Perspectives

As seen in Patient Safety and Quality Healthcare.

In April, Patient Safety and Quality Healthcare published an article summarizing a recent webinar presented through our Center for Safety and Clinical Excellence. The article is titled “Smart Pump Workarounds – What’s the Legal Risk?”, and it focuses on personal accountability on the part of caregivers in safely operating Smart IV pumps.  

Caregiver accountability has been a hot topic in recent months. As it relates to IV medication safety, it’s a critical issue and worth paying attention to. It’s been shown that clinicians often implement process workarounds, including not utilizing the drug library, overriding soft dose and concentration alerts, reprogramming infusions as rate in ml/hr following hard limits, and occasionally removing IV tubing from pumps and delivering medication boluses by gravity to avoid a high dose alert.  Although no formal study to date has explored the reasons for non-compliance, there are many potential contributing factors, including time, the belief among some caregivers that they do not make mistakes, alert settings that may not be consistent with current medication practices, and administration practices that are outside established hospital policies. 

Regardless of the reasons why, it’s become clear that compliant use of medication safety technologies varies within and between hospitals. But, when you combine high-risk IV medications and the frequency of programming errors, anything less than full compliance is a patient safety risk.  Lately, there’s been an increased focus on the “second victim” of medical errors—the clinician. In an earlier webinar and a recent Perspectives blog, we discussed the case of Eric Cropp, a pharmacist who served jail time after missing a medication error that ultimately took the life of two-year-old Emily Jerry. Eric did not have access to a technology solution that could have helped identify and prevent the compounding error. But, in cases where caregivers have a choice and choose to work around best practice and compliance guidelines, the concept of the second victim takes on a whole new meaning.

This topic brought me back to a familiar line from Hill Street Blues—one of my all-time favorite TV series. Based on a New York police department, each show began with Michael Conrad reminding his police force, “Let’s be careful out there!” Great advice for all of us.

As seen in Infection Control Today.

For the past 20 years I have attended many conferences, both national and international, on the topic of healthcare-associated infections (HAIs). The fundamental debate still continues, however, as to the actual frequency of HAIs. Most infectious disease physicians, infection preventionists and epidemiologists agree that HAIs are under-reported. Why? Could it be in the way we conduct our surveillance?

Today, most HAI surveillance is passive, relying on data retrospectively gathered from medical records. Conversely, active surveillance involves prospective steps to identify patients who have or who may develop HAIs, using standardized definitions of infection, pre-determined criteria, and protocols that result in risk-adjusted HAI incidence rates.

Implementing and maintaining an active surveillance system requires personnel and financial resources, and so it’s often crucial to justify the investment with improved patient outcomes. Outcomes may then be used to develop targeted intervention programs. At a high level:

• Active surveillance may be most directly associated with monitoring and controlling the risk of outbreaks of drug-resistant pathogens, such as methicillin-resistant Staphylococcus aureus (MRSA).
• Increasingly, active surveillance has been used to identify patients at high risk for infections associated with surgery and hospitalization in intensive care units (ICUs). 

Here are several more detailed examples of published outcomes from active surveillance programs:

 
Active surveillance to decrease MRSA isolates
Healthcare institutions are acutely aware of the rise in drug-resistant pathogens. In 1980, MRSA accounted for about 2 percent of all S. aureus HAIs. By 2006, it accounted for more than 60 percent.¹ In response, some hospitals initiated active surveillance testing of patients considered high-risk for active MRSA infections or colonization. One hospital system using passive and ICU-targeted surveillance recorded no change in MRSA isolates over a three-year period. They implemented an active surveillance program to universally screen all patients upon admission for nasal colonization with MRSA.² Patients found to be colonized received treatment with mupirocin nasal ointment and periodic bathing with antisepsis soap. For each year after initiation of active universal screening, the hospital recorded decreases in MRSA and total S. aureus clinical isolates compared to each of the prior three years of passive surveillance (P < 0.0001). The author of this study suggests that the decrease in MRSA isolates correlates with decreased disease.
Active surveillance to decrease surgical site infections
Active surveillance may be particularly useful in identifying surgical site infections (SSIs), which can develop up to 30 days after a patient is discharged. In one study of SSI rates identified passively by neurosurgeons,surgeons missed 36 percent of SSIs using passive surveillance, as evidenced by results from active surveillance performed by infection control professionals.³ Under-reporting HAIs with passive surveillance has been shown to be more likely among certain types of surgical patients during the post-discharge period. In a Dutch study of post-discharge SSI rates for various surgeries, more SSIs were identified with a recommended active surveillance protocol (43 percent) than with passive surveillance (25 percent).⁴  This study also demonstrated that for common surgeries including appendectomy, knee prosthesis surgery, mastectomy and hysterectomy, most SSIs developed after discharge and were underestimated when passive surveillance was used.

