptible to the effects of multi-tasking: you unlock your smartphone to call someone, but are interrupted by an incoming text message, followed by an email from your supervisor. Before you know it, you have forgotten what you were doing with your phone in the first place. Health care is no different  —  the rapid pace of delivering care in the ambulatory setting, coupled with the wealth of data to process complex medical decisions, poses a similar multi-tasking risk to busy clinicians. What often keeps clinicians up at night is worrying about missing a diagnosis of cancer due to not following up on an abnormal test result.

You may wonder, how could this happen? Imagine that you undergo a CT scan of your chest for shortness of breath — although a serious diagnosis such as a blood clot or lung cancer is not found during the exam, a small incidental lung nodule is discovered. The nodule may or may not lead to cancer, but it often requires a follow-up CT scan in several months, or up to one year.

Or, consider a colonoscopy to screen for colon cancer that detects a few polyps.  These polyps are not cancerous but they warrant another colonoscopy be performed in a few years. The issue with these follow-up exams is that physicians’ offices often do not have reliable recall systems to ensure that all patients with incidental lung nodules or abnormal polyps return for the repeat testing they need months or years from when the first test was done – this is how something can fall through the cracks.

Recently at Brigham Health, we  piloted the concept of Ambulatory Safety Nets to help catch potential findings that could lead to cancer diagnoses, modeled after work done through the Kaiser Permanente SureNet programs.1 Ambulatory Safety Nets provide a way to help offload the cognitive burden on busy clinicians by creating a team that can help to centrally identify, coordinate, contact and track patients who need follow-up tests. At the Brigham, this project is being piloted for colon and lung cancer screenings. Ambulatory Safety Nets take a more proactive and centralized approach that can leverage technology to work closely with primary care practices. In our early efforts for the colon cancer safety net, we have been able to complete over 200 colonoscopies for patients at-risk for colon cancer based on abnormal prior colonoscopies and symptoms such as rectal bleeding and iron deficiency anemia. To date, we have identified at least one patient with a high-risk precancerous finding requiring surgery and several patients with polyps.

For our lung cancer safety net, we have found over 300 patients with incidental lung nodules using artificial intelligence on radiology reports. We have developed follow-up care plans with primary care and radiology for determining whether patients need further imaging or referral. We have launched a new program, Radiology Result Alert and Acknowledge for Development of Automated Resolution (RADAR), which leverages a web-based radiology result notification system to create collaborative care plans between radiologists and ordering clinicians, assists with scheduling and patient outreach of follow-up imaging, and tracks whether appropriate care has been delivered to patients.2

Reducing the burden on our physicians and developing an engaged team has provided the opportunity to raise the standard of care that we provide to our patients. We are working on expanding our pilot to encompass more preventive opportunities in breast, cervical and prostate cancer and to design safety nets for ambulatory medication errors and diagnostic errors.

References:

1 Emani S, Sequist TD, Lacson R, Khorasani R, Jajoo K, Holtz L, Desai S. Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer. Jt Comm J Qual Patient Saf. 2019 Jul 05. PMID: 31285149

2 Hammer MM, Kapoor N, Desai SP, Sivashanker KS, Lacson R, Demers JP, Khorasani R. Adoption of a Closed-Loop Communication Tool to Establish and Execute a Collaborative Follow-Up Plan for Incidental Pulmonary Nodules. AJR Am J Roentgenol. 2019 Feb 19; 1-5. PMID: 30779667

The Conference for Professionals Who Plan, Manage, or Support Quality and Safety Initiatives

9/18/19

Within both ambulatory and inpatient settings, there is mounting pressure to improve quality, safety and efficiency. The key question, however, is how? Attendees of the 2019 Healthcare Quality & Safety Conference will leave with evidence-based quality and safety strategies from Brigham Health and Harvard Medical School leaders that will enable them to effectively execute these approaches for sustainable daily practice. This year, the conference will have a new addition of quality and safety in radiology.

At the internationally attended conference, professionals come together to learn from each other’s experience towards improving our systems. The conference will take place on Nov. 6 and 7, at the Wyndham Hotel in Boston. To learn more about the conference and register, visit the conference website: https://quality.bwh.harvard.edu.

Topics include:

  • Health care quality and compliance
  • Innovative care delivery
  • Learning health systems and high reliability
  • Leveraging technology to advance care and improve quality performance
  • Improving patient and provider experience
  • Leadership and governance
  • Quality and safety in radiologyHealthcare Quality and Safety Picture

Quality Measurement for Clostridium Difficile Infection: Turning Lemons into Lemonade

May 20, 2019

For this post, we asked one of our Department of Quality and Safety medical directors, Marc Pimentel, MD, MPH, CPPS, to discuss hospital-acquired health conditions, specifically quality measurement for Clostridium difficile (C. difficile), an infection that can occur in the hospital after receiving antibiotic medicine.

