Ana Gutierrez was a 52-year-old Hispanic woman who presented to a teaching hospital emergency department (ED) with abdominal pain and a fever. She spoke little English. The emergency medicine...
Ana Gutierrez* was a 52-year-old Hispanic woman who presented to a teaching hospital emergency department (ED) with abdominal pain and a fever. She spoke little English. The emergency medicine resident noted a prior nephrectomy some years ago, which along with a history of diabetes, left her with chronic renal insufficiency. These facts were noted in her chart.Gutierrez’s evaluation was discussed with the resident’s attending; given her elevated creatinine of 2.1, a noncontrast CT scan of the abdomen was ordered. It was understood that this may not have been the best imaging modality; however, an IV contrast study in someone with a marginally functioning solitary kidney was felt to be too risky when balanced against the additional information it may have yielded.
Another female patient in the hospital had a different clinical picture, and an abdominal CT with IV contrast was ordered. Both patients were called for their studies at the same time. Gutierrez was mistakenly given a bolus of contrast media before having her scan. As it turned out, her renal function remained unchanged and she experienced no ill effects from the error. These events are significant not because they could have ended disastrously in renal failure, but rather because of their banality: there were no deaths, no lawsuits, and no anguished media-wide indictments of the safety of our healthcare system. It was simply one of many dodged bullets experienced in hospitals worldwide every minute of every day.
The Impetus for Improving Hospital Safety
Experts have long been aware of the problem of hospital misses and near-misses, but when the Institute of Medicine (IOM) published To Err is Human in 1999, patient safety acquired a dramatic notoriety. Relying on data from two studies on medical error-related deaths and extrapolating from national hospital admission statistics, the IOM estimated that between 44,000 and 98,000 such deaths occur each year.
The original studies’ methods have been criticized, yet the IOM’s conclusion that large numbers of hospital patients are killed or injured from mistakes is inescapable. The importance of its report was not so much the number, but rather the consciousness-raising that followed. Almost overnight, patient safety was burned into the public psyche. Headlines trumpeted the “jumbo jet a day” of lives lost. Hospitalists, who specialize in inpatient care, have been among those leading the way toward improving safety. Robert M. Wachter, MD, Chief of the Division of Hospital Medicine at the University of California — San Francisco (UCSF), is an expert in both hospital medicine and patient safety, and coined the term “hospitalist” in a 1996 article for the New England Journal of Medicine. He edits the widely used textbook Hospital Medicine and is also co-author of the New York Times bestseller, Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes.
He describes hospitalists’ involvement this way: “As a field, we have positioned ourselves and really branded ourselves as having two patients: the individual in front of you and this sick building that we work in. Our jobs are to make both of them healthier.”
A Culture of Safety
The IOM’s central message was the promotion of a “culture” of patient safety within hospitals. The importance of this concept cannot be overstated. All high-risk endeavors (eg, commercial aviation) must foster such a culture and balance it with their fundamental missions. Healthcare delivery is no exception. This culture must be inculcated in everyone from the hospital CEO down to the person delivering the meal trays. Edith Rodriguez died at California’s Martin Luther King Jr. — Harbor Hospital after writhing in pain on the floor of the ED lobby for 45 minutes with a perforated bowel. A triage nurse blamed for failing to help her was placed on leave and reported to the state nursing board. Yet under this new paradigm, the real culprit in Rodriguez’s death was not a callous nurse but a failure of the hospital’s basic culture that permitted six other employees who, despite witnessing this patient’s plight, also did nothing.
An institution’s commitment to educate employees to find and communicate risky situations is one manifestation of a successful culture. There are others as well, such as the promotion of clinical pathways. Such pathways are a guideline derived by codifying the best evidence for the treatment of a disease. Several studies have demonstrated their benefit. Last year, a multi-hospital study involving nearly 65,000 patients revealed that for every 10% increase in compliance with guidelines for the treatment of acute coronary syndrome (ACS), there was a 10% decline in mortality. Such results
justify clinical pathways as well as the tracking of their use. In general, doctors resent having “big brother” supervising their decisions. However, standardization of patient care to improve outcomes is often sought by hospitalists—the doctors most affected by such policies. As beneficiaries of a hospital with good outcomes, hospitalists are invested in promoting quality care. Commercial pilots, when expressing their safety concerns, have pointed out that they’re the first ones at the scene of a crash; hospitalists can say much the same thing.
The Efficacy of the EMR
Wachter is emphatic about the benefits of the electronic medical record (EMR): “There’s no question that we have to computerize everything. Ten different people who are all in different places need to see the same data at the same time . Matters of efficiency, matters of setting limits on certain types of medicine, all that sort of stuff. It’s just impossible to even conceive of doing it without information technology.”
Access to legible patient data is only one aspect of the EMR. Computerized physician order entry (CPOE) is another highly desirable component. When the physician inputs orders for studies, medications, etc, there is less of a “signal drop-off ” than when clerks must enter this information from barely legible, handwritten instructions. Whether this translates into better outcomes hasn’t been established. Yet it is hard to imagine that “bypassing the middleman” doesn’t make good sense.
EMRs can also facilitate real-time decision support—for example, flagging potential drug allergies or drug—drug interactions as the physician is entering a medication order. Decision support has been built into EMRs to perform other tasks as well. A recent study tested whether software that flagged newly admitted patients at increased risk of thromboembolic events (TEEs) could improve outcomes. Half of such patients were randomized to having their high-risk status communicated by computer to their physicians, who could decide whether to use TEE prophylaxis. The other half’s high-risk status was not transmitted to their physicians.
