Two SCAMPs Shed Light on How to Improve Care for Kidney Failure and Chest Pain
Jeffrey Greenberg, MD, MBA, medical director of the SCAMPs program and Siddharth Parmar, MD, MPH, manager of Care Redesign for BWH and the Center for Clinical Innovation
SCAMPs, or Standardized Clinical Assessment and Management Plans, are helping BWH transform care in a variety of important ways from the Emergency Department (ED) to the Medical Intensive Care Unit (MICU).
Originally developed at Boston Children’s Hospital, SCAMPs were first implemented in several areas at BWH and BWFH in 2012 as part of care redesign efforts. With a goal of developing guidelines for standardizing and improving care, SCAMPs facilitate the collection and analysis of clinician decision data in areas where there is variation in clinical practice. BWH’s SCAMPs team partners with clinicians on designing and implementing individual SCAMPs and collecting, managing and assessing the data.
Recent results from two SCAMPs projects reveal how the collection of real-world data and analysis can help transform patient care.
Kidney failure outcomes in the MICU
Back in October 2012, BWH’s SCAMPs team sought to standardize care for patients with kidney failure in the MICU.
“This SCAMP was originally set up because there is a lot of uncertainty in the field of nephrology and in how to manage inpatients in the MICU who have renal failure,” said Jeffrey Greenberg, MD, MBA, medical director of the SCAMPs program and associate medical director of the Brigham and Women’s Physicians Organization (BWPO). “Kidney failure is a grave diagnosis with a high mortality rate, and there are all kinds of questions concerning when to start dialysis and what should trigger starting it.”
Working with the Renal consult team and Renal fellows, the SCAMPs team developed a pathway that uses a nuanced algorithm to predict when to start dialysis based on clinical factors. The team then tested the algorithm in two phases—the first from Oct. 2012 through Nov. 2013, and the second from Nov. 2013 through Dec. 2014. The team relied on physicians to record whether or not they would follow the SCAMP for each applicable patient and the rationale for their decision. Fellows helped to engage physicians and document the data each day.
“We learned that a number of doctors would defer on starting dialysis because they believed patients’ kidneys were going to recover on their own, but this wasn’t always the case,” said Greenberg. “When physicians followed the SCAMP pathway, however, the rate of mortality for low-risk kidney failure patients in the hospital and 60 days post-discharge decreased from 65 percent to 29 percent.”
The pilot found no difference in mortality rate for high-risk patients. Though this was not a randomized controlled trial and there could be confounding factors, Greenberg says the results are compelling and indicate a way toward better outcomes for kidney failure patients.
“This SCAMP has shed light on an important element of delivering care to this vulnerable patient population,” said Mallika Mendu, MD, MBA, of the Renal Division. “We have learned that following SCAMP guidelines might improve outcomes for our patients, and based on this, we will be conducting further study to confirm our findings.”
Chest pain in the ED
Another area of great clinical practice variation is in treating patients who present in the ED with chest pain.
“Chest pain is one of the most common reasons patients visit the ED, and it’s not always easy to know if they are experiencing a heart attack,” said Chris Baugh, MD, MBA, of Emergency Medicine. “As a result, a number of patients get hospitalized or advanced testing who may not need it.”
As part of a SCAMP created in 2013, the SCAMPs team worked with emergency physicians to stratify patients into the categories of low, medium and high risk for heart attack, using the HEART score. The SCAMP made recommendations concerning when to use the HEART score and what to do with the results.
“For low-risk patients—which comprised a fifth to a quarter of patients coming to the ED with chest pain—the recommendation was to perform serial blood tests and ECGs and send them home if they were normal,” said Greenberg. “The SCAMP showed us that 60 percent of these patients were sent to the ED Observation Unit, and not one of the 54 patients ended up having a heart attack or returning to the Brigham within 30 days.”
Through this SCAMP, the team found a practice pattern; physicians didn’t completely trust the SCAMP algorithm or pathway recommendation at the moment of making decisions about patient care. But when the SCAMPs team shared the results, the ED team realized they could use the ED Observation Unit a lot less and could safely send more patients home, thus decreasing hospital costs and opening up space for patients who really need to be observed or admitted.
Getting clinician buy-in
Greenberg says the best way to continue this work and get clinicians onboard is to show them the data.
“Nothing talks to people like data,” he said. “SCAMPs give us the ability to measure our practice and see what happens. Physicians create the pathways themselves and are allowed to deviate from them, so when we share the data, it is more meaningful to them.”
Added Siddharth Parmar, MD, MPH, manager of Care Redesign for BWH and the Center for Clinical Innovation: “We’re trying to create a learning system where we’re constantly pulling data and seeing what doctors do as they take care of patients and why they make the decisions they do. We then correlate this information with outcomes and feed it back to physicians to foster continuous learning about what they’re doing. We want to make the process much more streamlined and connected, so that physicians are always learning from what they’re doing and what their colleagues are doing.”
Check out more stories about SCAMP in Clinical & Research News:
SCAMP Team Marks One Year of Improving Care
http://bwhclinicalandresearchnews.org/2013/07/11/scamps-team-marks-one-year-of-improving-care/
SCAMP Improves Care of Hypertrophic Cardiomyopathy Patients
Have an idea for an area that could benefit from a SCAMP? Email your suggestion to sparmar@partners.org.