Clinical Thoughts

Join CareFusion clinical experts as they address issues affecting the practice and process of healthcare today and into the future. Browse entries below by topic area or author, subscribe to Perspectives to receive the latest updates, and join the conversation on Twitter.

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Dr. Carlos Nunez - CareFusion Chief Medical Officer

Unless you have been in hiding, you have probably noticed a great deal of buzz about "Accountable Care Organizations" (ACOs) as a way to accomplish some of the goals of healthcare reform.

Unless you have been in hiding, you have probably noticed a great deal of buzz about “Accountable Care Organizations” (ACOs) as a way to accomplish some of the goals of healthcare reform. And, if you have been paying attention, you may have also noticed that once the Centers for Medicare and Medicaid Services (CMS) published the proposed rules and regulations for implementing an ACO, many organizations jumped right off the bandwagon. One of the most thoughtful hospital system CMOs that I have the privilege of knowing said it best: “I like the concept of Accountable Care, I just don’t like the way CMS has constructed the Organization aspect of ACOs.”

The ACO is an attempt to craft a solution for one of the fundamental problems we face:  We don’t really have a “health care” system; we have a “disease intervention” system. Too many Americans wait until they are sick before they go to the doctor, which often leads to the least efficient and most costly care. And, because most payment models are currently structured to reimburse providers for doing “stuff,” these sick patients run up bigger bills and bring in more revenue than a healthy patient coming in for a routine checkup. What often gets lost in this discussion is that the ACO is just one part of a demonstration project aimed at reversing the financial incentives that contribute to higher costs and inefficiencies that plague the system.

In an ACO-type model, a population of patients is cared for by an organization of primary and acute care providers and facilities. The goal is to align the financial incentives with maintaining the overall health of that population of patients. That should result in fewer costly procedures and lower rates of hospital admissions. If such a fundamental shift is to be successful, it will require higher adoption of evidence-based practice in an attempt to drive improvements in outcomes and cost. The management of health and chronic disease, the medications that are prescribed and the procedures that are performed will be increasingly based on evidence over preference. While there will always be outliers and clinically justifiable reasons to deviate from established standards of care, the financial incentives to do so may not exist much longer.

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Dr. Tim Vanderveen - Vice President, Center for Safety and Clinical Excellence, CareFusion

This year marks the 10th anniversary of adding dose error reduction software (DERS) to IV infusion smart pumps. Today, virtually every infusion device on the market has incorporated some form of IV software to help protect patients from potentially serious IV infusion programming errors. The adoption of smart pumps, when compared to other medication safety technologies such as barcode medication administration (BCMA) and computerized physician order entry (CPOE), has been remarkably fast. In fact, 65 percent of the general purpose pumps in use today include DERS. In addition, over the past 10 years, DERS has continued to evolve and today can protect virtually every drug and method of administration. Likewise, the ease with which DERS can be managed using wireless technology has dramatically improved the speed of adding new drugs, adjusting dose limits, and capturing “good catches” and other data related to the clinical use of infusion pumps.

This year marks the 10th anniversary of adding dose error reduction software (DERS) to IV infusion smart pumps. Today, virtually every infusion device on the market has incorporated some form of IV software to help protect patients from potentially serious IV infusion programming errors. The adoption of smart pumps, when compared to other medication safety technologies such as barcode medication administration (BCMA) and computerized physician order entry (CPOE), has been remarkably fast. In fact, 65 percent of the general purpose pumps in use today include DERS. In addition, over the past 10 years, DERS has continued to evolve and today can protect virtually every drug and method of administration. Likewise, the ease with which DERS can be managed using wireless technology has dramatically improved the speed of adding new drugs, adjusting dose limits, and capturing “good catches” and other data related to the clinical use of infusion pumps.

Despite these advances, there are many opportunities to create even safer systems to administer high-risk medications. I believe the future of IV medication safety will be largely driven by two key technological developments:

  1. Bi-directional wireless connectivity—Pumps will no longer function as islands of information but will receive and output data as part of a larger network of devices throughout the hospital.
  2. HIT and IV device integration—While this poses significant technological, regulatory, cost and cultural challenges, the opportunity to create a safer, more productive HIT/IV system is already the focus of intense interest on the part of pump and HIT vendors, clinical thought leaders, professional organizations and the FDA. The same is true more broadly, as healthcare administrators look to maximize their HIT investments through connectivity and device interoperability in a “meaningful” way.

