Skip Drips, FLIP Patients
Taking a cue from Costs of Care and ABIM Foundation’s Teaching Value and Choosing Wisely Challenge, the University of Chicago Medicine and Biological Sciences Division recently launched its own competition to identify promising bright ideas for implementation of the campaign at the medical center.
The competition was designed to inspire house staff and fellows to implement quality improvement (QI) projects aligned with the goals of Choosing Wisely: reducing waste and promoting high-quality care. Two inaugural Choosing Wisely Challenge winners and an honorable mention were announced in May.
Winning project: “FLIP-ing the patient for discharge – How the bundling of Choosing Wisely recommendations through an EMR Dashboard can improve patient care” by Charlie Wray, DO, with collaborators Poushali Bhattacharjee, MD, and Aelaf Worku, MD
Wray and his colleagues looked at the five Society of Hospital Medicine (SHM) Choosing Wisely recommendations and hypothesized that bundling them together—instead of tackling individual items—would be more efficient and have longer lasting effects.
The project was designed to simultaneously implement four of the five SHM recommendations using the easy-to-remember mnemonic “FLIP the patient for discharge” to inspire staff to constantly assess:
- Is there a need for a Foley catheter?
- Is there a need for daily Labs?
- Are there Indications for telemetry?
- Is there a need for ulcer Prophylaxis?
“As clinicians, we’ve seen time and time again that any one of these four things can slow the discharge process,” Dr. Wray said. “We wanted to create an easy way for staff to think about these barriers to discharge. Asking ‘have you FLIP-ed your patient yet?’ a day or two prior to discharge would hopefully help the process run smoothly.”
In order to operationalize the idea of “FLIPing the patient,” Dr. Wray proposed creating a waste dashboard in the Electronic Medical Record (EMR). Each time a physician opened the patient’s chart, a FLIP icon would appear and provide an option to discontinue those respective orders.
Ultimately, Wray and colleagues hope to track metrics and gauge their success, by examining:
- discharges prior to noon;
- usage of Foley catheters and telemetry, and;
- hospital length of stay.
Wray submitted his winning proposal to the chief medical officer and local QI committee to initiate the implementation process. Future plans involve meeting with EMR programmers to work on the dashboard and working to educate fellow physicians about “FLIPing their patients.”
Winning project: “Skip The Drips – Reining in unnecessary continuous intravenous infusions” by Andrew Levy, MD, and Nikhil Bassi, MD
Inspired by Choosing Wisely’s goal to promote high-value care, Drs. Levy and Bassi identified three scenarios in which providers should assess the use of continuous intravenous drips:
- Continuous IV diuretic therapy ordered for congestive heart failure patients
- Proton pump inhibitor IV prescribed for patients with gastrointestinal (GI) bleed
- Bicarbonate IV ordered for ICU patients who have lactic acidosis, or too much acid in their blood
“We had to think about it from the patient’s point of view,” Dr. Bassi said. “Being connected to an IV drip makes small tasks like getting out of bed and going to the bathroom another hurdle.”
Drs. Levy and Bassi found recent research that the sodium bicarbonate IV has no benefit, and may cause harm, for patients with lactic acidosis, as their condition is likely terminal.
Other studies have shown intermittent doses – administered via a shot twice a day – were more effective than the continuous IV diuretic and proton pump inhibitor IV drips, and have been theorized to decrease the risk of C. difficile, a hospital-acquired infection that can cause severe diarrhea.
“For doctors it’s easy to order continuous medication for a patient and assume that it will make them better,” Dr. Levy said. “But it doesn’t make sense if it isn’t helping patients and creates a burden on the staff who has to create and monitor the dose.”
The pharmacy provided Drs. Levy and Bassi with data on how many times the drips were ordered in the past year. Since the University of Chicago Department of Medicine had the highest utilization rates, their project targets all adult patients in the medical center, including in the Emergency Department, on the wards and in the ICU.
They designed an intervention with three approaches, including:
- education with help from collaborators across several departments;
- building a reminder about recent evidence on continuous IV drips into the EMR and;
- requiring the ordering physician to provide a reason why they are ordering a drip.
They plan to monitor how often the three medications are used, with the goal of seeing a decrease in the use of non-evidence-based continuous IV infusions.
“We’ve been very encouraged by positive reception,” Dr. Bassi said. “When we won, we got ideas from our collaborators on how to implement our proposal.”