AHRQ's clinical care tools help clinicians ensure better and safer care
Research Activities, August 2011, No. 372
"Marcella" is a 52-year-old Hispanic woman, who has diabetes and speaks limited English. Like many patients, her care is better and safer due to clinical tools funded by the Agency for Healthcare Research and Quality (AHRQ). Thanks to these clinical tools—software applications, checklists, strategies, and care protocols—Marcella gets the preventive services she needs during office visits, waits less time to see an emergency department doctor, is less likely to develop complications after surgery, and is less apt to be readmitted to the hospital due to problems after hospital discharge.
Preventive Care Screening Tool
For example, Marcella visits her primary care doctor for a regular checkup. During the visit, Marcella's doctor uses his stethoscope and blood pressure cuff, typical tools of the trade, during the physical exam. Then he pulls out his laptop, iPad, or cell phone to use a software application, the Electronic Preventive Services Selector (ePSS) , which indicates the clinical preventive services (screening, counseling, and preventive medications) Marcella should receive based on her age, sex, whether or not she smokes, and other risk factors. After the doctor enters Marcella's data, the ePSS shows that Marcella should be screened for colorectal cancer, which is recommended for people between the ages of 50 and 75 years.
The ePSS tool provides access to the latest evidence-based recommendations from the AHRQ-sponsored U.S. Preventive Services Task Force (USPSTF) . "It's hard to squeeze preventive services into primary care visits," says Timothy Quigley, M.P.H., P.A.-C., Director of Student Affairs, MEDEX Division of Physician Assistant Studies at the University of Washington School of Medicine.
"Rather than get this information in a 10-minute discussion during a short visit, you can use the ePSS to enter a few items and get a comprehensive list of recommendations for the patient. In less than a minute you've covered all the bases... It also enriches the dialog with patients, because it doesn't look like it's just your random opinion about what preventive services they need." The ePSS is a helpful tool given that Americans fail to receive recommended care nearly half the time, according to a 2003 landmark study by the RAND Corporation.
The ePSS tool helps clinicians select the right preventive service for the right patient in real time—in Marcella's case, a screening for colorectal cancer.
"The AHRQ ePSS app is a must-have program for its ability to facilitate the practice of optimal preventive care, an increasingly vital element of good medicine," notes Amit Patel, M.D., of Washington University School of Medicine/Barnes-Jewish Hospital, in a recent Web review of the tool. He also designated the ePSS one of the top 10 iPhone medical applications for internal medicine physicians and residents.
The ePSS contains approximately 110 recommendations for specific populations covering about 59 separate preventive service topics. When Marcella's doctor keyed in her characteristics, it produced a report tailored for her that her doctor could discuss with her.
Workflow Assessment for Health IT Toolkit
Next, Marcella's doctor uses his laptop to access her medical history in her personal electronic health record (EHR) and finds that she has not had her blood-sugar tested and diabetes-related eye and foot checks in over a year and that prescriptions for her diabetes medications are inconsistent. Marcella's doctor did not always have an EHR, but his patients have benefited since he adopted this tool into his practice. Many physicians are struggling with how to integrate EHRs and other health information technology (IT) systems into their practice, with just over half of office-based physicians having full or partial EHR systems in 2010, according to the Centers for Disease Control and Prevention. Practices without EHRs will soon have a tool, the Workflow Assessment for Health IT Toolkit , which provides a roadmap to ease the integration of EHR systems into their practices.
This toolkit helps small- and medium-sized practices assess and redesign their workflows when transitioning from paper to electronic records. "The toolkit can be used to identify workflow issues and problems before health IT is implemented, therefore preventing or mitigating workarounds, inefficiencies, and safety problems," notes Pascale Carayon, Ph.D., of the University of Wisconsin-Madison.
The Workflow Assessment for Health IT Toolkit also provides examples of the experiences of similar clinics, so practices can gauge how the integration of health IT into their practice will affect workflow, including changing staff roles, need for training, and time spent entering patient data. In Marcella's case, because her doctor's practice analyzed user needs prior to EHR implementation, the practice made sure the system would allow the doctor to easily pinpoint gaps in Marcella's diabetes care during her visit.
Health Literacy Universal Precautions Toolkit
Like over one-third of patients in the United States who have limited health literacy, Marcella finds it difficult to obtain, process, and understand basic health information. Luckily for her, her doctor uses tips from Health Literacy Universal Precautions Toolkit (developed for AHRQ) to make sure she understands their discussion of diabetes management and medications. Low health literacy in older Americans is linked to more emergency department visits and hospitalizations and higher risk of death, according to an evidence report by AHRQ.
"Of all the things we're doing to improve care, if we ignore the health literacy piece of this and we don't ensure that patients know what they need to know and do, all these other strategies aren't going to get us very far in health care improvement," asserts Laura Noonan, M.D., director of the Center for Pediatric Excellence at Levine Children's Hospital.
The health literacy toolkit enables practices to assess gaps in their communication with patients and then directs them to one of 20 tools in the kit to improve communication with less literate patients. These tools include tips on communicating clearly, strategies to encourage patients to ask questions, the teach-back method to ensure patients understand what the clinician has said, a brown bag medication review, and strategies to address language and cultural differences.
