SSI -final

Hospitals Battling to Reduce Hospital Readmission Due to Surgical Site Infections 1
Hospitals Battling to Reduce Readmission
Due to Surgical Site Infections
Under the Microscope: Recommendations for Improvement at St. Mary’s Hospital
Eric Cybulski
Agnes Erickson
James Falco
Clinton Ingersol
Emmanuel Kumi
Quinnipiac University
Fall 2014

Introduction
If there were ever an uphill battle in healthcare, it would be fighting surgical site infections
(SSI). The battle is endless, requiring the constant vigilance of a surgical team to maintain
the most sterile environment possible during surgery. Surgical Site Infections (SSIs) occur in
2-5% of patients undergoing surgery in the United States, resulting in approximately
500,000 SSIs each year. Each SSI is associated with approximately 7-10 additional days of
postoperative hospitalization and increases the risk of patient death 2-11 times (Patterson,
2010). Unfortunately, as many surgeons can testify, the surgical process is only one piece of
the puzzle in understanding the causes of infection.
Certain risk factors can place patients at higher risk for SSI. Risk factors include smoking,
age, weight, pre-existing medical conditions, and "functional health.” Other risk factors
currently under investigation include the use of certain medications to treat GERD and
treatment of preoperative surgical site areas with antimicrobial washes.
One of the largest system factors affecting SSI is the ever changing healthcare environment.
Both providers and payers want patients out of the hospital as soon as possible. This
transition has brought with it the term "drive by deliveries," and postoperative lengths of
stay have become increasingly short. With these shorter hospitalizations, it is unclear what
the post surgical interventions are in most US hospitals. Two studies conducted in France
and England using post-discharge surveillance concluded that there is a large portion of SSI
detected following discharge from the hospital. In France, almost 75% were detected in the
first 15 days, and in England over 41% of SSIs were detected following discharge to home.
(998.5 Postoperative infection; surgical site infection, 2013). US hospitals are sending many
patients home with minimal or no follow up in the first 14 days. Studies show that SSI
typically occurs 10-14 days postoperatively, and over 70% of these cases occur after
discharge from the hospital. In one study in Finland, “a total of 216 SSIs (56%) were
detected after discharge; the proportion was highest for knee arthroplasty and lowest for
hip arthroplasty. Overall, 86% of organ/space SSIs, 80% of deep incisional SSIs, and 46% of
superficial incisional SSIs were detected after discharge. Most of the severe infections (i.e.,
deep incisional and organ/space SSIs) were identified on readmission” (Huotari, K. and
Lyytikäinen, O., 2006).
For many categories of surgery, SSIs do not become apparent until after discharge.
Numerous studies have found that up to 70% of SSIs were detected post-discharge,
depending on the type of surgery and median length of postoperative stay (Stockley et al,
2001; Reilly et al, 2006). One study of readmissions following hip and knee arthroplasty
found that over 43% of patients who were diagnosed with a SSI received the diagnosis over
90 days after surgery (Miletic, 2014).
Root Cause Analysis of Readmission Rates due to SSI

By performing a systems analysis, one can derive the following conclusion: 70% of SSIs are
detected post-discharge. 40% of SSIs are determined upon hospital readmission (Huotari, K.
and Lyytikäinen, O., 2006). The purpose of this paper is to investigate options that Saint
Mary’s and other healthcare organizations can take to prevent hospital readmissions from
SSIs and thereby develop a higher level of quality care to patients undergoing surgery.
National Hospital Costs Associated with SSI
According to the Centers for Disease Control and Prevention, SSIs are the second most
common cause of healthcare-associated infections, with approximately 500,000 occurring
annually in the United States. Costs and adverse outcomes secondary to SSIs can vary by
location and surgery type; the direct and indirect costs of SSIs run in the billions annually
(Perencevich EN, Sands KE, Cosgrove SE, et al., 2003). The attributable cost of SSIs varies,
but published estimates range from $3,000 to $29,000, depending on the type of operative
procedure and the infecting pathogen (Patterson, 2013). One study indicated that SSIs result
in over 900,000 extra inpatient days and approximately $1.6 billion in additional costs
annually in the United States (de Lissovoy, 2009). Another study concluded that SSIs
account for $3.3 billion in healthcare spending annually, the most costly overall of any
healthcare-associated infection (Zimlichman, 2013). According to a news release by the
Association for Professionals in Infection Control and Epidemiology (2012), a study
conducted in the Detroit metro area with insurance claims data between 2007-2009 found
that of 2,134 patients with SSI,
...870 patients with SSI (40.8 percent) were hospitalized for other reasons labeled “all
cause” during the year after their diagnosis, accounting for 1,770 readmissions…
Subsequent rehospitalizations for SSI were associated with an average hospital stay
of 8.6 days, costing on average $26,812. Additional all-cause hospital readmissions
were associated with an average hospital stay of 6.2 days and a cost of $31,046
(Rehospitalizations, 2012).
Why is there no continuous monitoring by the hospital of post-surgical patients?
Cost of implementation traditionally outweighed benefit
Why is there inadequate monitoring of patient's condition post-surgery?
The need to monitor a patient post-surgery for SSI has not been utilized by the hospital
Why are patients not detecting their infection?
Patients are not medically trained to assess onset of infection
Why are there SSI readmissions?
SSI are not being completely detected within the first 15 days post-op