 
Active surveillance of device-associated infections
Patients at risk for device-associated infections such as catheter-associated urinary tract infections (CAUTIs) and ventilator-associated pneumonia (VAP) may benefit from active surveillance designed to identify risk factors that are unique to a particular patient population or hospital unit. An active surveillance program undertaken at Alexandria University Hospital in Egypt included an objective to identify etiologic and antibiotic resistance patterns associated with CAUTIs in the facility’s four ICUs.⁵ During a 13-month study period, 757 patients in the ICU who had existing urinary catheters or who were catheterized after ICU admission were monitored. The overall infection rate was 15.7 CAUTIs per 1,000 catheter days, with the following risk factors identified:

• Female gender
• Previous catheterization within the same hospital admission
• Admission to the chest unit
• Patient age 40 or older
• Prolonged duration of catheterization
• Prolonged hospital and ICU stay

In addition, the pathogen profile was identified, including Candida (51 percent), Gram-negative pathogens (33.5 percent), and Gram-positive organisms (15.4 percent). The prevalence of extended-spectrum beta-lactamase-producing organisms included E. coli (78.6 percent) and K. pneumoniae (56 percent). Investigators concluded that existing infection control policies were inadequate, and a tailored intervention to address these specific risk factors and microorganisms is now being designed.

Active surveillance was also used to guide evidence-based VAP prevention strategies in one tertiary medical-surgical trauma ICU in Saudi Arabia.⁶ VAP cases were diagnosed according to predefined criteria, and VAP microbiology, risk factors, and outcomes were recorded. The intervention program resulted in a decrease in VAP infection from 19.1 to 6.3 per 1,000 ventilator days from 2003 to 2009.  Active surveillance identified the following risk factors for VAP:

• Accidental extubation
• Trauma versus medical diagnosis
• Chronic obstructive pulmonary disease
• Neuromuscular blockade

The most common isolated pathogens were Gram-negative organisms. Investigators realized a reduction in VAP rates with active surveillance, reporting, and evidence-based preventive strategies and identified modifiable risk factors to be included in additional interventions.
Of note, another active surveillance testing program designed to identify MRSA colonization and institute contact isolation of affected patients in two Michigan hospitals also resulted in a decrease in VAP in both hospitals, although MRSA infection decreased in only one hospital.⁷ The investigators concluded that active surveillance testing with contact precautions was effective in reducing both VAP and MRSA in their facilities.
Economic consequences of surveillance
These studies are just a few examples of successful active surveillance programs that resulted in reduced infection rates. But even if active surveillance is shown to improve patient outcomes, are we prepared to actively capture HAI data? I would speculate that many institutions are not. A common objection to implementing active surveillance is the cost of labor and economic resources, particularly during a time when healthcare institutions are under pressure to reduce the cost of care. Those providers who are not taking steps to lower the risk and incidence of HAIs, however, may be taking an even greater financial risk.  Extended lengths of stay, antibiotic days, and readmissions are costly and create longer-term economic pressure. In a study by Dimick et al. (2004), median total hospital costs for patients with and without post-operative infection alone were $13,083 vs. $ 5,044, a statistically significant result.⁸

The difference between passive and active surveillance may seem like an academic debate among infection control professionals, but the consequences in terms of patient morbidity and costs of care are real and affect everyone. 

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References

1. Hall G, Flayhart D. Active surveillance culture as a promising new tool. Infection Control Today. Available at: http://www.infectioncontroltoday.com/articles/2006/02/approaches-to-infection-control.aspx. Accessed on February 15, 2012.
2. Hacek DM, Paule SM, Thomson RB Jr, Robicsek A, Peterson LR. Implementation of a universal admission surveillance and decolonization program for methicillin-resistant staphylococcus aureus (MRSA) reduces the number of MRSA and total number of S. aureus isolates reported by the clinical laboratory. J Clin Microbiol. 2009;47:3749-52.
3. Heipel D, Ober JF, Edmond MB, Bearman GM. Surgical site infection surveillance for neurosurgical procedures: a comparison of passive surveillance by surgeons to active surveillance by infection control professionals. Am J Infect Control. 2007;35:200-2.
4. Manniën J, Wille JC, Snoeren RLMM, van den Hof S. Impact of postdischarge surveillance on surgical site infection rates for several surgical procedures: results from the Nosocomial Surveillance Network in The Netherlands. Infect Control Hosp Epidemiol. 2006:27:809-16.
5. Talaat M, Hafez S, Saied T, et al. Surveillance of catheter-associated urinary tract infection in 4 intensive care units at Alexandria university hospitals in Egypt. Am J Infect Control. 2010;38:222-8.
6. Al-Dorzi HM, El-Saed A, Rishu AH, et al. The results of a 6-year epidemiologic surveillance for ventilator-associated pneumonia at a tertiary care intensive care unit in Saudi Arabia. Am J Infect Control. 2012. [Epub ahead of print]
7. Martinez-Capolino C, Reyes K, Johnson L, et al. Impact of active surveillance on meticillin-resistant Staphylococcus aureus transmission and hospital resource utilisation. J Hosp Infect. 2010;74(3):232-7. 
8. Dimick JB, Chen SL, Taheri PA, Henderson WG, Khuri SF, Campbell DA Jr. Hospital costs associated with surgical complications: a report from the private-sector National Surgical Quality Improvement Program. J Am Coll Surg. 2004;199:531-7.

