Hospitals Focus on Doing No Harm

Fixes looks at solutions to social problems and why they work.

Second of two articles. Read the first.

Last week, I reported on the problem of preventable harm in hospitals. It has been estimated that each year between 98,000 and 440,000 people die as a result of preventable errors in hospital. Many readers wrote in with comments about family members who were victims of flawed care. They revealed a sense of betrayal and hurt. How could hospitals — institutions we turn to for comfort when we are most vulnerable — so often increase pain and suffering?

It’s natural to seek to assign blame when harm occurs. But patient safety experts say that medical errors are more a function of faulty systems than faulty people. In recent years, with leadership from the Institute for Healthcare Improvement, the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine, federal programs like the Partnership for Patients and many others, numerous hospitals have made focused efforts to reduce harm. Here’s a look at some of them.

Reducing hospital-acquired infections
About one in 25 patients contracts an infection in the hospital, resulting in 75,000 deaths each year, but hospitals have been cutting this risk by adhering to stricter protocols. The most basic is getting hospital staff members to wash their hands before touching patients. More than 160 years after Florence Nightingale cut the death rate by 95 percent in British military hospitals in Crimea largely by improving hygiene, hand washing remains inconsistent in American hospitals. It’s the most important cause of hospital-acquired infections. Without reminders and watchdogging, hospital workers forget to wash their hands most of the time before they touch patients.

My colleague Tina Rosenberg has reported on ways that hospitals are attacking the problem, including using video cameras, placing sinks in standard locations and installing sensors. Many hospitals also have prioritized hygiene around critical procedures like the insertion of catheters into major arteries or veins. Over the past four years, Ascension Health, the largest nonprofit health system in the United States, has halved its rate of bloodstream infections associated with these central line catheterizations, says Ann Hendrich, a registered nurse who heads Ascension’s quality and patient safety efforts.

Ascension Health created local patient safety teams, examined current practices, compared them with recommended practices, and brought teams together to agree on standardized “bundles” (sets of steps) — including things like how often to change a central line and how to dress it. It also instituted common standards for tracking infections, said Hendrich. Staff at Ascension Health facilities now avoid needless catheterizations and act quickly to remove them at the earliest possible moments.

One area where hospitals have struggled to cut infection rates is surgery. Part of the problem is that numerous factors contribute to infections there. Working with the Institute for Healthcare Improvement over the past four years, Orlando Health, which operates seven hospitals in the Orlando, Fla., area, has reduced deaths from incidents of patient harm by 44 percent.

Orlando Health, however, has struggled with surgical site infections. “The rate was staying flat,” explained Thomas Kelley, chief of quality and clinical transformation for the network. “So we dug deeply and created a comprehensive response. There’s no single magic bullet.”

They let surgeons know their own rates of infection and how they compared with those of peers and national benchmarks. “It had a profound impact,” said Kelley. Instead of having to impose changes, he said, surgeons came to him asking: “What should I be doing differently?”

They began limiting entrances and exits to operating rooms and stopped surgical teams from bringing in backpacks, cellphones or external scrubs; became more careful about the timely administration of antibiotics; paid more attention pre-admission to blood sugar levels, which can increase infection risks even for non-diabetic patients; and began using ultraviolet disinfection in operating rooms. The changes led in 2015 to a 21 percent reduction in surgical site infections, Kelley said.

(For more solutions, see this highly practical book: Preventing Hospital Infections.)

Preventing pressure ulcers
Confined to beds, hospital patients run the risk of developing pressure ulcers, which can lead to life-threatening infections. Risks are exacerbated if patients don’t eat or drink enough, if their skin remains wet for extended periods, or if medical devices continually rest on the skin.

There’s no mystery to preventing pressure ulcers: it requires regular skin inspections and attention to hygiene, incontinence, nutrition and dehydration. Pressure ulcers can develop in as little as two hours, so the challenge is staying vigilant. When hospitals make it a priority, they see changes. The Minnesota Hospital Association reduced pressure ulcers by 40 percent with a coordinated approach. Hospitals in Pennsylvania have reported important progress, and Ascension Health, which has been focusing on this problem since 2003, reports that its rate of hospital acquired pressure ulcers is less than one-fifteenth the national average (pdf).

Preventing blood clots
Another risk associated with immobility is blood clots. Hospitals routinely screen patients — then fail to start treatment fast enough to prevent clots. Orlando Health has shifted its approach. Previously, nurses did an initial assessment, then waited for a physician to decide on treatment. Now physicians assess blood clot risks when they enter admission orders. “We created a hard stop in the medical record,” said Kelley. “They can’t go forward until that risk is assessed.” From 2011 to 2015, Orlando Health saw a 32 percent decrease in patients who developed a blood clot while in the hospital.

