June 24, 2015 Liz Borkowski, MPH 0Comment

Innovation in healthcare doesn’t just mean new drugs and devices; sometimes, studying and updating procedures can result in big improvements for patients’ health. In the New York Times, Gina Kolata reports on procedure changes hospitals have made to improve care for heart-attack patients:

With no new medical discoveries, no new technologies, no payment incentives — and little public notice — hospitals in recent years have slashed the time it takes to clear a blockage in a patient’s arteries and get blood flowing again to the heart.

The changes have been driven by a detailed analysis of the holdups in treating patients and a nationwide campaign led by the American College of Cardiology, a professional society for specialists in heart disease, and the American Heart Association. Hospitals across the country have adopted common-sense steps that include having paramedics transmit electrocardiogram readings directly from ambulances to emergency rooms and summoning medical teams with a single call that sets off all beepers at once.

The impetus for these changes, Kolata explains, was Medicare’s creation of a database showing individual hospitals’ “door-to-balloon” time — the amount of time from when a patient arrives at a hospital to when a medical team inserts a catheter and inflates a tiny balloon to clear a blocked artery. Yale cardiologist Harlan Krumholz and his colleagues studied this data, and then investigated the strategies used by the hospitals with the shortest door-to-balloon times.

In a study published in the Journal of the American College of Cardiology in 2005, Krumholz and his co-authors reported their findings from in-depth interviews of staff at eleven top-performing hospitals. They described “several critical innovations,” including “use of pre-hospital electrocardiograms (ECGs) to activate the catheterization laboratory, allowing emergency physicians to activate the catheterization laboratory, and substantial interdisciplinary collaboration throughout the process.” They concluded that process design efforts could allow hospitals to achieve the recommended door-to-balloon time of 90 minutes or less, but “the recommended best practices involve extensive interdisciplinary collaboration and will likely require explicit strategies for overcoming barriers to organizational change.” Krumholz’s team then went on to survey 365 hospitals on 28 specific surveys they identified. The resulting article, published in the New England Journal of Medicine in 2006, described six specific strategies for decreasing door-to-balloon time:

In multivariate analysis, six strategies were significantly associated with a faster door-to-balloon time. These strategies included having emergency medicine physicians activate the catheterization laboratory (mean reduction in door-to-balloon time, 8.2 minutes), having a single call to a central page operator activate the laboratory (13.8 minutes), having the emergency department activate the catheterization laboratory while the patient is en route to the hospital (15.4 minutes), expecting staff to arrive in the catheterization laboratory within 20 minutes after being paged (vs. >30 minutes) (19.3 minutes), having an attending cardiologist always on site (14.6 minutes), and having staff in the emergency department and the catheterization laboratory use real-time data feedback (8.6 minutes). Despite the effectiveness of these strategies, only a minority of hospitals surveyed were using them.

Kolata reports that hospitals across the country have since adopted such strategies; door-to-balloon times have dropped, as has heart-disease mortality.

This reminded me of Atul Gawande’s 2007 New Yorker article “The Checklist,” in which he describes the benefits of having hospital teams create and follow checklists for multi-step procedures. Gawande writes about an investigation by Johns Hopkins Hopsital cricital-care specialist Peter Pronovost into the steps necessary to avoid infections when putting a line into a patient:

On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting a line in. Doctors are supposed to (1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a sterile mask, hat, gown, and gloves, and (5) put a sterile dressing over the catheter site once the line is in. Check, check, check, check, check. These steps are no-brainers; they have been known and taught for years. So it seemed silly to make a checklist just for them. Still, Pronovost asked the nurses in his I.C.U. to observe the doctors for a month as they put lines into patients, and record how often they completed each step. In more than a third of patients, they skipped at least one.

Pronovost also relied on nurses, with backup from the hospital administration, to address the problem his research identified:

The next month, he and his team persuaded the hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask them each day whether any lines ought to be removed, so as not to leave them in longer than necessary. This was revolutionary. Nurses have always had their ways of nudging a doctor into doing the right thing, ranging from the gentle reminder (“Um, did you forget to put on your mask, doctor?”) to more forceful methods (I’ve had a nurse bodycheck me when she thought I hadn’t put enough drapes on a patient). But many nurses aren’t sure whether this is their place, or whether a given step is worth a confrontation. (Does it really matter whether a patient’s legs are draped for a line going into the chest?) The new rule made it clear: if doctors didn’t follow every step on the checklist, the nurses would have backup from the administration to intervene.

Pronovost and his colleagues monitored what happened for a year afterward. The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from eleven per cent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths, and saved two million dollars in costs.

A larger test came in Michigan, where as part of a state-wide safety initiative Pronovost’s team persuaded 108 intensive-care units to participate in a study of an intervention to decrease catheter-related bloodstream infections. The intervention included the use of a checklist to ensure clinicians followed infection-control practices — and stopping providers who weren’t following these practices — as well as creation of a central-line cart with all necessary supplies, discussions of catheter removals at daily rounds, and regular feedback for teams on the number and rate of catheter-related bloodstream infections.In a 2007 New England Journal of Medicine article, Pronovost and his colleagues reported “a large and sustained reduction (up to 66%) in rates of catheter-related bloodstream infection that was maintained throughout the 18-month study period.”

It appears that this innovation is also catching on. Earlier this month, Current Infectious Disease Reports published an article by Asad Latif, Muhammad Sohail Halim, and Peter Pronovost on eliminating central line-associated bloodstream infections (CLABSI) in the ICU. The authors note that the approach used in the Michigan project has spread, and report that CLABSI rates in the US dropped 46% between 2008 and 2013.

Adopting relatively simple procedural changes can yield big improvements in health outcomes — although the process necessary to implement changes can be tricky. Hospitals can’t just close down for weeks at a time to re-train their staffs or reorganize their ICUs; it takes careful planning and dedicated work to improve care quality while continuing to deliver care. The improvements in heart-attack care and central-line infections show that hospitals are capable of changing their procedures, and in doing so, save millions of lives.

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