"Based on our practice assessment, we targeted the teach-back tool," says Dr. Noonan. The teach-back method involves having the patient repeat back, in his/her own words, what he/she heard from the clinician. "We trained our staff to learn this method and practice it so they could work it into their workflow," adds Dr. Noonan. "The teach-back is key, and also encouraging patients to ask questions. Our staff asks patients if they have any questions from the time they get called back to be weighed all the way to checkout. We also ask them if they got all their questions answered." Dr. Noonan also notes the benefit of the brown bag tool, which provides strategies clinicians can use to help patients remember to bring their medicines to their office visits. There the doctor can identify any medication problems and educate patients about their medications.
Based on guidance from the Health Literacy Universal Precautions Toolkit, the doctor asks to see Marcella's medications, and corrects her confusion about how often to take them, which probably caused some of her recent symptoms. He also talks to her about the importance of regular blood-glucose testing and diet and exercise to control her diabetes using the teach-back method. He asks Marcella to repeat back what she understood and if any dietary suggestions or other parts of her diabetes action plan will not work with her culture or would be difficult for her to carry out. The doctor answers all her questions and then orders the required tests and schedules Marcella for a colorectal screening test.
Door-To-Doc Patient Safety Toolkit
A month after her routine checkup, in an unrelated development, Marcella develops acute abdominal pain and ends up in the emergency department (ED). Following a triage protocol, the Door-to-Doc Patient Safety Toolkit (https://innovations.ahrq.gov/qualitytools/door-doc-patient-safety-toolkit), the ED staff gives her a quick look and escorts her to an ED bed for clinical evaluation. The Door-to-Doc tool reorganizes the ED patient flow process. When a patient arrives in the ED, she is given a "quick look" rather than full triage and identified as "less sick" or "sicker." Sicker patients are escorted to an ED bed where a clinical team evaluates them and orders diagnostic tests and treatments. Less sick patients, who tend to be ambulatory, are not assigned beds. Instead they move among treatment areas away from the flow of other patients, while they wait for lab and other test results.
The ED staff can use the Emergency Severity Index (http://www.ahrq.gov/research/esi/esi1.htm), one tool in the toolkit, to stratify patients into five groups from 1 (most urgent) to 5 (least urgent). This approach accurately identifies patients who need to be seen immediately from those who can safely wait to be seen. Severity is determined by stability of vital functions and potential for life, limb, or organ threat. In Marcella's case, the ED team suspects a ruptured appendix and makes plans to prepare her for surgery. Eight emergency departments in the Banner Health System that adapted this two-track patient flow model reduced the patients who left without ED treatment from 7.1 to 1.7 percent, average ED length of stay by 14 percent (from 310 to 268 minutes), and door-to-doc waiting times by more than an hour (from 117 to 49 minutes).
To avoid the many errors that can happen before, during, and after surgery, Marcella's hospital uses TeamSTEPPS®—strategies and tools to improve communication and crucial teamwork skills among health care professionals. "Communication failures and lack of teamwork are major contributing factors to patient injury and harm," notes Carolyn M. Clancy, M.D., director of AHRQ. TeamSTEPPS , developed by the Department of Defense (DOD) and AHRQ, is comprised of four teachable-learnable skills: leadership, situation monitoring, mutual support, and communication.
TeamSTEPPS® provides steps and techniques to become an effective team leader and to monitor the status of the patient, team members (for example, for fatigue that can lead to mistakes), the clinical environment, and progress toward the care goal. TeamSTEPPS® also provides tips on how to provide mutual support to protect team members from work overload and how to freely ask for help, as well as how to assertively advocate for corrective action to protect the patient. Finally, TeamSTEPPS® provides communication strategies that can be used to convey critical information that requires immediate attention, to ensure information conveyed by one team member is understood by the other, and to transfer information during care transitions such as shift changes or patient transfers from one unit to another.
TeamSTEPPS® has reduced adverse events by 40 percent, according to the DOD. Using this approach, Marcella's surgical team communicates her medication allergies and diabetes, confirms her patient ID and the specific surgery to be performed, and organizes itself to prepare for Marcella's appendectomy. The team member responsible for reviewing completion of pre-op protocols finds that Marcella was not given pre-operative antibiotics to prevent post-surgical site infections and takes steps to correct it. This saves Marcella from a potentially longer hospital stay and her recovery from the surgery is quick and uneventful.
Once Marcella recovers and is ready to go home, a nurse discharge advocate, a central figure in Project RED (Re-engineered Discharge), prevents Marcella from being one of the millions of patients each year who are readmitted to hospitals. Project RED developer, Brian Jack, M.D., of Boston University Medical Center, developed this approach to tackle the fragmentation and misinformation involved in the discharge process to avoid adverse events following hospital discharge that often force people back into the hospital.
The Project RED checklist involves 11 steps that range from reconciling medications and making follow-up appointments to arranging for post-discharge services and sending a discharge summary to the patient's primary care physician. These steps are applied to each patient and culminate in an After Hospital Care Plan the patient can understand.
When Project RED was tested in 750 adult patients at the Boston University Medical Center, Dr. Jack documented a 30 percent decrease in hospital readmissions at the end of 30 days for Project RED patients compared with patients who underwent a typical discharge.
Thanks to Project RED, Marcella is discharged home with a care plan and guide for how to take care of herself when she leaves the hospital (Taking Care of Myself: A Guide for When I Leave the Hospital ).
Editor's Note: To access some of AHRQ's other clinical care tools, as well as data, assessment, and quality measurement tools, go to Topic: Tools .