The Brigham Care Redesign Incubator and Startup Program (BCRISP) strives to rapidly identify successful pilots and position them to grow within the organization. To be successful, pilots must address Brigham Health Areas of Strategic Focus (Scalable Innovation, Advanced Expert Care, Improve Health, Timely Access, Exceptional Experience, Highest Quality/Safe Care, Affordability), as well as BCRISP’s priority areas for the fiscal year. This year, three multidisciplinary teams from Brigham and Women’s Faulkner Hospital had proposals accepted and are now working on projects with support from BCRISP.
Florencia Halperin, MD, Chief of Endocrinology
Meaghan Paris, PharmD, BCPS, Clinical Pharmacy Specialist
Scott Schissel, MD, PhD, Chief of Medicine and ICU Attending Physician
Brian Zikaras, PharmD, Director of Pharmacy Services
Poor blood sugar control during a hospital stay can lead to poor outcomes. In fact, hyperglycemia (high blood sugar) is associated with increased infection rates, length of stay, readmission, disability after a hospital stay and mortality. Hypoglycemia (low blood sugar) is associated with increased hospital mortality, length of stay and death within one year.
Knowing this, Brigham and Women’s Faulkner Hospital has recently started participating in the Society of Hospital Medicine Glycemic Control Electronic Quality Improvement Programs (eQUIPS) Program, which collects and synthesizes hospital data on blood sugar levels and helps providers identify areas in need of improvement. This has been the basis for many quality improvement initiatives at BWFH. Most recently, Chief of Endocrinology Dr. Florencia Halperin has led a multidisciplinary team in the design of a new intervention, which is currently supported by BCRISP, to address blood sugar control in the ICU.
Under the pilot, ICU pharmacists, who already round with the care team, are tracking and documenting insulin given to patients and making recommendations to the care team. “It’s really a partnership between Endocrinology, the ICU care team and the Pharmacy team,” explains Dr. Halperin. “The focus is on training the pharmacists and giving them the role of assisting with in-depth review of the patient’s blood sugar levels and insulin doses, then coming up with recommendations based on an algorithm we’ve created.”
The group is also creating a video that can be shown to new members of the ICU care team to educate them on best practices around blood sugar control.
The ultimate goal of the project is to decrease length of stay for patients in the ICU with diabetes by improving blood sugar control during their ICU stay. But there are other motivating factors. “We want to lower rates of both high blood sugar and low blood sugar. We also want to show a return on investment in relationship to the grant. That would possibly make the intervention self-sustaining and it can continue beyond this year,” says Dr. Halperin.
Luis Lobón, MD, MS, Chief of Emergency Medicine
Naomi Schmelzer, MD, MPH, Department of Psychiatry Consultation Liaison Director
Heather Burrell Ward, MD, Psychiatry Resident
Dana Im, MD, MPP, Emergency Medicine Resident
Anthony Ho, Emergency Department Operations Manager
Throughout the United States, there are limited numbers of inpatient psychiatric beds and insufficient community mental health services. As a result, patients in need of care often present to the Emergency Department. At BWFH, these patients are more likely to board (that is the time from the decision to admit the patient to the actual admission or transfer to inpatient level of care) in the Emergency Department longer than other medical/surgical patients. As a result of these long stays in the Emergency Department, bed turnover times are impacted as well as other resources leading to adverse patient outcomes and decreased quality of care.
These issues are not unique to BWFH’s Emergency Department, and Chief of Emergency Medicine Dr. Luis Lobón hopes that his team’s care redesign project will prove scalable to other Emergency Departments within Partners HealthCare and beyond.
Under the project, the entire interdisciplinary care team, including the Department of Psychiatry’s Consultation Liaison Service, round on behavioral health patients in the Emergency Department. “We need to figure out how to take care of these patients together,” explains Dr. Lobón. “By bringing the team together, we brainstorm how best to reduce length of stay as well improve patient progression, resource utilization and quality and safety.”
In fact, Dr. Lobón and his team have been rounding on their behavioral health patients in this way for some time and know just how effective it is. With the support of BCRISP, they hope to be able to prove their success with data and continue further with the redesign. As such, the BCRISP project will include an additional phase 3 of intervention>analysis>care redesign=benchmarking that aims at identifying milestones which will dramatically improve the care of behavioral health boarders in the Emergency Department. “This is a true multidisciplinary and collaborative approach to care redesign that widely represents the Brigham Health model of healthcare innovation for others to follow,” he says.
Kerstin Palm, OTR/L, CHT, MA, Outpatient Rehabilitation Services Manager
James Manna, PT, DPT, OCS, Outpatient Physical Therapist
Eric Philips, PT, DPT, OCS, Outpatient Physical Therapist
Angela Serig, OTR/L, CHT, CLT-LANA, Certified Hand Therapist
Brandon Earp, MD, Chief of Orthopaedics
Philip Blazar, MD, Chief of the Hand and Upper Extremity Service
Many of BWFH’s patients require intensive physical and occupational therapy post-operatively. Access to these therapy services can be impacted by a patient’s challenges with scheduling, mobility, transportation or distant geography. With support from their BCRISP funding, the BWFH Rehabilitation Services Department is developing a model for post-operative clinical care inclusive of virtual therapy visits in line with the standards of Brigham Health surgical and rehabilitative protocols. The program allows patients to continue receiving their care from therapists very familiar with their surgeon’s protocols in the convenience of their home. The team hopes to demonstrate that virtual visits facilitate greater access to therapy services while also improving patient satisfaction, convenience and compliance with post-operative therapy.
Project leader and Outpatient Rehabilitation Services Manager Kerstin Palm, OTR/L, CHT, CLT, MA, says, “Our goal right now is to validate that virtual visits are convenient and beneficial to patients, and that they are advantageous in achieving clinical outcomes. Once we can validate those things, the potential is there for a whole host of opportunities for both patients and therapists.”
The team is using its BCRISP grant primarily to fund a research assistant and for a wide breadth of data collection and analysis aimed at documenting the feasibility of virtual visits for therapy services, as well as printed and therapy materials. They will enroll 50 patients to pilot the program, 25 of whom will be thumb CMC arthroplasty patients and 25 of whom will be reverse total shoulder arthroplasty patients. Under the pilot model, patients visit the Rehabilitation Services Department at BWFH for a first post-operative visit where they are provided with an illustrated manual, which has been custom developed by the therapy team to tailor therapy interventions to the virtual visit format. These materials provide a shared reference between the therapist and patient and facilitate progression along the treatment trajectory that is in line with the current standard of care.
During the virtual visit, the therapist will walk the patient through their post-operative precautions, review their home exercise program and address any concerns, referring to the booklet when necessary. “We are learning how to adapt in-clinic visits to the virtual visit format. This is a new innovation for care delivery and there is a learning curve in the process, particularly for fields such as physical therapy and occupational therapy that have historically been very ‘hands-on,’” says Palm of the virtual interactions.
The team anticipates that as healthcare delivery continues to evolve, virtual visits will be more broadly included and reimbursable. “The BCRISP grant allows us to take the time to develop a solid clinical program for virtual visits that is built on best practice and carefully monitored,” says Palm. “We hope what we learn along the way will be helpful to other clinical services lines as we all navigate the rapidly changing healthcare landscape.”
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