After successful efforts in 30-day heart failure readmission prevention, a decrease in length of stay (LOS) for Caesarean section (C-section) deliveries, and a decrease in sepsis mortality and patient LOS, a community hospital in Homestead, Florida, earned one of the most prestigious awards in healthcare information technology. Located in the heart of south Miami-Dade and part of Baptist Health South Florida (BHSF), Homestead Hospital (HH) is a recipient of the 2020 HIMSS Enterprise Davies Award.
HH joins a small group of healthcare organizations who have won a HIMSS Davies Award, but an even smaller group who have reached HIMSS Stage 6, Stage 7, and Davies, in the same year.1
“We’re a small facility 30 miles from the nearest hospital where people can come for their medical needs,” said Joan F. Baker, MSN, RN, CCRN, CNRN, CCPC, patient care manager. “We care for patients who are very sick. It’s phenomenal we are able to shine albeit all the challenges we have faced.”
30-day heart failure readmission prevention
Knowing the Centers for Medicare & Medicaid Services (CMS) assesses quality outcomes and has a fee specific to readmissions, HH staff examined their heart failure readmissions and explored various ways to reduce them.
“We looked at what the best practice was at each entity and what they were doing,” said Baker. “We decided to focus on patient education, families and community awareness, so we organized a support group and developed teaching materials for these patients.”
Beginning in 2011, with a blueprint for successful improvement in the 30-day CMS heart failure readmission rate, the continuous improvement process has taken the 30-day heart failure readmission rate from as high as 33.3% to as low as 11.1%.2 Additionally, the utilization of PowerPlans™ increased the heart failure bundle compliance rate from below the organizational benchmark of 30% to rates as high as 60%.3 Within the electronic health record, PowerPlans help facilitate comprehensive multidisciplinary planning and coordination of care for the patient in the acute care setting. They also provide clinicians the ability to individualize patient-specific, problem-driven plans of care, including multidisciplinary clinical pathways, care protocols and nursing care plans.
HH had a nurse do rounds on patients to see if they knew about their disease and help determine what they should do when they went home. The hospital also had discharge follow-up calls, and later found the readmission numbers were decreasing.
“We engaged pharmacists to help us because patients often didn’t know what they were supposed to do, which was a big problem on polypharmacy,” said Baker. “It helped provide medication for those who couldn't afford it so they could stay out of the hospital. We also looked at patients who qualified for hospice because then we weren't going to be penalized by CMS if someone really needed to come back in that situation.”
At one point, HH hired a full-time advanced practice nurse who not only completes rounds but also enters orders and collaborates with providers.
HH staff continues to configure PowerPlans to make them more user-friendly for the physicians.
“Our nurse practitioner is doing a great job in collaborating with transitions of care to reach out to these patients who have multiple admissions in the last six months to see how they can keep them out,” said Baker. “We are doing a great job providing education to the nurses and physicians.”
Decreased LOS for C-sections
To help address concerns with care delivery and improve the standard of care and outcomes of patients undergoing a C-section procedure, HH staff implemented PowerPlans in 2017.
HH also initiated an enhanced recovery after surgery (ERAS) pilot for elective C-sections. The goal is to serve as a supplement to current practices geared toward delivering a multidisciplinary approach to care with a defined multimodal perioperative care pathway. This is designed to reduce the stress response to surgery and accelerate a patient’s recovery. Analytics measuring the PowerPlans utilization helped support the measurement of adherence to the standard of care compliance. The overall LOS for the C-section population with the implementation of PowerPlans decreased from 3.0 days to 2.30 days.4
In addition to a decrease in overall LOS for C-sections, HH staff focused on combatting opioid use for post-operative care and saw improvements.5
“The decrease in opioid use for post-operative care means many of our patients have achieved non-opioid or multimodal pain relief through ibuprofen and acetaminophen,” said Charles Anderson Augustus, MD, OB/GYN. “You hear one-third of the people who get addicted to opioids first get introduced through post-operative care. And secondly, for pregnancy, breastfeeding moms are not exposing their newborns to amounts of excreted opioids in their breast milk. All these things mean potentially positive cognitive outcomes to babies, long term.”
