It's not unusual for a nurse to approach a physician at Hackensack (N.J.) University Medical Center and talk about the right clinical steps to take on behalf of a patient. Surprisingly, it's not unusual for the doctor to take direction from the nurse.
But it's for an unusually good reason. The impact of this collegial exchange, and the program that encourages it, is so evident at the 635-bed hospital that the practice of using clinically specialized nurses to monitor and prompt doctors is becoming routine in cardiac and pulmonary care, where the approach was first tried during the past few years.
"You can come up to a doctor and he'll say, `You know, you're absolutely right, go ahead and do it,' " says Karen Setti, an advanced-practice nurse specializing in cardiology.
Based on successes and lessons learned in the critical areas of heart and lung treatment, hospital management is spreading the technique throughout the facility.
The benefits for hospital operations include dramatically higher compliance with proven standards of clinical treatment, along with business bonuses that include lower cost per case and the opportunity to earn millions in extra revenue by improving outcomes and freeing up beds faster.
For example, near-perfect adherence to a strategy for treating pneumonia resulted last year in a decrease of $444 in the cost per case and a reduction in stay of 1.3 days. For Hackensack, which operates at full capacity, filling the empty beds brought in more than $300,000 in additional revenue. That's from improving just one course of treatment among hundreds.
For patients, those moments the nurses spend with doctors are aimed at quicker improvement in their condition, less time in the hospital, less likelihood of complications and better long-term health prospects.
When applied to pneumonia care, the biggest improvements came in selecting the correct antibiotics and starting them within four hours of patients showing symptoms, says Peter Gross, M.D., leader of Hackensack's project to gain unerring compliance with indicators of quality medicine. Gross is chairman of the medical center's department of internal medicine.
The concentration on pneumonia care also heightened awareness that patients normally should get a vaccine that fights the bacterial cause of the disease, says Linda Aho, the nurse who took charge of that project. Nationally, only 40% of patients get the vaccine when indicated. Hackensack improved that to 80%.
Obstacles to good medicine
These are interventions well-known to the medical field and amply supported by clinical research, but in general they're not yet part of the cure for patients or the business case for hospital efficiency, Gross says. Usually it takes many years to foster practices acknowledged as safer and cost-effective, even after they are coalesced into a step-by-step guide that doctors should heed in the course of treating a patient for a certain condition.
"There are a lot of guidelines out there and nobody's using them," Gross says.
The central aim of the Hackensack clinicians' collaboration, he says, is to bridge the gap between published breakthroughs in medical care and their adoption in the healthcare routine.
The failure of clinicians to harness solid new science for the good of patients is a much-studied shortcoming of the healthcare field and has become a major focus of action to improve public health and reduce errors.
Because of the unprecedented rate of medical advancement, there is "more to know, more to do, more to manage, more to watch and more people involved than ever before," according to a 2001 report by the Institute of Medicine that was highly critical of current healthcare norms.
"Faced with such rapid changes, the nation's healthcare delivery system has fallen far short in its ability to translate knowledge into practice and to apply new technology safely and appropriately," according to the report.
That report, Crossing the Quality Chasm, only underscored what medical leadership already knew and had been trying to fix within the existing routine of medical practice.
The Medicare program, for example, isolated a handful of disease processes three years ago and published steps to take during treatment that were proven in medical literature to improve the likelihood of positive outcomes.
Medicare's peer-review organizations were assigned to foster the use of these "quality indicators" and monitor levels of compliance. But a recent study measured median compliance at only 69%.
At Hackensack, previous efforts to disseminate and gain adoption of the Medicare performance measures included improving access to practice guidelines, lecturing about their importance in medical grand rounds and meeting with groups of physicians to overcome their objections and get them to comply.
None of it worked; compliance continued to lag behind established standards. Treatment of pneumonia, for example, fared poorly in most instances. Medicare's guidelines were followed 30% of the time or even less, with one exception at 80%.
