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Operation
Safety
New
programs cut medical errors and improve patient care
Related
links:
- Electronic prescribing: Rx
for pharmacy orders?
- Belt tightening and moves to
greener pastures help hospitals earn profits
by
Marjolijn Bijlefeld
Virginia
Business
November 2003
Two
o’clock in the morning in the intensive care unit
and a patient’s lab results have just arrived.
The critical-care nurses have a decision to make: either
wake a physician to change the patient’s care,
or do nothing until the doctors make regular morning
rounds. Too often at many hospital ICUs, decisions about
treatments are made only during a few hours each day.
But at Sentara CarePlex Hospital in Hampton, those decisions
are made on the spot by a critical-care physician and
nurse — sitting 40 miles away. In a room with a
bank of monitors and two-way teleconferencing equipment,
Sentara runs an eICU, a program that brings round-the-clock
critical care to three Sentara hospitals, with a fourth
one coming online this month.
Those
kinds of quick interventions can save lives and get
patients home sooner, says Dr. Gary Yates, vice president
of clinical effectiveness at Sentara Healthcare. The
eICU, begun in 2000, is credited with cutting the number
of deaths by 25 percent at Sentara Norfolk General Hospital.
Staffed by a doctor, a critical care nurse and assistants,
the eICU is open from noon to 7 a.m., when doctors aren’t
typically in the ICU. The team gets real-time data on
dozens of patients and can change treatment as soon
as is needed. The attention helps — patients on
ventilators, for example, risk developing pneumonia
if they’re on too long. In traditional ICUs, patients
are weaned off the ventilator only while a physician
is on hand to monitor. “You want them on there
as long as they need, but not a minute more,” says
Yates.
Sentara’s
push to improve the quality of care in its ICUs is part
of an industry wide initiative that has its roots in
a 1999 report by the Institute of Medicine. That study
attributed up to 98,000 deaths in the U.S. annually
to medical errors. Today, hospitals are under pressure
to cut mistakes or risk losing accreditation from the
Joint Commission on Accreditation of Healthcare Organizations.
Virginia’s hospitals have done relatively well
in quality of care initiatives. The state was ranked
11th in the nation in hospital quality in a recent study,
and a number of new quality-of-care initiatives are
underway at hospitals across the state.
Besides
its eICU, Sentara has scattered pharmacists throughout
the hospital and linked them with a computer network
that tracks patient medications. The system software
helps avoid mistakes such as incorrect dosages. “The
alerts from this system go off more than 1,000 times
each month,” says Yates. That doesn’t mean
there were 1,000 errors, but the software can flag potential
problems or list options. “It helps us identify
situations where we can avoid harm to patients,”
he says.
Tracking
medication is the goal of a new system at Retreat Hospital
in Richmond, which has implemented a bar coding system
to reduce medication errors. Nurses can double check
medications before giving them to patients by scanning
the patient’s wristband, with its unique bar code
and the matching bar coded medicine packets. The time,
dosage and person administering the medication are automatically
entered into a laptop computer the nurse keeps on a
cart, says Lori White, Retreat’s accreditation
coordinator. “It also allows nurses to spend more
time on patient care than on paperwork,” she says.
At
two Carilion Health System hospitals in Roanoke, they’ve
taken the bar-coding approach a step further. Nurses
use wireless scanners to track patient medications and
care, says Eric Earnhart, hospital spokesman. And at
Carilion’s Roanoke Memorial Hospital, a new seven-story
wing called Mountain Pav-ilion opened last month with
an entirely different design from the traditional long
hospital corridors and central nursing station. Four
rooms are clustered in a pod and served by a small but
fully stocked nurses’ station. “The patient
sees the nurse more often, the supplies are right there
and with the wireless bar coding technology, she no
longer has to go back to the nurses’ station to
enter data in the terminal. We’re combining technology
and architecture to bring improvement to the critical
care setting,” Earnhart says.
The
new wing will also have six “smart ORs,” which
use voice recognition software so a surgeon can control
lighting and some equipment through voice commands.
