Implementing evidence-based practices is key to outpatient referral.
Dear Director,
As our ED group has started reducing work ups on patients with asymptomatic hypertension and begun discharging low risk PE patients, I’m getting more and more complaints from our PMDs who refer patients to us. They’re questioning our quality and decision making. How can I get them to catch up with the times?
I had a conversation with Dr C., one of our pulmonary-critical care docs, a few years ago after the hospitalists started pushing us to discharge some PE patients from the ED with next day follow-up with the pulmonary team. This was first requested of us with a patient that was admitted at 9 p.m., but would be boarded in the ED overnight. The hospitalist suggested the ED team discharge the patient since they were treated with a NOAC, were “stable” and would just be discharged 12 hours later after morning rounds.
Days later, as Dr C. and I were discussing this case, we were both uncomfortable with the logic and had concerns about where the trends were going. Around the same time, I was studying for my board re-certs and couldn’t help but notice the amount of questions on asymptomatic hypertension. The correct answer generally was do nothing and have the patient follow-up with their PMD. Now in 2020, many emergency physicians across the country are comfortable with discharging a subset of patients with PE. Conversely, JAMA published an article on the variability of clinical practice guidelines regarding the management of hypertension, potentially confusing the issue of our “minimalist” approach for asymptomatic hypertension.[1]
It may take up to 17 years for evidence-based practices (EBP) to become mainstream in medicine.[2] Many EBP may not generate enough momentum to become mainstream. Implementation science can be defined as “the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services.”[3]
As most of us in emergency medicine management know, all politics is local. That means one of the keys to success when implementing an EBP is getting engagement from the medical staff. Engagement can be defined as buy-in or commitment. As we develop pathways that extend beyond the ED, physician engagement needs to start with the emergency physicians, but ultimately will need to extend beyond our walls to anyone in the hospital community who may be impacted by our pathway.
Engagement
One of the keys to leading the pathway process, and changing how we traditionally manage patients, is getting engagement from your hospital community. Engagement comes in three phases — when you’re developing the pathway, implementing the pathway and sustaining the pathway.
It’s helpful to have a pathway champion — ideally someone who isn’t the department chair or medical director. This motivated physician will review the literature and existing guidelines from other institutions, as well as, create the first draft. The other providers are then given an opportunity to provide feedback. This provides confidence to your clinician group that the guideline has been vetted by their peers and is suitable for their practice environment.
As the pathway is nearing its final stages, now is the time to engage the other specialists who will be involved with these patients in your hospital community. After all, it’s hard to have an effective chest pain rapid rule out pathway if you haven’t engaged your cardiologists about providing close follow-up. We have had great success with our specialists by asking them to provide input.
Specialists obviously bring their own knowledge of the literature to the table and sometime supplement our knowledge gaps. Typically, they enhance our final product. As we’ve now gotten the specialists engaged in the pathway and move towards implementation, it allows us to say that we’ve worked with our colleagues from upstairs. Our specialist colleagues can also assist with planning outpatient follow-up. We learned very quickly that expecting primary care docs to be able to urgently see and manage discharged PE patients was an obstacle for discharge. Conversely, the pulmonologists were happy to help and take responsibility for providing follow-up to these patients.
We had similar success in working with our cardiologists for our asymptomatic hypertension patients. As I often say to these patients, my view of hypertension is very different than how their primary care docs view their blood pressure. I’m responsible for their health over the next several hours to weeks while their primary care doc worries about the long-term consequences of hypertension. But that doesn’t mean I should ignore everything. Sometimes we need to adjust medications or start BP meds. We used emergency medicine best practices, but picked the cardiologists’ brains on what to do in certain scenarios.
Additionally, we encourage our docs to communicate with the PMD or with the cardiologist to create a plan and close follow-up, specifically related to what the choice of initial blood pressure medication in certain patient populations. Often the plan is as simple as keeping a blood pressure log, but it may involve starting new medications. It is also critically important to obtain input from your hospitalist colleagues whenever developing a clinical pathway that impacts the decision to admit a patient. In the case of our PE discharge pathway, we obviously wanted to avoid the scenario where we ask a hospitalist to admit a patient and they either are not aware of the pathway or disagree with the risk stratification and guidance provided by the pathway.
