Wednesday, April 7, 2010

Trendspotter: Safety Procedures Known to Save Lives Are Not Being Used

By Ken Terry

Safety and quality checklists can save lives in hospitals, as a new British Medical Journal study reiterates. Yet only a fraction of U.S. hospitals are using the World Health Organization (WHO) surgical safety checklist, which was introduced here 15 months ago. And the Leapfrog Group, a public-private consortium that presses for quality improvement in hospitals, has found that a minority of hospitals adhere to nationally endorsed process measures that have been shown to reduce mortality.

Interestingly, the checklist approach does not require electronic health records. Both the WHO surgical safety checklist and the “care bundle” approach used in three London hospitals rely on paper documentation. So, while there are indications that EHR use can save lives, much can be done even without information technology.

In the BMJ study, the care bundle method—which requires doctors to check off certain treatment steps—was associated with a major drop in patient deaths. While there were 255 fewer deaths in these hospitals during the study year than in the previous 12 months, 174 of those were related to the 13 targeted diagnoses. Despite a 5.7 percent increase in admissions, the mortality rate fell 14.5 percent. Both the drop in overall deaths and the decreased mortality among patients with the targeted conditions were statistically significant.
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The eight checklists addressed these diagnoses: peritonitis and intestinal abscess, senility and organic mental disorders, pleurisy pneumothorax pulmonary collapse, aspiration pneumonitis food/vomitus, skin and subcutaneous tissue infections, acute bronchitis, urinary tract infections, acute cerebrovascular disease, other gastrointestinal disorders, septicemia (except in labor), pneumonia, chronic obstructive pulmonary disease and bronchiectasis, and congestive heart failure (non-hypertensive).

The clinical areas covered by the checklists, which were introduced in April 2007, included central venous catheter/line sepsis, diarrhea and vomiting, stroke, ventilator acquired pneumonia, methicillin resistant Staphylococcus aureus infections, heart failure, surgical site infections, and chronic obstructive pulmonary disease.

Nearly 700 hospitals were using the WHO surgical safety checklist a year ago, and 300 more had committed to trying it, but there have been no updates since then from the Institute for Healthcare Improvement, which is spearheading the checklist campaign. The WHO checklist goes beyond the Joint Commission’s patient and site identification requirements by ensuring that everything is ready for an operation, that everybody on the team knows the safety procedures, and that there’s good communication among team members. A multinational WHO study showed the use of the checklist decreased mortality by nearly half. While it’s expected to have a much smaller impact in the U.S., where surgical mortality is fairly low, it could have a marked impact on reducing complications.

The Leapfrog survey, using 2008 data, found that relatively small percentages of U.S. hospitals were adhering to evidence-based guidelines that are known to save lives. Among the areas where compliance was poor: heart bypass surgery (43 percent), angioplasty (35 percent), high-risk deliveries (32 percent), pancreatic resection (23 percent), bariatric surgery (16 percent), esophagectomy (15 percent), aortic valve replacement (7 percent), and aortic abdominal aneurysm repair (5 percet). Moreover, 65 percent of Leapfrog’s participating hospitals lacked policies to prevent common hospital-acquired infections.

Now, it’s possible that the evidence is poor for some of the surgical protocols, and reducing infection rates poses a number of challenges, both human and technical. But physicians and hospitals that aim to be accountable and form “accountable care organizations” owe us all a better effort to improve patient safety. There’s no excuse for not trying to save lives when we know how to do it.

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