As seen in Surgical Products magazine and TechNation.

Recently, on our way to a morning meeting, Dr. Carlos Nunez and I got to talking about model railroads – a mutual interest and hobby. We recounted the history of Digital Command Control [DCC] – a system that utilizes digital computer technology to operate model railroad trains. DCC was first introduced in the 1990s and dramatically changed model railroad technology: For the first time, when running multiple locomotives on the same track, you could move each train in different directions and at different speeds.

Similar to most technological breakthroughs, numerous manufacturers began engineering their own early and highly proprietary versions of Command Control for model railroads. While this brought the technology to the marketplace, it introduced a new problem for users as these early approaches were incompatible with one another. We could now run trains independently on a model railroad, but couldn’t take a locomotive to a friend’s house with a different system and expect it to run. 

Enter the National Model Railroad Association (NMRA) who assembled a working group to develop a common standard in model train technology. German firm Lenz Electronics gave – yes gave – their previously proprietary protocol to the NMRA to be adopted as a standard¹. Suddenly, in order to obtain the NMRA imprimatur, all manufacturers had to conform to single technical standard. Not only did the technology succeed but it literally exploded. It now supports amazing lighting effects, an array of advanced automation capabilities and even digital sound. Best of all, the technology is fully interoperable. Some firms chose not to adopt the common standard and eventually disappeared. But most of those who embraced the NMRA DCC standard continue to thrive today. 

It was at this point in our discussion that Carlos asked, “Where is the NMRA for healthcare?” Great question! Today, CMS is creating incentives for hospitals to adopt enhanced healthcare information technology (HIT), introducing new concepts and standards like “meaningful use.” But what is the future for widespread interoperability in healthcare and what will that journey require?

To me, one of the benefits to interoperability is that it changes the criteria for success from simply having the data to what can be accomplished with the data. It’s about transforming data into actionable information. Consider the following patient data elements: Age, obesity, bed rest, use of hormone replacement therapy or oral contraceptives, planned major surgery, known diagnosis of cancer, history of venous thromboembolism [VTE] and hypercoagulability. This data comes from varied sources – the ambulatory electronic medical record, the laboratory system, the admission diagnoses, the order entry system and the patient’s medication list.

But when you bring them all together, a score can be calculated, and if that score reaches four, a computer algorithm could search the order system for evidence of mechanical or pharmacological prophylactic measures to prevent venous thromboembolism. The absence of such prophylactic orders creates the opportunity for an electronic intervention in the form of a recommendation for VTE prophylaxis.

Several years ago, investigators at the Brigham and Women’s Hospital in Boston² set out to understand if such an intervention had quantifiable merit. They established a study, assigning patients to either the use of electronic alerts or to the conventional standard of care. The primary end point was deep-vein thrombosis [DVT] or pulmonary embolism [PE] in 90 days. The results were stunning. The algorithm reduced the risk of DVT or PE in 90 days by 41 percent. What’s even more impressive is that the prophylaxis compliance rate in the intervention group was only 33 percent. Of course, some of the cases had clear reasons not to anticoagulate, but that does not explain why mechanical measures were not employed. Better data always opens the door of opportunity, but that door will often have surprising new doors behind it. 

This year’s annual HIMSS conference continued to prioritize the importance of interoperability in the meaningful use era but at the same time balanced the magnitude of achieving interoperability as a challenge that faces the healthcare industry overall.  There’s no doubt that interoperability is a monumental goal for healthcare^3,4,5.  But, how is it going to happen; who’s going to lead the way, and when?

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References:

1)      Polesgrove M,DCC Projects and Applications. Kalmbach Publishing, 2006.

