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Study shows disappointing results in many safety indicators
Every 1.7 minutes a Medicare beneficiary has a patient safety event
With all the attention that's been paid to patient safety in recent years, one would have hoped for better results. But as the latest HealthGrades analysis of patient safety among Medicare patients shows, we still have a long way to go.
The survey, which looked at performance in all of the nearly 5,000 U.S. non-federal hospitals based on 15 indicators of patient safety developed by the federal government's Agency for Healthcare Research and Quality (AHRQ), showed that between 2005 and 2007, performance in seven of those indicators actually worsened.
Referring to them as "some of the most common and most serious indicators," Golden, CO-based HealthGrades said they included decubitus ulcer (bed sores), sepsis, respiratory failure, deep vein thrombosis (blood clots in the legs), and pulmonary embolism.
Here are some of the other study highlights:
• Large safety gaps identified between top- and bottom- performing hospitals.
Patients treated at top-performing hospitals had, on average, a 43% lower chance of experiencing one or more medical errors compared to the poorest-performing hospitals.
• Patient safety events are common at U.S. hospitals.
Between 2005 and 2007 there were 913,215 total patient safety events among Medicare beneficiaries.
• Common patient safety events are very costly.
Between 2005 and 2007 these patient safety events were associated with more than $6.9 billion of wasted health care cost.
• Approximately one in 10 Medicare patients with patient safety events died.
Between 2005 and 2007, 97,755 actual in-hospital deaths occurred among patients who experienced one or more of the 15 patient safety events.
Between 2005 and 2007, according to the study, 913,215 total patient safety events were recorded among Medicare beneficiaries which, HealthGrades said, represents 2.3% of the nearly 38 million Medicare hospitalizations. This, they noted, equates to one reported patient safety event every 1.7 minutes. (A full copy of the report is available at www.healthgrades.com/research.)
Why performance dropped
Why has performance dropped in such "common and serious" areas? "It's very interesting; we've been pondering that a lot," admits Rick May, MD, senior physician consultant at HealthGrades and co-author of the study. "If you delve down into the actual computations, there may be some understanding from a clinical standpoint as to what's going on."
May looks to the medical literature to help explain, for example, the findings for decubitus ulcers. "There are two things going on," May observes. "First, we are seeing more skin problems. The population in general is getting older, and there is more widespread use of steroids for many conditions, and people in nursing homes are living longer. All of those are risk factors for decubitus ulcers. Also — and this is scarier — we're seeing an increase in the rate of sepsis post-op."
"Every organization is struggling with this," adds David Cooke, MD, vice president of quality and safety at Central DuPage Hospital in Winfield, IL. Central DuPage was one of the 2009 HealthGrades Patient Safety Excellence Award recipients identified as part of the report. (HealthGrades estimates that if all hospitals had performed at the level of Patient Safety Excellence Award hospitals, about 211,697 patient safety events and 22,771 Medicare deaths could have been avoided while saving the U.S. about $2 billion from 2005 through 2007.)
However, he says that the fault does not entirely lie with the hospitals. "Some of this is due to the fact that patients, in reality, are just sicker," he asserts. In addition, he notes, the way some data are reported may present a less than accurate picture.
"The way they were entered into the administrative database, until recently there was no distinguishing a patient who came from a chronic care facility vs. one who developed the ulcers while in the hospital," he shares. "For example, when I look at the first three quarters of 2008, we had 80 cases, but only 14 developed here at the hospital."
A good deal of discipline is required to be able to separate the two sets of data, he continues. "These things hide and may not be the main medical problem," he observes. "The nurses have to do a very careful [skin] examination and document what they found, but it doesn't count unless the physician documents it — and the physician may find it not to be part of the patient's acute illness. So, you need a nursing staff that's very good at searching and documenting and has a way of prompting the doctor to document."
Cooke notes that on Jan. 1, 2008, Medicare began requiring a code under the column present on admission. "HealthGrades has not yet used that 'present on admission' data," he points out. Still, he says, "Even if we had 14 cases in nine months, that's 14 too many. I want no misunderstandings; you have to make your performance better and better."
Post-op sepsis and respiratory failure, he says, also are widespread problems — but again, he notes these are complicated issues. "Frankly, our society expects us to take action when surgery could be lifesaving — even in people whose conditions make them a bad risk," he asserts. "In the past you could more elegantly choose not to do the surgery. So, to some degree, this also speaks to the acuity of the patients."