Early detection of sepsis
One of the most deadly infections is sepsis, which accounts for a quarter of hospital deaths. Each year 750,000 patients in the United States develop sepsis and 220,000 die. It’s the most expensive condition to treat in hospitals. Sepsis, which causes blood vessels to leak fluid, can cause organs to shut down and send the body into shock. It’s particularly dangerous for children. Doctors in busy emergency rooms can miss an early diagnosis of sepsis, which can be mistaken for a lower grade infection.

Treating sepsis early saves lives. Northwell Health, which operates a network of hospitals in New York City and Long Island, reports that its mortality rate from severe sepsis declined by more than 50 percent from 2009 to 2014. Now, when a patient comes into the hospital, staff members are on alert for signs including low blood pressure, high heart and respiratory rates, and high or low body temperature. “The combination of several of these factors causes a Code Sepsis,” explained Mark P. Jarrett, Northwell Health’s chief quality officer. The hospital will start the patient on fluids, rush a blood test, and perhaps start antibiotics. “Time is really of the essence. If it turns out they don’t have septic shock, you’re not going to worsen things by being more aggressive.”

In recent years, the Washington State Hospital Association has also attacked sepsis. Carol Wagner, the senior vice president for patient safety, reports that between 2011 and 2014, state hospitals saw a 36 percent reduction in severe sepsis and septic shock compared with the 2010 rate. The hospital association estimates that this reduction has saved 3,600 lives.

Preventing injuries from falls
For elderly patients, the most important daily risk is falling. It’s impossible to prevent all falls, but precautions can reduce the likelihood of serious fall injuries, especially hip fractures. Since the Department of Veterans Affairs introduced a fall-prevention initiative in 2005, it has seen a 40 percent decrease in hip fracture rates.

The medical profession distinguishes falls based on the cause: accidents (because of an unsafe environment), anticipated physiological falls (associated with a known health condition) and unanticipated physiological falls (from sudden events, like a heart attack or stroke). Many hospitals focus on the environment, eliminating slippery or trip-prone surfaces, placing grab bars or walking aids within reach, and keeping beds and chairs at the right height. But most can do more to prevent anticipated falls. “Our approach has been to identify risk factors for patients, mitigate if treatable, or compensate,” said Patricia Quigley, associate director of the patient safety center of inquiry for the V.A.’s Sunshine Healthcare Network.

Many elderly people have poor sensation in their feet. Better management of diabetes, and exercise, can improve this. Good rubber-soled shoes with closed heels and toes are important, says Quigley. (Tennis shoes are ideal.) Elderly patients often experience a dizzying drop in blood pressure when they stand up. Cutting back on diuretics, giving fluids, or modifying other medications, can help. For stroke patients, it’s important to get out of bed from the “safe exit side.” Gerontologists know these things; but, as with hand washing, the challenge is getting patients, hospital staff and families to remember them. “For us, the primary outcome has been reducing injury from falls,” says Quigley.

More From Fixes

Read previous contributions to this series.

Culture change
There are many other ways that hospitals are working to improve care: reducing the risks of harmful reactions to medications; stopping early elective deliveries; identifying clinical deterioration promptly in child patients (watch this speech by Dr. Steven Meuthing of the Cincinnati Children’s Hospital); and coordinating post-discharge transitions with families and primary care doctors.

Some hospitals even extend the concept of preventable harm beyond the physical. Beth Israel Deaconess Medical Center, in Boston, tries to limit harm to respect or dignity. When patients receive unwanted or unwarranted end of life care, treatments can diminish their quality of life — or even shorten life.

Successful change often boils down to a few key factors. Peter Pronovost, who directs the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine, points to four common elements: hospital leaders declare ambitious goals, establish structures devoted to quality improvement, engage front line clinicians in peer learning communities, and transparently report results and hold people accountable.

There are different ways to systematize improvement. Ascension Health employs a dyad structure, with doctors and nurses co-leading the organization from the top down. The Greater Baltimore Medical Center employs “Lean Daily Management” to identify problems, come up with solutions, and standardize practices. Each morning at 9, hospital leaders discuss progress in key improvement areas and visit units to speak with front-line staff members. “Our goal is to say thank you and to ask if they have what they need to get the job done, said John B. Chessare, the center’s chief executive. “It’s been a great change to create an organization of focused problem solvers.”

Hospital cultures must support these changes. Nurses have to feel comfortable correcting doctors without fear of reprisal. Patients and family members should be engaged in care, to watch for problems or alert staff members when they notice changes in patients. Above all, doctors need to become more comfortable talking about mistakes. There’s a policy implication: government reporting requirements should penalize physicians for reckless behavior, but not honest human errors.

“The ultimate goal is to create a culture of learning, transparency and improvement,” says Timothy McDonald, a national patient safety expert who is chairman of the department of anesthesia at Sidra Medical and Research Center in Qatar. McDonald advocates an approach to patient harm that involves open and honest communication between care providers and patients and families, including emotional support, candid apologies and appropriate compensation when inappropriate care has hurt them. “That’s the transformation that’s essential to medicine becoming highly reliable.” (pdf)

I’ll continue to report on this issue, so please write in with ideas or personal experiences.

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