Though physicians were aware that tests and drugs should be ordered in certain situations and within set timelines, the need to concentrate on acute problems and rush from one task to another made it difficult to remember every optimum treatment detail and preventive measure appropriate to their list of patients, Gross says.
"This is such a busy hospital," says William Salerno, M.D., a cardiologist on staff. "Things move so fast that some things can fall through the cracks."
What doctors needed was someone to look after those details for them, someone knowledgeable enough about a medical process to have standing with physicians when making treatment calls.
Medical leaders settled on using an advanced-practice pulmonary nurse to scrutinize compliance in pneumonia care. Hackensack assigned Aho to review computer-fed data on physician practices and intervene when compliance was absent. Within six months, performance on most measures improved to 90% or better in the majority of cases, Gross says.
Nurses assume pivotal roles
An advanced-practice nurse, also known as a nurse practitioner, has a master's degree and a base of knowledge in a particular disease process, says Jane Crotty, administrative director of nursing. "She's seen as credible by the physician. With her giving the information, he feels comfortable giving the order," she says.
The use of advanced-practice nurses became the first of three new models that, combined with a sophisticated information technology infrastructure, work together to foster better communications, more complete coordination of care and rapid improvement in competency throughout the institution, Hackensack officials say.
The models break the mold of care delivery in ways that were strongly urged in the IOM report. Only by redesigning the clinician teams who give the care--"microsystems" in the jargon of the report--will there be any headway in healthcare improvement, the report's authors say.
Hackensack's development of new and more effective units of work at the basic care level is being underwritten in part by a $20.9 million initiative of the Robert Wood Johnson Foundation, dubbed Pursuing Perfection, which encourages healthcare organizations to devise and put into practice the recommendations of the IOM Chasm report.
In addition to the collaboration headed by advance-practice nurses, a daily gathering called multidisciplinary rounds is being piloted in several medical units to carry the nurse-doctor collaboration to the front lines of care. A senior physician heads the sessions, which seek to ensure that each patient's plan of care is clear and that the lead doctor in complex treatment cases is clearly identified in case conditions change, says Louis Teichholz, M.D., Hackensack's medical director of cardiac services.
The specialists works with the APNs, dietitians, discharge planners, social workers, staff nurses and others who need to learn from each other the complete picture on each of their patients. In addition, they swap information on factors such as insurance compliance, placement after leaving the hospital, family issues and other challenges to preparing a patient for discharge, Teichholz says.
A third model just beginning implementation will serve as a backstop to make sure the protocols for Medicare quality indicators and other internally developed protocols are implemented once APNs have done their jobs and the multidisciplinary rounds have adjourned for the day. Two senior staff nurses will be assigned to each nursing unit, one for coordination of care and the other for education.
The coordinator will provide the last measure of redundancy in the campaign to execute the targeted clinical guidelines while keeping vigilant for issues of patient safety. The other senior nurse will be responsible for continually educating staff nurses on which symptoms and warning signs to watch for and how to better assess conditions, Teichholz says.
For example, nurses have been trained to look for signs of fluid-volume overload in patients with congestive heart failure, including telltale lung sounds and a shift in fluid when a patient changes position, says Michele Gilbert, education coordinator of the heart failure program. Those signs might not otherwise be noted unless the doctor is there to perform an exam, she says.
All three models put nurses in new or expanded roles of authority. None of the approaches were possible under the old system of professional autonomy and control, Hackensack officials emphasize. "The old model of doctor as the captain of the ship--but no crew--has not worked," Teichholz says.
Ammunition for other fronts
Although medical process innovation is the principal objective, the experience surrounding the Hackensack initiative can be applied to several other challenges becoming more common in healthcare:
Attracting and retaining nurses. The pivotal role of APNs provides one more plus for becoming a specialized nurse and for practicing at Hackensack. The new role of senior staff nurse also gets registered nurses more involved and gives them a career path to aim for instead of being stuck in the same position indefinitely, Teichholz says.
