Optimizing Fail-Safe Use of Complex Medical Devices.

As part of its comprehensive journey toward high reliability, Memorial Hermann Health System has implemented multiple patient safety initiatives. An instance of actual patient harm due to staff unfamiliarity with a medical device triggered a project to ensure the competence of clinical staff in the operation of all approved new and updated medical devices. Medical devices are classified by level of risk to patients if caregivers are not reliably educated. Educational rigor, with tracking and accountability management, is then scaled to that risk assessment. The objective is to decrease safety events related to use of medical devices by ensuring failure-free medical device use. An interdisciplinary team was created to design a "fail-safe" process to analyze and scale training for use of medical devices, with a risk assessment tool predicting the potential severity and frequency of harm to patients. The fail-safe process became an approved procedure and practice standard at the institution.

Using the Targeted Solutions Tool® to Improve Hand Hygiene Compliance Is Associated with Decreased Health Care-Associated Infections.

BACKGROUND: In 2010 Memorial Hermann Health System (MHHS) implemented the Joint Commission Center for Transforming Healthcare's (the Center's) Web-based Targeted Solutions Tool ®(TST ®) for improving hand hygiene through-out its 12 hospitals after participating in the Center's first project on hand hygiene, pilot testing the TST, and achieving significant improvement for each pilot unit. Because hand hygiene is a key contributing factor in health care-associated infections (HAIs), this project was an important part of MHHS's strategy to eliminate HAIs. METHODS: MHHS implemented the TST for hand hygiene in 150 inpatient units in 12 hospitals and conducted a system wide process improvement project from October 2010 through December 2014. The TST enabled MHHS to measure compliance rates, identify reasons for noncompliance, implement tested interventions provided by the TST, and sustain the improvements. Data on rates of ICU central line- associated bloodstream infections (CLABSIs) and ventilator- associated pneumonia (VAP) were also collected and analyzed. RESULTS: Based on 31,600 observations (October 2010- May 2011), MHHS's system wide hand hygiene compliance baseline rate averaged 58.1%. Compliance averaged 84.4% during the "improve" phase (June 2011-November 2012), 94.7% in the first 13 months of the "control phase" (December 2012-December 2014) and 95.6% in the final 12 months (p < 0.0001 for all comparisons to baseline). Con comitantly, adult ICU CLABSI and VAP rates decreased by 49% (p = 0.024) and 45% (p = 0.045), respectively. CONCLUSION: MHHS substantially improved hand hygiene compliance in its hospitals and sustained high levels of compliance for 25 months following implementation. Adult ICU CLABSI and VAP rates decreased in association with the hand hygiene compliance improvements.

Memorial Hermann: high reliability from board to bedside.

BACKGROUND: In 2006 the Memorial Hermann Health System (MHHS), which includes 12 hospitals, began applying principles embraced by high reliability organizations (HROs). Three factors support its HRO journey: (1) aligned organizational structure with transparent management systems and compressed reporting processes; (2) Robust Process Improvement (RPI) with high-reliability interventions; and (3) cultural establishment, sustainment, and evolution. METHODS: The Quality and Safety strategic plan contains three domains, each with a specific set of measures that provide goals for performance: (1) "Clinical Excellence;" (2) "Do No Harm;" and (3) "Saving Lives," as measured by the Serious Safety Event rate. MHHS uses a uniform approach to performance improvement--RPI, which includes Six Sigma, Lean, and change management, to solve difficult safety and quality problems. RESULTS: The 9 acute care hospitals provide multiple opportunities to integrate high-reliability interventions and best practices across MHHS. For example, MHHS partnered with the Joint Commission Center for Transforming Healthcare in its inaugural project to establish reliable hand hygiene behaviors, which improved MHHS's average hand hygiene compliance rate from 44% to 92% currently. Soon after compliance exceeded 85% at all 12 hospitals, the average rate of central line-associated bloodstream and ventilator-associated pneumonias decreased to essentially zero. CONCLUSION: MHHS's size and diversity require a disciplined approach to performance improvement and systemwide achievement of measurable success. The most significant cultural change at MHHS has been the expectation for 100% compliance with evidence-based quality measures and 0% incidence of patient harm.

Improving erythropoietin-stimulating agent administration in a multihospital system through quality improvement initiatives: a pre-post comparison study.

INTRODUCTION: : Erythropoietin-stimulating agent (ESA) use is associated with serious adverse events in patients with hemoglobin levels of 12 g/dL or higher at the time of administration. Our aim was to determine whether inappropriate ESA use has changed over time since the implementation of new drug warning alerts and local quality improvement initiatives. MATERIALS AND METHODS: : We performed a retrospective review of ESA administration practices at Memorial Hermann Healthcare System (Houston, Tex). Our primary outcome measure was the proportion of inpatient encounters (one entire inpatient hospital stay) with 1 or more inappropriate uses of ESA (defined as ESA administration for a patient with hemoglobin ≥12 g/dL). We analyzed the potential influence of local and national interventions on ESA utilization patterns. RESULTS: : Between May 1, 2006, and May 31, 2009, 15,642 inpatients were treated with ESAs in our system. We classified inpatients as before intervention (n = 6350) and after intervention (n = 9292) based on the date of implementation of a synchronous alert in the electronic medical record. We found a significant decrease in inappropriate ESA administration before to after intervention (9.03%-6.21%; P < 0.001), which can be translated into a 31.25% (05% CI, 21.93%-40.75%) relative risk reduction. Reduced odds ratios for inappropriate ESA use changed little after controlling for relevant demographic variables and clinical characteristics. CONCLUSIONS: : Following several quality improvement interventions to improve patient safety related to ESA use, we found a significant reduction in inappropriate ESA administration to inpatients in a large health care system.