How Other Healthcare Organizations are Addressing SSI
SSIs present a complex problem that requires innovative solutions. As such, healthcare
organizations across the US are experimenting with different protocols and procedures to
detect and reduce their incidence of SSI.
Naval Hospital Camp Pendleton Perspective: Post-operative Processes to Avoid SSI
Historically, surgical site infections occur in 1-2% of surgical patients at Naval Hospital
Camp Pendleton. The goal SSI rate for the 2014 Infection Prevention and Control Measures
of Success at Naval Hospital Camp Pendleton stands at ≤0.7%. The SSI rate for the year
ended 2013 was 0.53% (16 infections in 2997 cases). Of the 21 risk factors identified in a
Risk Assessment, the Joint Commission or BUMED (Bureau of Medicine) require
surveillance of 16 of the measures. These 16 measures were therefore selected for
surveillance. SSI ranks fourth on the prioritized risks and goals for 2014.
Rationale: Surgery is the highest volume procedure performed at NHCP, with over 3000
cases in 2013. SSIs have a significant impact on the personal health and careers of active
duty members, and impact the overall operational readiness of the command. While NHCP
has traditionally achieved a very low surgical site infection rate, further reductions can
always be made.
Post-Operative Surveillance
Naval Hospital Camp Pendleton strictly adheres to CDC definitions of SSIs without
modification for identifying SSIs among surgical inpatients and outpatients. For inpatient
case-findings and monitoring, a direct detection approach is used where the surgeon
assesses the patient for undesired outcomes from surgery during the entire period of
hospitalization. Post-discharge surveillance continues for 30 days following surgery, or one
year if an implant is placed. Patients are phoned the first day after surgery by a registered
nurse from the Same Day Surgery Department to check on patients and ensure they
understand all the medication instructions and how to care for their wounds. Patients are
also contacted on the weekend if they had surgery the day before. If a patient develops any
unusual pain or symptoms after surgery, and it happens to be on the weekend, the surgeon
and anesthesiologist on duty that day are informed. On the weekend, it is the responsibility
of the duty O.R. Nurse that day to make the call. Patients are also given the number to the ER
to call on the weekends if they have any unusual feelings after surgery. Mandatory follow up
with the surgeon is scheduled between 48 hours and 14 days after surgery. Readmissions
are monitored to capture patients who had surgery within the last 30 days and determine
whether a current infection is related to previous surgery or has a different cause. An
Infection Preventionist (IP) collects data for readmissions, including those linked to
previous surgery, and reports appropriately stratified operation-specific SSI rates to
surgical team members and the leadership at the hospital. Neither the hospital nor
providers gain from readmissions. However, strict adherence to surgical consciousness and
follow up policies ensures a very low SSI rate (Lieutenant Lind M., Infection Control Nurse,
NHCP).

Pilot Program: Remote Monitoring of SSI via Mobile Device
One hospital in Wisconsin, recognizing the importance of monitoring and identifying wound
infections post-discharge, is using funding from an Agency for Healthcare Research and
Quality grant to study the effectiveness of having patients use their smartphones to send
daily pictures of their wounds to the surgical service. The Outpatient Wound Surveillance
Program (OWSP), as it is called, will evaluate whether medical providers can accurately
identify improperly healing wounds and the feasibility of full pilot implementation (Patient-
centered, 2014).
The National Healthcare Safety Network
In 2006, Colorado enacted the Health Facility Acquired Infections Disclosure Statute, which
requires licensed hospitals, ambulatory surgical centers, and dialysis treatment centers to
collect and regularly report data on surgical site infections to the National Healthcare Safety
Network (NHSN) system, an Internet-based reporting system that allows a variety of
healthcare facilities to share data in a timely manner while maintaining confidentiality and
data security. The Colorado Hospital Association (CHA) is a leading voice of the state’s
hospital community, representing 100 hospitals and health systems throughout Colorado.
CHA was awarded a grant in December 2009 from the Colorado Department of Public
Health and Environment to lead an infection prevention collaborative project, which
included procedures to prevent SSI in hospitals and ambulatory surgical centers in the state.
The CHA made a number of recommendations. Physicians are to report any healthcare-
associated infections they diagnose at follow-up visits to the healthcare facility where the
medical procedure was performed to help ensure accurate surveillance. Use of the NHSN
system will help ensure that healthcare facilities use the same recommended,
epidemiologically sound definitions and that data are stratified according to appropriate
risk factors (Colorado, 2011).
There are multiple purposes to using a surveillance system like NHSN, including the ability
to estimate the magnitude of adverse events and adherence to best practices for prevention.
Use of shared surveillance definitions allows for more accurate comparisons between
healthcare facilities and within different units of a hospital or ambulatory surgical center.
Although the NHSN monitoring system is in place and can aid healthcare facilities in
conducting accurate surveillance, there are many challenges for the infection preventionist
in identifying and accurately classifying cases of SSI. At present, there is no single method
that may be universally recommended.
The project stated that there are two types of inpatient surveillance, direct and indirect.
Direct observation is considered to be the most accurate method; it involves a surgeon,
nurse, or infection preventionist visually observing and assessing the patient for signs of
infection during their stay at the hospital. Indirect observation consists of the infection
preventionist reviewing any or all of the following data sources to identify patients with
infections, depending on availability:
• Laboratory reports
• Medical records