“It frees up the nursing staff and decreases the
actual time of surgery by 15 percent. In a long surgery,
that’s significant. In all cases, it reduces the
amount of time a patient is under anesthesia,”
Earnhart says. Plus, there’s the efficiency of
being able to use that operating room for additional
cases each day. That kind of clinical efficiency offsets
some of the investment in the technology, he says.
While
saving lives and speeding recovery are the main goals,
the technology to support quality initiatives can be
expensive. That’s why Anthem Blue Cross Blue Shield
introduced a new program called Quality-In-Sights Hospital
Incentive Program (Q-HIP). Hospitals that score at least
90 percent on a 100-point rating scale can receive a
one percent higher reimbursement from the insurance
company. Patient safety improvements, measurable improvements
in health outcomes and, to a lesser degree, patient
satisfaction, determine the scoring.
Dr.
Dick Grinnan, who developed the system at Anthem, says
the incentive of a higher reimbursement is needed. “Hospitals
are under a lot of pressure to improve quality and safety.
We also know they are struggling with infrastructure.”
So the program offered enticements that would help not
only Anthem members, but also the hospital overall.
Dr. Randy Axelrod, Anthem’s chief medical officer,
says if hospitals have to “start from scratch”
by putting in computers for doctors to enter lab, test
and medication orders, and integrate that data into
the hospital’s lab system, “it will run into
the tens of millions of dollars. Hospitals understand
it’s imperative they look at this, but they needed
a nudge to get going.” Since Anthem’s program
started in July, 16 hospitals in Virginia have signed
on.
Health
plans are well suited to contribute to the body of data
needed in evidence-based health care, says Joy M. Lombard,
director of policy for the Virginia Association of Health
Plans. She notes that the vast majority of health plans
already have systems for collecting data and evaluating
medical errors and patient safety concerns. Ditto for
medication safety practices to avoid medical errors
and pharmacy data to determine which patients could
benefit most from disease management programs.
That
data can help create strategies that are less expensive
and can be easily implemented. Retreat Hospital, for
example, was the first hospital in the Richmond area
to use the American Heart Association’s “Get
With the Guidelines” program. Doctors get data
showing how well they perform the recommended treatments
for heart patients and can compare themselves to colleagues.
Sarah Golightly, cardiac rehabilitative services coordinator,
says by documenting that each cardiac patient receives
full care and education, the hospital expects to see
fewer patients return. Heart failure is a chronic disease
that can be managed, she says. But patients must be
educated in danger signs and what they can do to improve
their own health.
Some
initiatives extend beyond the hospital. For example,
Inova Health Systems in Northern Virginia started Operation
Stroke four years ago, says Peggy Cressy, a director
of community health for Inova. The program includes
an intensive community education campaign, education
and awareness for emergency services workers and a system
wide initiative to improve care in its four hospitals
that care for adult patients. Now, Inova Alexandria
Hospital has a separate stroke unit and Inova Fairfax
Hospital has a medical stroke director. Stroke patients
are now leaving Inova hospitals sooner, on average,
and there are fewer complications. The community education
portion has also been effective, says Cressy. In 2000,
only 59 percent of the people surveyed knew what the
signs and symptoms of stroke were — or realized
that it was a medical emergency requiring a 911 call.
Eighteen months after the program began, the number
increased to 70 percent. The challenge for the health
system now is how to institutionalize the progress it
has made “so that it is entrenched,” she says.
Some
strategies seem remarkably simple, but making them part
of everyone’s actions, every day is not. Sentara
has teamed up with Performance Improvement International,
an organization that has provided workplace safety programs
to nuclear power and aviation industries, says Dr. Yates.
“We’re trying to apply some of the concepts
that they have found to be successful there. For example,
if the listener repeats back, ‘Here’s what
I heard you say,’ and the first person confirms
that, it decreases the chance of an error from occurring.”
Deborah
Mobley, past president of the Virginia Association of
Healthcare Quality, says that a culture of safety goes
hand in hand with health care. “Deep down inside,
every health care provider comes to work to make a difference,”
she says. While hospitals can quantify some of the factors
— shorter hospital stays or fewer medication mistakes
— the one that counts is hardest to measure. A
saved life? Priceless.
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