We use quality measures to drive improvements in caring for our patients — focusing our efforts on preventing patient falls, blood clots and infections. Quality measures, such as how often we wash our hands, help us focus efforts on our trouble spots. Quality measurement is not perfect, but what if a hospital’s measured rate of patients who get a C. difficile infection was off by 20–40 percent? Could we still use this quality measurement for improvement?

In an article published last year in BMJ Quality and Safety, Brigham Health experts wrote about how pursuing a seemingly imperfect measurement still led to improved care. During hospital stays, up to 15 percent of patients will have diarrhea, usually from medication side effects or their own illness.

For some of our patients, there’s another reason: C. difficile infection, which causes up to 20 percent of inpatient diarrhea, usually as a complication of receiving antibiotic medicine. When patients have diarrhea in the hospital, we often send a test for C. difficile in hopes of identifying a treatable cause for the diarrhea.

Unfortunately, the test (like most) is not perfect. Because C. difficile is part of the normal gut flora, at least one out of five patients will have a false-positive test result for C. difficile. Despite this issue, we still count every positive C. difficile result toward our infection rate to allow hospitals to compare their performance to each other, without having to review every single case. Unfortunately, this method of reporting can lead to artificially inflated rates of C. difficile infections in our quality measures.

A team at the Brigham took the time to understand all our care processes that contribute to our positive C. difficile tests. We found several items to address, such as our clinician education for proper testing and interpreting the results. After this and other efforts were performed, such as improving our room disinfection practices, we were able to reduce our measured infection rate by 30 percent, while improving the accuracy of our quality improvement data.

This work has led to more transparency and trust from our patients that we are ensuring delivery of high-quality care and their safety, always.

Promoting Opioid Safety for Student Athletes

March 6, 2019

Scott G. Weiner, MD, MPH, a medical director in the Department of Quality and Safety and director of the Brigham Comprehensive Opioid Response and Education (B-CORE) program at Brigham and Women’s Hospital, discusses promoting opioid safety for student athletes.

The opioid epidemic continues to take a record number of lives in this country — 47,600 people died from opioid-related overdoses in 2017 (1). It is staggering to see that the average U.S. life expectancy has declined over the past two years, which is attributed mainly to preventable deaths, such as those caused by drug overdose (2).

To ultimately solve the opioid epidemic, an important step is working to prevent new cases of opioid use disorder from occurring. I like the mantra: “keep patients opioid naïve whenever possible.” If you don’t start taking an opioid, then you can’t get hooked on one. Of course, I don’t advocate for undertreating pain, but multiple studies about conditions ranging from back pain (3) to hip replacement (4) demonstrate that non-opioid pain relievers like ibuprofen and acetaminophen work just as well as opioids for many types of acute pain. From a safety perspective, Brigham and Women’s Hospital has also demonstrated that, for inpatients, adverse reactions to opioids are quite common (5).

One of the most at-risk groups for developing an opioid use disorder is athletes. Think about it: Athletes are prone to injury, particularly at the elite level. Sometimes, despite better judgment, athletes want to do whatever it takes to get back to their sport, even when not completely healed. Several colleagues and I collaborated with athlete Alex White, an alumnus of Harvard University, who had suffered a sports-related injury while in school. We spoke to him about the mindset of an injured athlete amidst the opioid epidemic. Combine that desire with lenient opioid prescribing and a recipe for disaster is created. Athletes need to know the dangers of these opioids, the fact that non-opioids can work just as well as opioids, and — most importantly — that opioids only mask pain so the body thinks it’s healed.

The Brigham is grateful for a donation from two non-profit organizations, Hanging with Ted and the ADK Charities, to create a video (see below) for student athletes that educates them about opioid use. Our goal is to have student athletes and their families view the video and be prompted to talk to their physicians about how to safely take opioids if prescribed and discuss alternative pain-relief options. We encourage you to share the link widely with your network.

Alex White, the student athlete featured in the video, has experience with sports-related injuries, but has not personally experienced opioid misuse or dependency. An earlier version of this post incorrectly stated that Alex had struggled with opioid dependency.