But these are only the latest moves to value nurses and reap that value. Hackensack's concerted effort to improve the working climate and respect for nursing goes back to the mid-1980s, and today its reputation for embracing the profession is reflected in a turnover rate half the national average. There's even a waiting list to get onto the staff in medical-surgical areas, so no position is vacant any longer than it takes to get a new hire on board, Crotty says. The average length of service for a registered nurse is 11 years.
Operating a full hospital. Hackensack has all the patients it can handle, continuing to benefit from demand that included more than doubled inpatient admissions from 1990 to 2000, from 31,003 to 63,442. The challenge is to handle more admissions without compromising care. Ultimately, more effective care results in more capacity to serve a population, says Robert Garrett, senior vice president and chief operating officer. "It's about turning over the bed," he says.
Any reduction in length of stay brings in more revenue with little additional cost to the hospital, Garrett says. Even with the higher labor costs of hiring APNs to facilitate the actions that reduce time in the hospital, "this is so effective that we're going to roll this out to all medical-surgical floors," he says.
Computerization's role. Hackensack has invested $40 million in computer software systems and ease of information access. Investments range from a new admission discharge-transfer system to the latest software and Internet technology for tracking clinical and financial data for analysis and patient-care purposes, Garrett says. Those capabilities are important for getting details to clinicians on cost per case, length of stay and variation from guidelines by practitioner, he says.
But unless the working relationship between doctors and nurses is sound and the information is powering a process that already has enthusiasm behind it, the best information technology won't be put to good use, Crotty says. "You can't jump into IT first," she says.
Initial proof of impact
Hackensack's enthusiasm for putting nurses in positions of authority started in December 1999 with a practical solution to a shortage of vital-sign monitors for heart patients, Teichholz says.
Before moving someone from the emergency room to a hospital bed, a caregiver had to find either a wireless telemetry device or a free bed in a wired unit so the patient's heartbeat and rhythm could be monitored continuously and staff could respond quickly to problems, he says.
But there was no system for taking patients off the units when their conditions warranted, and often that caused unnecessary backups in the ER. "If the right patients are on telemetry for the right reasons, we have ample supply," Crotty says.
"The old solution was to buy more units, hire more people," Teichholz says. This time, however, medical leaders reached consensus to have an APN track telemetry--granting her authority to request an order to discontinue the monitoring after gently reminding doctors that most patients don't need to be on the devices for more than 24 to 48 hours, he says.
"We found it worked well, and the physician didn't yell and scream at this nurse and say, `Who the hell are you?' " Gross says.
The number of telemetry patients handled per month went from fewer than 400 in January 1999 to more than 500 by May 2001. Meanwhile, the average amount of time patients spent on telemetry decreased to about 45 hours in May 2001 after peaking at more than 70 hours in May 1999.
Hackensack already employed more than 30 APNs, who are licensed in New Jersey to assist doctors and prescribe medications, Gross says. The success with telemetry coordination was the impetus to make use of additional APNs in other areas that could benefit from such clinical coordination, Teichholz says.
One such area was hospitalization for pneumonia, which indicates advanced progression of the disease and an urgency to get it under control. Hackensack saw 550 to 600 cases per year.
Incidence of death is rare in outpatient treatment, but the U.S. death rate averages 12% for patients requiring hospitalization, approaching 40% among those who require intensive care, according to the American Thoracic Society.
Medicare's quality-improvement guidelines--emphasizing aggressive treatment upon admission and vaccinations to reduce the odds of recurrence--were met at Hackensack less than one-third of the time at best. But within months of launching the monitoring program, 100% of diagnosed pneumonia patients received an initial antibiotic within the eight-hour timeframe prescribed in the Medicare quality indicator. In fact, physicians amended the guideline to require the antibiotic within four hours, says Aho, the APN directing the program.
That required procedural changes. Antibiotics were stocked in the ER, premixed and ready, avoiding the need to go through a central pharmacy, she says. If pneumonia wasn't conclusively diagnosed but was among a list of several possibilities, the patient was started on an antibiotic anyway--physicians decided the practice would do no harm even if the disease was later ruled out, she says.
