Saved medical center hundreds of thousands of dollars annually by reducing patient re-admission rates from 20 per month to almost none, by creating a high-performance 10-member team and aligning them to use modern treatments:
Patients with epilepsy at a major hospital in the South were being readmitted almost every month. They were either having break-through seizures or complications from their medicine.
Break-through seizures come despite someone taking a seemingly correct dose of an accepted medicine. Sometimes a second problem has come up: stress, another illness. Sometimes the medicine isn’t really the right one. Sometimes the medicine isn’t monitored and the patient is actually getting too little or too much. Sometimes a well-meaning healthcare provider, untrained in neurology, adds a second medicine arbitrarily because the patient had a breakthrough seizure, so the seizures come more often and are more severe.
The treatments at this hospital were within accepted national standards, but the details were outmoded. Several problems were occurring and reoccurring.
The hospital wasn’t using the newer medicines which had fewer side-effects and fewer break-through seizures. Doses weren’t being monitored: neither blood levels in the morning before the first dose of the day, nor patient’s or the family recording on a calendar each seizure, (with a note of other matters: a cold. flu, an argument). ER doctors and nurse-practitioners merely increased the dose of the medicine after a breakthrough seizure was on, or added a second one, without getting advice from a neurologist.
The medical center asked me to create a new neurology service with 18 inpatient beds and a weekly clinic. There were excellent nurses, therapists, social workers, neurologists, and residents to staff it. They needed to be formed into a team, aligned, and inspired to high performance. Of course each one had been taught in school or early in clinical training to care for epilepsy, had done it for years, thought they knew how, and were no more interested in change for change’s sake than anybody else.
There was what was done; there was how it was done.
What was done is given below. It’s technical.
How? People on the team were already troubled by the frequent readmissions of their epilepsy patients. Even the people most adverse to change were willing to try a new approach for 3 months to see if it made a difference. Over those months fewer and fewer patients were readmitted, and as more and more showed up in clinic grateful for the improved control of their epilepsy, the entire team became advocates for the new methods and used them enthusiastically: we developed into an aligned, high-performance team. The team was willing to consider ways to improve care for other neurological diseases.
The patients had better treatment and better quality of life. The readmissions decreased to essentially none. Each readmission cost the hospital thousands of dollars, and the dozens of seizure patients had in total 20 readmissions each month. The new approach and aligned team saved the medical center several hundred-thousands of dollars annually, well over four times my annual salary, a clear Return On Investment.
What was done was discussing and writing down the current, the modern approaches and teaching them to everyone on the team (including the neurologists and residents who rotated in for a month or two). The approaches were 1) using brand-name anti-epilepsy drugs (whose blood levels are more constant from refill to refill than generics), 2) using new drugs for the specific forms of epilepsy they treated best; 3) measuring blood levels before the first dose of the day (“trough” levels) once a month and 4) getting a trough level the morning after any break-through seizure; 5) having the ER physicians call a neurologist about patients who came in with a break-through seizure instead of arbitrarily changing the regimen, 6) adjusting doses so the blood levels were in the therapeutic range, avoiding side effects, 7) using seizure calendars as guides, and 8) following the patients regularly in the clinic.