Clinical inertia in hospitals and 24-7-365 care: a limited series, part 3

Overcoming clinical inertia

Complexity science views health care as a complex adaptive system, i.e. it has properties including nonlinear interactive components, self-organization, emergent phenomena, unpredictability etc. A complexity science analysis of healthcare would focus on patterns of interactions and relationships among parts, that when viewed holistically provide insights regarding the unpredictable nature of the system.

Take for example patient-centered interdisciplinary rounds, which include multiple stakeholders, multifaceted issues, differing and contrasting opinions, different levels of experience and expertise, as well as language complexities. Yet, patient centered interdisciplinary teams, with all their complexity, have been found to lead to more successful interactions with patients and families than the traditional model of single stakeholder interactions with patients (Ciemins et al., 2016). The components of patient centered interdisciplinary teams, when done well, can overcome many contributing factors to clinical inertia:

• Engaging patients and families,

• Shared decision making,

• Multidisciplinary perspectives,

• Improved information accuracy,

• Cross-checking of data,

• Discussions about the rationale for treatment or ‘masterly inactivity’.

Several studies report that the utilization of checklists, care protocols, flowsheets or bundles can improve care (Fulbrook and Mooney, 2003, Patterson et al., 2007, Rello et al., 2010, Cox et al., 2017). These do not require complex technological interventions and are therefore relatively inexpensive to implement, though implementation can be difficult and requires a focus on process interventions. But when implemented successfully, they address the fundamental underlying issues that lead to clinical inertia: a timely check of the risk-state, i.e. detection, and an opportunity to initiate the required response to mitigate the risk.

Process Opportunities for Improvements in Care and Outcomes

Complexity science understands knowledge to be a 'thing' and 'flow', i.e. knowledge about a patient or their condition is not static but dynamic (Sturmberg and Miles, 2013). As such, the following is true, according to (Sturmberg and Miles, 2013):

1. “Knowledge can only be volunteered: it cannot be conscripted”.
   It is impossible to know if someone is using their knowledge. But it is possible to know if they have complied with a process or standard operating procedure, such as a checklist.

2. “We can always know more than we can tell, and we will always tell more than we can write down.”
   People will always know more than the time available to write it all down. Writing something down is reflective, i.e. it uses additional cognitive processes in which information must be retrieved, phrased and then written. Writing pertinent information down in a medical chart, which must then be sourced at a later time by another stakeholder who may not be familiar with abbreviations used and does not have the opportunity to ask questions directly or clarify uncertainties, is not particularly efficient.

3. “We only know what we know when we need to know it.”
   Understanding and knowledge are contextual, and triggered by circumstance. It is therefore imperative to share a contextually relevant setting in which to disseminate knowledge, as new information, understanding or knowledge can emerge. Interdisciplinary rounds (IDRs) that do not occur at the bedside with the patient, inherently lack context and triggers that may lead to emergent knowledge or understanding of the patient’s condition.

Interdisciplinary patient centered teams are therefore a design that fits well within the solution set, nature and knowledge of complex adaptive systems (Ciemins et al., 2016). When utilizing processes and tools that feed knowledge forward between shifts and across stakeholder groups, it is possible to provide proactive care, i.e. proactively manage complex patient conditions and emergent risk states. Peer supported cooperative work processes, checklists, handover tools, and interdisciplinary bedside rounds that can link these discrete but connected resources together, support the sharing of diverse perspectives and the knowledge necessary to treat and respond to emerging issues. These also support and enable shared decision making among the team and patient so that outcomes can be optimized with respect to patient preferences, appropriateness of intervention and cost.

The interdisciplinary team approach to care may initially appear a more costly delivery of care, but the potential for providing better and more cost effective care must be evaluated in parallel. This is particularly true in recent years where resources are stretched, there are misaligned cost incentives, insurance reimbursements can be independent of outcomes, the demand for new technologies, wasteful use of resources and inappropriate utilization of resources (Ciemins et al., 2016).

In our experience the key features of care that will lead to improvements in clinical, cost and satisfaction outcomes are:

• Unit oriented care teams;

• Patient centered care, i.e. engaging patients and families in bedside handovers and Structured Interdisciplinary Bedside Rounds (SIBR rounds);

• Unit leadership, across shifts and stakeholder groups;

• Unit based data, so staff know their efforts are making a difference for their patients. This can and should be quantitative and qualitative data.

