Dean's Newsletter

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Crossing the Quality Chasm at the School of Medicine and Dentistry

July 07, 2006

Consider the following recent clinical cases, which correspond to the six aims for health care quality promulgated by the Institute of Medicine's Committee on the Quality of Health Care in America:

An internist who was taking over the care of a patient while on call wrote a prescription for amoxicillin by electronic order entry. He was informed by the pharmacy that his patient was allergic to penicillin, and was able to change the antibiotic order before the patient received any amoxicillin.
A patient who was diagnosed with an early tubal ectopic pregnancy and referred for surgery was instead treated successfully with methotrexate.
A patient with urinary symptoms was found to have benign prostatic hypertrophy. Surgery could improve the symptoms significantly, but with the risk of reduced sexual functioning. He was counseled extensively, using evidence from the literature and local experience, and decided on a plan of "watchful waiting" rather than surgery.
A patient in an assisted living facility with severe osteoporosis slips in her bathroom, falls, and has severe lower back pain. She is seen the same day in the urgent care program of the musculoskeletal center. She is found to have a vertebral compression fracture and a plan of conservative management is developed with her and her family.
A patient develops a deep venous thrombosis (DVT) after a long car trip and is seen in the ED. Instead of being admitted to the hospital for several days of intravenous heparin, after a short observation she is discharged on subcutaneous low molecular weight heparin and oral Coumadin with close follow-up by a visiting nurse and her PCP.
A patient with acute asthma is seen in the Emergency Department and needs to be admitted to the hospital for further management. Although this patient has no health insurance, he is evaluated and treated by the same faculty hospitalist who cares for other patients in the hospital who have varying forms of insurance coverage--commercial, Medicaid and Medicare.

In 2001, the Institute of Medicine's Committee on the Quality of Health Care in America published a monograph entitled Crossing the Quality Chasm: A New Health System for the 21st Century. Although the Committee suggested that Americans "should be able to count on receiving care that meets their needs and is based on the best scientific knowledge," they concluded that this was "frequently not the case," and that the "American health care delivery system is in need of fundamental change."

Each of the bullet points above are favorable examples of the six general aims for improvement that the IOM Committee identified as important in addressing "key dimensions in which today's health care system functions at far lower levels than it can and should." Specifically, the Committee stated that health care should be:

Safe--avoiding injuries to patients from the care that is intended to help them.
Effective--providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit.
Patient-centered--providing care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions
Timely--reducing waits and sometimes harmful delays for both those who receive and those who give care.
Efficient--avoiding waste, including waste of equipment, supplies, ideas and energy.
Equitable--providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

Favorable examples notwithstanding, there is no doubt that there is significant opportunity for improvement in all of these aims at SMD and URMC, just as there are nationally. For the remainder of this newsletter, I will summarize the astonishing results of a national campaign to save lives by improving quality, and share a key role played by faculty and staff at Strong Memorial Hospital.

micu group

(From L. to R., seated): Robert Panzer, M.D., Michelle Bonyak, R.N., Barry A. Evans, R.N., M.S.N., C.N.S., Lucille Nelson, R.N., Timothy J. Kehl, R.N., M.S.N. Top Row: Kathy Doolin, R.N., Cherri Witscheber, R.N., Meg Gage, R.N., Michael J. Apostolakos, M.D., Emily Kate Ireland, R.N., Ann Peters, R.N., Mary Wicks, R.N., M.P.A.

In December, 2004, the Institute for Healthcare Improvement (IHI), headed by Donald Berwick, MD, launched the 100,000 Lives Campaign. Under the guiding principle that "some is not a number and soon is not a time," the Institute challenged U.S. hospitals to avoid 100,000 unnecessary deaths over 18 months--from January 2005 to June 2006. The Campaign sought to accomplish this ambitious goal by helping hospitals adopt six evidence-based interventions that are known to reduce harm and death when implemented reliably, interventions that fall squarely within the IOM aims for care that is "Safe" and "Effective":

Activate a Rapid Response Team at the first sign that a patient's condition is worsening and may lead to a more serious medical emergency.
Prevent patients from dying of heart attacks by delivering evidence-based care, such as appropriate administration of aspirin and beta-blockers to prevent further heart muscle damage.
Prevent medication errors by ensuring that accurate and continually updated lists of patients' medications are reviewed and reconciled during their hospital stay, particularly at transition points.
Prevent patients who are receiving medicines and fluids through central lines from developing infections by following five steps, including proper hand washing and cleaning the patient's skin.
Prevent patients undergoing surgery from developing infections by following a series of steps, including the timely administration of antibiotics.
Prevent patients on ventilators from developing pneumonia by following four steps, including raising the head of the patient's bed between 30 and 45 degrees.

The campaign defined a life saved as a patient who survived a hospital stay who would have died had he or she received that hospital's pre-campaign (2004) level of care. It calculated lives saved by comparing a hospital's mortality data for each month during the campaign with mortality data for the corresponding month in 2004. The monthly lives saved are aggregated across all months and all participating hospitals with an adjustment to account for changes in national risk of patient mortality between 2004 and the campaign period.

