I am on a plane on my way back to Minnesota after being professionally rejuvenated by the content of the Institute of Healthcare Improvement’s 16th Annual Forum, in Orlando, FL. The theme of the meeting called on all hospitals, and hence I believe all hospitalists, to save lives. Dr. Donald Berwick, President and CEO of the Institute of Healthcare Improvement (IHI) kicked off this years’ Annual Forum with his plenary speech “Some is not a number, Soon is not a time.” Saving some lives, some time in the future is not a clear goal. “Some is not a number and soon is not a time.” So, he put the challenge forth for hospitals to join IHI in a campaign to save 100K lives by June 14, 2006 at 9:00 a.m. EDT.
“Some is not a number. Soon is not a time.” We all get “why” this is important, at least in so much as what we have been told by the Institute of Medicine Reports “To Err is Human” and “Crossing the Quality Chasm”. But “how” can this be done? By doing things that we already know impact mortality in a hospital setting. By engaging in the reliable care delivery of six changes that save lives. These include recommendations in each of the following areas: rapid response or emergency medical teams, reliable care for acute myocardial infarctions, reliable use of the ventilator pneumonia and central venous line “bundles”, surgical site infection prophylaxis, and prevention of adverse drug events with reconciliation. Each is described in more detail below.
- Rapid Response Teams (also known as Medical Emergency or Pre-Code Teams): This is a team of healthcare providers that may be summoned at any time by anyone in the hospital to assist in the care of a patient who appears acutely ill, before the patient has respiratory failure, a cardiac arrest or other adverse event. The aim is to prevent situations of “failure to rescue”, to recognize the early signs and symptoms of clinical deterioration prior to requiring transfer to the intensive care unit.
- Reliable Care for Acute Myocardial Infarction (AMI): For appropriate AMI patients, reliable use of all of the following treatments: early administration of aspirin, aspirin at discharge, early administration of a beta-blocker, beta-blocker at discharge, ACE‑inhibitor or angiotensin receptor blocker (ARB) at discharge (if systolic dysfunction), timely reperfusion, and smoking cessation counseling.
- Reliable use of the Ventilator Bundle: A number of hospitals have initiated the use of the ventilator bundle to prevent ventilator associated pneumonia (VAP). VAP carries a high mortality rate. The “bundle” is a grouping of 5 treatments/preventions measured as a composite (% of patients that get all 5).
- Elevate head of bed to 30 degrees
- Peptic ulcer prophylaxis
- Deep venous thrombosis prophylaxis
- Daily “sedation vacation”
- Daily assessment of readiness to extubate
Not all of the items have a specific relationship to VAP (e.g., DVT prophylaxis), but when reliably performed in concert with the other items, leads to a decrease in VAP.
- Reliable use of Central Venous Line Bundles: This is a grouping of 5 preventative measures that when done in concert and measured as a composite have had maximal effectiveness for the reduction of central line associated blood stream infections (CLABs) in some hospitals.
- Hand hygiene
- Maximal barrier precautions
- Chlorhexidine skin antisepsis
- Appropriate catheter site and administration system care
- No routine line replacement
- Surgical site infection (SSI) prophylaxis with a “SSI bundle”: Hospitals participating with the IHI in a variety of different formats have found the most substantial reduction/prevention of SSIs when 3 preventative measures are done in concert with each other for every surgical patient. These preventative measures include:
- Guideline-based use of prophylactic perioperative antibiotics (including both choice and timing of administration of antibiotic)
- Appropriate hair removal (avoiding shaving)
- Perioperative glucose control
- Prevention of adverse drug events with medication reconciliation: This refers to the procedures that can be put in place at the time of any transition of care to mitigate the increased risk of wrong dose of medication or even wrong drug being administered immediately following that transition. Each time we have to transfer information from one sheet of paper to another or from a sheet of paper to a computer, there is chance for human error. Medication reconciliation can virtually eliminate errors occurring at transitions in care.
I have placed in Table 1, the information (goals, background, proposed interventions and success stories) handed out during Dr. Donald Berwick’s opening plenary session, the kick-off for the campaign to save 100,000 lives.
Two key components of the descriptions above deserve further explanation. One of the key components is the concept of reliability. Reliability is how often something in health care does what it is supposed to do, in the time frame it is supposed to do it in. The formula is the number of times that something (delivery of a medication or service) is done correctly divided by the number of times that same something is attempted. In work published by Karl Weick, one common principle within high reliability organizations is that of a preoccupation with failure. As such, the notation of reliability is a measure of defects. Currently much of healthcare (including use of beta-blockers after AMI) functions at a 10-1 level of performance (one defect in 10 tries) or less than a 90% success rate. Organizations that have actively embraced this concept of reliability in their quality improvement work have rejected the usual satisfaction with 10-1 performance. Shouldn’t 99 out of 100 (or 999 out of a 1,000) patients with an AMI get what they are supposed to get?
The other key component embedded within some of the six items that save lives is the concept of bundles. Rather than considering individual measures for each of the items within a bundle, a composite or aggregate measure is reported. Bottom line is that doing any one or two of the items in a bundle is not good enough. It will not achieve the same reduction in hospital acquired infection rates or mortality, as doing all of the items in concert for every appropriate patient.
How can hospitalists help achieve this national goal, to participate in this campaign with the IHI? As individuals, we can be a hospital “precinct captain” or champion, speak to our hospital boards, convene colleagues to standardize to science, start medication reconciliation, and seek composite reliability in our own individual practices.
The IHI will measure this campaign in four ways.
Level 1. Number of hospitals “signing up”
Level 2. Changes in process of care reported
Level 3. Actual changes in deaths and death rates (sample amongst volunteer hospitals)
Level 4. Hospital Standardized Mortality Rates (work of Brian Jarman)
More detailed and specific information about the campaign (and how to participate) can be found on IHI’s Web site (www.ihi.org/ihi/programs/campaign).
“Some is not a number. Soon is not a time.”
The number: 100,000 lives.
The time: June 14, 2006 – 9 a.m. EDT.
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