MAY/JUNE 2006

LIVES CAMPAIGN

Takes Patient Safety to a New Level
By Diana Smith

In Texas and across the country, hospitals have taken on a bold new initiative to improve patient safety and prevent deaths from medical errors. The specific goal: 100,000 lives saved in one year. Read on to discover some of the important lessons learned by seven Texas hospitals.

Saving lives always has been the premiere calling of hospitals, but an ambitious, new initiative has taken that effort a step further. The 100,000 Lives Campaign, launched nationwide by the Institute for Healthcare Improvement to engage U.S. hospitals in improving patient care and preventing avoidable deaths, will complete its first phase in June.

The 100,000 Lives Campaign is the first-ever national campaign to promote saving a specified number of lives in hospitals by a certain date through the implementation of proven, evidence-based practices and procedures. In Texas, the TMF Health Quality Institute provided assessment tools and ongoing education and suppor

More than 3,000 hospitals joined the 100,000 Lives Campaign, including 143 in Texas. “Hospitals taking part in this campaign are demonstrating that rapid improvement in health care – driven not solely by regulation or incentive, but by the commitment and spirit of health care providers – is entirely possible,” says Diane Jacobsen, M.P.H., CPHQ, a national director at IHI. “Their tremendous effort has yielded improvement on a scale previously unimagined in the American health care system, and has introduced a new standard of care.”

Participating hospitals and their medical and clinical staffs have implemented some or all of six lifesaving best practices that have been shown to improve health care quality and safety significantly and to reduce mortality. The interventions include:

§        Deploying rapid response teams at the first sign of patient decline;

§        Implementing medication reconciliation, which includes listing and evaluating all of a patient’s drugs to prevent adverse events;

§        Preventing central venous catheter-related bloodstream infection and related deaths by implementing a set of recommended interventions in all patients requiring a central line;

§        Preventing surgical site infection and related deaths by reliably implementing a set of recommended interventions in all surgical patients;

§        Preventing ventilator-associated pneumonia and related deaths and other complications in patients on ventilators by reliably implementing a set of recommended interventions, and

§        Delivering evidence-based care for patients with acute myocardial infarction.

Texas  Interventions
In Texas, a number of hospitals reported impressive results and valuable lessons learned. On May 12, TMF held the workshop, “Sharing Best Practices in Patient Safety,” at which participating hospitals discussed their successes and obstacles. Here’s a look at how hospitals around the state are working to improve patient safety.

Rapid Response Team

To improve patient safety, Covenant Health System in Lubbock and Memorial Hermann Northwest Hospital in Houston aggressively addressed the issue of patient codes outside the intensive care unit. In each facility, a team including an ICU nurse and a respiratory therapist may be called to the bedside of a non-ICU patient in early distress at any time.  

Both hospitals coined catchy mottos to encourage the use of the Rapid Response Team. According to Michael Palmentera, RN, charge nurse in the Medical Intensive Care Unit at Covenant, the Rapid Response Team’s motto is “When in doubt, shout.” At Memorial Hermann Northwest, the team is known as the ACT, Assessment Consultation Team, and its motto is “ACT now, not later!”

“Often, based on strong assessment skills, a bedside nurse will intuitively know something is not quite right with a patient,” says Palmentera. “We strongly encourage them to call the RRT for assistance, and we have provided them with playing cards that have our phone number and assert that we are their ‘ace in the hole.’ ”

According to Palmentera, the RRT has set some lofty goals, including:

§        No needless deaths;

§        No helpless or anxious patients;

§        No stressful or all-consuming nursing situations; and

§        No unwanted delays in transferring patients from a medical/surgical unit to a higher level of care.

To meet these goals, Palmentera and his team educated physicians and staff, sending letters to physicians’ homes, posting flyers in the medical staff dining rooms and personally visiting each nursing unit. Continued visibility and promotion are critical to the team’s success. “We found that calls for the team would decrease when we were not as visible and actively educating staff,” he says.

Margaret Geater, RN, director of ICU/respiratory care at Memorial Hermann Northwest, agrees. Memorial Hermann staff also developed a strong education program for ACT team members, staff and physicians, using buttons, pens, e-mail blasts and monthly updates on how many times the team was called and the outcomes. They even developed example scripts for nurses to use when calling physicians with a concern.

“Now, physicians are asking why an ACT was not called when a patient’s condition changed – a real win for us,” she says.

Palmentera notes, “We feel every code outside of the ICU is a missed opportunity for Rapid Response Team intervention. The benefits are obvious – better patient outcomes, improved staff nurses’ satisfaction, physician satisfaction and alleviated family concern.”

Medication Reconciliation

According to IHI, experience from hundreds of organizations has shown that poor communication of medical information at transition points is responsible for as many as 50 percent of all medication errors and up to 20 percent of adverse drug events in the hospital.

