An older physician colleague once described the first time his mentors used furosemide at the now-defunct Baltimore City Hospital. Patented but not yet approved for market in 1959, furosemide was recognized as a powerful diuretic that could induce a heart failure patient's kidneys to release excess fluid from the circulatory system, thereby relieving congested lungs and easing the ability to breathe.1 However, furosemide's diuretic effect on a patient's vascular system posed significant risks: too high a dose would markedly lower blood pressure, sending the patient into shock. My colleague, then an intern, described great trepidation as his mentors started testing the compound in experimental trials. A patient with advanced heart failure and willing to undergo the experimental therapy was recruited, and they gathered in the intensive care unit. There, his mentor slowly injected 10 mg intravenously over a suspenseful 30 minutes, while an emergency team carefully monitored the patient, standing ready to resuscitate should his vascular system collapse. The treatment resulted in ... nothing.
Modern medical interns might be forgiven for laughing at my colleague's story. Furosemide is one of the most commonly used treatments today. Interns routinely prescribe it intravenously in 40-mg or higher doses, sometimes as high as 160 mg multiple times a day, and nurses in heart failure clinics often instruct patients on how to self-titrate oral furosemide at home. Our professional forebears prescribed too low a dose, administered it too slowly, and did it in a setting that, in hindsight, seems comical. Yet, their caution was laudable. Although they had carefully read the documentation about this experimental drug, they had little experience in actually using it.
APPLYING PROMISING IDEAS WELL AT THE BEDSIDE
Health care leaders face a similar challenge when trying to translate promising ideas from the literature into quality improvement initiatives. Although many readers of Quality Management in Health Care devote considerable effort to accelerating the process of applying evidence-based strategies to the bedside, there may be value in reflecting on what challenges we must overcome in order to do this well.
Novel approaches for improving health care delivery are often characterized vaguely and frequently described in terms of features that overlap with unsuccessful interventions. Thus, health care leaders may find it difficult to select appropriate strategies to promote. Furthermore, published descriptions of promising strategies typically report only key characteristics or important principles, which convey the essence of an intervention but lack operationally relevant details. Even when detailed protocols are available, health care leaders still must modify the "evidence-based" interventions for their specific settings. At Johns Hopkins Medicine (JHM), our experience implementing a nurse-led postdischarge telephone follow-up program illustrates these principles.
A 2006 Cochrane Review concluded that although promising programs had been described, the overall evidence found little benefit associated with telephone follow-up after hospital discharge.2 Nevertheless, in 2013, JHM established the Patient Access Line (PAL) as part of a multicomponent strategy designed to improve quality of care and reduce readmissions after hospital discharge.3 Patient Access Line consists of a team of clinically experienced nurses who call patients within 48 to 72 hours of hospital discharge if the patient returned home without an assigned transition guide nurse, home care, or other transitional support service. An evaluation of PAL in 2017 reported that patients who received a PAL call had 24% lower adjusted odds of readmission than those who did not, resulting in considerable savings from readmission penalty avoidance.4
WHAT MAKES AN INTERVENTION WORK WELL?
Why was PAL effective in contrast to the interventions described in the Cochrane Review? Without a controlled study, we cannot be certain. But unsuccessful programs were often anemic; for example, automated phone calls that allowed patients to respond via phone tree, or calls made by clinical staff devoting only part of their time to the task. We believe that PAL differs from those earlier attempts in 3 important ways.
1. PAL has nurses specifically trained for and tasked with making follow-up phone calls. Thus, patients benefit from interacting with health care professionals who are highly experienced in connecting and communicating through the telephone at a human level and problem-solving issues in real time.
2. PAL is integrated with a comprehensive set of care transition support services, including transition guide nurses (who can visit patients at home), pharmacists (who can remediate medication concerns), and others. PAL nurses identify a clinical concern in approximately one-third of calls, most of which are medication-related. Having links to care transition support services allows them to intervene without requiring patients to return to the hospital or the emergency department.
3. PAL systematically collects and analyzes data from postdischarge calls, which allows hospital leaders to identify hospital units or patient populations with higher risk for readmissions, thereby facilitating continuous quality improvement.
In other words, PAL provides patients with an adequate dose of telephone follow-up, administered in an effective way.
These examples serve to remind us that while conventional wisdom dictates the need to rapidly translate published, evidence-based strategies into daily practice, it is important to thoughtfully consider not only what worked but also why it worked, how much of it was needed to work, what was needed to allow it to work, and for whom it worked.
PAUSE, ASSESS, ADJUST
Like clinical therapies, systems interventions may also need to evolve if they are to remain effective. In 2013, the Centers for Medicare & Medicaid Services released billing codes that incentivize primary care practices to call patients after hospital discharge.5 Thus, in the same year that JHM established PAL, nurses at JHM's primary care practices also began calling patients after hospital discharge. In contrast to PAL calls, those made by primary care nurses are informal, made by nurses who intersperse calls among other duties, screen for concerns without the benefit of comprehensive transitions of care support services, and do not systematically collect data to support quality improvement.
With attention now focused on reducing overlapping services and eliminating waste, JHM executives have asked primary care practices, PAL, and other similar programs to align their activities in order to eliminate overlapping calls, while preserving what is best about each initiative. As we begin this work, we again find ourselves asking the same questions: What is the right dose? How should we apply it? And for which patients?
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