The study group patients had a higher likelihood of being placed on TEE prophylaxis. More importantly, they experienced a 41% reduction in events. This type of intervention is almost impossible without EMRs. EMRs are not a panacea, however. At one university hospital, mortality in its pediatric ICU went up after an EMR was introduced. Ultimately, their implementation was noted to be faulty. Likewise, Cedars-Sinai Medical Center in Los Angeles had a poor experience with its $35 million EMR; the system was so unwieldy and time-consuming that the medical staff demanded it be jettisoned.
In fact, EMRs are enormously complex and expensive, with significant mythology surrounding them. “There’s been a lot of
magical thinking,” says Wachter. “You just computerize. It’s pretty easy. You spend a few bucks. You airlift in a computer. You turn it on and everything is better.” Th e reality is different: the system at Wachter’s institution will take years to fully implement and will cost $100 million. “In order to make these systems work better, you’ve got to go through a huge number of iterations that include user feedback and people screaming that this thing stinks,” he said.
Hospitals shouldn’t be deterred from embracing EMRs, however. “It’s very tough but that can’t mean that the answer is not to try,” Wachter said.
Rapid Response Teams
When an inpatient becomes catastrophically ill, a “code blue” is called, mobilizing a team of physicians, nurses, pharmacists, respiratory therapists, and others. Obviously, the costs of a code in terms of personnel can be great. Accordingly, hospital staff often don’t want to call codes for fear of crying wolf: some patients turn out to not be that ill. There are also situations in which a patient’s condition changes in ways that, although potentially serious, do not warrant such a high level of care.
Hospitals may help resolve these problems by using Rapid Response Teams (RRTs). A RRT is smaller than a code team and is often led by a trained nurse. A physician is usually available for phone consultation. Staff are encouraged to call for a RRT if the patient meets formal criteria or even if one has a mere suspicion that something is wrong. The benefit is a greater willingness to call for a RRT than a code team. No judgment is made of the person who makes that call. Also, a RRT might be called at an earlier stage in the patient’s “unstableness.” The team may intervene early in simple ways, like giving fluids or a respiratory treatment, and thus prevent a full code.
Although RRTs seem to make sense, their cost-effectiveness remains to be proven. Several small studies suggest that they improve outcomes, but the one large multi-center study performed to date showed no benefit. “The problems the RRTs were designed to fix are real,” says Wachter. “How can it be that a new system that helps identify deteriorating patients quickly and brings to bear previously unavailable resources to help fix the problem is not a good thing?” But, he continues, “Is the evidence strong enough that this should be a national standard, that every hospital should have a RRT? I believe the answer is no.”
Nevertheless, in December 2004, the influential Institute for Healthcare Improvement (IHI) designated RRTs as one of six interventions advocated by its 100,000 Lives campaign. The hope is that better implementation of RRTs will ultimately improve inpatient care and save lives.
Hospital-acquired infections (HAIs) are a safety issue that cannot be ignored. One estimate suggests that 2,000,000 such infections occur annually, costing some $4.5 billion. Of the six interventions recommended as national standards by the IHI, three address reducing HAIs.
In fact, the Centers for Disease Control (CDC) has demonstrated a decline in the rates of such infections. Given the higher acuity of inpatients compared to previous years, as well as the more extensive reporting that is now the norm, this trend can only be explained by changes in practice. Several interventions have been shown to work. In one multi-hospital study, a program involving staff education, monitoring, and feedback was instituted to promote five interventions to prevent central line infections (use of sterile barriers during insertion and prompt removal of unnecessary lines, for example). The results were dramatic. As Loren Miller, MD, Director of Harbor-UCLA Medical Center’s Infection Control Program, points out, “It is a radical change in thinking that an ICU or institution can have a catheter infection
rate of zero. At least in some centers, this was achieved.”
Miller suggests that simple things can be useful. “To get rid of bacteria on your hands, you’ll need to wash for 15 seconds with warm water and soap. If you do that between every patient, you’ll never have time to do anything else. Alcohol gel may be preferable because you need less time to use it. You can put it in more locations, so there’s less of a distance to walk. Also, you can carry it in your pocket.” “Another intervention that’s important,” Miller adds, “is empowering nurses to stop a procedure and say ‘Look, I saw you break sterile technique, and you have to start again.’ That’s a culture change, as physicians aren’t used to having nurses tell them what to do.”
In the field of infection control, it is axiomatic that a productive hospital culture is the key. “Technological changes probably have a modest impact on hospital infections, but changes in human behavior will have a much larger impact,” says Miller.
Are We Getting Safer?
Th e real question in patient safety is whether things have improved since the 1999 IOM report. We may never have a definitive answer. The original studies on medical errors would cost $50-100 million to repeat. Yet, it is clear that certain specific types of errors have declined. Also, processes leading to enhanced safety are being more broadly applied.
As Wachter speculates, “When you look at discrete areas like medication errors and you look at the processes now in place to prevent them, such as patient reconciliation… when you look at HAIs and you look at the markedly increased frequency of hand washing… and when you ask patients what it’s like to come into the hospital and have everybody who comes up to them ask them either for their name or their hospital number, in some ways, it defies logic to believe that all of these efforts are not bearing some fruit.”
When bearing fruit means saving thousands of lives annually, all any of us in healthcare can do is press on.
John S. Ford, MD, MPH, is a hospitalist and Assistant Professor of Medicine at David Geffen School of Medicine at UCLA.. He is also the founder of the medical blog California Medicine Man.
* The patient's name and details were altered to maintain confidentiality.