Scott and White Memorial Hospital in Temple and Memorial Hermann Southeast Hospital in Houston have addressed this issue and implemented specific medication reconciliation programs to prevent adverse drug events in their facilities.

Emory S. Martin III, Pharm.D., director of pharmacy at Scott and White Memorial Hospitals and Clinics, said his large teaching facility has developed a system that relies on advanced computerized documentation with reconciliation at numerous checkpoints including admission, pre- and post-procedure as well as discharge. The medicine reconciliation system even includes a special window on the patient’s medical record that shows drugs reported upon admission and current medications.

In this physician-driven system, Scott and White physicians collect the data from the patient and family, transcribe home medications at admission and mark out those not to be given in the hospital. Martin reported that the system has increased awareness because physicians now have immediate electronic access to know what the patient is taking at admission as well as before and after a hospital procedure. Additionally, besides discharge orders and instructions, the patient goes home with a legal prescription generated by the system and a specific list of medications.

At Memorial Hermann Southeast Hospital, the smaller, less-computerized facility took a different, but no less successful, approach. Laura Rodriguez, RN, director of the ICU, said her multi-disciplinary team focused first on the education of physicians, clinical managers and staff. “We had to convey that medication reconciliation is a patient safety goal and to clarify the difference between a standard and a goal,” she says.

The team closely evaluated current processes and identified barriers to appropriately reconciling medications. First, they adopted a medication reconciliation form from a sister hospital. However, this did not work well because physicians would write discharge medications on separate prescription pads and not notify the primary care nurse, resulting in patient confusion at discharge.

After “a lot of sweat and tears,” Rodriquez says the team created a functional, patient-friendly form that is produced in triplicate. First, a nurse collects data upon admission. Then medications are reconciled at “entry into every procedural area where medications or anesthesia given could affect a patient’s response to treatment or services.” Finally, the data is collected again at discharge. The form has a prescription pad printed directly onto it for physicians to write discharge prescriptions.

The key to the success of this process was changing an ingrained culture, Rodriquez adds, and realizing the effort was a marathon, not a sprint.

Preventing Central Line Infections
At Baptist St. Anthony’s Health System in Amarillo, 1,000 to 1,500 central line insertions are performed each year. After implementation of a “central line bundle” as part of the 100,000 Lives Campaign, central line infections at BSA decreased by 58.2 percent in the last year, equating to a conservative cost savings of approximately $66,000. Charlotte Wheeler, RN, manager of infection control, says the keys to success were strong administrative support, a multidisciplinary team, a shared vision, set protocols and recruiting physician champions.

This intervention’s goal is to prevent central venous catheter-related blood- stream infection deaths by implementing central line bundles in all patients requiring a central line. The bundle consists of hand hygiene, maximal barrier precautions, chlorhexidine skin antisepsis, optimal site placement and appropriate catheter site evaluation.

Wheeler and her team immediately saw the potential benefits of this intervention and were eager to implement it, she explained. Yet, they encountered some hefty obstacles, including multiple clinical policies and protocols (BSA had six), practitioners inserting central lines using self-determined protocols and significant resistance to change.

In addition, infection control staff developed central line carts with standardized equipment. “We were on a limited budget and used plastic storage bins from Wal-Mart,” Wheeler says. The carts are all located in one specified location on each floor for easy accessibility, and they are kept fully stocked. The results included a decrease of more than 50 percent in central line infections and a 91 percent compliance rate for usage of components of the IHI central line bundle. “Needless to say, we are very excited about the results,” says Wheeler.

Preventing Surgical Site Infections

Covenant Medical Center, a 1,200-bed facility in Lubbock, was quick to embrace the IHI 100,000 Lives Campaign and undertook the initiative to prevent surgical site infections in June 2005. This intervention’s goal is to prevent surgical site infections and related deaths by implementing evidence-based interventions for surgical patients. The surgical site infection intervention consists of guideline-based use of prophylactic antibiotics, appropriate hair removal and postoperative glucose control.

According to Renae Harris, RN, infection control team leader for Covenant Health System, the components of the initiative were phased in beginning with hair removal in June 2005. Next came efforts to remove razors from the OR in September, followed by environmental temperature control in October and antibiotic recommendations in January. Finally, revised physician orders that reflected new medications were implemented this past April.

“We, like some others who have taken on the IHI challenge, thought hair removal would be the easiest initiative to implement,” says Harris. “After all, the recommendation to avoid razors has been around for years. But, we found some of our staff weren’t aware of the risks associated with razors, so multidisciplinary education for this component has been initiated. Education has stressed not just the avoidance of razors, but the importance of correct documentation of hair removal,” she adds.

Harris reported good success with pre-op antibiotic usage, though she said pre-op antibiotic timing and post-op discontinuation were more challenging.