2)      Kucher N, Koo S, Quiroz R, Cooper JM, Paterno MD, Soukonnikov B, Goldhaber SZ. Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med. 2005 Mar 10;352(10):969-77.

3)      James B. E-health: steps on the road to interoperability. Health Aff (Millwood). 2005 Jan-Jun;Suppl Web Exclusives:W5-26-W5-30.

4)      Jha AK, DesRoches CM, Campbell EG, Donelan K, Rao SR, Ferris TG, Shields A, Rosenbaum S, Blumenthal D. Use of electronic health records in U.S. hospitals. N Engl J Med. 2009 Apr 16;360(16):1628-38.

5)      Kuo MH, Kushniruk AW, Borycki EM, Hsu CY, Lai CL. National strategies for health data interoperability. Stud Health Technol Inform. 2011;164:238-42.

As appeared in Healthcare Finance News , Healthcare Purchasing News blogline and Patient Safety & Quality Healthcare. 

A curious thing is happening.

As the health care conversation moved front and center over the last several years, a correlation developed linking cost and quality. Politicians and providers, payors and patients have embraced these complementary themes as the “one-two punch” that will win the fight to keep our health care system safe, solvent and sustainable. As far as punches go, it sounds almost painless: Make the system better and safer, and the savings will follow. Who would argue with that logic?

Now it seems that some prominent voices have started to pivot the conversation toward the need for greater cost control, suggesting that quality and safety efforts alone may not deliver the necessary savings. Recently, three opinion pieces appeared in the New England Journal of Medicine (NEJM) and the Journal of the American Medical Association (JAMA) that call into question some basic assumptions about the economics of our health care system. Another article, published in Healthcare Finance News, added a new sense of urgency to this pivot in opinion.

The first article, “Where are the Health Care Cost Savings?” appeared in the January “Viewpoint” section of JAMA. The author pokes some pretty big holes into several commonly held beliefs about the drivers of health care costs. He references a number of sources to make the case that defensive medicine, insurance and pharmaceutical profits, and the often heroic and expensive care doled out to a small percentage of patients, account for much less spending than what is generally assumed. His argument points to the 10 percent of the population that accounts for 64 percent of health care spending, driven largely by seven major categories of chronic disease conditions. This allows him to make a cost and quality connection, calling for continued efforts to reduce avoidable complications and improve tertiary prevention. The new message here is subtle, but real. His editorial is about putting cost first and about the fundamental changes that need to take place to get spending under control.

The second piece is not subtle at all. It appeared the same week as the JAMA article, in the “Perspectives” section of the NEJM. The title says it all: “The Savings Illusion — Why Clinical Quality Improvement Fails to Deliver Bottom-Line Results.” The authors question why costs continue to climb despite improved clinical quality. They suggest the explanation lies in the rigid cost structure common to most health care settings. The existing cost structure perpetuates a system whereby improvements in clinical quality typically lead to additional capacity requirements instead of bottom-line savings. The authors describe a four-layer cost structure where clinical improvements that help reduce truly variable costs, such as medications and supplies, generally lead to measurable savings. They argue that clinical improvements that reduce semi-variable costs (direct hourly personnel), semi-fixed costs (equipment, OR time), and fixed costs (administrative time) are increasingly less likely to yield true savings. They go on to say that “hospitals will need to adapt their cost structures and capacity to accommodate lower per capita utilization rates as well as reductions in the per-episode intensity of care.”

Just a few weeks later, the NEJM ran an article titled “What We Talk about When We Talk about Health Care Costs.” The author drew inspiration from the newly published ethics guidelines from the American College of Physicians that call for physicians to practice “parsimonious care.” He uses the word “parsimonious” to illustrate the difficulty of talking simply about health care costs. He displays no difficulty, however, when he writes, “The problem is that no one in charge seems willing to acknowledge that getting a handle on cost growth will also involve uncomfortable trade-offs. We cannot as a society provide patients with unlimited access and unlimited choice. Providing better quality care, though it is vital, won’t change that reality.”

Finally, we come to the article published in Healthcare Finance News that recapped an interview with Dr. Donald Berwick, the former administrator of the Centers for Medicare and Medicaid Services (CMS), and Gerry Shea, an executive with the AFL-CIO. The piece summarized the main themes from the interview in a list of “six things to know about the current state of America’s health care system.” What I found so interesting about this piece is that Berwick, long known as the standard bearer for quality and safety, and Shea, a powerful union leader, both agreed that the top six things we need to know about healthcare ALL had to do with the problem of cost. Here’s my summary of their list: (You can read their remarks here.)