Notes were placed on charts when the targeted steps weren't taken. If that didn't do the job, Gross says, the APN called a physician to suggest the tests or drugs that were called for, and she immediately executed those orders after gaining the doctor's go-ahead.
To further coordinate care, medical leaders modified guidelines on when to switch patients to oral antibiotics, with the APN monitoring for signs patients had recovered enough to eat and drink, their blood counts were returning to normal and fever had subsided for at least a day. The switch to oral antibiotics became one of several criteria for discharging a patient, along with such factors as good oxygenation, white-blood-cell counts below a set threshold and no other conditions that had to be brought under control, Aho says.
The combination of interventions helped reduce the average stay to 5.28 days from 6.56, and cost per case declined to $2,622 from $3,359. No increase in the readmission rate for pneumonia was detected after 30 and 60 days of managing the earlier discharges.
"We believe that this approach provided more efficient and less costly care," Gross says.
Expanding nurse-led coordination
The approach now is helping to standardize performance levels in the care of cardiac and circulatory diseases such as heart attack, congestive heart failure, irregular heartbeat and stroke.
No results on the business impact are available yet, but already some objectives are being met nearly all the time, according to hospital staff reports.
Among the results for the first six months of 2002:
* 95% of patients meeting criteria for an acute myocardial infarction received beta blockers with 24 hours of arrival, a practice recommended by authorities ranging from Medicare to the National Committee for Quality Assurance.
* 93% of those patients whose hearts were not pumping blood strongly enough were prescribed a drug called an ACE inhibitor at the time of discharge to correct the problem.
* 85% of AMI patients received an electrocardiogram within 15 minutes of reaching the emergency department.
* 85% of AMI patients received aspirin within 15 minutes of arrival if they hadn't already taken it that day.
* 96% of emergency patients with symptoms of heart failure were tested for a substance in the blood that research recently identified as extremely effective to confirm the commonly misdiagnosed condition; test results were available within 30 minutes in 97% of the cases.
With continuing evidence of benefits, physicians generally have accepted the gentle nudges that sometimes are necessary, Gross says. "Most of the doctors look at this as help, not interference," he says.
"I think the days of false bravado are gone," says cardiologist Salerno. Physicians have to "downplay their egos and listen to anyone who's making sense," he says.
If a clinician can present the evidence for taking an action or making a particular decision, Salerno says, it shouldn't matter whether the clinician is an attending physician, a resident or a nurse. "If you're right, you're right," he says.
Having a full hospital adds to the pressure to discharge patients in fewer days, says Setti, the APN monitoring the AMI project. Twenty beds are available for heart attack patients in the critical-care unit. "Every day it's full," she says.
That state of affairs also creates an incentive for doctors to accept the new approaches, says COO Garrett. If the program works, they're more likely to get their patients into an inpatient bed in a timely fashion instead of having them languish in the emergency room, he says.
As the goals pursued by coordinating nurses have become widely recognized and the nurses' visits to caregivers for noncompliance have become predictable, the result has been adherence without much need to intervene, Teichholz says.
Teichholz, who has to follow up with physicians when reminders from the APN aren't enough, says he rarely has to visit recalcitrant doctors anymore, and the emphasis has shifted to maintaining the gains achieved so far.
"The system is now in control," he says, "and we monitor it to make sure it stays in control."
Recognizing her lessened need to keep the pressure on pneumonia-care targets, Aho has moved on to other critical conditions such as chronic obstructive pulmonary disease.
For example, she has adapted the guidelines for switching to oral medications, in this case for intravenous steroids given to pulmonary patients early in their hospitalization. The switch to pills is coming earlier without reluctance from physicians, she says.
"It's a lot easier to implement this because the culture has already changed," Aho says.
The role of the registered nurses in cementing the gains is also becoming a priority, Crotty says. Although APN project coordinators and physicians are improving the clinical attention to essential care, the collaborators "are making it happen through the professional nursing staff," she says.
"It has to happen at 4 o'clock in the morning on Sunday, not just when the APN is around."