Program requirements for fellowship education in the subspecialty of clinical informatics.

The Program Requirements for Fellowship Education identify the knowledge and skills that physicians must master through the course of a training program to be certified in the subspecialty of clinical informatics. They also specify accreditation requirements for clinical informatics training programs. The AMIA Board of Directors approved this document in November 2008.

A 2-minute pre-extubation protocol for ventilated intensive care unit patients.

BACKGROUND: Clinicians often are challenged with safely predicting the optimal time of extubation for ventilated patients. Commonly used weaning parameters have poor positive predictive value for successful extubation. METHODS: A total of 213 intubated patients in our 20-bed surgical intensive care unit were enrolled in a trial to test a prospective, observational, 2-minute extubation protocol (TMEP). Daily measurements were obtained on all intubated patients who met criteria, which included adequate oxygenation, systolic blood pressure, heart rate, hemoglobin, Glasgow Coma Score greater than 10t, absence of significant metabolic/respiratory acidosis, and absence of therapeutic or neurologic paralysis. During TMEP, endotracheally intubated patients were physically disconnected from the ventilator for a 2-minute period of observation while spontaneously breathing room air. Patients were extubated if they tolerated the trial without clinically significant desaturation or alteration of vital signs or mental status. RESULTS: The TMEP reliably predicted successful extubations in 203 of 213 patients (95.3%). Patients who required reintubation had a longer intensive care unit stay and a longer hospital stay. CONCLUSIONS: TMEP is a simple and reliable method of predicting successful extubation.

Evaluating collaborative features of critical care systems: a methodological study of information technology in surgical intensive care units.

PURPOSE: This study evaluates the collaborative features of a critical care system, CV, used in a surgical intensive care unit (SICU). In the evaluation, we take a socio-technical perspective--a view that the technical features of the system and social features of the work are fundamentally interrelated. METHODS: We utilized qualitative data collection and analysis methods. We undertook seven months of observations and conducted more than thirty interviews of healthcare providers in the SICU. RESULTS: We found that there are a wide variety of collaborative activities such as morning rounds and medication administration that a critical care system must support. We further found that CV supports healthcare providers by providing them awareness of others' activities. DISCUSSION: We discuss the issue of awareness in greater detail. We also provide some recommendations on how to evaluate how well a system supports collaborative features such as multiple perspectives on information, workflow dependences, and context.

Obesity does not affect mortality after trauma.

Although obesity has been proposed as a risk factor for adverse outcomes after trauma, numerous studies report conflicting results. The objective of this study was to compare outcomes of obese and nonobese patients after trauma. The study population consisted of all trauma patients admitted to a surgical intensive care unit in a Level I trauma center from January 1999 to December 2002. Admission data, demographics, injury severity score (ISS), severity of illness, hospital course, complications, and outcomes were compared between obese (OB; body mass index [BMI] > or = 30), and nonobese patients (NOB; BMI < or = 29). A total of 918 patients was included in the study, 135 OB (14.7%) and 783 NOB (85.3%). There was no significant difference in demographic data, ISS, APACHE II score, and hospital stay. Intensive care unit stay was longer for OB patients (6.8 vs 4.8 days, P = 0.04). Overall mortality was 5.9 per cent for OB and 8.0 per cent for NOB patients (P = 0.48). Mortality by mechanism of injury was 3.4 per cent OB versus 7.4 per cent NOB (P = 0.26) for blunt and 10.6 per cent OB versus 10.2 per cent NOB (P = 0.9) for penetrating injury. The three most common complications associated with death were pulmonary, cardiovascular, and neurological deterioration. Using logistic regression analysis, age and ISS and APACHE II scores were associated with mortality, but BMI was not. We conclude that obesity does not appear to be a risk factor for adverse outcomes after blunt or penetrating trauma. Further research is warranted to uncover the reason for discrepant findings between centers.

Readmission to surgical intensive care increases severity-adjusted patient mortality.