• We must address health care costs with urgency and as a primary goal.
• The country cannot afford health care spending at current levels.
• The working class is affected most by rapidly rising costs.
• We need to bring the same commitment to lowering costs as we have to improving quality.
• Goals need to be set and increased focus needs to be put on costs.
• Quick, drastic measures will not deliver a long-term solution.

So, what does this all mean? Are we done pursuing quality and safety? Do we begin rationing care and denying services? I believe that the opinions expressed by these thought leaders, in the pages of some of the most respected medical publications, represent the beginning of an important next phase. As we work to remake our health care system into one that is safer and sustainable, we need to begin the conversations that will lead us through the tough choices and challenges and on to real opportunities for lasting change. We must reach past the low-hanging fruit to the real goal — doing what is best for patients. This means focusing our safety and quality efforts on areas where the potential to save lives and dollars is greatest, and to help adapt our systems to work well within a new economic reality that favors best practices, improved outcomes and patient and provider satisfaction. We need to acknowledge that no one can expect unlimited access to unlimited choices, without unlimited resources. If we do this, we can build a system that allows for appropriate access to the best choices, so that it performs better than ever, in a manner that is safe and sustainable, for generations to come.

As seen on HIStalk.com

Walking the aisles of the exhibit hall and participating in HISTalkapalooza at the world’s largest gathering of healthcare IT professionals and the companies that do business with them led to several interesting discoveries.  

All of the usual suspects were well represented in the exhibit hall (Epic, Cerner, GE, etc.), along with the expected collection of smaller IT vendors and specialty niche solutions (did you know that Rubbermaid makes hospital-grade computer carts?). And, of course, you found companies like IBM, Oracle and Microsoft that also play in this space.

Coming in to the meeting, it was expected that ICD-10 would be a big topic of focus, but with the recently announced delay in the implementation requirement, that story seemed less relevant. There was also the announcement  that the stage two requirements for Meaningful Use were ready to be published in the Federal Register, but likely wouldn’t be available until after HIMSS. The announcement was big news, but it came too late to have any discernible impact on the conference floor. Finally, the trend toward mobile devices and cloud-based solutions is still grabbing a great deal of attention and booth space.

The trend that was most interesting was the rise and growing prominence of companies exhibiting at HIMSS that – at first glance – may seem out of place. For example, I had a meeting with the folks from Lockheed Martin. Yes, the same Lockheed Martin that makes fighter planes and satellites also has a healthcare business and is now partnering with Johns Hopkins on a patient safety and quality initiative. One of the larger booths in the exhibit hall belonged to a collection of IT and benefits management businesses that were recently cobbled together by one of the major insurance companies. I guess it should come as no surprise that as the American healthcare system continues to grab more attention (and more dollars) than any other segment of the economy, businesses new and old would look for their place at the table.

This trend got me thinking about my own place at HIMSS, and more specifically, where CareFusion should be slotted in the spectrum of industry represented there. To the uninitiated, you might think that CareFusion belongs closer to the Rubbermaid end of the spectrum, especially if you only focus on the “things” that CareFusion makes. What do surgical instruments, infection prevention, or infusion pumps have to do with information technology? However, when you realize those “things” are key components in a portfolio of solutions, many of which are tied together by the very technology that defines HIMSS, you begin to see that CareFusion brings a unique perspective and vision to the HIT conversation.

What became vividly apparent this year at HIMSS is that Healthcare IT today, and the concept of Meaningful Use, is much more than an EMR. It is the information ecosystem that supports every patient encounter. It is the millions of clinical data points streaming from a ventilator or an infusion pump, into a server or into the cloud. It is a medication order entered in a CPOE system, tracked and secured through an automated pharmacy system, and the surveillance engine on a constant vigil for inappropriate medication dosing or signs of infection.  It is new technology designed to make devices and HIT systems talk to one another and provide critical patient data to caregivers when and where they need it, seamlessly across hospitals and systems.

Initiatives like Meaningful Use can sometimes make us forget that healthcare IT is more than just software or the systems we build to collect and store data; it’s how those systems enable us to convert data into useful information to help improve workflow, efficiency and patient safety. As many providers begin to focus on Stage 2 Meaningful Use requirements, broader concepts like interoperability and standardization will emerge as critical objectives in achieving the desired end goal.

Or, as ONC chief Farzad Mostashari, MD, asserted in his keynote speech at HIMSS, “we’re on the right track to make meaningful use of meaningful use.” What I saw and heard at HIMSS was a promising acknowledgement of our shared responsibility to improve healthcare. It’s a challenge that’s breaking down barriers between providers, suppliers and companies of all industries and competencies working to make a contribution. I was proud to represent a company bringing so many meaningful solutions to the table.