Thursday, October 30, 2014

Finding Truth and Taking the Appropriate Action

I received a call last week from a family member asking me, in the wake of the Ebola outbreak and media frenzy, if it was safe to fly on US commercial aviation. I told her that unless she was flying to West Africa and headed to one of the three Ebola-ridden countries, I did not see any reason why it would be unsafe.  This is a prime example of fear affecting people.  The fact that this family member called me was a good thing, but I am very concerned about well-intentioned people acting in ways that actually make a situation worse.

As we enter flu season, there is a great public health risk that people will take actions out of fear and ignorance and neglect actions that will actually protect them….like getting a flu shot. Because Ebola has a high mortality rate and the media has been talking about it for weeks now, we are all on heightened alert. But one must have direct contact with the body fluids of a patient with active Ebola to contract the disease. What has happened in Dallas should allay people’s fears about the communicability of Ebola.   The influenza virus is much more easily transmitted than Ebola. It is spread by respiratory droplet through coughing, sneezing, touching contaminated surfaces or shaking hands.

It is important to know the facts, to investigate the truth about something before making decisions, and this is particularly true about immunizations. I remember one day in 2005, when I was taking care of children on the inpatient unit at Boston Medical Center, a big inner-city trauma hospital, that we received a call from the Life Flight system.  We were getting a child from Nantucket. I immediately thought that the child must have been the victim of trauma, but I instead learned that the boy was suffering from invasive haemophilus influenza type B bacterial disease. The residents working with me had never seen a case of this disease.  This was because the Hib immunization came out in the mid 1980s, but when I was a resident in the early 1980’s, we had many cases and a significant number of children with serious complications and death.  Then the vaccine came out, and it was so effective that within a few years the disease became nearly eradicated in the States. Why, then, 20 years later, was this child being Life Flighted to Boston Medical Center from Nantucket, sick with a case of H-flu?  Because his parents did not believe in immunizations, and the child was on the verge of death from a preventable illness. The parents had never seen a child sick with the disease or heard about the devastation that it caused, so they minimized the risk. They also fell victim to misinformation and ignorance about the risks and benefits of the immunization. Luckily for them, the child survived the disease and did not have a significant complication.

We should be worried that people will drop their guard on influenza (the viral disease that we get annual immunizations to prevent) because they are scared about Ebola. Ebola has affected a mere handful of people in the United States, whereas influenza kills an average of 30,000 people per year.  If my family member had called me and said, “I’m going on a plane, what would you recommend?” I would have responded, “Get your influenza vaccine.”  Since influenza does not generally kill otherwise healthy people, many people ignore the evidence and don’t take the appropriate precautions.

Unless someone is less than 6 months of age, has a true chicken egg allergy or has had Guillain Barre syndrome after a previous immunization, there is no contraindication to the influenza immunization.  In our society, we have a tendency to fall into the trap of fads and pseudoscience, believing in ideas that are contrary to the actual facts.

GBMC must work hard to help people get the care that will cure them or keep them healthy. Let’s work to maximize the rate of influenza vaccine this season, and help get the facts out about Ebola to minimize fear and the nonsensical actions that fear can trigger.

Tuesday, October 21, 2014

Getting to Level 3 Mistake Proofing

Lean Daily Management (LDM) has been a very valuable tool in moving us closer to our vision, creating many more focused problem solvers than we’ve ever had. Phil Komenda, our Director of Imaging and Cardiac Services, and his team have been working to move our electrocardiogram (EKG) reading closer to 100% reliability. Their standard for success is that every EKG will be officially read by a cardiologist within 24 hours of the completion of the study.

Phil’s team of nurses, technicians, cardiologists and other managers has significantly improved the percentage of EKGs read within 24 hours.

Some of the changes that Phil’s team has adopted include:

a.      Placing written instructions and reminders on each EKG cart.
b.      Having the nursing units transmit EKGs instead of waiting for the cardiology tech.
c.      Assigning cardiology techs on each unit to help with staff training.
d.      Sorting the EKGs to be read from the oldest to most current.
e.      Increasing the stream of communication to inform cardiologists when there is an EKG to be read.

When they began their improvement efforts, roughly 9 out of 10 EKGs were read within 24 hours. Now, roughly 97 out of 100 are read on time. This is great improvement, increased reliability by almost a factor of 10!