• Consulting with providers
• Wound culture reports
• Antibiotic reports
• Admissions, transfers, and readmissions lists
• Operating room reports
A critical component: post-discharge and outpatient surveillance
Post-discharge and outpatient surveillance plays a significant role in the identification of the
SSI patient, with an estimated 12%–84% of SSIs detected following the patient’s hospital
discharge. A majority of SSIs are thought to develop within 21 days following the procedure,
making post discharge surveillance a critical component of patient care. Elements of a post-
discharge surveillance program include:
• Examination during follow-up visits with primary care providers or surgeons
• Review of medical records, outpatient culture reports and antibiotic usage data
• Conducting patient follow-up surveys by phone, mail, fax, or electronic methods
One study estimated that up to 50% of SSIs may be missed if effective post-discharge
surveillance systems are not in place. Additionally, patients may not return to the same
hospital for follow-up care, so efforts must be made to maintain relationships with local
provider offices to capture accurate SSI data.
The downside to patient follow-up is that patients may not know what to look for and tend
to have low response rates. According to CHA, patient surveys should be included with
discharge packets, include risks associated with SSIs, and explain what symptoms to look for
that may indicate a SSI (Colorado, 2011).
Current SSI Surveillance at Saint Mary’s
Saint Mary’s Hospital is an acute care, community teaching hospital located at 56 Franklin
Street in Waterbury, CT. With 168 active beds, the hospital offers a Level II Trauma Center
and annually conducts over 3,100 inpatient surgeries at the St. Mary’s campus and over
13,000 in outpatient settings.
According to Chief of Surgery, Philip Corvo M.D., patients at Saint Mary’s are contacted by
the hospital within 24 hours following surgery, and within the first or second week the
treating physician sees patients for follow up. A registered nurse employed by the hospital
tracks SSI infections. She has three methods of tracking SSI. See figure 1.
1). Surgeon report: a questionnaire-like form is completed by the surgeon describing the
infection and sent to the hospital.
2). Patient report: a follow-up
survey sent out by the
hospital is returned by mail.
3). Hospital administration
records: billing codes
associated with infection are
flagged. Some data mining is
Figure1

performed using patient identifiers and billing codes associated with infections. However,
this method lacks the capability to identify the severity of the infection (K. O’Meara,
Personal Communication, October 24, 2014).
The designated Quality Improvement Nurse tracks SSIs using a web-based platform called
the American College of Surgeons National Surgical Quality Improvement Program (ACS
NSQIP). According to NSQIP’s website:
The American College of Surgeons National Surgical Quality Improvement Program
(ACS NSQIP®) is the first nationally validated, risk-adjusted, outcomes-based
program to measure and improve the quality of surgical care. ACS NSQIP is designed
to help hospitals improve surgical care through the use of risk-adjusted clinical data.
The program will place hospitals in the national lead in providing high-quality,
effective surgical care.
Saint Mary’s is a member of NSQIP. This allows the hospital to share its data with other
hospitals both locally and nationally. On a monthly basis, the nurse tracking SSIs reviews 40
random post-op patients and enters their results into the NSQIP data bank. NSQIP uses a
risk factor analysis of each patient in its database, weighting hospitals’ data according to
their patients’ preexisting risk factors for SSI. Patient risk factors include age, weight, past
medical history, and current medications. By assessing patient risk factors, NSQIP’s surgical
outcome data provide a more nuanced view of SSI rates that takes into consideration more
of the risk factors over which surgeons have no control.
None of the tracking methods used by the nurse can account for 100% of SSI data. However,
through use of NSQIP and its database of hospitals throughout the country, Saint Mary’s
surgeons can better assess trends and rates of infection. The hospital can also use NSQIP’s
data to compare its SSI rates to those of other hospitals locally or nationally.
While St. Mary’s utilizes NSQIP data to track their progress in reducing SSIs internally, there
are relatively few data publicly available. Since 2009, the Centers for Medicare and Medicaid
Services (CMS) has attempted to incentivize hospitals to prioritize readmissions reduction
strategies, such as better care coordination, by publishing hospital readmission rates on the
Hospital Compare website (Health Policy Brief, 2013). The data available on Hospital
Compare are based on 30-day readmission and 30-day mortality. Both measures come from
a dataset consisting of original fee-for-service Medicare patients who underwent the
procedure in question and then returned to a hospital within 30 days for care that was not
previously planned. These measures are risk adjusted for age, past medical history, and
other comorbidities (Hospital Compare, 2014).
SSI and Reimbursement
ICD-10
According to Philip Corvo M.D., surgeons are typically paid on a per-procedure basis. When
a patient is readmitted for a SSI, the surgeon will not be compensated for the required care.

