I will explore some key causes and solutions to medication errors associated with care transitions using components of Hope Street Group’s analytical model: “Amplify” our productivity- Improve the quality and cost of transitions between acute and other types of care.

Care transitions have been identified as points in the health care continuum that can increase risk of medication errors due to poor coordination (California HealthCare Foundation, 2007). Approaches to improving medication errors during care transitions include: checklists, computerized order entry, medication reconciliation, improving the “safety culture” and teamwork (Agency for Healthcare Research and Quality).  This post will discuss the overall impact of post-hospital adverse events. Subsequent posts this week, will discuss the feasibility, appropriateness and evidence for the leading potential solutions/interventions based upon a review of the literature.

The overall incidence of post-hospital adverse events has been reported to be 20% within 3 weeks of discharge(Forster, Murff, Peterson, Ganhi, & Bates, 2003). Moreover, the same researchers stated that nearly 75% of those adverse events could have been prevented or ameliorated (Forster, Murff, Peterson, Ganhi, & Bates, 2003).   It has also been argued that care transitions are especially important for elderly patients and other high-risk patients who have multiple medications and comorbidities (Halasyamani, et al., 2006).  Despite the lack of official numbers, researchers agree that the risk for post-hospital adverse events continues to mount as the elderly and other high-risk patients make the transition to a nursing home(Halasyamani, et al., 2006).

However, a combination of individual, team and organizational issues contribute to the challenges of lowering the risk of medication errors during care transitions to nursing homes and long-term care facilities from hospitals (Table 1).

While the research focus here is between hospitals and nursing homes, lessons can be applied to any situation where there is a transition of care in the health eco-system.

As we look to see if these approaches to improving medication errors during care transitions really help this week, please tell us about your experiences with:

• checklists,
• computerized order entry,
• medication reconciliation,
• improving the “safety culture”/teamwork  and;
• shovel ready interventions (i.e. TeamSTEPPS)

California HealthCare Foundation. (2007). Fast Facts: Coordinating Care Transitions. Oakland: California HealthCare Foundation.

Agency for Healthcare Research and Quality. (2011 February). Nursing Home Survey on Patient Safety Culture. Retrieved 2011 14-March from Agency for Healthcare Research and Qulaity: http://www.ahrq.org.gov/qual/patientsafetyculture/nhsurvindex.htm

Forster, A., Murff, H., Peterson, J., Ganhi, T., & Bates, D. (2003). The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital. Annals of Internal Medicine , 138 (3), 161-167.

Halasyamani, L., Kripalani, S., Coleman, E., Schnipper, J., vanWalraven, C., Nagamine, J., et al. (2006). Transition of Care for Hospitalized Elderly Patients: Development of a Discharge Checklist for Hospitalists. Journal fo Hospital Medicine , 1 (6), 354-360.

Where does the healthcare continuum really begin?

With prevention?

In the home?

With the Primary Care Provider?

In the Emergency Department?

Although an argument can certainly be made for any of the four choices above, I’d like to challenge your opinion and perspective with a different answer…the continuum for many begins with Emergency Medical Services (EMS).

This past year I had the privilege to be included in two standard setting and forward thinking discussion forums-- AHRQ’s 2010 Annual Conference and HCIE Innovators Event as well as Hope Street Group’s Policy 2.0: Using Open Innovation to Reinvent Primary Care Project. Both of these events offered diverse perspectives from diverse participants in academia, corporations and all levels of government and localities who gathered to discuss and make recommendations to improve the health care system. Interestingly, the first responder perspective of EMS was only a footnote in these discussions. I believe that policy makers and leaders within healthcare all too often fail to look outside their sphere of influence and familiarity for answers or more importantly the critical questions. That said, I know this minimalization was not intended or planned, but a result of historical processes and comfort levels.

The numbers…

EMS contributes 15% or 17.25 million patients to the nations 123.8 million annual Emergency Department (ED) visits (CDC, 2008), yet Fire, EMS or Law Enforcement respond to over 240 million 911 calls per year (NENA, 2009). It’s difficult to accurately breakdown the national percentages of 911 call types, but upwards of 60% of EMS calls are generally considered low-acuity or non-emergent. To put this into a local perspective, the City of Tucson AZ with a population of approximately 530,000 (2005) generates approx. 79,000 Fire and EMS 911 calls per year, 84% or ~67,000 of these are medical in nature and 60% of those, ~46,000 require only Basic Life Support (BLS) care (TFD, 2009).

So what does that really mean? It means that the 911 system provides a substantial safety net for the Nation’s healthcare system. While this should come as no surprise, the volume of patients utilizing EMS, Emergency Departments and the 911 system continues to grow. Over 15 years ago, the National Highway Traffic Safety Administration and the Health Resources and Services Administration joined with leaders from the EMS community to put forth an EMS plan that would require significant collaboration with acute care, primary care and public health. This provided one of the earliest, nationwide, use of the scale-up-and spread model and was published as the1996 EMS Agenda for the Future (NHTSA, 1996).

The past…

To implement that vision and professional template, EMS has continued to grow it’s service provision model from one that was historically created for stabilization and transport of the acutely ill and injured; one that was set-up to intervene only when patients needed emergent support; one that operated in relative isolation from other health care and community resources; one that was not involved in the business of ensuring social service follow-up and one that did not have a working knowledge of community health care providers and regional health care organizations (NHTSA, 1996).

The present…

Today, EMS is integrated with other health care providers, public health and public safety agencies to provide community-based healthcare and management. EMS agencies and providers are involved in activities related to prevention education, illness and injury risk, acute illness and injury care, follow-up, treatment of chronic conditions and community health monitoring. This vision is also shared by the Injury Response Division of the National Center for Injury Prevention and Control/Centers for Disease Control and Prevention (NCIPC/CDC) and the American College of Emergency Physicians (ACEP) who have called for a better understanding of roles and collaboration between Public Health and EMS through their Appleseed Project initiative (CDC, 2004).