What is emerging is an exciting future with a shared vision of transforming IV therapy. Over the next 10 years, we envision the following:

  • All infusion pumps will be connected to a hospital wireless network
  • Image recognition (barcode, radio frequency ID tags) will be required to identify the IV drug/concentration being infused
  • Infusion pump programming will be automatically compared to the physician’s order to ensure appropriate dose
  • All IV infusion data will be automatically recorded in patients’ electronic health record
  • Critical lab values and missing lab values that impact IV infusions will be immediately communicated to the appropriate caregiver
  • All patients receiving high-risk IV medications will be continuously monitored with appropriate vital sign monitoring
  • Critical infusion (and physiological) alarms associated with high-risk IV infusions will be immediately presented to the appropriate caregiver

Recently the CareFusion Center for Safety and Clinical Excellence hosted an invitational conference on “Infusion Therapy and Information Technology—Taking IV Therapy to New Levels of Safety with IT Integration.” Bringing together 40 key opinion leaders to present their experience, share their expertise, discuss their strategies, and help prioritize the elements of the shared vision, proved to be a great start to this new decade of innovation. I’ll discuss more specific aspects of the conference in the coming weeks.

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Dr. Tim Vanderveen - Vice President, Center for Safety and Clinical Excellence, CareFusion

“Personal accountability” is the new hot topic in hospital conversations. We are all accountable for our decisions and our actions. Every time we speed, run a red light, fail to use our seatbelts, or forget to wash our hands, we’re putting ourselves and/or others at risk. The same is true for failing to use safety […]

“Personal accountability” is the new hot topic in hospital conversations. We are all accountable for our decisions and our actions. Every time we speed, run a red light, fail to use our seatbelts, or forget to wash our hands, we’re putting ourselves and/or others at risk. The same is true for failing to use safety technology that is available to help prevent high-risk medication errors. In a recent webcast hosted by the CareFusion Center for Safety and Clinical Excellence, an expert faculty discussed the risks clinicians take when they choose not to use available safety technologies. It is clear that we are entering a new era of personal accountability and, therefore, personal risk.

Since our webcast, we have learned of two additional errors that had tragic consequences. In a Chicago hospital, a neonatal nutritional formula was compounded in error as a result of a technician’s mistake that led to a 10-fold overdose of sodium chloride. The nutritional formula was prepared using a computerized compounding machine that is highly accurate in its preparation – it measures out each ingredient in exactly the amount as programmed. Unfortunately, the pharmacy technician programmed 10-times more sodium chloride than what the physician had ordered. For reasons that have not been disclosed, the dose checking software feature that could have alerted the technician and pharmacist to this error was not operational. The overdose of sodium chloride resulted in the baby’s death. In this case, the technician was a victim of someone else’s choice to neglect the technology’s safety features.

We also recently learned of a nurse who administered a 10-fold overdose of calcium that led to the death of a neonate, and afterward, took her own life. While there are no facts that point to a choice to not use available safety and error alert technology, this story reveals the deep feelings of guilt and personal grief that engulfed this competent and experienced caregiver.

These stories reminded me of the “second victim” of medication errors – a concept that’s been discussed by several national experts. The focus on the second victim began in 2006 when a Wisconsin nurse failed to use a bar code system that might have prevented a patient’s death when she administered an epidural infusion intravenously, instead of an IV antibiotic. The nurse was terminated, charged with two felony counts and ultimately was prohibited from direct patient care for a 5-year period. She has since revealed that she also considered taking her own life.

Clearly, the adoption and proper use of technology that can improve safety requires changes in long-standing practices and introduces new legal risks. Change is never easy, but addressing these issues is necessary. Our patients demand and deserve the safest care we can provide.