However, under current ICD-9 coding, the hospital can still be paid for the readmission as
patients are admitted with a different diagnosis, a practice that is fairly prevalent. It is
anticipated that this will change once ICD-10 is fully implemented (P. Corvo, Personal
Communication, November 14, 2014).
Healthcare providers in the US are required by law to employ standardized diagnosis and
procedure codes for billing purposes (ICD-10 Overview). ICD-10 is the 10th edition of the
International Classification of Diseases, put out by the World Health Organization to
facilitate standardized collection and analysis of health and disease data. It was approved in
1990 and first came into use in 1994. The 11th edition of ICD is scheduled for release in
2017 (International classification of diseases, 2014).
The US currently uses ICD-9-CM for inpatient procedures. However, ICD-10-CM will soon be
used to code diagnoses and ICD-10-PCS will be used for coding inpatient hospital
procedures. The ICD-10 codes will differ significantly from the previous ICD-9, and will
require changes in the coverage and reimbursement of healthcare services. According to the
CDC, “ICD-10 will enable significant improvements in care management, public health
reporting, research, and quality measurement” (ICD-10 Overview). By October 1, 2015, all
US healthcare entities covered under the Health Insurance Portability and Accountability
Act (HIPAA) must transition to ICD-10. ICD-10 expands the number of codes from 13,000 to
68,000 and allows providers to give a much more nuanced picture of the patient’s illness
and treatment (The ICD-10 Transition: AN INTRODUCTION). According to the final ICD-10
Guidelines, which were finalized for use in the US in 2012, there are a number of links to SSI
and postoperative care related to readmissions. For example, the CDC website on ICD-10
states that, “when the admission is for treatment of a complication resulting from surgery or
other medical care, the complication code is sequenced as the principal diagnosis” (ICD-10-
CM Official Guidelines ).
Hospital Readmissions Reduction Program
The majority of Medicare hospital payments are made through the inpatient prospective
payment system (IPPS). The amount paid is based on the patient’s diagnosis, without regard
to how much is actually spent on care for that patient. No additional payment is available to
cover measures intended to prevent readmissions, and hospitals could lose revenue from
reducing readmissions if the newly vacant beds are not filled by other patients (Health
Policy Brief, 2013).
The Hospital Readmissions Reduction Program (HRRP) was established under the
Affordable Care Act. HRRP reduces a hospital’s “base operating DRG payment” if the hospital
reports greater than average readmissions for certain high-volume conditions and
procedures. During fiscal years (FY) 2013 and 2014, three conditions were included in the
program: heart failure, pneumonia, and acute myocardial infarction. Beginning October 1,
2014, the program expanded for FY 2015 to also include Chronic Obstructive Pulmonary
Disease and elective Total Hip Arthroplasty and Total Knee Arthroplasty. The program will
be additionally expanded in FY 2017 with the inclusion of Coronary Artery Bypass Graft
procedures, and more conditions could follow in the coming years. (FY 2015 LTCH PPS Final

Rule). At least 25 discharges are required for each condition in order to be counted toward
that hospital’s readmission rate (Health Policy Brief, 2013).
The average penalty for Connecticut hospitals in FY 2015, based on data collected from
October 1, 2013 to September 30, 2014, was 0.65% (Readmissions penalties by state: Year
3). St. Mary’s Medicare readmission penalties for fiscal years 2013, 2014, and 2015 were
0.46%, 0.13%, and 0.06%, respectively (Medicare readmissions penalties, 2014).
According to Bratzler and Hunt (2006),
The CMS is currently tracking use of vancomycin at the hospital level and has
documented wide variation in use among hospitals. As a function of its public health
responsibility, the CMS may explore targeted assessments of hospitals with high
rates of vancomycin use to determine if they have documented the rationale or
created policies regarding use of vancomycin. Although some hospitals use
vancomycin for prophylaxis because of high “institutional prevalence” of MRSA
infections, use of vancomycin because of institutional prevalence should be based on
surveillance of organisms specifically causing SSIs.
Tracking rates of vancomycin administration may be used by CMS to derive rates of SSI and
readmissions related to MRSA infections, and further demonstrates the priority CMS is
placing on pushing hospitals to improve patient safety and quality of care by various means.
Using high functioning interdisciplinary teams to drive quality
improvement
Alone we can do so little; together we can do much
-Helen Keller
Appendix C demonstrates the benefits of an interdisciplinary approach to SSI detection,
both in the hospital and during post-op surveillance. The study, conducted in Switzerland,
wanted to assess the reliability of surgeon report alone compared with a dedicated infection
control team performing post-op surveillance. The study showed an additional 36%
detection of SSI through use of post-discharge surveillance, and for superficial infections,
50% were identified post-discharge (Rosenthal et al., 2010).
The American College of Physician Executives (ACPE), the American Hospital Association
(AHA), as well as other organizations have recognized the importance of teamwork at
hospitals. High performance teams aim “to redesign care delivery to provide optimal value
to hospitalized patients.” Delivering safe and effective care is of critical importance to all
health care service providers. “Hospitals with high teamwork ratings experience higher
patient satisfaction, higher nurse retention, and lower hospital costs” (O’Leary et al. 2012).
The concept of teamwork is not a new phenomenon. Interdisciplinary teams have proven to
be successful since the 1960’s. Kaoru Ishikawa, a professor at Tokyo University, developed

