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Saving money — $5,400 a day — is 1 goal behind hospitals' move to reduce heart rhythm monitoring

When it comes to medical procedures, less is sometimes better for patients — and, in some cases, for health care costs.

That’s been the case with an initiative CHI Health has undertaken over the past year.

By sticking more strictly to national guidelines, the health system has reduced by about 20% the number of patients receiving cardiac telemetry, the continuous monitoring of a patient’s heart rhythm in the hospital.

It’s a procedure that’s important for patient care, when done for the right reasons and in the right patients, said Dr. Thomas Frederickson, CHI Health’s medical director.

But when it’s not warranted, it can produce false findings and lead to unnecessary follow-up tests or procedures — and even extend hospital stays.

At a time of growing concern about rising health care costs, any savings that come by avoiding scans, tests and treatments that don’t help patients are considered a good thing. To be sure, a hospital stay still can be expensive. That’s why efforts are under way to focus on preventive care and keep people out of them.

In CHI’s case, the health system is using telemetry on about 60 fewer patients a day, Frederickson said. At $90 a day per patient, that could add up to about $5,400 savings a day, or $1.97 million a year.

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“We have to reduce the cost of care, and we have to make it better and safer for the patient,” Frederickson said. “In order to do those simultaneously, the only way you can do that is (to) find out where there’s waste and overuse.”

The appropriate use of cardiac telemetry is among nearly 600 recommendations laid out by Choosing Wisely, a seven-year-old national campaign aimed at reducing unnecessary tests and treatments. The campaign is an initiative of the American Board of Internal Medicine Foundation.

Daniel Wolfson, executive vice president and chief operating officer for the foundation, said the recommendations are aimed at enhancing quality, improving safety and avoiding harm. But the group recognizes that many also save money, although it hasn’t tracked how many hospitals are following the recommendations or what savings they’ve produced.

“If we can improve quality and safety and doing no harm and at the same time enhance the affordability of health care, all the better,” he said.

According to Choosing Wisely, the Congressional Budget Office has estimated that up to 30% of care in the United States goes toward unnecessary tests, procedures and hospital stays.

U.S. spending on health care grew 3.9% in 2017, according to the latest report from the Centers for Medicare & Medicaid Services, reaching $3.5 trillion, or $10,739 per person. Health spending accounted for 17.9% of the nation’s gross domestic product. Under current law, spending is projected to grow an average of 5.5% a year between 2018 and 2027.

The U.S. spends more than any other nation on health care. However, studies point out that its results across the population lag those of many other developed and lesser-spending nations.

Dr. Cliff Robertson, CHI Health’s chief executive, said the health system, to be able to lower the price of care for patients, has to reduce the cost of delivering it internally. 

Heart monitoring, he said, is an area where there’s significant variation across the country in how it’s used. Treatment recommendations change as new evidence becomes available, and those changes can take time to catch on.

Providers, for instance, used to routinely prescribe antibiotics for ear infections. Now they recognize that overusing antibiotics can drive microbes’ resistance to the medications. The Choosing Wisely campaign recommends that parents first call a doctor and treat the pain but then explore a wait-and-see approach when it comes to antibiotics to see if the infection clears on its own. Some infections are caused by viruses, which aren’t affected by antibiotics.

“What we’re all trying to do is understand what is best practice and implement that best practice consistently across the country,” Robertson said.

CHI Health is not alone in undertaking such initiatives. Right-sizing the use of cardiac telemetry is just one of many steps health systems are taking to improve health care that have the side effect of reducing internal costs — reductions that can be passed on to patients.

CHI Health and others, for instance, have taken similar approaches to the use of bladder catheters, large IV lines and antibiotic stewardship.

But Frederickson said the cardiac telemetry initiative stands out because it involves so many patients and has resulted in a significant reduction in use. It also involves entire teams, important at a time when practicing medicine increasingly involves teams with members representing many disciplines. Involving medical students and residents also is important, so they take good practices with them from their training.

Instead of roughly 60% of patients cared for by hospital medicine teams receiving heart monitoring, the number is down to about 40%. That adds up to about 60 fewer patients a day. Those who still receive monitoring are patients in the intensive care unit and most with heart and neurological problems.

The initiative is now in place in all of CHI’s metro area hospitals. The health system plans to expand it to all CHI Health hospitals in the coming weeks.

Methodist Health System also has addressed both heart monitoring and antibiotic stewardship. But the health system also has put significant effort toward implementing enhanced recovery protocols before, during and after surgery, said Dr. Ann Polich, vice president for quality and performance improvement.

