Published in the June 2005 issue of Today’s Hospitalist
When it comes to reducing inpatient mortality, hospitalists have an excellent opportunity to play a leading role.
In April, a trio of presenters at the annual meeting of the Society of Hospital Medicine in Chicago said that a growing body of evidence points to strategies that can reduce patient deaths in the hospital, along with the adverse events that contribute to inpatient mortality. But they also pointed out those approaches, which include standardized order sets and rapid response teams, are woefully underused at many hospitals.
The problem? Many of the most effective strategies employ team and systems approaches that are relatively foreign to much of U.S. health care. These strategies take a long view and go beyond more than one disease state or a single group of clinicians when it comes to improving quality.
“There’s nothing wrong with using a disease-specific focus for reducing in-hospital mortality for COPD, AMI or other conditions, but we decided on system-level changes,” said John Whittington, MD, coordinator for clinical effectiveness and corporate patient safety officer for St. Francis Healthcare System in Peoria, Ill. “We live in a world where we act as individuals, but what we’ve found with CAP is that if we use standardized order sets, outcomes are better. You as the system are better, not just you the physician.”
That approach may sound like common sense, but it’s not commonly used. When physicians, quality improvement professionals and risk management teams identify the chief factor in an adverse event or “avoidable” outcome, for example, they frequently discover that the root cause lies in a system failure or the lack of a team structure.
Co-presenter and anesthesiologist Paul Barach, MD, MPH, associate dean of the University of Miami School of Medicine and director of its center for patient safety, asked attendees to recall adverse events and avoidable deaths in their institutions. When analyzing a situation in which a patient was harmed because of omission or commission, he said he finds it helpful to ask two key questions: What was the role of the team when the event occurred, and was someone with the knowledge or skills to prevent that event available “down the hall, for example “at the time it occurred?
That analysis, Dr. Barach said, often leads to the distressing discovery that the presence of what he calls “team function” would have helped remedy the situation before an error ever occurred. “How often do we kick ourselves when we realize that someone actually had the information but not the vehicle to incorporate that information into the decision-making?” Dr. Barach asked.
Resources and awareness
The reality, however, is that integrating an approach that focuses on the importance of systems and the team, not individuals, is difficult for a variety reasons.
For one, Dr. Barach explained, there is the issue of resources. “To introduce team training in health care, we need to ramp it up to a very different level,” he said. “That will require a lot of resources and a lot of awareness of the environment around the team.” The issue of awareness can be a barrier, Dr. Barach said, because many physicians think they are excellent communicators and therefore don’t need “supports” to ensure their message gets across. The evidence, however, paints a different picture.
“We think we’re wonderful communicators,” he explained, “but the literature suggests that we don’t do that very well. Patients walk away understanding about 40 percent to 50 percent of what they hear from us.”
Another problem? Too many clinicians, from residents to attending physicians and nurses, are reluctant to call for help, in part because of the emphasis U.S. health care puts on the notion of self-reliance.
Rapid response teams
One of the most effective team models to emerge in recent years as a way to reduce in-hospital mortality is the rapid response team. This approach takes the concept of teamwork to a new level by creating a group of clinicians to bring critical care expertise to the bedside when patients suddenly take a turn for the worse.
Rapid response teams have proven effective in reducing mortality; Australian studies, for example, have reported major mortality gains with rapid response teams. Dr. Whittington said the teams are able to make a dent in inpatient mortality rates because they address respiratory problems before the patient becomes critical.
By quickly assessing patients who appear to be getting into trouble and transferring them to the ICU before problems become critical, these teams can reduce or prevent avoidable cardiac arrests that lead to patient death in more than 80 percent of cases when a code is called.
The concept, Dr. Whittington said, arose from studies that found in more than 70% of in-hospital cardiac arrests, hospital staff had noted ongoing instability or abnormal signs and symptoms six to eight hours before an event occurred.
Timing is everything
In most cases, nurses on duty call the rapid response team and request help evaluating a patient whose condition appears to be deteriorating. Team members may include physicians, critical care nurses, pharmacists and respiratory therapists.
These teams can be mobilized at a moment’s notice. Within five to 10 minutes, they can assess and stabilize the patient and transfer the person to the ICU if necessary.
Session co-presenter Terri Simmonds, RN, a director and faculty member of the Institute for Healthcare Improvement, said that the most important issue is not the makeup of the team, but whether the system will support the individuals’ involvement and how team members respond to calls.
“Team members must be available to respond in a timely manner when the nurse on a floor activates the team,” she said, “and they must show up with smiles on their faces. The first time those people show up and say, ‘Why did you call me?’, how soon will that nurse call the team again?”
Dr. Whittington said that hospitalists can help promote the creation of rapid-response teams within their institutions, and he added that they stand to be among the chief beneficiaries of such teams’ efforts. “If you get your [rapid response] system together well,” he said, “you can do a good job as a hospitalist because you have become the quarterback of the team.”
Bonnie Darves is a freelance writer specializing in health care. She is based in Lake Oswego, Ore.
Signs that U.S. health care may be ready for systems approaches
Despite some reluctance to adopt a systems approach to improve quality and reduce errors, there are signs that the model is slowly gaining traction in U.S. health care.
According to Paul Barach, MD, MPH, associate dean of the University of Miami School of Medicine and director of its center for patient safety, groups like the Boston-based Institute for Healthcare Improvement (IHI) are working on ways to take the team model from a concept whose merits are hard to dispute to a mechanism for managing care delivery.
Dr. Barach told hospitalists at the recent annual meeting of the Society of Hospital Medicine that the IHI and other groups trying to improve patient safety are working with groups like the Accreditation Council for Graduate Medical Education, the National Board of Medical Examiners and the Joint Commission on Accreditation of Healthcare Organizations. The goal is to help incorporate the science of team training into medical school and resident training.
Dr. Barach said those efforts are focusing on the following areas:
“¢ Creating what he called a “crosswalk” in the competencies of core team members. Ideally, he said, clinicians should be able to stand in for one another.
“¢ Developing clear competencies in team-science and team-member skills as a requirement for residency. The residency review committee (RRC) for surgery recently adopted this requirement, which means that methods for evaluating individuals will be supplemented by methods for evaluating resident teams.
“¢ Developing evidence-based guidelines for creating and evaluating clinical care teams. The American Board of Medical Specialties is looking at team proficiency as a requirement for maintaining specialty certification.