the ideal of a quality circle. Organizations aimed to engage staff from all levels to drive
quality improvement. The purpose behind engaging front line interdisciplinary teams was
not only to identify process issues, but also to come up with potential solutions that can be
tested on a small scale with the intention to spread across the organization, leading to
system level changes. High-performing teams have the ability to better communicate,
identify day-to-day challenges, assess team performance, and deliver efficient and effective
interventions using systematic improvement methodologies. One important contributing
factor to a high performing team is successful flattening of the hierarchy. This ensures that
all members of the team are engaged in the conversation, and their comments and concerns
are heard and respected. O’Leary et al. describes the unique barriers and challenges to
effective communication at hospitals. The teams are often very large and are ad hoc. To
better illustrate, think of a nurse who is caring for patients and interacting with four
different hospitalists. The Joint Commission reported that communication failure was the
root cause for two-thirds of the 3,584 sentinel events that were reported from 1995 to 2005
(O’Leary et al. 2012).
Health care organizations have to be flexible and able to adapt quickly to changes in order to
stay competitive in the market. Some of these changes are regulatory in nature. We have
referred earlier to changes relative to hospital penalization due to readmission rate. The
current ICD-9 system is not stringent, lacks the logic structure behind diagnoses codes, and
is therefore unable to connect the dots in many of the re-hospitalization instances in a way
that favors hospitals.
Change is challenging and stressful to most people; the issue behind change is truly the
unknown. What is going to happen to me? How is this change going to impact my job? Is my
job going to be eliminated? Am I going to be replaced? What if I am unable to perform to
meet the demand and expectations? These are some of the questions that keep people
captive and scared when the word “change” is mentioned. Change is only welcomed when
people are positively impacted by it or not impacted at all.
At the Community Health Center, Inc., the following quote is recited frequently, empowering
staff to be part of the change: “If you want to make true and lasting change, ask the people
who do the work how to go about it!” This line could be very powerful; it beams respect
towards everyone’s work while recognizing the individuals’ competence in their area of
expertise.
Several studies indicate that, despite the potential benefits of electronic health records,
implementation of the technology faces multiple barriers, the greatest of which is resistance
to change (Ajami & Arab-Chadegani, 2013). The need for change can come from two
directions: top down or bottom up. Top down change could come internally in the form of a
strategic goal or performance improvement plan, or externally from the Joint Commission
or Licensing, State and Federal regulatory agencies. Change initiated by front line staff is
referred to as bottom up. Working with interdisciplinary teams, the members will not only
get buy-in, but more importantly ownership of the new process. When the team takes
ownership over a process change, they will have a higher likelihood of achieving successful

outcomes. This ability of a healthcare organization to successfully drive change will provide
a competitive advantage.
Embracing patient centered technology
Dr. Wah, president of the American Medical Association (AMA), is urging the medical
community to look at technology as a tool “which helps us take better care of our patients,”
with the caveat that “physicians must harness technology, not let technology harness us.”
The medical community can “now be open to new ideas, new techniques and new
perspectives,” leveraging “an application of science that promotes well-being and advances
tradition” (Jeter, 2014).
A recent article published in Forbes magazine stated that, “close to 42 percent of physicians
are comfortable relying on at-home test results to prescribe medication.” Aditionally,
“nearly 66 percent of physicians would prescribe an app to help patients manage chronic
diseases such as diabetes” (Glatter, 2014).
The SSI gap analysis at St. Mary’s Hospital highlights the need for post-operative care
improvement. Remote Patient Monitoring is a recommended solution for consideration.
Remote patient monitoring (RPM), also called home care telehealth, is a type of ambulatory
healthcare that allows a patient to use a mobile medical device to perform a routine test and
send the test data to a healthcare professional in real-time (Rouse, 2014).
Remote Patient Monitoring (RPM) has been utilized at a hospital based in Texas, where
adherence to treatment plans was identified as a critical need. “Additionally, remote
monitoring provides physicians with real-time, clinically actionable information after
patients are discharged, which can help eliminate gaps in follow-up care. Analyzing trends
in patients’ biometric data can alert clinicians to aberrant readings, thereby permitting
timely interventions and potentially averting decompensation that could lead to an ED visit
or readmission” (Glavan, R. 2014).
A report by Berg Insight shows that 3 million patients worldwide are connected to a remote
monitoring device monitored at home or by a professional caregiver. That number is
projected to grow to 19 million by 2018 (Fagerberg & Kurkinen, 2014).
According to the National Broadband Plan drafted earlier this year by the Federal
Communications Commission (FCC), the use of remote patient monitoring technology in
conjunction with electronic health records (EHR) could save the healthcare industry $700
billion over 15 to 20 years (Rouse, M., 2014). Physician buy-in is a vital component and will
impact the overall success and uptake of remote patient monitoring.
Our hypothesis is that Remote Patient Monitoring (RPM) has the potential and the ability to
reduce SSI by focusing on prevention post-operatively, after patients are discharged from
the hospital. To illustrate this, we have reviewed a pilot study of Remote Patient Monitoring,
Improving Health at Home: Remote Patient Monitoring and Chronic Disease, conducted by

