Centers for Medicare & Medicaid Services reimbursement changes have added urgency to the prevention of "never events" such as hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA). But as we look ahead to a future when reimbursement for care may no longer be bound by hospital walls, consider how we can "think out of the box" to expand prevention efforts.
We had a unique opportunity to envision future care for MRSA prevention and management during a guided visioning roundtable with 8 other nursing executives at the 2008 Nursing Leadership Congress in Scottsdale, Arizona. What follow are ideas generated during this energizing session-not by experts in infectious disease but experienced nurse executives who had a chance to let go and imagine how tomorrow could be.
The Hidden Infection: A Current State Scenario
Our roundtable was presented with the following scenario that could be typical today.
Joseph Night is a 78-year-old man with Parkinson disease. His admitting diagnosis is community-acquired pneumonia. He seems very ill with a high temperature, rales in both lung bases, and overall general malaise. His condition deteriorates, so he is transferred to the ICU for 2 nights and then returns to a medical-surgical unit. Now, after several days and in his third nursing unit in your facility, you discover that he has S aureus septicemia and is positive for MRSA.
Our objective was to envision how to move from the current state of care to what could be the ideal state. We were instructed to look at least 5 years into the future and assume that technology advances and the ongoing nursing shortage would have important impacts. We were also encouraged to envision the effects of new clinical roles on care models and processes. The results are focused on MRSA but extend beyond it as well.
Start in the Community
In the future, we could take a more proactive approach to infection control by initiating detection and prevention efforts in the community through health fairs and coordinated communication efforts. Hospitals, physician offices, health departments, school nurses, and even hairstylists could work together to reach all citizens with a common message regarding community cleanliness.
Reach Out to Call Centers
Could a community-based call center triage patients for infectious disease before they come to your emergency department?
Ideas to consider:
* Include local call centers when contracting with third-party payers, tying a screening effort to contract renewal.
* Build relationships between your home health service line and call centers. For example, analyze your 10 highest "frequent flier" emergency department patients and project the financial impact of enrolling them in a call center triage program.
* Use your home health service or call centers to identify useful medical information that is known by one entity but not others.
Reach Out to Primary Care
In the ideal future state, relevant patient information would be available when a patient presents for hospital admission or outpatient treatment. Everyone will have a primary care practitioner (PCP), either chosen or assigned through his/her insurer. Although the patient is the true owner of his/her health history, the PCP will be considered his/her "primary keeper."
Until then, how can your system team up with PCPs to make a difference? From a public safety perspective, we have a responsibility to forge a path that encourages base screening for infectious disease in the medical office and sharing of that information across the continuum.
The next challenge is getting that information from the medical office to autopopulate the admission history when a patient presents for inpatient admission. Better still would be one longitudinal medical record across the continuum securely accessible by any caregiver as well as the patient.
If your organization owns a primary care office, discuss what you could do in the meantime, such as tagging information onto your medication reconciliation system, or a common laboratory or other ancillary system. Consider assigning a liaison to meet with school nurses and find a way to share information with your local health department.
A New Model for the Hospital
The roundtable envisioned admission assessment and screening quite differently in the future as standardized processes with no invasive procedures. A "breathalyzer" assessment tool could autopopulate documentation with current information and incorporate previous laboratory results and sex and age information into risk algorithms that assist with diagnosis and treatment planning. An instant test, like today's early pregnancy tests, will screen sweat or other body fluids for infectious pathogens. Genetic profiles in the record will help the healthcare system know what to expect, patient by patient.
Such advances will take time, but there are actions you can take today. Your information technology system could include an automatic alert to clinical staff on any returning patient with a previous MRSA diagnosis.
Seeking information from the community is more challenging. As a start, consider assigning an advanced practice nurse to develop an MRSA risk assessment tool that could be used in primary care clinics and schools. When secure health information exchange becomes more pervasive, those data will be available for sharing.
The Role of Payers
Our roundtable envisioned a much different role for payers in the future. Most are currently set up to reimburse providers based on service volume. Few plans are designed to consider the best place for a patient to receive care, whether it is in the home, a hospice, or your hospital. Could you work with a payer to develop a demonstration project supporting reimbursement changes that align care delivery decisions toward the best location?
The roundtable believed hospitals should receive some incentive for early identification of MRSA or any condition that may harm other patients. Prevention evidence is lacking in this area; however, additional verification studies could drive change. Encourage your chief executive officer to discuss such policy recommendations at the state hospital association level, enlisting other organizations to harness the power of one industry voice.
The Role of Emerging Technologies
Imagine using a GPS to recreate previous locations where an infected patient has been or nanotechnology to implant a tiny device that could travel the body looking for signs of infection and attach to the virus for targeted drug delivery. What about "germ magnets" that could pull microbes off as people and equipment enter a room? Although these technologies seem far-fetched, research is already under way to develop nanotechnology.
Evolving Clinical Roles
We envisioned a new community care coordinator role, someone who could reduce risk of infectious disease not only for individual patients but also for the entire community. A skilled and experienced older nurse could be such a "wisdom worker," communicating with patients before and after hospitalization, determining appropriate care delivery locations, and acting as a liaison with call centers, skilled nursing facilities, and home health providers.
Advances in Medication Therapies
Consider how the traditional 10-day antibiotic regimen is down to 5 with the advent of today's "Z-pack." Dose requirements will continue to reduce, helping prevent self-administration errors and incomplete compliance. New administration mechanisms such as nasal mists or tiny chip implants could further improve patient compliance and convenience.
The Future-State Scenario
The path to the future will not be easy. It will require a complex set of strategies including a fresh look at processes, the emergence of new roles, more research, anticipated changes in reimbursement, and advances in technology. Our roundtable envisioned a dramatically different infection control management scenario for the future (Figure 1).
As physicist Niels Bohr once quipped, "Prediction is very difficult, especially about the future." Our roundtable participants concluded that we will manage infectious diseases in the future much better than we are right now based on the following anticipated changes:
* Secure electronic medical records available across the care continuum
* Standardized approaches to the collection and communication of patient history
* Personalized medical screening with risk modeling for disease states based on genomic and other individualized information
* Aligned reimbursement across the healthcare industry with incentives for disease prevention
* Broad-based national and local education on infection prevention
* State-of-the-art germ detection and disinfection methods
The authors thank the Nursing Leadership Congress roundtable participants for the dynamic session that provided these ideas.
© 2010 Lippincott Williams & Wilkins, Inc.