BACKGROUND: This study aims to determine whether severity-adjusted outcomes including mortality are adversely impacted by readmission to a surgical intensive care unit (SICU) during the same hospital stay. METHODS: The study included all patients admitted to the 20-bed tertiary care SICU in an urban teaching Level I trauma center and multiorgan transplant center from January 1, 1996 to December 31, 2001. This was a prospective observational study with secondary data analysis. Acute Physiology and Chronic Health Evaluation (APACHE II) and Simplified Acute Physiology (SAPS) severity scores were calculated by a clinical information system. Outcomes were extracted from a computerized data warehouse. RESULTS: In-hospital mortality and SICU length of stay (LOS) were measured for patients admitted and readmitted to the SICU. Of 10,840 patients admitted to the SICU, 296 (2.73%) required readmission to the SICU during the same hospital stay. The length of the original SICU stay was 4.9 +/- 6.7 days for readmitted patients compared with 3.2 +/- 6.0 days for nonreadmitted patients (p < 0.001). Readmitted patients had a higher mean APACHE II score on the day of original SICU discharge compared with nonreadmitted patients, 15.7 +/- 6.7 versus 13.8 +/- 7.1 (p < 0.001). The average APACHE II score increased from 15.7 +/- 6.7 to 18.1 +/- 8.6 between the day of SICU discharge and readmission (p < 0.001) and SAPS increased from 12.2 +/- 4.8 to 13.5 +/- 5.4 (p < 0.001). The distributions of severity-adjusted hospital mortality for both APACHE II and SAPS revealed that readmission to the SICU significantly increased mortality independent of the admission severity score. CONCLUSIONS: Readmission to the SICU significantly increases the risk of death beyond that predicted by the APACHE II or SAPS scores alone. Higher APACHE II and SAPS scores upon discharge from the SICU and longer SICU LOS are associated with an increased incidence of readmission to the SICU on the same hospital stay. These results may be used to optimize the timing of SICU discharge and reduce the chance of readmission to intensive care.

Technology, work, and information flows: lessons from the implementation of a wireless alert pager system.

The combination of collaborative work practices and information technology affect the flow of information in clinical settings. The introduction of a new technology into these settings can change not only established work practices but also the information flows. In this paper, we examine the introduction of a wireless alerts pager in a surgical intensive care unit (SICU). Through a qualitative study, we analyze the effects that this new information tool had on both the work practices in the SICU and the information flow in the unit. We describe four challenges that SICU staff members faced with respect to the alerts pagers. We found that the pager provided new routes of information to SICU staff but in doing so disrupted existing work practices and information flows.

Automated data acquisition and scoring for JCAHO ICU core measures.

The Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) has recently established six Core Measures as indicators of quality in the delivery of care to adult Intensive Care Unit (ICU) patients. These Core Measures are demanding in terms of the amount of physiologic, medication, treatment and observational data required for measurement. At Cedars-Sinai Medical Center (CSMC), a Clinical Information System (CIS) gathers data for all ICU patients. For 72 beds in eight adult ICUs, the CIS was configured to ensure automated and easy charting of Core Measure observations. Severity of illness is automatically calculated from physiologic and admission data. All data is automatically transferred to a relational database daily. A Core Measure scoring program was devised to produce weekly and monthly run charts of JCAHO ICU Core Measure performance for each ICU. Internal publication of results and refinement of care processes led to progressive improvement in compliance with Core Measure treatments.

The electronic medical record, safety, and critical care.

The goal of this article is to introduce the elements of the Electronic Medical Record as they pertain to critical care medicine including order communications and decision support.

The CRIT Study: Anemia and blood transfusion in the critically ill--current clinical practice in the United States.

OBJECTIVE: To quantify the incidence of anemia and red blood cell (RBC) transfusion practice in critically ill patients and to examine the relationship of anemia and RBC transfusion to clinical outcomes. DESIGN: Prospective, multiple center, observational cohort study of intensive care unit (ICU) patients in the United States. Enrollment period was from August 2000 to April 2001. Patients were enrolled within 48 hrs of ICU admission. Patient follow-up was for 30 days, hospital discharge, or death, whichever occurred first. SETTING: A total of 284 ICUs (medical, surgical, or medical-surgical) in 213 hospitals participated in the study. PATIENTS: A total of 4,892 patients were enrolled in the study. MEASUREMENTS AND MAIN RESULTS: The mean hemoglobin level at baseline was 11.0 +/- 2.4 g/dL. Hemoglobin level decreased throughout the duration of the study. Overall, 44% of patients received one or more RBC units while in the ICU (mean, 4.6 +/- 4.9 units). The mean pretransfusion hemoglobin was 8.6 +/- 1.7 g/dL. The mean time to first ICU transfusion was 2.3 +/- 3.7 days. More RBC transfusions were given in study week 1; however, in subsequent weeks, subjects received one to two RBC units per week while in the ICU. The number of RBC transfusions a patient received during the study was independently associated with longer ICU and hospital lengths of stay and an increase in mortality. Patients who received transfusions also had more total complications and were more likely to experience a complication. Baseline hemoglobin was related to the number of RBC transfusions, but it was not an independent predictor of length of stay or mortality. However, a nadir hemoglobin level of <9 g/dL was a predictor of increased mortality and length of stay. CONCLUSIONS: Anemia is common in the critically ill and results in a large number of RBC transfusions. Transfusion practice has changed little during the past decade. The number of RBC units transfused is an independent predictor of worse clinical outcome.