CHRISTUS Health, one of the top 10 Catholic health systems in the US. The system has more
than 40 hospitals and facilities in seven states as well as Mexico, with assets totaling more
than $6.4 billion. CHRISTUS St. Michael Health System had previous successes with reducing
hospital readmissions and engaged in the RPM pilot study to build on its accomplishments
and to make successful strides on this very complex and difficult task. The hospital engaged
in the case study to decrease hospital readmission, to improve patient satisfaction, and to
reduce the cost of care. The goal was successfully reached, leading to:
1. Overall Patient satisfaction of 4.77 on a 5.00 scale
2. ROI of $2.44 at 5-month metric review
3. 90% decrease in the average cost of care
Dr. Erick Coleman, Associate Professor of Medicine at the University of Colorado, stated the
following about the intervention with the RPM: “Patients are able to both learn and apply
new self-care skills to help them assert a more active role during care transitions.” RPM bas
been described as:
…a home-based monitoring system that helps to engage patients and family
members in their own care, while seamlessly involving healthcare providers through
integration with their clinical information systems. Wireless connectivity sends data
from personal health devices at the patient’s home including tablets, weight scales,
blood pressure cuffs, and pulse oximeters to be shared with caregivers at the hospital
in a highly-secure manner.
This pilot is focused on the care transitioning of its high-risk patients that were diagnosed
with specific chronic illnesses such as Congestive Heart Failure (CHF), Coronary Artery
Disease (CAD), Hypertension, Diabetes, Myocardial Infarction (MI), Pneumonia, and Chronic
Obstructive Pulmonary Disease (COPD). These diagnoses have been identified as leading to
increased complications and higher readmission rates within 30 days of discharge.
The Transition Care Nurse (CTN) has a critical role in the success of the pilot. The CTN’s role
begins with identifying the high risk patients based on the targeted diagnoses; she visits
with the patient prior to discharge, reviews medications and self-management, and provides
an overview and training for the patient using the RPM system.
Patients enrolled into the pilot study will answer a series of 10-15 questions on a daily basis.
The number of questions presented depends on the patient’s responses. Patients are
prompted by an alarm preset on the tablet, and those who are not responding to the daily
questions are reminded to do so by via phone call. The data gathered by the patients are
updated on Vivify Health, and the CTN is able to access those via a secure login. Should there
be a health concern based on the patient’s responses, the CTN will be alerted via text and
email. These interactive communications via RPM lead to effective and increased timely
communication with patients requiring clinical attention and to reduction in hospital
readmissions.

Recommendations and Conclusion
Millions of dollars and countless years in research have been spent to battle Surgical Site
Infections. The primary focus of this paper is to bring out new and innovative ideas that can
support further reduction of the SSI readmission rates at St. Mary’s Hospital. St. Mary’s
Medicare readmissions penalties have been below the state of Connecticut average for the
past three years and have declined each year. The secondary goal of this work is to provide
a positive long-term financial impact for the hospital by reducing the penalty associated
with readmission. The Centers for Medicaid and Medicare Services (CMS) instituted a
penalty for 30-day readmission for heart failure, heart attack and pneumonia. Other health
conditions will be added to the list and penalties will increase as well. “Health care
providers will be financially motivated to reduce the number of readmissions” (Glavan,
2014).
It is evident from numerous studies throughout the world that true SSI rates are not being
completely detected or reported following patient discharge from the hospital. The annual
cost of SSI and its associated hospital readmissions to the national healthcare system could
possibly be in the billions; a financial burden that can be corrected. The new ICD-10 coding
guidelines will require hospitals to report the cause of readmissions related to post surgical
intervention.
In light of these findings, our team recommends the following improvement opportunities
for consideration:
1. Post Surgical Surveillance Team
Our team recommends the use of an interdisciplinary post surgical surveillance team
following all discharges for at least the first 15 to 20 days after discharge from the hospital.
Although there is no perfect system, the use of an interdisciplinary monitoring team to track
all patients post-operatively could help better identify the true SSI rate of the hospital.
Through use of the post op surveillance team, surgeons would receive real-time information
on SSI rates. This can allow surgical teams to quickly address any trends that have been
detected and promptly work to decrease SSI rates throughout the hospital. We recognize
that there are costs associated with development and utilization of surveillance.
2. Remote Patient Monitoring
Remote patient monitoring has been greatly underutilized and overlooked. As accountable
care organizations grow and value-based care gains prominence, remote patient monitoring
is likely to experience exponential growth. The leading cause of readmission is failures in
the transition of care from hospital to home.
Remote patient monitoring provides real time data and clinically actionable information.
Providers will be able to review continuous clinical data as they care for their patients
rather than relying on snapshots from appointments or the patient's memory. Early
estimates with use of this technology indicate that it is extremely cost effective. Patients can
be monitored in the comforts of their home. If the surveillance team detects an infection, the
infection can be treated at an earlier stage more efficiently, effectively, and perhaps

completely avoiding a hospital readmission. HIPPA-compliant remote monitoring is
available at a reasonable cost. It is our team’s belief that Saint Mary’s Hospital would be
leading the effort to reduce SSI and re-hospitalization with the utilization of remote patient
monitoring for patients that are considered high-risk.
3. Remote Monitoring via Mobile Device
Adherence to treatment can lead to reduction is SSIs. Most patients are not equipped to
make clinically sounds decisions regarding their wound care. Patients may doubt their
ability to recognize infection and will delay necessary care by waiting to a point where
rehospitalization is necessary. Smartphone technology has come a long way, as phones are
now able to capture high-quality pictures. Allowing and encouraging patients to take
pictures of their wounds daily using their smartphones and send them to the surgical
service will give an opportunity to identify developing infections and provide timely,
efficient and safe care.
Prevention is the key,and the final word with whichwe wouldlike to closeour recommendations.
Aligning the available resources to provide value-based care in an accountable care environment
will lead to prevention, and ultimately to substantial health care cost savings.