What quality managers are doing
Despite these obstacles, top-performing hospitals have developed processes to help reduce the occurrence of these conditions. "For respiratory failure we discovered five years ago we had a significant increase that was sometimes related to simple narcotics use," notesLee Johnson, RN, MSN, CPHQ, administrative director for quality at Trinity Mother Frances Hospital in Tyler, TX, another 2009 HealthGrades Patient Safety Excellence Award recipient. "We also implemented a rapid response team that has evolved, and we have now put in 'Condition H,' which allows patients' families to call a response. That has been extremely helpful in identifying patients in very early respiratory failure, where years ago they would have gone on to have a full respiratory arrest."
"We acknowledge that a portion of our patients are at higher risk for bed sores, either because they are nutritionally depleted, bedbound, or because of surgical complications they cannot not get around," adds Ralph Carroll, MBA, hospital patient safety officer at Mother Frances.
"For 15 years our orthopedic and cardiac populations have received very aggressive rehab to keep up and moving, and that's done a great deal for improving general outcomes. Also, we recently incorporated the concept of hourly rounding. We found that patients were using the call button a lot and when we responded it kept us from treating other patients; so we tried to get ahead of that by rounding, inquiring about pain, about whether the patient needed to go the bathroom, and we also do a very quick assessment of those areas at greatest risk for pressure sores." This way, Carroll explains, staff can identify areas of redness before they actually become sores.
A few years ago, Carroll continues, the hospital made "a big push" toward more sophisticated wound management — giving doctors and nurses special training with special treatment, and using the Braden scale to assess risk of developing sores. "Also, you can't underestimate the importance of adequate hydration and nutrition, and we have an active nutritional program throughout the whole hospital," he says.
Cooke says his facility has created a performance improvement project around every step of bed sore prevention he outlined earlier (i.e., nurse exams, documentation). "We've actually done a study of this," he continues. "One day we will send out a team of wound experts and examine every single patient in the hospital. They determine if they already have decubitus ulcers and compare that to our documentation. It's a great way of improving documentation."
Cooke notes that serious pressure ulcers are considered "never events," for which a hospital cannot be reimbursed. "Two quarters ago we showed a 5% rate of patients with bed sores, which is not as good as we had been doing, but there were none in the severe category," he reports. This quarter that number was 1%.
May says that more active monitoring can help address sepsis, "but the concerning piece is the ongoing emergence of more resistant bacteria." Monitoring is also a key to improvement in the area of decubitus ulcers, he notes. "For example, many nursing intake exams now include things like rolling the patient over, so you'll find more sores on admission," he says. "What I expect to see over time is that we are documenting fewer as complications."
Characteristics of safety
In addition to specific initiatives, says May, top-performing hospitals have several characteristics in common that lead to improvement in all key safety indicators. "They have several characteristics they build into their systems, which make them superior," he says. "They do not achieve their results by accident; they are very methodical and very deliberate in terms of what they do."
For example, "They make patient safety a very high priority," May notes. "Then, they push for full transparency in terms of quality and safety data — both internally and externally. They are willing to look at data and also be completely frank and open talking about data at every level — not just with doctors in a closed, dark room, but with everybody involved with the process — nurses, respiratory technicians, the administration team, and so forth."
"One of the keys to overall success has to be a culture in the organization for quality and patient safety," adds Robin Fabre, MD, an internal medicine physician and vice president of quality at Mother Frances. "Leadership has to be engaged and have a mentality of excellence towards performance."
Fabre says that performance improvement "has been part of our overall system of commitment to quality — even before public reporting was required; it's been hard-wired into accountabilities, from senior management down to directors of departments." Quality, she continues, is one of the system's five "pillars" (the others are service, people, finance, and growth). "We have annual evaluations in regards to our performance; right now we are setting goals for the quality pillar this year — things we want to improve upon. If we do not reach our targets, our bonuses would be affected by that."
May agrees that leadership involvement is critical. "Quality managers are those who are most aware of quality issues and most focused on improving quality and patient safety, but what we find is they absolutely have to have 100% public buy-in and support from upper level management — up to and including the CEO, and even the board of the hospital," he says. "For many hospitals you're talking about a big cultural shift, and that can make a lot of people initially uncomfortable. It's difficult for a quality manager to do that in isolation."
[For more information, contact:
David Cooke, MD, Vice President of Quality and Safety, Central DuPage Hospital, Winfield, IL. Phone: (630) 933-3012.
Robin Fabre, MD, Vice President of Quality; Ralph Carroll, MBA, Hospital Patient Safety Officer; Lee Johnson, RN, MSN, CPHQ, Administrative Director for Quality, Trinity Mother Frances Hospital, Tyler, TX. Phone: (800) 535-9799.
Rick May, MD, Senior Physician Consultant, HealthGrades, Golden. CO. Phone: (303) 919-2242.]