The holy grail of US healthcare modernization is to improve patient outcomes while reducing costs by decreasing nonvalue-added care. On at least three fronts already, Dr. Michael Zaroukian has recently overseen and reported on examples where Lansing, Michigan-based Sparrow Health System has achieved that difficult goal.
Zaroukian is a practicing general internist and board-certified clinical informaticist who collaborates with other healthcare and IT professionals to analyze, design, implement, and evaluate solutions that support transformational improvements in healthcare quality and value. As Sparrow’s vice president, chief medical information officer, and chief transformation officer, Zaroukian is well positioned to lead programs to improve the effective use of EMRs and other health information technology (HIT). In fact, Sparrow was recognized in October 2018 by the Health Information and Management Systems Society (HIMSS), with the 2018 HIMSS Davies Enterprise Award for three HIT use cases that dramatically improved patient outcomes.
Zaroukian’s leadership in HIT helped Sparrow deliver key improvements in care and value with information and technology. But, Zaroukian is clear in his view that the successes in each case depended on having an organizational culture that embraces excellence and change—and leverages information technology as a valuable tool.
Reducing In-Hospital Opioid Complications
While street use of opioids is being treated a national emergency, complications from overuse of physician-ordered opioids in hospitalized patients is also a problem, one that requires a different approach. Without ongoing awareness of other sedating medications a hospitalized patient may be taking, drug interactions or increasing an opioid dosage can cause some patients to experience respiratory arrest. If this occurs, it requires clinicians to rescue patients with Naloxone, an opioid antagonist.
“We want to do all we can to keep opioids from harming the patients we are trying to help,” Zaroukian says. “We do this by using information technology to promote respiratory depression risk assessment and intervention before Naloxone is required.”
Zaroukian says this is done by providing clinicians with EMR-integrated tools to automatically calculate a patient’s risk of respiratory depression based on EMR-recorded information, including their respiratory rate and oxygen levels. Sparrow clinicians employ the Michigan Opioid Safety Score (MOSS), which incorporates assessments of health risk, respiratory rate, and level of sedation to determine the risk of respiratory depression and to provide guidance regarding more intensive monitoring, modification of opioid dosing, using alternate pain management strategies, or getting direct physician input. “MOSS enables nurses to assess patient risk, providing a score and actionable decision support when certain risk thresholds are exceeded,” he says.
Sparrow reports that Naloxone rescue therapy is down by half, reducing patient length of stay, morbidity, and related costs. “This is a one example of why our caregivers are increasingly sold on the value of our EMR and HIT. It’s a three-step process to transform a healthcare organization,” Zaroukian adds. “First, we provide them with HIT that works. Second, we help them use HIT pervasively and well. Third, we build on this to hardwire EMR-integrated best practices to truly transform care. We look at the data, find out where gaps exist, then use the data to identify and implement solutions that work.”
Reducing Overuse of Blood Product Transfusions
Blood and platelets are expensive and in short supply, yet about 35 percent of blood transfusions and 60 percent of platelet transfusions are deemed medically unnecessary. “Although reducing overall transfusions is an important goal, in emergency situations, such as at our Level I trauma center, seconds matter and rapid availability of multiple units of blood products is essential,” Zaroukian says.
Sparrow recognized that overuse of red blood cell (RBC) and platelet transfusions was a significant problem, working to address this through a multidisciplinary project that replaced stand-alone blood product orders with evidence-based, guideline-compliant order sets, EMR-integrated clinical decision support, and compliance reports that encouraged transfusion ordering only when appropriate indications were documented. The organization also discouraged ordering more than one unit of RBCs in nonemergency situations. Provisions were also made for one-click ordering of emergent and massive transfusions when necessary.
Four-and-a-half years after implementation, RBC transfusions have decreased by 32 percent, while platelet transfusions have dropped by 25 percent. From a cost standpoint alone, that has amounted to $35.9 million in savings related to the purchase, administration, and costs of complications of blood product use.
“This initiative has also saved twenty-seven thousand hours of caregiver time that would otherwise have been spent in preparing and administering transfusions that were not medically necessary,” Zaroukian says. “Sometimes less is more when it comes to healthcare.”
Decreasing Catheter-Associated Urinary Tract Infections
Use of urinary catheters is necessary for millions of patients. But about five hundred thousand catheter patients suffer infections from their use each year, and of that group thirteen thousand die of related infections.
Reducing catheter-associated urinary tract infections (CAUTI) draws from a strategy that relied on people and processes, informed by data. “Our goal was to remove catheters that are no longer medically necessary as soon as possible,” Zaroukian says. “With our CAUTI rates increasing for several years, we had to figure this out.”
Led by Chris Nemets, Sparrow’s chief nursing informatics officer, teams researched timely catheter removal protocols for patients slated for short-term catheter use (forty-eight hours or less) and for those needing longer-term catheters. When physician-facing protocols did not yield improvements, nurses volunteered to take the lead on catheter management and timely removal. To succeed, they needed what the EMR could provide: data on catheter use, tools for documenting catheter-related information, and clinical decision support to promote timely removal. They built new EMR protocols and used data reports to achieve an 81 percent decrease in CAUTI, from 52 patients in 2014 to 10 in 2018.
“This was a matter of nurses and doctors working together, with nurses empowered by data and protocols to make decisions on catheter use and removal,” Zaroukian says. “It also helped us to avoid $1.1 million in CAUTI-related costs, with more than $300,000 per year in savings.”
