Published in the December 2010 AAMC Reporter
By Whitney L.J. Howell, special to the Reporter
Congress has a clear message for America’s hospitals— improve patient safety, or it will cost you. A lot.
The new health care reform law requires hospitals to reduce readmissions and minimize hospital-acquired infections. Penalties take effect in 2012, but reaching these goals could be expensive in and of itself. While these benchmarks may present challenges, several academic medical centers and teaching hospitals are ahead of the game with innovations—some of them fairly unusual or completely unique—designed to enhance patient safety.
Academic medical centers have proven to be at the forefront when it comes to exploring new technologies and techniques that hold promise for bolstering safety.
“By adopting technology and innovations, academic medicine is actively furthering good outcomes and good patient safety,” said Roger Ray, M.D., chief medical officer at Carolinas HealthCare System.
The Institute of Medicine’s watershed 1999 “To Err is Human” report is just one of many that launched patient safety toward the forefront of health care dialogues in recent years.
Many safety efforts have been implemented or are underway across the health care system, but the extent of their success may depend on whom you ask or what you are measuring. In a report released in April, the federal Agency for Healthcare Research and Quality found that postoperative pneumonia rates have dropped 12 percent from last year, but at the same time, bloodstream infections and urinary tract infections have increased by 8 percent and 4 percent, respectively.
According to Peter Pronovost, M.D., Ph.D., medical director of the Quality and Safety Research Group at Johns Hopkins Hospital, medical schools and teaching hospitals may have a lead role to play in improving safety.
“Academic medical centers are hugely beneficial for society,” Pronovost said. “I have a vision of these centers locally directing projects and sharing their findings on patient safety with other practices throughout their states.”
Fulfilling this dream will not necessarily be easy. A 2006 study published in Academic Medicine, titled, “Safety in the Academic Medical Center: Transforming Challenges into Ingredients for Improvement,” identified three characteristics that may present challenges to academic medicine in improving safety performance. One is the three-pronged mission of medical schools and teaching hospitals, which can make it difficult for administrations to keep faculty focused on new patient safety initiatives. The size and complexity of academic medical centers and the propensity of their personnel to think as individuals rather than as a system can also hinder safety efforts. In addition, the sheer geographical breadth of academic medical centers generates many institutional issues and needs that often overshadow patient safety conversations.
Medical schools and teaching hospitals can prompt widespread safety enhancements, however, if administrators
institute incentives, including potential promotions, for researchers and providers who impact patient safety, Pronovost said. He said, academic medical centers can serve as valuable proving grounds for new technologies.
For example, patients at Carolinas HealthCare no longer worry about electronic health record mix-ups because the hospital implemented a virtually fail-safe patient identification system called Palm Scanner.
At registration, patients who agree place their hand on a molded-plastic cradle that quickly scans and creates an electronic image of the veins in their palm. Palm Scanner converts the image into a number unique to each patient, ensuring the hospital will not confuse health information for people with the same names and identical birthdates. Registration is faster for subsequent appointments, Ray said, but Palm Scanner can also save lives. Carolinas HealthCare launched the initiative in 2009, Ray said, and to date nearly a million patients have enrolled with one of the 700 Palm Scanners at Carolinas HealthCare’s 260 locations.
“We’ve had a few instances where unconscious patients have been brought to the emergency room without identification,” he said. “Because they were enrolled in our Palm Scanner program, we were able to find out who they were, access their medical records, and provide the best and safest treatment possible.”
At Loyola University Medical Center in Chicago, a machine called SurgiCount keeps track of sponges and other items used in surgeries, ensuring surgeons and nurses remove all equipment when they complete an operation.
Much like a grocery store scanner, SurgiCount reads barcodes attached to larger sponge packets and individual sponges. When a surgery begins, a nurse scans the sponge packet and then scans individual sponges as they are used. When the operation is over, the sponges are again scanned, so SurgiCount can alert practitioners if a used sponge is missing.
“Failing to remove all surgical sponges places patients at increased risk for infection—foreign bodies in a human being trigger immune responses that can turn fatal,” said Deborah Serwa, R.N., practice director for Loyola’s Ambulatory Surgery Center. “We’ve had a very safe record, but we’re using SurgiCount as an extra safety device that gives us a greater level of confidence.”
Patient confidence is also rising along with health care safety. The University of Florida Medical Center and Shands Hospital recently concluded an 18-month hand hygiene pilot test that guarantees cleanliness in a way patients can see. HyGreen is a three-part system that warns practitioners if their hands are not clean enough for patient contact.
Before approaching a patient, doctors and nurses wash their hands with alcohol gel. They pass their hands under a HyGreen detector, and if the machine identifies alcohol on the hands and clears them for patient contact, it sends a signal to the practitioner’s identification badge, turning an embedded LED light green. As a last step, an acoustic boundary from another HyGreen sensor above the patient’s bed searches for hygiene messages from practitioner badges. If a practitioner passes through this perimeter with unclean hands, the badge will buzz, alerting the practitioner to the problem, giving him or her six seconds to use sanitizer before buzzing again. The HyGreen system collects the date, time, practitioner information, and patient identity of each encounter. Since implementing HyGreen, the hospital-acquired infection rate in Shands’ neurosurgery intensive care unit has fallen to zero, and the hospital plans to install HyGreen detectors in other units soon. Hospitals throughout the Southeast have expressed interest in the system, as has the restaurant industry.
“This is an effective infection control tool,” said Robert Melker, M.D., an anesthesiology professor at the University of Florida College of Medicine and a HyGreen co-developer. “But we were amazed at how quickly patients and families recognized it as such. They all wanted to see the blinking green lights.”
New technologies are undoubtedly useful, but true change comes in altering the culture of an institution. Developing a climate in which safety practices are second nature requires consistent modeling from medical educators and administrators, said Bela Patel, M.D., critical care division director at the University of Texas Medical School at Houston. Patel leads a safety initiative that has prevented all ventilator-associated pneumonia cases since 2007.
“Patient safety in academic medical centers must be taught at all levels, from medical school through to residency,” she said. “We must train the trainers. We cannot expect medical students to learn all they need to learn about patient safety in the classroom. Their teachers should model it, as well.”
Loyola addressed patient safety through modeling in 2009 when it mandated all employees receive the seasonal flu vaccine. The hospital’s chief medical officer and chief nursing officer were among the first in line after the administration announced the requirement last September. Making the shot a condition of employment was the right thing to do, said Jorge Parada, M.D., M.P.H., associate professor of medicine and infectious diseases at Loyola.
“It’s the nature of our profession. We are ultimately responsible for ensuring that we, ourselves, do not make our patients sicker,” he said. “The flu vaccine is just one of many vaccines that health care workers must get. Everyone should get it without question.”
Loyola used a triplicate-form system to track employees’ compliance. The employee, employer, and employee health department all received a copy of the form as proof of vaccination.
Employees who could not receive the vaccine for health reasons applied for exemption waivers from human resources. The medical director of occupational health validated the waivers, and those employees wore masks in public settings to reduce the risk of getting or transmitting the virus.
According to Michael Koller, M.D., associate professor of general internal medicine at Loyola University Medical Center, three employees refused the vaccination without a health-related reason, and they were fired.
According to Pronovost, these initiatives have made patients safer, and they point to the fact that academic medical centers can lead the science of patient safety.
“These strategies help us be more accountable for the plans of care we choose,” he said. “We’re no longer only focused on the delivery of health care. We are now readily accountable for the outcomes of the patient safety measures we use.”