The reality …

As you can see, EMS has developed into more than a group of fire departments, rescue services and ambulance companies. While providing these additional and collaborative services, EMS remains the public’s emergency medical safety net.  Looking back to those 240 million 911 calls and the 17.25 million EMS-to-ED admissions, it’s clear that a significant amount of health assessment, care and triage occurs outside the hospital walls. In fact, there are no other healthcare providers that see patients in their own home or living environment quite like EMS. The “scene assessment” which is a fundamental EMS skill reveals more information about a person, their living conditions, their health, their support system and their coping mechanisms than any other assessment tool.  How many Primary Care providers, case managers or health plan administrators have this perspective into their own patient’s lives?

From where I sit with over 30 years of experience as an RN in Maternal-Child Health and EMS, I see several important questions that need further discussion and clarification before we can begin to understand how to move forward in improving the healthcare of our Nation.

• How can we better educate individuals to utilize the 911 system for acuity appropriate reasons?
  
• How do we encourage the use of Primary Care practitioners for non-emergent and urgent medical and injury complaints instead of defaulting to the approach of “if this is a medical emergency, please hang up and dial 911?
  
• How do we share the burden of after-hours and weekend low-acuity patient needs?
  
• How do we facilitate better communication and collaboration between EMS, public health, acute and chronic care case management, behavioral health and community services?
  
• How do we move patients calling 911 for non-emergent or non-healthcare reasons into a public or human services system that will better meet their needs?
  

Communication, collaboration, connectivity, consistency and caring are all functions of healthcare, yet as the patient numbers and range of patient complaints increase, we all need to utilize each others skills, knowledge and expertise to meet the needs of our patient population. Reaching out to our colleagues may be the first step toward improvement, integration and understanding of our healthcare system.

http://www.911dispatch.com/info/fact_figures.html

http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/nhamcsed2008.pdf

http://cms3.tucsonaz.gov/sites/default/files/imported/data/demographic/eecpop00_05.pdf

http://www.nena.org/911-statistics

http://www.cdc.gov/injury/publications/index.html

http://www.nremt.org/nremt/about/emsAgendaFuture.asp

http://www.tucsonaz.gov/fire/AnnualReport.pdf

Nova Scotia Premier Darrell Dexter has announced in a speech earlier this month plans for a $16-million collaborative primary care clinic in Queens County. The overarching goal is to bring Better Care Sooner to Nova Scotia residents by reshaping how emergency care is delivered.

The collaborative care clinic will have space for five  family  physicians, a nurse practitioner, family practice nurses and  other  health professionals.The new plans also call for an upgraded 22-bed  inpatient unit.

Additionally the Better Care Sooner is poised to:

-improve access to primary care, especially in smaller communities.

-make emergency care more patient-centered and streamlined.

-provide care that is better tailored to those whose needs are more complex (i.e. seniors).

-increase public awareness of 911 and the healthlink nurse line 811.

-make changes to the way health care is funded (reward better, patient-centered care).

The government states that roughly 84 percent of ER visits at the hospital would be better addressed by primary care.

Dexter says the province is committing $2.5 million to the project while the Region of Queens Municipality has committed $1 million.

About $11 million comes from the Queens Foundation and private donors, and another $1.5 million still needs to be raised.

Check out the whole story at http://www.canadaviews.ca/2010/12/23/improvements-will-ease-er-overcrowding-access-to-care/

Paul Krugman, from the New York Times thinks so, and he also thinks we can expand coverage AND still cut costs in health care. In the current haze of health care legislative pessimism, most people view these concepts as a dichotomy, rooted in the notion that an expansion of health care coverage would translate into a complete financial collapse of our health care system, but CMS projections don't support this assertion:

"Take the CMS projection of total health care spending in 2018: it’s more than $4.5 trillion. So the direct cost of expanding coverage — the initial bump in the [cost curve} — is less than 4 percent of total health care spending. That’s the amount by which, on the current trajectory, health spending rises every 7 months.

 

Against that you have to set the fact that this reform makes the first serious effort, ever, to rein in costs. It’s not at all hard to believe that after a few years this will lead to lower, not higher, spending."

Ok, so really- how does providing everyone with health care curb costs? Here's one take on it:

- Patients seeking care without medical insurance turn to the nation’s “Health Care Safety Net”, which is defined (not ironically) by the American College of Emergency Physicians as “providers who have a legal mandate/mission to offer medical care to all patients, regardless of their ability to pay.” This includes emergency departments, community health centers, public hospitals, and charitable clinics.

- According to an ACEP survey released in March 2003, emergency physicians estimated that one out of every three patients they personally treated were uninsured.

- Many of the nation's uninsured delay needed care and live with serious medical conditions because they do not have affordable access to health care when they need it and only turn to the "health care safety net" when their conditions turn dire, and unfortunately, expensive.

- 55% of emergency care goes uncompensated and hospitals and physicians shoulder the financial burden by incurring billions in bad debt.

- Outpatient care, including same-day hospital vists (aka, ER visits) is by far the largest and fastest growing part of the US health system, accounting for $436 billion or two-thirds of spending expected and 40% of health care spending.[i]

In short, my point is that by extending coverage to the uninsured we'll be cutting some of the 40% of health care spending being used to provide them with care, which is one of the major causes for the cost problem.

However, what happens if the CMS and CBO projections are wrong? Should there be a failsafe mechanism that requires the private industry to cut costs by a certain amount over the next ten years or an independent commission will intervene?

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[i] McKinsey Global Institute, Accounting For The Cost of US Health Care: A New Look At Why Americans Spend More, November 2008