So now the challenge is how to get rid of the 3 errors per 100. One of the most common reasons why the study is read more than 24 hours after it was completed is because it was not transmitted to the cardiologists in time. Phil’s team has tried educating staff members of the importance of transmitting the study as soon as it is done, citing getting it read quickly so as not to miss a possible heart attack or arrhythmia as critical. This is called level 1 mistake proofing. Education is a powerful tool if the staff members are not aware of the importance of the official read.

The written instructions and the reminder on the cart itself to transmit the EKG as soon as it completed is an example of level 2 mistake proofing.  This is a more powerful strategy than simply reeducating staff members because it the text is actually present on the cart in front of the person doing the study when he or she has completed it. As you can see from Phil’s team’s results, this has helped. However, you can imagine a nurse or nursing tech who has just done an EKG and showed the strip to a Hospitalist then getting interrupted and forgetting to push the TRANSMIT button. The reminder on the cart is helpful but imperfect.

This week I had a discussion with Phil about meeting with the suppliers of EKG machines to see if any of them have a device that automatically sends the study when it is done, thereby taking operator forgetfulness out of the mix. This is an example of level 3 mistake proofing and it is what all good engineers, especially those working in high-risk industries, strive for. If it was your child who was being checked for a potentially life-threatening but uncommon arrhythmia, 3 errors in 100 is just not good enough. Let’s see what Phil learns…..stay tuned.

I want to thank those that posted comments on my recent blog that focused on the first Ebola Virus Disease (EVD) case in the U.S.

While it is still very unlikely that we will see a case of Ebola at GBMC, we must prepare for that possibility. Our ED has responded a few times over the last few weeks when patients presented with positive responses to the screening questions but were later found to not be at risk for Ebola.  I am very grateful for our staff’s hard work and for the fact that they were prepared, using the appropriate personal protective equipment until they found that the patient was not at risk.

We have a team, led by our Chief Operating Officer, Keith Poisson, that is following this situation very closely and is assuring GBMC’s readiness according to the directives from the Centers for Disease Control. Our work in Ebola preparedness can be found on the Infoweb. There you will find a schedule for training our people in the use of personal protective equipment. We are starting with those most likely to need to use the equipment.

GBMC must be ready to serve our community if a patient with Ebola ever presents. We must communicate well and remain calm. We must avoid contributing to misinformation and doing things that are not indicated by the evidence, for these responses only make people more fearful. My thanks to the entire GBMC team for their professionalism and their commitment to evidence-based care.

Thursday, October 9, 2014

A Lesson Learned from the First Ebola Death in the U.S.

It is with great sadness that I write about the Ebola patient case at a hospital in Dallas, Texas. The patient has now died. All healthcare providers would be well served by studying what happened in this case. In late September a man walked into a hospital with a fever, complaining of abdominal pain and a sharp headache.  When the patient was asked whether he had nausea, vomiting, or diarrhea, he said “No.”  At that time his symptoms, which were not severe, could have been associated with many infectious diseases, as well as many other types of illness.  He was also asked if he had been around anyone who had been ill, to which he said “No” and if he had traveled outside the United States within the last four weeks. He responded that he had been in Africa.  A nurse entered that information in the electronic medical record. From what we know it appears that he was sent home with antibiotics.  The patient returned two days later saying he was worse and this time he was admitted to the hospital and placed into isolation with possible Ebola.  Ultimately, the U.S. Centers for Disease Control released the information that this individual tested positive for Ebola and has now died of that disease.

Ebola scares us because it has a high mortality rate and its initial signs and symptoms are not unique. The current outbreak can and will be contained and extinguished but this will require a well-designed and executed international plan.

Is our current health care delivery system capable of creating and executing this plan? Well, everyone knows that we don’t have an international health care system. We have many national health systems of varying capabilities.  A country like Sierra Leone, for example, doesn’t have a well-developed public health infrastructure or primary care system. In our own country our healthcare system has more capacity, but, the events in Dallas show that you can have extensive financial resources deployed in a healthcare system, but, have it poorly designed to meet a need of the community it serves. 

In this case, the hospital in Dallas appears to have had a major “latent” error (hole in the Swiss Cheese) that was waiting to be part of a trajectory that would lead to the catastrophe of putting a patient with Ebola back out on the street. I am afraid that the very same latent error is present in many healthcare organizations throughout our country. That latent error is the absence of direct concise communication between members of the healthcare team. I should be cautious commenting on this case without all of the facts, but it appears that at least one team member knew that the patient had recently traveled from Africa and yet the patient was discharged from the emergency department only to be admitted later with Ebola, thereby having potentially spread the disease to multiple other individuals.