Such protocols are aimed at getting patients on their feet faster after procedures and minimizing the potential for complications, she said. Both also can reduce time in the hospital.

The health system also uses a system that tracks the heartbeats of babies in the neonatal intensive care unit, which physicians can use to help determine whether a baby is developing an infection such as sepsis and make important decisions about care. That can reduce NICU time or rule it out altogether.

In the Nebraska Medicine health system, teams have devoted significant effort to working out the appropriate lab tests and blood products for patients, as well as the appropriate timing, said Dr. Scott Koepsell, medical director of the system’s clinical laboratory.

While the main goal is to do the right thing for patients, he said, it creates a lot of momentum when that aligns with lower costs.

The lab team also can consult with providers to help them make sure they’re choosing the right tests. Some tests, for example, may take weeks or cost thousands of dollars. In some cases, a physician might decide that the results will take too long to be of help. Then providers can also discuss such tests with patients and clear them with insurers.

Within the lab, the team also has reviewed the cost of bringing in tests that it previously sent out. In one such case, it decided to bring in a particular test — a costly upfront investment — because it allowed providers to get results faster and, if negative, end a costly daily therapy sooner. Koepsell estimated that the hospital has saved about $25,000 over the past year by avoiding unnecessary therapy.

“We’re trying very hard to do that in the lab,” he said.

17 rare and unusual health stories out of Omaha

Nebraska
Nebraska lawmaker, a Republican, says his own party enables white supremacy

WASHINGTON — Nebraska State Sen. John McCollister is speaking out against his own Republican Party and President Donald Trump.

“The Republican Party is enabling white supremacy in our country,” McCollister wrote on Twitter on Sunday night. “As a lifelong Republican, it pains me to say this, but it’s the truth.”

In a phone interview Monday, McCollister said he has been concerned about the direction of his party for some time, but the horrors of people being gunned down over the weekend represented a tipping point.

McCollister’s Twitter posts came after the mass shooting in El Paso, Texas, on Saturday that left 22 people dead and 24 injured. Authorities have linked the gunman to a manifesto posted online that railed against an “invasion” of Latino immigrants, particularly in Texas.

McCollister, 72, has identified as a moderate voice in the party and represents a district in central Omaha. His father, the late John Y. McCollister, was a Republican who served in the U.S. House of Representatives in the 1970s.

McCollister wrote on Twitter that he’s not suggesting that all Republicans are white supremacists or even that the average Republican is a racist.

“What I am saying though is that the Republican Party is COMPLICIT to obvious racist and immoral activity inside our party,” he wrote. “We have a Republican president who continually stokes racist fears in his base. He calls certain countries ‘sh*tholes,’ tells women of color to ‘go back’ to where they came from and lies more than he tells the truth.”

He said Republican lawmakers look the other way and say nothing because they are afraid of losing elections.

“No more,” he wrote. “When the history books are written, I refuse to be someone who said nothing. The time is now for us Republicans to be honest with what is happening inside our party. We are better than this and I implore my Republican colleagues to stand up and do the right thing.”

Nebraska’s Republican Gov. Pete Ricketts appeared to respond to McCollister on Monday afternoon with his own series of tweets, although he did not refer to the legislator by name.

“White supremacy and racism have no place in our country, and they must be driven out. I have said this repeatedly and will say it again and again,” Ricketts tweeted. “Contrary to baseless accusations made on social media, the Republican Party does not tolerate such hateful views.”

The executive director of the Nebraska Republican Party, Ryan Hamilton, responded to McCollister by issuing a statement via Twitter suggesting that the state senator re-register as a Democrat.

Hamilton said McCollister has opposed conservative policy positions on issues ranging from taxes to abortion.

“His latest false statement about Republicans should come as no surprise to anyone who is paying attention and we’re happy he has finally shed all pretense of being a conservative,” Hamilton said.

In the interview, McCollister specifically cited members of Nebraska’s all-GOP congressional delegation as lacking in their responses to the president and his rhetoric.

For example, Trump said that several women of color in the House, all citizens, should go back to where they came from.

Rep. Don Bacon responded by calling the statements “unacceptable” but stopped short of labeling them racist. And he has stood by his endorsement of Trump.

Other members of the delegation also offered muted criticisms or simply avoided commenting on Trump’s statements altogether.

“I’d like to see some moral outrage from some of our Republican officeholders,” McCollister said. “The silence is deafening.”

McCollister told The World-Herald that his father wouldn’t recognize today’s GOP. He said his hope is that enough people will speak up that party leaders will have to take notice.