Dr. Berwick announced the national results of the Campaign, which surpassed its goals, on June 14th. "When we decided to launch the Campaign, we didn't know if hospitals could take on another challenge," said Dr. Berwick. "But they have risen to this challenge impressively. The participating hospitals have not only prevented an estimated 122,300 unnecessary deaths, but they've also proven that it's possible for the health care community to come together voluntarily to rapidly make significant changes in patient care. I have never before witnessed such widespread collaboration and commitment on the part of health care leaders and front-line staff to moving the system giant steps forward."

At Strong Memorial Hospital, Michael J. Apostolakos, M.D., Associate Professor of Medicine and Director of Adult Critical Care and the Medical Intensive Care Unit (MICU), played a key role in the sixth intervention, reduction of ventilator associated pneumonia. Together with Nursing leaders such as Mary Wicks, then nurse manager for the MICU, in late 2002 Mike led a team from SMH that joined the Critical Care Collaborative within the IHI's newly created "IMPACT Network". One of the key interventions in this collaborative was implementing a "bundle" of interventions for patients on ventilators.

As background, ventilator associated pneumonia (VAP) refers to pneumonia developing in a mechanically ventilated patient more than 48 hours after intubation. VAP prolongs mechanical ventilation, ICU stays and post-ICU hospital stays, and increases the cost per patient by at least $20,000. It has an attributable mortality estimated to be 20-33% and in one study accounted for about 60% of all deaths due to hospital-associated infections.

The IHI collaborative leaders asked: What if a series of simple interventions, readily available in hospitals, could reduce the risk of VAP? Moreover, what if all of those interventions were done all of the time on each patient? The result, they surmised, would be reduced morbidity and mortality, reduced cost, and an overall improvement in the satisfaction level of families, nursing staff and physicians.

Based on this premise, in late 2002 the SMH MICU began to implement the "Ventilator Bundle," a package of evidence-based interventions to reduce VAP. Elements of the Ventilator Bundle include: elevation of the head of the bed to between 30 and 45 degrees, meticulous oral care, daily "sedation vacation," daily assessment of readiness to extubate, peptic ulcer disease prophylaxis, and deep vein thrombosis prophylaxis. Implementation commenced in December, 2002, and full implementation was complete by April, 2004.

The results showed that, when implemented together for all patients on mechanical ventilation, the Ventilator Bundle resulted in dramatic reductions in the incidence of VAP at SMH. SMH was one of the first hospitals in the US to show that the reduction was dramatic, and far beyond what any of the experts had predicted.

The frequency of VAP in the MICU declined from a relatively constant rate of about 6% in 2002 (already better than the national estimate of 10-15%), to virtually 0% since September, 2003 (just one case at the end of 2004 and one case in mid-2005). This translated to an estimated reduction in MICU VAP cases by 27.5 per year. With a conservative excess mortality estimate of 20%, the estimated savings in lives is 5 per year from this one intervention in one ICU. Length of stay in the MICU has been reduced from an average of 7.5 days to 6 days, allowing 220 more patients per year in need of ICU care to have ready access to such care, and reducing the cost of ICU care by over $3 million. The other SMH ICU's have since begun implementing the same "bundle" with similar results beginning to appear. Based on its success in reducing VAP, the SMH MICU received a NYS Department of Health "Patient Safety Award" in 2005.

Dr. Robert Panzer, Professor of Medicine and of Community & Preventive Medicine, and the Medical Center's Chief Quality Officer, points out that "to achieve the best results for our patients, we need to become highly reliable in providing all of the care they need, relying on the best research about what works and what doesn't work." He reminds us that SMH was one of the first hospitals in the US to begin working closely with IHI's leaders, from their beginning work on health care quality improvement in 1987. The role of the SMH MICU in being one of the first to reliably implement and thereby discover the true effectiveness of the Ventilator Bundle continues SMH's leadership role in the quality improvement movement.

Quality improvement experts such as Dr. Berwick point out that "Every system is perfectly 'designed' to achieve exactly the results that are actually observed." Therefore, if we wish to improve our results, it's not good enough to work harder using the existing design--our faculty and staff work plenty hard in the system in which they find themselves. Rather, we need to re-design systems of providing care, as was done with VAP, to deliver sustainable results.

None of us wish to accept as inevitable any patient care system that reduces the likelihood of safe, effective, patient-centered, timely, efficient and equitable care. Instead, we need to design in quality and reliability and design out delays and mistakes waiting to happen.

Here's a challenge: think of a patient care process in your area that adversely impacts on one or many of the six IOM Quality Committee aims, and propose a process re-engineering that will lead to improved quality and reduced cost. I can assure you that such proposals will receive a hearing and their authors will receive feedback. Maybe the next Ventilator Bundle will emerge from this challenge!

Meliora,

David S. Guzick, MD, PhD
Dean, School of Medicine and Dentistry