Protocol Driven Care
Often proclaimed as the most effective method of reducing costs for hospitals, standardization is said to promote quality patient care at a cost-effective price. Standardization reduces waste, makes treatment predictable and controllable, and defines clear responsibilities for all team members. Standardization leads to more efficient, less costly care, and a more consistent patient experience — outcomes that become critical as the industry accelerates the adoption of value-based and risk-based models. Standardization and the reduction of unwanted clinical variation are top of mind for most healthcare leaders. In fact, unwarranted variation in clinical care represents an estimated $20M-$30M per $1B in revenue of actionable savings opportunity for a typical health organization.
Increasingly, consensus-based protocols are being developed to drive the consistent application of standardized approaches to the delivery of health care. Clinical protocols improve the quality of clinical decisions by offering explicit recommendations for clinicians who are uncertain about how to proceed, overturning the beliefs of doctors accustomed to outdated practices, and providing evidence-based recommendations that reassure practitioners about the appropriateness of their treatment policies. It has been argued that much of an experienced practitioner’s daily practice has less to do with solving problems than remembering solutions. Moreover, one-half of all clinical decisions are reached without adequate medical evidence to inform choices.
Clinicians, policymakers, and payers see protocols as a tool for making care more consistent and efficient and for closing the gap between what clinicians do and what scientific evidence supports. However, simply establishing a protocol does not necessarily mean clinical teams are implementing it into their workflow. To be truly effective, once a protocol has been implemented, its utilization needs to be monitored for compliance and effectiveness. How do you know if a protocol is working if you don’t measure adherence and the impact on KPIs on a consistent basis? Understanding protocol adherence requires resources to pull and analyze data, but this is often time and cost prohibitive. Some institutions have clinical effectiveness groups that provide a collection of activities and tools based on research and measurement that are used to improve the quality of healthcare. These activities include protocol development, audit, research, and evaluation. But they often face the same resource constraints and an inability to access comprehensive EMR data, therefore the utilization and effectiveness of many protocols remain unknown.
By using the right data analysis tools, healthcare providers and health system administrators can measure and track compliance with clinical protocols, identify physician practice variations and areas for education, see the results in the effectiveness of patient treatment and outcomes, and even identify areas for change to the protocol. When fully utilized, protocols can provide the framework for continuous improvement.
Standardizing Nutrition Delivery
Meeting appropriate nutritional demands in the inpatient setting is a fundamental aspect of optimal patient care. However, malnutrition is a common and complex problem in hospitals, due in part to nutrition education being underrepresented in many medical schools and residency programs. Malnutrition increases risks of mortality and complications and results in longer hospital stays, more frequent readmissions, and increased costs, placing a large burden on patients and the health care system,. According to a new study, malnutrition among people with chronic disease costs $15.5 billion in additional healthcare spending per year. Patients who develop malnutrition represent a missed opportunity to deliver the critical nutrients needed and prevent the ramifications that come with a malnourished state. Despite extensive research regarding the delivery of nutrients to hospitalized patients, there are still many questions and extensive variability in care, especially in the critically ill and one of the most vulnerable patient populations, preterm infants.
Optimizing nutrition management in the NICU, particularly through the successful progression of enteral and oral feeding of preterm infants, remains a major challenge for clinicians. Optimal nutrition during this critical period in early life can positively impact preterm infants’ physical growth, as well as neurological development. However, feeding difficulties are the primary contributor to increased NICU resource utilization and length of stay and result in the prolonged duration of central line days, parenteral nutrition (PN), and intra-gastric feeding, all leading to an increased risk of hospital-acquired infections and the smallest, most immature infants suffering the worst postnatal malnutrition,,. Standardizing the process for preterm infant feeding is one way to ensure the successful progression of enteral and oral feeding, and thus optimal nutrition management. Many clinical practice groups have developed consensus-based enteral feeding protocols for nutrition management to provide evidence-based care with less variability.
However, clinician variability in individual practice attitudes, experience, and knowledge can impede the implementation of a feeding strategy therefore, compliance monitoring is necessary to be truly effective. Creating systems aimed at identifying patients at significant nutritional risk and monitoring adherence to evidenced-based nutritional care practices have the potential to significantly improve patient outcomes and reduce costs.
