Published in the February 2007 issue of Today’s Hospitalist.
When it comes to patient safety, the last five years have seen an explosion in the number and types of strategies hospitals can use to keep patients out of harm’s way. But just how well are some of the more common techniques working?
Not very well, says patient safety expert Kaveh Shojania, MD. While Dr. Shojania is a big supporter of the patient safety movement, he is also a pragmatist. And when he looks at the data on many of the most popular patient safety initiatives, he says he sees a lot of room for improvement.
According to Dr. Shojania, who is a hospitalist at the University of Ottawa and holds the Canada Research Chair in Patient Safety and Quality Improvement, a surprising number of patient safety strategies have little evidence showing that they improve patient outcomes. That can be a problem, he adds, for hospitals that expect concrete results for the time and money they pour into projects.
Rapid response teams are one example, he says. After a number of relatively simple before-and-after studies seemed to show dramatic improvements, rapid response teams soared in popularity at U.S. hospitals. The problem is that the only large randomized, controlled trial to look at rapid response teams found that they provided no benefit in terms of reducing mortality or cardiac arrests.
That doesn’t mean that hospitals should start dismantling the rapid response teams, Dr. Shojania quickly notes. Even if the strategy doesn’t significantly reduce morbidity or mortality, it may serve other purposes, such as motivating clinicians to embrace other safety initiatives and improving morale for both doctors and nurses.
But the fact that so many hospitals are latching onto strategies without solid evidence may cause problems down the road for the patient safety movement, says Dr. Shojania.
He also points out that the high visibility of some strategies, like rapid response teams, shouldn’t deter hospitalists from championing more modest initiatives that may have more evidence behind them.
"Walk, don’t run"
Because the data on so many interventions are either lacking or still being collected, Dr. Shojania advocates a conservative approach, particularly for newcomers to the field. Borrowing a phrase from a commentary published in the Oct. 4, 2006, Journal of the American Medical Association, he says that hospitals should "walk, not run" to embrace patient safety initiatives.
Dr. Shojania will speak about patient safety during the Keynote Luncheon at the Spring 2007 Hospitalist CME Series, which will be held in Redondo Beach, Calif., from Feb. 11-12, and in Cambridge, Mass., from March 11-12.
He urges hospitals and physicians to start by tackling the "low-hanging fruit." Instead of trying to install a new information system or slash mortality in all ICU patients, for instance, try sticking to tried-and-true strategies that are not only evidence-based, but relatively easy to implement.
Preventing central line infections is one such initiative, he says. By implementing fairly basic strategies-using full gowns and gloves when inserting a central line, and removing central lines as soon as possible-hospitals can relatively easily show concrete improvements.
Strategies to reduce infections from urinary catheters are likewise grounded in good evidence and are easy to implement. "Simply having an automatic stop order that says these catheters should be removed after 72 hours unless a physician overrides the order has an important effect," Dr. Shojania says.
At the same time, Dr. Shojania acknowledges the importance of some strategies that don’t have great evidence behind them. They may have the potential to exert a broader impact or generate momentum and enthusiasm, galvanizing staff into championing other initiatives.
The trick is factoring evidence into the cost in terms of time and money, and making an informed decision.
"You need to know that for some patient safety initiatives, particularly ones that are costly and complex, the evidence isn’t very good," he says. "You can then make your own decision about whether the strategy is right for your hospital."
Another factor to take into account? Whether you can align the initiatives you choose to tackle with other patient safety efforts being made in your hospital.
"It’s better to succeed at one or two well thought-out initiatives," he says, "than fail at five or 10."
Pick focused initiatives over "sexy" ones
Dr. Shojania says he knows that in a world where everyone is talking about "sexy" projects that involve systems design and computerization, more low-tech or targeted strategies may seem a little boring.
He notes that targeted strategies like reducing infections are particularly well-suited to hospitalists’ skills. "These are good examples," he points out, "of something hospitalists could do that wouldn’t require a big change in hospital policy or an investment of resources."
But what if your hospital has breezed through patient safety 101 and is ready for something more complex? Dr. Shojania says that there are a number of high-profile strategies to try, from executive walk rounds to medication reconciliation.
He warns, however, that the evidence on the effectiveness of these interventions in reducing adverse events is still spotty, and that they can be much harder to launch.
One compelling area for hospitalists to focus on is problems that occur around and after patients are discharged. While there is very little evidence supporting patient safety strategies for discharge, he notes, researchers have done a good job of defining the problems. Now it is up to physicians like hospitalists to collect more data on solutions.
Dr. Shojania plans to speak about each of the following areas during his presentation:
Studies published in the last few years have shown that about 20% of patients have a post-discharge event after leaving the hospital. Dr. Shojania plans to highlight several strategies that hospitals around the country have used to catch post-discharge problems. Most of them use some form of phone-call system to check up on patients a day or two after discharge.
"There’s not great evidence, but anecdotal evidence suggests that this is a reasonable thing to do," he says. "Hospitalist groups could decide to either automate the process or identify high-risk patients that they’re going to phone themselves."
Researchers have documented another problem: diagnostic tests that are still pending at discharge and are never reported to patients’ primary care physicians. "Most hospitals have no protocol in place to make sure these results are followed up on," Dr. Shojania says.
"Hospitalist groups could create very simple electronic or paper-based reminder systems to make sure that certain test results, like a blood culture or radiological test, get sent to the primary care provider."
Because there is very little in the way of standardization in sign-outs, Dr. Shojania says that almost any effort to standardize these communications could improve patient safety. And while high-tech approaches get most of the attention, lower-tech approaches can also get the job done.
According to Dr. Shojania, several studies have shown that using fairly simple computer-based templates to standardize sign-out communications provide a benefit. He notes that one hospital that implemented an electronic sign-out template did so without having a sophisticated computer system. That means many community hospitals could implement a similar project.
"This is something that everyone needs to tackle in the next few years," Dr. Shojania points out. "You don’t have to wait for your hospital to implement an entire clinical information system."
Edward Doyle is Editor of Today’s Hospitalist.
Kaveh Shojania, MD, will be the Keynote Speaker discussing patient safety at the Spring 2007 Hospitalist CME Series being held in Los Angeles/Redondo Beach on Feb. 11-12, and in Boston/Cambridge on March 11-12. For more information, go online http://www.hospitalistconferences.com.