Appendix A: Pilot Case Study
Case Study: Remote Patient Monitoring for
Care Transition Intervention Program, utilizing
Remote Patient Monitoring System (RPMS)
from Vivify Health.
The CHRISTUS Health Care Transition Program undertook this pilot
project to reduce the hospital readmissions of high-risk patients
diagnosed with specific chronic illnesses: Congestive Heart Failure
(CHF), Coronary Artery Disease (CAD), Hypertension, Diabetes,
Myocardial Infarction (MI), Pneumonia, and Chronic Obstructive
Pulmonary Disease (COPD). Patients with these diseases commonly
have complications that result in readmissions to the hospital within
30 days of discharge and are a targeted population for this
community based program.
The Care Transition Intervention Program mission is to teach patients
to apply new skills that enable them to improve their ability to care
for themselves when transitioning from the hospital and at home.
This program relies on a trained and certified Care Transition Nurse
(CTN) who identifies appropriate patients for the program, enrolls
the patients, and begins their care cycle. Prior to discharge, the CTN
visits the patient to begin the successful transition from hospital to
home, including medication review and preparing the patient to
begin self-management at home. Post discharge, the CTN makes an
initial visit to the home to review medication orders, educate
patients about their condition and warning signs, review the Personal
Health Record, and communicate with family care givers.
While successful, the Care Transitions program did have a few
challenges. . First, some patients did not want a CTN to come to their
home and refused to consent to the CTN coming to their home. This
was the main reason patients declined to participate in the Care
Transition Program. Second, some patients live up to 50 miles away
from the hospital, requiring the CTN to spend approximately 500
hours annually traveling to and from patient homes, reducing the
amount of time for actual patient care.. This reduces the number of
patients the CTN can transition and care for. Third, the CTN has
limited interaction time with patients enrolled in the program
because of the time spent driving to and from the initial home visit,
thus limiting patient engagement and satisfaction CHRISTUS
anticipated the pilot would have a positive effect on these
challenges.
The RPMS is a cloud based (Seas) Remote Care Management
Platform utilizing consumer electronics, in this case an Android
Tablet, and the following Bluetooth enabled personal health devices:
weight scale, blood pressure monitor, and pulse dosimeter. Patient
protocols and care plans were easily customized for each patient, and
the intuitive user interface was simple and easy for almost all
patients to use. Patients could answer questions, send biometric
Location: CHRISTUS Health System,
St. Michael Hospital, Texarkana TX
Purpose: Decrease Hospital
Readmissions, Improve Patient
Satisfaction
Results:
90% Reduction in overall cost of care
65% Reduction in hospital
readmissions
95% patient adoption
95% overall patient satisfaction
ROI of $ 2.44 return for every dollar
invested was reached in month 5
and continued to improve
Technology: Vivify Health, Remote
Patient Management Platform,
Remote Patient Monitoring System
(RPMS) including 10” Android tablet,
and Bluetooth paired personal
health devices: weight scale, blood
pressure monitor, pulse oximeter
Pilot Duration: 1 year
Patient Group: 44 completed,
average age 66 years, Congestive
Heart Failure (CHF) primary diagnosis
Governance: Institutional Review
Board, Pilot Research Team bi-
monthly meetings
CHRISTUS Pilot leadership:
Luke Webster, MD, VP & CMIO
(RPMS Principle Investigator)
Shannon Clifton, Director of
Connected Care (RPMS Pilot Sub
Investigator)
Ellen Ford, Clinical and Strategic
Analyst (RPMS Pilot Study
Coordinator)
Hank Fanberg, Technology Advocacy