McCollister won a second term in the Nebraska Legislature last year by defeating left-leaning Democratic opponents. He did not garner a challenge from the right, despite having shown a willingness to buck party leaders.

That included voting against “Choose Life” license plates, seeking to expand Medicaid coverage and asking the Nebraska attorney general to back off trying to end the Deferred Action for Childhood Arrivals program.

McCollister’s Sunday tweets garnered lots of attention. Though some criticized the senator’s tweets, he noted that his followers had increased tenfold to more than 6,500 by Monday morning and that the number was continuing to climb.

“The overwhelming message that I’m getting from people is, ‘Thanks for speaking up — I’ve felt this way for a long time,’ ” he said.


Articles
Life in mass-shooting-era America: 'You can't just not go'
Weekend shootings raise questions about how fear affects our public activities

COVERAGE INSIDE

DEATH TOLL RISES

Two more succumb to injuries in Texas; many still in Ohio hospitals

TWO PRESIDENTS

Trump rejects racism; Obama speaks of leaders who feed 'climate of fear'

VIDEO GAMES

They aren't linked to real-life violence, several studies have found

Ohio: A bar district where friends gathered for drinks on a warm Saturday night. Texas: A Walmart stocked with supplies for back-to-school shopping on an August morning. California: A family-focused festival that celebrates garlic, the local cash crop.

Two consecutive summer weekends. Less than seven days. More than 30 fellow human beings gone in moments, in public places exactly like those where huge swaths of the American population go without a second thought.

Or perhaps not. Perhaps no longer. Have we crossed into an era of second, third, even fourth thoughts?

"I don't like to go out, especially without my husband. It's really scary being out by myself," preschool teacher Courtney Grier, 21, said Sunday outside a grocery store in Virginia Beach, Virginia, where a gunman killed 12 in a city building in late May.

But, Grier says, "You still have to go to the grocery store to get dinner. You can't just not go."

That might be an apt slogan for America in 2019: You can't just not go.

Civic life, particularly the public portion of it, has been a foundation of American society since the beginnings. That may have ebbed in today's nose-in-your-device world, but events like festivals, going out for the evening and, in particular, shopping remain enduring communal activities. Now those three venues have given us lethal and very public shootings in the space of less than a week.

Add other daily life institutions that have been visited by mass shootings — houses of worship, movie theaters, malls, a newsroom and, of course, schools — and the question becomes more pressing: Are these loud, sudden events starting to fundamentally change America in quiet, incremental ways?

The sites where bullets flew and people fell this past week are not simply places where random people gather publicly and informally. More important, if you're an American, they're places like the ones where people like you gather publicly and informally — particularly in the summer, when so many are not as hunkered down by weather and obligation.

These aren't only mass shootings (Gilroy, in fact, with three dead other than the shooter, technically isn't a "mass shooting" by some of today's metrics). They are also mass public events that make us deal with something that other places have faced for years-long stretches: assessing daily life's danger while moving through it with loved ones.

The chances of an American being caught up in a publicmass shooting remain incredibly slim. Nevertheless, the sometimes-toxic cocktail of the events themselves, social media echo chambers and the distorting factors of the 24-hour news cycle can be affect people's behavior.

El Paso's 22, Dayton's nine and Gilroy's three have caused online outpourings around many questions, some more political than others. But variations of these two keep cropping up: Are regular places safe anymore? Should we assume that they are?

There are, loosely, two types of reactions that sometimes overlap. One is to back off some, to take more precautions. One is to be defiant. That's the approach that retired Marine Richard Ruiz, a Gilroy native, says he's seen in Gilroy in the week since the garlic festival shooting.

"The thing that has changed in Gilroy is our focus," said Ruiz, 42. "No one is showing signs of being worried or fearful in public. We're emboldened. We want to go out more."

In Squirrel Hill, the Pittsburgh neighborhood where a shooter killed 11 people at Tree of Life Synagogue last fall, a commitment to doing exactly that has helped ensure that civic life remains vibrant. There is little visible change except for the "Stronger than Hate" signs in shop windows that encourage two things — a return to normal life and a commitment to never forgetting.

In Dayton, Nikita Papillon, 23, described the site of the killings that happened across the street from her Saturday night as the kind of location "where you don't have to worry about someone shooting up the place."

But does "that kind of place" exist anymore? And if not, how does that affect American life in ways that defy measurements and metrics?

From Britain, which grappled with a spate of Irish Republican Army attacks from the 1970s through the 1990s, to Afghanistan and Iraq, where public explosions and attacks have been commonplace during the past two decades, the world's citizens have grappled in many ways with balancing regular life and increased vigilance.

