UH Digestive Health Team Establishes High Reliability Medicine Initiative for GI Bleeding

High reliability care for gastrointestinal bleeding

Innovations in Digestive Health | Fall 2019

Brooke Glessing, MD

From peptic ulcers to diverticulosis to complications from liver disease, a number of conditions can cause gastrointestinal (GI) bleeding. Although any sign of GI bleeding is a source of alarm for patients, the degree of bleeding can range from microscopic levels to noticeable amounts of blood visualized in the stool or emesis – meaning not every patient with GI bleeding requires hospitalization.

Published studies, in fact, have shown that about 15 to 25 percent of patients who present to the emergency room (ER) with suspected acute upper GI bleed may not need to get admitted. They can be discharged from the ER with early outpatient follow-up.

University Hospitals Digestive Health Institute has formed a multidisciplinary team to develop a protocol that uses the principles of high reliability medicine (HRM) to improve the way in which University Hospitals manages patients who present with GI bleeding.

WHAT IS HIGH RELIABILITY MEDICINE?

"High reliability to us means standardizing care delivery through evidence-based practices by decreasing mindless variation while augmenting mindful variation to deliver consistent positive results with the patient at the center of everything we do,” says gastroenterologist Brooke Glessing, MD, Medical Director of Endoscopy at University Hospitals Cleveland Medical Center and GI Medical Director at University Hospitals Ahuja Medical Center. “The goal of our HRM is to optimize quality of care, decrease variation, improve resource utilization and minimize waste in healthcare.”

Dr. Glessing points to four strategic pillars of UH’s HRM: 

• Determine the appropriateness of admission.
• Integrate care management guidelines to drive clinical efficiency.
• Optimize next site of care for patients to ensure seamless transition. 
• Empower patients with education and resources to stay healthy and prevent readmissions.

The Agency for Healthcare Research and Quality (AHRQ) defines high reliability as "a condition of persistent mindfulness within an organization." High reliability organizations generally operate in high hazard domains for extended periods without "catastrophic failures."

The concept involves standardization as well as the ability to make adjustments in real time to maintain high safety standards. Although HRM at UH involves standardizing aspects of care using evidence-based medicine, physicians still make final clinical judgments based on individual patient needs.

"We value clinical decision-making," says Dr. Glessing. "Our goal is to apply evidence-based medicine to patient care. By reducing unnecessary variation in the way we practice medicine, these guidelines will help us provide the highest quality of care consistently and effectively.”

THREE-STEP APPROACH FOR TREATING GI BLEEDING WITH HRM

The GI bleeding HRM initiative includes three components:

• Clinical Practice Guideline (CPG). All UH doctors will have access to the GI bleed CPG to help them send patients down the appropriate care path. By answering a series of questions around clinical variables, doctors can determine which patients require admission versus which can be discharged home with early outpatient follow-up, what level of inpatient care is most appropriate, and which resources are needed to care for these patients. Variables include prior history of GI bleed, comorbidities, vital signs and risk of rebleeding, among other factors.
• Clinical Care Pathway. This management guideline will help integrate order sets and management principles to help ensure that treating physicians and care teams follow the same clinical care pathway when evaluating patients. "We want to make sure every patient receives the most appropriate workup, treatment and access to consultants in a timely and efficient manner," says Dr. Glessing.
• Patient Self-Management Guide. Patient care and disease management don't stop when patients leave the hospital. The self-management guide is a tool for patients to reference when they have questions about what symptoms to watch out for, which medications to avoid and what diet to follow, among other issues. "The guide is our way of enabling our patients to be their own health advocate. It arms them with patient education and activation measures. We want patients to be active participants in their health,” says Dr. Glessing.

The guide uses three zones for self-diagnosis:

• Green zone – no bleeding, good energy level, normal bowel movements. Continue with home care plan as usual.
• Yellow zone – small amount of bleeding, change in appetite or energy, new abdominal discomfort. Schedule a doctor's appointment. 
• Red zone – significant or persistent bleeding, abdominal pain, signs of shock (nausea, confusion, dizziness). Call 911 or seek emergency treatment.

HRM AT UNIVERSITY HOSPITALS

The GI bleeding HRM initiative is the latest of multiple HRM action plans established at UH. The University Hospitals Department of Orthopaedics leads a systemwide total joint replacement (TJR) HRM initiative that involves 16 UH hospitals. At the start of the program, doctors and clinicians from across disciplines analyzed, evaluated and revamped their patient care process from pre-op through recovery.

After about two years, a data review showed length of stay for TJR patients decreased by 0.6 days over six months, saving 2,500 hospital days at $500 per day. HRM principles also led to 96 percent of hip replacement patients and 92 percent of knee replacement patients going home rather than to a skilled nursing facility after surgery – a 30 percent improvement compared with the previous year.

HRM is another way UH holds true to its mission: to heal, to teach, to discover. "By decreasing variation, all sites are optimized for managing GI bleeds, and in doing so, all patients have access to the highest standard of care,” says Dr. Glessing. “UH’s commitment to this HRM initiative highlights the conscientious use of an improvement process platform, disseminates a culture of patient safety, and proves its continual dynamic development.” 

To find out more about the GI bleeding HRM initiative, contact Dr. Abirammy Sundaramoorthy or Dr. John Dumot at 216-553-1976.