The knowledge of what happened in Dallas is a potential treasure for the rest of us in the US healthcare system. We must learn from this and redouble our efforts to operate as a high-functioning team with freely flowing information and people not afraid to speak up if they have a safety concern.

Physician Assistants WeekPlease join me in celebrating all GBMC physician assistants (PAs). This week is National PA week (Oct. 6-12) and is a time when PAs celebrate their profession and showcase the value they bring to today’s healthcare team.

A physician assistant (PA) is a nationally certified and state-licensed medical professional who begin their careers with rigorous education in a highly competitive field.  Upon completion of a bachelor’s degree, prospective students must then attend an intense three year PA program and complete at least 2,000 hours of supervised clinical practice.  They then must pass the Physician Assistant National Certifying Exam (PANCE), which is administered by the National Commission on Certification of Physician Assistants (NCCPA). 

The PA staff at GBMC practice in many areas from the outpatient offices to the inpatient units in a wide variety of specialties. Please join me in thanking our PA’s for their hard work and for their important role in caring for our patients.

Wednesday, October 1, 2014

Some Awards Mean Something

In previous blogs I have talked about certain “awards” or recognitions in health care that don’t have much merit. They are bestowed on individuals and organizations of beliefs that are not backed by data or they are based on the opinions of people with a vested interest in the outcome. There are other awards that are based on facts and the receivers of the recognition should be proud.

This week GBMC was officially presented with the 2014 Delmarva Foundation Excellence Award for Quality Improvement and we also celebrated our performance in the Centers for Medicare and Medicaid Services Partnership for Patients Initiative.  Both of these events demonstrate that we are on the right path towards our vision and in achieving our aims of  better heath and better care, with less waste and more joy for those providing the care in our health system.

The Delmarva Foundation for Medical Care (DFMC), the Medicare Quality Improvement Organization for Maryland, is an independent, not-for-profit health care quality improvement organization dedicated to monitoring and improving the quality and delivery of healthcare services in our state. To receive the Delmarva Foundation Excellence Award a hospital must meet specific performance improvement criteria on ten quality measures in two inpatient clinical areas:  medicine and surgery.  This is the second year we have received this award for outstanding performance against national standards.

The Centers for Medicare and Medicaid Services’ Partnership for Patients initiative, started in 2011, is a public-private partnership working to improve the quality, safety and affordability of health care for all Americans. The Partnership for Patients and its over 3,700 participating hospitals are focused on making hospital care safer, more reliable and less costly through the achievement of two goals: enhancing patient safety and Improving Care Transitions. At GBMC in an effort to meet this goal we assembled nine teams, each with accountability for an area of patient harm.  GBMC is achieving its goal in 12 of 14 measures. That means that if we continue at our current performance level we will meet the 40% reduction goal in 12 areas. Since January of 2014, these teams have eliminated 800 incidents of patient harm!!

Also, I am glad to announce that our Primary Stroke Center has once again been recognized by the American Heart Association/American Stroke Association’s (AHA/ASA) Get With The Guidelines® (GWTG) program for our commitment to quality patient care. Hospitals receiving the GWTG Gold plus Achievement Award have reached an aggressive goal of treating stroke patients with 85% or higher compliance to core standard levels of care as outlined by the AHA/ASA for 12 consecutive months. In addition, those hospitals have demonstrated 75% compliance in 5 out of 8 stroke quality measures during the 12-month period. Additionally we also achieved the Target: Stroke Honor Roll designation for meeting a specific GWTG achievement level and for improving stroke care. This designation means that at least 50 percent of eligible ischemic stroke patients have received IV rt-PA (TPA or “stroke buster” medication) within 60 minutes of arriving at the hospital (known as ‘door-to-needle’ time), assessed on a quarterly basis. This is the first year we have received the Target: Stroke Honor Roll highlighting the outstanding teamwork in our ED to identify and treat Acute Ischemic Stroke patients safely and rapidly.

All of these recognitions are for measurable improvements in care. I want to thank all of our clinicians for their hard work and dedication and for designing systems to get to this level of performance and for not relying on hard work and good intentions alone. Some awards definitely do mean something and we should be proud.