‘Interval Improvement’ Should Be a Marker in Patient Care

February 29, 2012

One of the ways we can cut costs and improve quality in hospitals today is to measure what I call “interval improvement” in our patients.

One of the ways we can cut costs and improve quality in hospitals today is to measure what I call “interval improvement” in our patients. Basically if a patient is admitted to the hospital, likely it is because they have a life-threatening medical problem. After a few hours, and definitely after the first day, there should be a demonstrable interval improvement in the patient’s clinical status. This can be measured via subjective questionnaire, physician documentation after rounding, labs, vitals, test results, etc. We need to focus on interval improvement as a way to ground clinical care in efficient, effective methodologies.

Already in the management of septic shock, we do have parameters measuring interval improvement. Also in the management of pneumonia, we have a six-hour window in which antibiotics are administered. We know from the evidence that if certain parameters are not met in a discrete time interval in the management of pneumonia and septic shock, the patient generally does clinically worse, has longer hospital stays, more complications, and more morbidity.

We need to apply this aggressive, efficient, quality-based approach to care in the management of all inpatient illnesses, especially heart failure, liver failure, infections, kidney failure, complications of hypertension and hyperglycemia, and COPD decompensations. With regards to gastrointestinal bleeding, myocardial infarction, and stroke, there already is a sense of pressing urgency to the clinical care, so I leave these three out. But the illnesses I do mention have a tendency to be recurrent and frequent, and often because of their frequency, less attention is paid to them, less of a sense of urgency.

Make no mistake: Every episode of decomensated heart or lung function is a sign of significant inflammatory burden. The patient basically is moving towards death. We need to be alarmed at even routine decompensated heart, liver, kidney, or lung failure.

So in measuring interval improvement, there is a long view and a short view. The short view is simply seeing if the patient is better six hours, 12 hours, 24 hours, 36 hours after admission. If they aren’t getting better, something needs to be done.

The long view is the overall arc of the patient’s health over months to years. If a patient over several months to years is noted to have deteriorating quality of life, functionality, cognitive function, and more hospitalizations, then this must be aggressively addressed. Insurance companies, case managers, and primary-care physicians need to keep tabs on the patients who do not have long-view interval improvement. Perhaps such patients need a home care physician or perhaps palliative care. Remember, as soon as a patient is diagnosed with a chronic illness, palliative care should be considered in the plan of care.

Having the interval improvement of patients measured on the second day of a hospital stay will likely significantly decrease hospital length of stays, decrease costs, and preemptively avoid disasters.

Find out more about Dushyant Viswanathan and our other Practice Notes bloggers.