data, and view educations videos. With appropriate connectivity, patients could engage in real time
interactive videoconferencing with care givers. . Wireless connectivity, provided by AT&T, sends data
from personal health devices at the patient’s home to a secure “cloud” where it can be securely logged
into by authorized caregivers via any browser.
Initially the Care Transition staff had reservations about implementing this solution for two reasons.
First, they wanted to continue making the initial home visit to establish and strengthen a personal
relationship with the patient and assess the patient in the home living environment. Second, the staff
questioned whether patients would use and benefit from the RPMS system since the majority of
patients enrolled were over the age of 65 and not technology savvy. To address these concerns, Vivify
Health demonstrated the simple and intuitive process the patient would use with the tablet. After this
demonstration, the Care Transition staff and hospital administrators thought that the elderly population
would not only be able to operate the equipment, but highly benefit from it. In addition, they felt the
number of patients they could impact would dramatically increase.
The patients selected for the study had an average age of 66 were given a kit containing a tablet, weight
scale, blood pressure cuff and a pulse oximeter. Upon completion of the program, analysis of return on
investment and changes in costs of care were calculated. The average ROI for Forty four 44 patients who
completed the program was f $2.44. Additionally, prior to enrollment in the program, the average cost
of care for the 44 patients was $12,937; after participation, that figure dropped to $1,231.
While one of the major outcomes of the Pilot was to reduce hospital readmissions, additional benefits
were realized. Some of the Care Transition Intervention existing processes that contributed to less than
ideal rates of patient participation (detailed in paragraph 3 above) were reduced or eliminated. With
RPMS, the patient took the solution kit home with them from the hospital and began using it. The
training and familiarization of the RPMS home kit given to the patients before they left the hospital
eliminated the need for the initial CTN visit. While at home, the medical devices acquired and
transmitted biometric data, the patient answered survey questions presented to them on the tablet,
and viewed educational videos about their condition. For the CTN, the need for the initial in-home visit
is greatly reduced, while the patient is monitored much more consistently. The CTN can effectively care
for patients, maintain efficient workflow, and spend more time with each patient.
Due to the success of the project, CHRISTUS Health is expanding RPMS across the health system, which remains
an important initiative for improving patient outcomes and satisfaction. Data Integration into the CHRISTUS
Electronic Medical Record is possible and is under consideration.
It must be noted that this Pilot occurred prior to Home Telemonitoring Reimbursement for Medicaid patients,
available in Texas as of October 1, 2013. Home Telemonitoring is defined as a health service that requires
scheduled remote monitoring of data related to a patient’s health and transmission of the data to a licensed
home health agency or a hospital. It has been calculated that ROI could approach $ 40.00 ($ 40 saved for every
$ 1 invested in RPM) with full utilization of possible reimbursement.
Authors:
Luke Webster, M.D., Chief Medical Information Officer
Shannon Clifton, Director Connected Care
Ellen Ford, Clinical & Strategic Analyst

Appendix B: Vivify – Vivify Remote Patient Monitoring

REV – 1.22 (10-25-2014)
Connected Care Platform
Service Levels
Per Member PLATFORM – Connected Care Management and Monitoring Platform
Connected Care Portal – remote care coordination and monitoring tools:
Monitoring dashboards, via provider interaction or patient engagement apps.
Customizable science-based care plans, including biometric thresholds.
Includes risk stratification, clinical documentation and medication management.
Incorporates virtual visits and integration with existing clinical workflows.
Per Member AT RISK – Patient Engagement and Reminders
Simple Patient Engagement – automated patient interaction and collection:
Interactive Voice Response (IVR) – automated collection via standard telephones.
Texting (BYOD) – automated collection via text surveys and responses.
Web App (BYOD) – automated collection via web app, with text reminders.
Per Patient RISING RISK – Advanced Patient Engagement and Monitoring
Advanced Patient Engagement – using patients’ existing iOS or Android phones:
Advanced Security – encrypted communications and HIPAA secured access.
Advanced Care Plans – science-based care plans, driving best practice outcomes.
Educational Videos – rich educational videos, condition and medication specific.
Video Conferencing – direct-to-patient virtual visits, via their own phone.
Per Encounter HIGH RISK – Integrated Connected Health Kit and Managed Services
Patient Engagement – mobile app driving patient compliance, including:
Care plan driven health assessments, educational videos and reminders.
Intuitive visually guided patient experience, including multilingual text-to-speech.
Remote Monitoring – mobile app integrating Bluetooth wireless biometric devices:
Care plan driven biometric readings from integrated wireless devices.
Patient-customized health surveys for any combination of clinical conditions.
Virtual Visits – mobile app seamlessly integrating video conferencing:
High definition video conferencing, including multi-party for coordinating care.
Integrated Health Kit – a custom-packaged take-home or drop-ship health kit:
Designed for self-setup by complex patients of any age and technical ability.
Integrated tablet with 4G data plan and Bluetooth devices, all remotely managed.
Includes 24x7x365 direct-to-patient HIPAA-compliant support and services.
OPTIONAL SERVICES
Fully-Managed Kit Logistics – simplifying the deployment and recycling of kits:
Managed logistics service for recycling, storing and just-in-time shipping of kits.
Completing the 100% end-to-end technology servicing of remote care.
Medical Command Center – 24x7 remote clinical services:
Remote outreach, engagement and monitoring, including escalation of services.
Care coordination, including risk assessment, needs analysis and education.
Data Integration – integration with existing clinical workflows and systems:
Bi-directional data exchange with EMR, PHR, HIE and Population Health systems.
Clinical workflows designed to assure best practices and optimal outcomes.
Care Management for your entire population.
Engaging At Risk patients to keep them in check.
Monitoring and education of Rising Risk patients.
Simplified end-to-end services for High Risk patients.
AT RISK
RISING RISK
HIGH RISK
PLATFORM

Appendix C: SSI Detection Rate Stratified by Type of Surveillance
SSI, surgical site infection; ASA, American Society of Anaesthesiologists; NNIS, National Nosocomial Infections Surveillance system risk index; NS, not significant.a P-value
for the difference between SSIs detected by surgeons only, the addition
of the infectioncontrol team and of post-discharge surveillance concerning the different variables. b 75th percentile time as defined in the NNIS system.

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