The challenging population carries over into the obstetrical realm because HH sees patients with hypertension and diabetes. HH is the only place within a 30-mile radius where someone can deliver a child.
“We also experienced a large decrease in variable cost to the institution and patient who had the C-section6,” said Augustus. “The latest advancements in the obstetrics ERAS program were incredible. We're still reaping the benefits today because we have one of the lower uses of opioids throughout the whole hospital. Accomplishing that with a challenging population is even more special to me.”
“It was a huge satisfier for the patients,” said Julie Brandt, RN, perinatal services manager. “This checked all the boxes for us because we were decreasing our costs and length of stay, and improving how patients felt about being in the hospital.”
Improving sepsis bundle compliance
HH’s percentage of sepsis cases meeting bundle requirements — a series of responses a medical team takes to treat sepsis — was below benchmark, and there were opportunities to improve both mortality and LOS. When HH staff initiated the sepsis program, the goal was to examine patient mortality and morbidity as it pertains to sepsis and trying to meet CMS sepsis requirements.
“We implemented something called an internal sepsis code in April 2017,” said Sherine Craig, emergency department director. “Cerner developed a surge alert that triggers a notification to both the special sepsis unit and our own internal medical management team at HH’s emergency department.”
The sepsis project includes near real-time monitoring of the patient and tracking patients as they come in.
“You're tracking the documentation and the results, not only from the virtual sepsis unit, but wherever the patient goes throughout their entire stay,” said Craig.
The sepsis mortality rate decreased from as high as 1.91 to as low as 0.45.7 Sepsis cases meeting the bundle compliance increased from as low as 52% to as high as 88%8, and LOS also decreased from a high of 6.83 days on average to as low as 3.88 days on average.9
If a patient came into the emergency department (ED) with fever, tachycardia, or two out of the many triggers, a sepsis alert will fire to the virtual sepsis unit. From there, the virtual sepsis unit is also in the background monitoring the documentation of fluid and lactic acid and that HH meets initial requirements for CMS guidelines.
BHSF experienced more than $300,000 savings in sepsis variable costs10 and more than $630,000 in total costs.11
“We believe reduced length of stay contributed to savings, as in-hospital expenses are one of the biggest costs to patients,” said Craig. “It's an overall team effort because everybody's included. Not only the medical providers, but performance improvement, clinicians, the virtual sepsis unit. On a global level, I think it's a win-win, not only for Homestead Hospital, but for us collaborating with Cerner, who harmonized the workflow.”
“It was good to see the collaboration and communication among Baptist Health’s hospitals and have Homestead Hospital come out on top, delivering high-quality, cost-effective care,” said Baker. “We learned a lot and continue learning more about what others do or what others have accomplished for our patient population.”
1 HIMSS Stage 6 achieved on Feb. 26, 2020 and HIMSS Stage 7 achieved on Nov. 4, 2020
2 Comparing Q2 2011 average to May 2019 average
3 Comparing 18% average in September 2018 to 63% average in November 2019
4 Comparing November 2017 to February 2020, pre-COVID-19
5 Non-Opioid use in ERAS patients was 80% and use of non-opioids in non-ERAS patients was 37.74%, comparing January 2019 to August 2019.
6 Comparing non-ERAS variable cost per case of $4,125.80 to ERAS variable cost per case of $9,037, from January 2019 to August 2019
7 Comparing Q1 2017 to Q2 2019 averages
8 Comparing January 2018 to August 2019 averages
9 Comparing January 2017 to August 2019 averages
10 Comparing FY18 to FY19
11 Comparing FY18 to FY19; excluding hospice, rehabilitation, and pediatrics