Implementation
There are several steps to take to ensure a successful implementation. Since the pathway has likely been in development for several weeks to months, it can be very helpful to circle back to the ED group and provide targeted education on the pathway. This is the time to include the “why” behind the pathway— i.e. patient safety, patient preference and reduce costs/hospitalizations. Reassure your group on the science and research behind the pathway, while reinforcing that well-reasoned (and documented) variability, i.e. the art of medicine, still has a role for patients when varying care from the pathway.
As you provide education to your group and pick your start date, you may also want to make the rounds to other key hospital meetings. This could include quality meetings, department meetings, the medical executive committee and/or the medical staff meeting. This is really where you get the bang for the buck having the specialists engaged in the process. Being able to say that “we teamed up with the cardiologists to develop outpatient management guidelines for asymptomatic hypertension” goes a very long way when presenting at the department of outpatient medicine group meeting. The presentation or discussion is generally the same. It’s very rare to have to go back to the drawing board, but if there are questions, now is the time to address them or make sure you have a plan going forward.
Give some thought as to how your providers will access the pathway during a shift. Pulling up a single-spaced word document from an old email or shared drive is not ideal. Consider developing an easy to read flow chart that can be easily accessed either electronically or via hard copy. Better yet, consider embedding clinical decision support to reflect content of the pathway in your EMR.
As you actually implement the pathway in the clinical setting, it’s important to find a way to provide feedback to the clinicians. For some clinical pathways, you may be able to fairly easily track the impact of the pathway on utilization of resources – for instance CT utilization or admission rate for a given condition. Determining the rate of adherence to the pathway is more difficult and often requires either hand audits of selected charts or generating data from your EMR if you went the extra mile and developed clinical decision support in your EMR that reflects the pathway content. With the pathways we’ve implemented at my site, we’ve found that being transparent in the data can help to drive change as well. No one really wants to be the outlier.
Sustainability
Developing and implementing a pathway is time consuming. By the time it’s started, it’s likely the focus of the physician champion and the ED chair has moved on to other projects. In order to successfully sustain results, it’s important to periodically review performance and provide feedback to the providers. This could be quarterly or semi-annually with the goal of getting data and a pathway refresher back in your doc’s forebrain. Your 72-hour or seven-day readmission or revisit rates may be helpful in determining if the initial management of the asymptomatic hypertensive patient or PE patient had appropriate decision making. Periodically update the clinical pathway (perhaps annually) as new literature and new guidelines are continuously published.
Answering the calls from the hospital community
When my consultants call me to complain about a requested consult, I frequently remind them that emergency physicians are calling consults because we need help or need a question answered. Admittedly, sometimes it’s a CYA or because the hospitalist wants it, but often it’s because we’re uncomfortable with a situation. The same applies for our PMDs who are now being asked to manage acute care medicine. Many of them are not comfortable with the acute care follow-up some of these patients require. Therefore, it’s critical to work with your primary care physicians to not only get a sense of their comfort level managing these types of patients, but also to get an understanding of how easily it is for them to build in patients that need urgent appointments. If close follow-up cannot be successfully arranged or if docs are uncomfortable managing certain acute patient types, follow-up with specialists may be the answer.
Conclusion
My uncle and my niece both died from PEs (different sides of the family). I know that this particular diagnosis can have life-threatening complications. The more I learned about discharging these patients, the more I realized that the decision to discharge a patient with a PE is much more complicated than simply calculating a PESI score. With that said, there will continue to be literature showing that many patients with PE can be managed as outpatients. The same can be said for asymptomatic hypertension. Our view of the world and responsibility to the patient is clearly different than the role of the primary care doc in managing hypertension. In both cases, we can achieve high quality care while rapidly changing how medicine is practiced. With the background of implementation science, and readily communicating and asking our specialists to be engaged in the process, we can successfully incorporate these pathways and improve care to our patients.
References
- https://jamanetwork.com/journals/jamanetworkopen/article-abstract/2755862
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4573926/
- https://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-1-1
- http://www.pecarn.org/documents/kuppermann_2009_the-lancet.pdf
EP Monthly review of outpatient PE management
https://epmonthly.wpengine.com/article/%EF%BB%BF%EF%BB%BFmanagement-strategies-outpatient-pe/