In Israel, during the second uprising against the government's long-running military rule over Palestinians, Palestinian militants carried out a series of suicide bombings and shootings, targeting cafes, malls and public buses. Between 2000 and 2005, many Israeli Jews stopped riding public buses and avoided crowded public spaces. Others fought to maintain normal routines.

Avraham Sela, a professor of international relations at the Hebrew University of Jerusalem, says many Israelis became scared to visit public places, though he says that, in the end, Israelis "never allowed our lives to be dictated by those fears."

The United States is hardly at that point. But the conversations that now take place - Should we go? Should we take the kids? What's that noise? - reflect a society that, no matter people's political beliefs, is starting to process what's taking place in its midst.

This year marked two decades since two student gunmen killed 12 schoolmates and a teacher at Columbine High School outside Denver, a watershed moment in mass shootings. Sam Haviland, who was a junior at Columbine in 1999, knows other survivors who are fearful in public places or avoid them completely. After years of post-traumatic stress, she chose a different path.

"I decided that I didn't want to live in fear and that I can't control it, and so I've just come to terms with the fact that I may not be safe in public," said Haviland, now director of counseling for the Denver Public Schools. "The number of shootings since then has just reaffirmed for me that, you know, it's a real possibility that shootings — that I might even survive another shooting."

Back in Virginia Beach, a couple sitting together at an outdoor shopping center offered differing views of how to navigate the changed landscape around them.

"If it's going to happen, it's going to happen," said Jerry Overstreet, 27, who served in the U.S. Army in Afghanistan and now operates heavy machinery at a coal terminal.

But Jasmine Luckey, 25, a social worker, is now "super alert," she says. When she goes to any major public events, she knows where the exits are and often leaves early.

"It just puts me on edge, and I don't want to be on edge," she said. "I want to be able to raise children in a place where they can freely leave my side for a little bit and not worry about them getting shot."


Livewellnebraska
Omaha woman with end-stage kidney failure weds in her hospital room — aided by strangers' kindness

Melissa Jordan and Boenerges Duran had been together for nine years, engaged for one.

Family members had been asking when they’d marry.

Then Jordan, 31, became critically ill, her condition quickly spiraling into liver and kidney failure.

Last week, Debra Reeg and a colleague decided to make the couple’s dream a reality, and she did it with the kindness of strangers.

Reeg, a palliative care nurse practitioner at Creighton University Medical Center-Bergan Mercy, posted on a Facebook wedding group she’s a part of, asking if someone would be willing to donate a dress.

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Within minutes, she had her first dress offer. Soon it was 30 or more. Within three hours, Reeg had offers of a cake, hairstyling and makeup help, a photographer, flowers, decorations and food.

“I was just overwhelmed by the generosity of perfect strangers who just wanted to reach out and help,” Reeg said.

On Monday, members of the couple’s families, including Jordan’s parents and brothers from Arizona, gathered around her bed in the intensive care unit. Duran walked down a hallway lined with hospital staff to her bedside, the medical equipment draped in purple, flowers on the tables, a sign overhead reading “Mr. and Mrs.”

Jordan wore a tiara and a wedding dress. Reeg and her team had printed out photos of all the offered dresses — in color — so Jordan could take a page from the popular reality TV show and “Say Yes to the Dress.”

Lorenzo Duran, the groom’s father, officiated.

Jordan, who is on a ventilator to help her breathe, nodded her head yes when the time came to make her vows. Then Duran presented the couple as Mr. and Mrs. Duran amid smiles and tears and cheers, from inside the room and out in the hall. Boenerges Duran spoke briefly of their time together, saying, “You’ve been on my side, and I’ll be on yours, no matter what, and now you’re my wife.”

Elise Chesson of Blair, Jordan’s sister, said she was astounded at the outpouring of support. The sisters had been planning a wedding very slowly, looking at photos on Pinterest and storing away ideas, as prospective brides do.

“I’m just so happy she was able to get her last wish,” Chesson said.

Reeg said the event was especially emotional for her, given her own plans to marry in October. But she’s not planning that one — it will be a destination wedding.

Boenerges Duran, who is with the Nebraska Army National Guard’s 402nd Military Police Battalion, said after the ceremony that he just wanted the day to happen. “Once I saw her, I was like, ‘Wow, that’s really her. That’s my wife. Now and forever,’ ” he said.

When people think of hospitals, he said, they think of a sad place. “But not today,” he said. “Today’s a happy day.”

Duran also thanked those who donated the wedding finery and food for an in-hospital reception. “This means a lot for both of us,” he said.

A roundup of inspirational stories from Midlanders with heart