Additional Resource:

References:

  • Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. Drug and Opioid-Involved Overdose Deaths – United States, 2013-2017. MMWR Morb Mortal Wkly Rep. 2018 Jan 4;67(5152):1419-1427.
  • NBC News. U.S. life expectancy falls for second straight year — as drug overdoses soar. Available at: https://www.nbcnews.com/storyline/americas-heroin-epidemic/u-s-life-expectancy-falls-second-straight-year-drug-overdoses-n831676
  • Friedman BW, Dym AA, Davitt M, Holden L, Solorzano C, Esses D, Bijur PE, Gallagher EJ. Naproxen with Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for Treating Acute Low Back Pain: A Randomized Clinical Trial. JAMA. 2015 Oct 20;314(15):1572-80.
  • Thybo KH, Hägi-Pedersen D, Dahl JB, Wetterslev J, Nersesjan M, Jakobsen JC, Pedersen NA, Overgaard S, Schrøder HM, Schmidt H, Bjørck JG, Skovmand K, Frederiksen R, Buus-Nielsen M, Sørensen CV, Kruuse LS, Lindholm P, Mathiesen O. Effect of Combination of Paracetamol (Acetaminophen) and Ibuprofen vs Either Alone on Patient-Controlled Morphine Consumption in the First 24 Hours After Total Hip Arthroplasty: The PANSAID Randomized Clinical Trial. JAMA. 2019 Feb 12;321(6):562-571.
  • Urman RD, Seger DL, Fiskio JM, Neville BA, Harry EM, Weiner SG, Lovelace B, Fain R, Cirillo J, Schnipper JL. The Burden of Opioid-Related Adverse Drug Events on Hospitalized Previously Opioid-Free Surgical Patients. J Patient Saf. 2019 Jan 21. [Epub ahead of print]

Continuous Quality Improvement: It’s a Bit Like “Groundhog Day”

A large, multi-ethnic audience in a movie theater, watching a movie, eating popcorn and drinking soda. The group of people are mixed ages, including children, teenagers, young adults, mid adults and mature men and women, families, friends and couples.In this piece, Jen Beloff, MSN, RN, APN, executive director of Quality and Safety at Brigham and Women’s Hospital, looks at how we use continuous quality improvement to identify and solve program and process challenges.

February 1, 2019

If you are working in a health care setting, you’ve undoubtedly heard of the term “Continuous Quality Improvement (CQI)” to describe the process of systematically identifying, delineating and analyzing a quality or safety problem, testing, implementing and learning from the process, and then repeating the process.

It’s a bit like the movie “Groundhog Day,” where Phil Connors, played by Bill Murray, repeatedly relives the same day, known as Groundhog Day, turning moments of monotony and at times hopelessness into opportunities for enlightenment and decisive action.

Despite being stuck in a perpetual time loop, Phil continuously learns from his daily observations and associated outcomes, and adapts his behavior and processes, sometimes leading to a different and often more positive outcome the next day.

The same can be said of introducing successful quality and safety improvement initiatives in health care. Creating a shared need and vision, gaining stakeholder support and implementing and sustaining improvement initiatives can often feel like you are waking up every morning in a perpetual time loop. This is partially because most quality and safety improvement initiatives will not be solved with one fix. Designing for continuous improvement and success means your work is never done. Some interventions simply won’t work, and that is perfectly OK.

Take, for example, Catheter-associated Urinary Tract Infection (CAUTI) prevention. In 2009, Brigham leadership and care providers formed a multidisciplinary taskforce charged with reducing the rate of infections related to urinary catheter devices. Over the last decade, the taskforce has implemented close to 50 interventions, such as back-to-basics education and the development of clinical-decision support. Some interventions were more successful than others, like eliminating yeast from the CAUTI definition and cancelling urine cultures for those patients with a negative urinalysis.

Just as Phil eventually learns to incorporate the knowledge gleaned from one day into the next, so too can quality improvement leaders. We strive to transform the monotonous and sometimes frustrating moments of quality and safety program implementation into moments of ingenuity and innovation, ultimately leading to better patient outcomes and experiences.

As I compare the 2009 and 2019 CAUTI Taskforce improvement plans, I can’t help but reflect on the fact that many of the initiatives are eerily similar. However, like Phil, I also know that tomorrow is a new day and that we will apply the lessons and successes of the past 10 years to advance the cycle of continuous quality improvement. Our CAUTI standardized infection rate at the Brigham is down 34 percent since we first started publicly reporting it in 2012 and I know through our efforts we will continue to improve.

 

-Jen Beloff, MSN, RN, APN, executive director, Quality and Safety

 

Reference:

“Groundhog Day.” Directed by Harold Ramos et al., Columbia Tri Star Home Video, 2002.