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Dr. Carlos Nunez - CareFusion Chief Medical Officer

Like healthcare reform in 2010, the political struggle to address rising deficits and the national debt has become the defining political meme of 2011. While the headlines may be different, the budget battle and the future of American healthcare are intimately intertwined.

Like healthcare reform in 2010, the political struggle to address rising deficits and the national debt has become the defining political meme of 2011. While the headlines may be different, the budget battle and the future of American healthcare are intimately intertwined. Spending on health care, through the Department of Health and Human Services (HHS), is the single largest item in the federal budget and a major contributor to our recent run of record deficits and a national debt that exceeds $14 trillion.

American healthcare faces a future where the only certainty is that providers will have to find ways to continue to improve the care that is delivered, while politicians figure out where and how to cut hundreds of billions of dollars in spending. A recent survey of nearly 800 hospital CEOs by the American College of Healthcare Executives (ACHE) shows that for the sixth consecutive year, “financial challenges” ranked as their highest concern. The second and third greatest concerns were “health care reform implementation” and “government mandates.”  Trailing behind at fourth was “patient safety and quality,” dropping from the number three spot it held in 2009.

As we work to adapt to the new economic realities that will define the future of American healthcare, I believe there are four areas of focus that hold the key to a successful transformation of the current system: Quality, safety, cost and efficiency. These four concepts do not exist in isolation, but rather as two sides of a value equation. Quality and/or safety are no longer good enough if they don’t also drive down cost and/or improve efficiency, and vice versa. For any new idea, drug, treatment, solution, device, workflow or paradigm to have a chance of adoption, it must first make an impact across both sides of this equation. In other words, it’s not about doing more with less; it’s about doing better with less.

This transformation will not be easy, but it can be successful; and, it can lead us to a healthcare system where we can help keep people healthy, provide better quality care and protect our bottom lines.

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Dr. Carlos Nunez - CareFusion Chief Medical Officer

The new economics of American healthcare will challenge all parties—providers, patients, payers, government, employers and industry—to work together to find solutions to the problems that not only put health and lives at risk, but also put undue financial strain on the system. Healthcare reform efforts in the U.S. have helped create a great deal of renewed interest in population health, chronic disease management and decreasing readmission rates. These areas of focus align perfectly with the concept of the Accountable Care Organization (ACO), where networks of providers and healthcare facilities collaborate to drive increases in quality and efficiency, while decreasing cost. One way to drive down the cost of care is to keep people healthy and out of the hospital; especially the expensive parts of the hospital, like the ICU.

The new economics of American healthcare will challenge all parties—providers, patients, payers, government, employers and industry—to work together to find solutions to the problems that not only put health and lives at risk, but also put undue financial strain on the system. Healthcare reform efforts in the U.S. have helped create a great deal of renewed interest in population health, chronic disease management and decreasing readmission rates. These areas of focus align perfectly with the concept of the Accountable Care Organization (ACO), where networks of providers and healthcare facilities collaborate to drive increases in quality and efficiency, while decreasing cost. One way to drive down the cost of care is to keep people healthy and out of the hospital; especially the expensive parts of the hospital, like the ICU.

A frequently quoted study published in Critical Care Medicine estimated the cost of ICU care to be as high as one percent of the GDP. The new economic reality makes it imperative that these high-cost areas fully embrace efforts that improve quality and decrease costs, such as the prevention of nosocomial infections. A quick look at the numbers helps to illustrate this point:

  • Nosocomial pneumonia affects up to 27 percent of all patients admitted to the ICU.
  • 86 percent of those pneumonia cases occur in patients who received mechanical ventilator therapy.
  • This represents as many as 300,000 cases of VAP per year, with a mortality that can be as high as 50 percent.
  • The average length of stay in the ICU for patients diagnosed with VAP can be more than three times longer (13 vs. four days), with an incremental cost as high as $20,000 per case.

This means that hundreds of thousands of lives and billions of dollars are at risk each year.

Despite the trend to move the axis of care further from the acute care setting, the management of patients suffering from respiratory failure and other conditions that require mechanical ventilation is still an important variable in the economic equation of cost and quality.

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Process vs. outcomes in healthcare delivery