How SIBR can help overcome clinical inertia

1. Enhanced Team Collaboration and Communication

• Interdisciplinary Collaboration: SIBR brings together a diverse team of healthcare professionals, including doctors, nurses, pharmacists, and other relevant specialists, to discuss each patient’s care plan at the bedside. This interdisciplinary approach ensures that different perspectives are considered, leading to more comprehensive and timely decision-making.

• Real-Time Communication: By discussing patient care directly at the bedside, all team members are on the same page regarding the patient’s condition, needs, and potential interventions. This reduces the risk of miscommunication or delays that can contribute to clinical inertia.

2. Patient-Centered Care

• Patient and Family Involvement: SIBR engages patients and their families in the discussions about their care. This transparency ensures that the care plan is aligned with the patient’s preferences and needs, and it can prompt quicker adjustments to the treatment plan if the patient’s condition changes.

• Immediate Feedback and Adjustment: With the patient and family present, the care team can receive immediate feedback leading to a more agile response to changes in the patient's condition, helping to overcome inertia.

3. Accountability and Documentation

• Structured and systematic: SIBR follows a structured format, which ensures that all relevant aspects of the patient’s care are addressed systematically. This structure reduces the likelihood of important issues being overlooked, preventing inertia.

4. Reduction of Hierarchical Barriers

• Flattened Hierarchy: SIBR promotes a more egalitarian approach to patient care, where input from all team members and the patient or family is valued. This flattening of traditional hierarchies empowers everyone to speak up about necessary changes in treatment, which might otherwise be delayed due to hierarchical constraints.

5. Continuous Education and Improvement

• Learning Environment: The regular, structured interaction among various healthcare professionals during SIBR provides an ongoing learning environment. This continuous exchange of knowledge and best practices can help reduce inertia by keeping all team members informed and proactive in patient care.

• Feedback Loop: SIBR creates a feedback loop where outcomes of the care plan are regularly reviewed, and timely adjustments are made. This ongoing review process ensures that clinical inertia is less likely to set in, as the care team is continually reassessing and optimizing the treatment plan.

6. Timely Intervention and Decision-Making

• Immediate Decision-Making: By having all key decision-makers present during rounds, SIBR facilitates prompt decision-making. This immediacy can be crucial in preventing delays in treatment adjustments, directly combating clinical inertia.

• Early Identification of Barriers: SIBR allows for the early identification of potential barriers to treatment, such as logistical issues or patient non-compliance, which can be addressed immediately to prevent inertia.

Used effectively, these can create a 24/7/365 care cycle that can reduce clinical inertia, improve masterly inactivity and support choosing wisely.

To learn more about how 1Unit supports hospital teams to overcome clinical inertia while reducing care costs and improving staff and patient satisfaction read more on our website or better yet join a webinar or book a call to get your specific questions answered.

References

Ciemins, E.L., Brant, J., Kersten, D., Mullette, E. & Dickerson, D., 2016. Why the interdisciplinary team approach works: Insights from complexity science. Journal of palliative medicine, 19, 767-770.

Cox, E.D., Jacobsohn, G.C., Rajamanickam, V.P., Carayon, P., Kelly, M.M., Wetterneck, T.B., Rathouz, P.J. & Brown, R.L., 2017. A family-centered rounds checklist, family engagement, and patient safety: a randomized trial. Pediatrics, e20161688.

Fulbrook, P. & Mooney, S., 2003. Care bundles in critical care: a practical approach to evidence-based practice. Nursing in Critical Care, 8, 249-255.

Rello, J., Lode, H., Cornaglia, G., Masterton, R. & The, V.a.P.C.B.C., 2010. A European care bundle for prevention of ventilator-associated pneumonia. Intensive Care Medicine, 36, 773-780.

Sturmberg, J.P. & Miles, A., 2013. The complex nature of knowledge. In J.P. Sturmberg & C.M. Martin (eds.) Handbook of systems and complexity in health. New York, NY: Springer Science+Business Media.