Nutrition Protocols and Compliance
Today, there are differing approaches to enteral feeding protocols in the NICU. Some hospitals lack standardized feeding practices and rely on the experience of the attending physician. Many prestigious academic medical centers will research and develop their own feeding protocols, while some hospitals will simply adopt published protocols from other hospitals. Unfortunately, for preterm infants in the NICU, there is no gold standard enteral feeding protocol. A review of the published feeding protocols at five top-tier NICUs found extensive variation among the different protocols including:
- Grouping babies by birth weight or gestational age at birth (see Table 1)
- Enteral feeding – first feed and advancement rates (see Table 2)
- Fortification of human milk
- Handling contraindications
Table 1. Differences in Groupings According to Birth Weight (Grams)
|Hospital A||Hospital C||Hospital E|
|≤1000 g||≤750 g||< 600 g|
|1001 – 1500 g||751 – 1250 g||600 – 799 g|
|1501 – 1800 g||1251 – 1500 g||800 – 1249 g|
|1801 – 2500+ g||1501 – 2000 g||1250 – 2000 g|
|2001 – 2500 g||> 2000 g|
|> 2500 g|
Table 2. First Official Enteral Feed and Advancement Rates
|Hospital A||Hospital B||Hospital C||Hospital D||Hospital E|
|First Feed (mL/ kg/day)||10||10 – 24||15 – 20||15||10|
|Advancement (mL/ kg/day)||↑ 10 after 12 hrs.||↑ 25-35 after 24 hrs.||↑ 20 on Day 4 or 6||↑ 15 on Day 5||↑ 10 on Day 3|
There is a high probability a preterm infant born at Hospital A will receive much different nutrition than if the same infant were born at Hospital C or E based on the differences outlined above. Currently, it is not known where this infant would thrive best. With an increased awareness of the lack of consensus and collaboration, there is a need for improved standardization in feeding and nutrition practices.
Embrace the Adoption of Technology
Currently, though, there is no practical way to evaluate adherence to nutrition protocols in the electronic medical record (EMR) or assess desired feeding and nutrition-related outcomes to improve the practice of care. Recent studies suggest that nutritional protocols across the majority of intensive care units are not being implemented. Lack of knowledge, no technology to support medical staff, and general noncompliance with nutritional protocols often result in higher mortality and infection complications. Protocol implementation and management is still a manual, self-reported process. There was an early promise of using the EMR to support research and provide clinical decision support, but the reality is that EMRs have created workflow disruption and do not provide insights related to feeding and nutritional goals in real time. Furthermore, many clinical practice groups end up with a wealth of collected data and no tool or process to mine the data for useful insights on protocol compliance, and whether or not the protocol is providing the desired outcomes.
To overcome the challenges of manual standardization, understand protocol adherence or lack thereof, and to gather useful insights from feeding data, clinical practice groups could benefit from an operational tool to implement a hospital’s feeding protocol and promote compliance more effectively. With data as the common denominator, tech-enabled digital tools allow clinicians to track and visualize nuanced detail, adherence to, and deviations from protocols, as well as examine how feeding decisions correspond to patient outcomes. Digital tools can provide automatic calculations for feed planning based on protocols, so clinicians are able to manage real-time care planning more efficiently. This will reduce the time required to prepare for and present during daily rounds while also providing a consistent communication tool for providers. Reduction in clinical time spent on these tasks will reduce unit costs, increase time at the bedside, reduce clinical burden and therefore increase quality of care and patient satisfaction.
The starting point of every improvement journey is good, quality data. Using data analytics and digital tools to measure historical practices and prospectively measure and monitor outcomes will lead to improved, evidence-based patient care. As the industry gets better at using data analytics in decision-making and automation finds more mainstream uses in operational, administrative, and clinical settings, the potential for optimal standardization will accelerate.
About Tammi Jantzen
As co-founder and former CFO of Astarte Medical, Tammi managed financial reporting, marketing and PR, human resources, investor relations, legal and equity management and oversaw internal operations. Prior to founding Astarte Medical, Tammi co-founded Astarte Ventures, a fund dedicated exclusively to the health and wellbeing of women and children. Astarte Medical is a portfolio company spinout of Astarte Ventures. More recently, Tammi successfully sold a business she co-founded to a publicly traded technology and development organization based in the UK.