“Ownership is key,” Harris says. “It is imperative to have participation from various disciplines – surgery, pharmacy, nursing, infection control, etc. Staff ‘buy in’ and process improvement ‘champions’ will help ensure your success.”

Ongoing reminders and education are critical as hospitals undertake this significant task. “Decide in advance how you will handle those who challenge your improvement efforts – and be consistent,” she says.

Preventing Ventilator-Associated Pneumonia

According to Virgie Fisher, CIC, manager of infection prevention/control for Memorial Hermann Texas Medical Center, approximately 300,000 cases of nosocomial pneumonia occur each year in the United States. Nosocomial pneumonia is 20 times more common in mechanically ventilated patients and can increase hospitalization costs by up to $50,000 per patient.

With staggering statistics such as these, Fisher and her team set out to design and implement a Ventilator-Associated Pneumonia (VAP) Prevention program, one of the six suggested IHI interventions for the 100,000 Lives Campaign.

The intervention is designed to prevent ventilator-associated pneumonia and related complications by implementing a “ventilator bundle.” Components of the Memorial Hermann ventilator bundle consist of elevation of the head of the bed to at least 30 degrees, endotracheal tube suctioning every four hours, strict hand hygiene, oral care every six hours, patients out of bed at least daily, change irrigation fluids daily, use of sleeved yankauer suctions, as well as daily “sedation vacations,” daily assessment of readiness to extubate, peptic ulcer disease prophylaxis and deep vein thrombosis prophylaxis.

Key steps for implementation of the program included:

§        Make VAP prevention a priority;

§        Track VAPs using established guidelines;

§        Establish a baseline;

§        Assemble a team; and

§        Foster “champions.”

After extensive education to introduce the bundle, Fisher and her team monitored compliance with the bundle, providing “real-time” feedback, which is a key component, she says. “The units could see at the end of every day exactly how well they complied with bundle measurements.” Another equally key factor is fostering ownership in the unit. “The entire unit must own the project,” Fisher says.

The charge nurses in the ICUs conducted bundle audits with the infection control practitioner as a team. Fisher says, “That allowed immediate intervention and demonstrated collaboration. We keep the staff engaged by providing and posting visual feedback in the form of ‘Days Without a VAP’ graphs to inspire a friendly competition between ICUs to see which unit can go the longest without a VAP.”

Though some units still proved to be challenging, Fisher says the overall results were remarkable. “Our stellar unit had 15 months without a single episode of VAP. That translates to $1 million saved in just one unit,” Fisher says.

“However, the real bottom line,” she emphasizes, “is mortality. Lowering mortality rates does translate into avoided deaths.” AtMemorial Hermann Texas Medical Center, an estimated 770 lives have been saved due to the IHI interventions.

Evidence-Based Care for Myocardial Infarctions

“The 100,000 Lives Campaign was a great opportunity for us to focus attention on an important area of intervention for heart patients,” says Michele Ingram, RN, administrative director of quality and process improvement at University Health System in San Antonio. “Cardiovascular disease is a leading cause of death among minority populations in the U.S. and Bexar County,” she adds.

Thanks to a grant from the Robert Wood Johnson Foundation, University Health System already had focused on specific improvements in the continuum of cardiovascular care provided to Hispanics and African-Americans. Part of a 10-member learning group made up of facilities across the country, University Health System had previously begun core measure work for evidence-based care.

The hospital set some important goals:

§        By January 2008, decrease cardiovascular morbidity and mortality by achieving 85 percent compliance with the American College of Cardiology/American Heart Association secondary prevention guidelines for adults with acute myocardial infarction, acute coronary syndrome and chronic heart failure; and

§        By January 2008, provide smoking cessation counseling to at least 85 percent of smokers admitted with AMI, ACS or CHF.

The cardiovascular improvement plan included all patients admitted to the cardiology telemetry unit of the CICU with the diagnosis of AMI, ACS or CHF. Baseline measures were taken and the program begun. “We came up against some barriers,” Ingram explains. “There was disconnect between inpatient and outpatient staff. Limited knowledge of smoking cessation programs, inconsistent processes and lack of appropriate tools to communicate the inpatient plan to the provider hindered progress. In addition, tobacco cessation often was not identified as a priority for acute-care staff who were busy saving lives.”

Intervention strategies, such as revising the patient history form and admission order set, partnering with an outpatient Health Education Department and creating a flow chart smoking cessation assessment and referral process, helped eliminate some of the obstacles.

Work continues on the intervention, but Ingram reports that valuable lessons have been learned:

§        Understand the great challenges faced by indigent and working poor patients – finances, language barriers and patient acceptance (feeling that they are second class citizens). Create a clear process to identify a primary care provider and funding source.