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Administrators at John Dempsey Hospital at the University of Connecticut Health Center in Farmington, CT, have bought into the idea of using checklists and similar tools to standardize and improve medical practices, and they have proven that such tools can be instrumental in moving key metrics in the right direction. A dramatic improvement in door-to-balloon times is just one example, according to Scott Allen, MD, the medical director for clinical effectiveness and patient safety at Dempsey Hospital.
"Three or four years ago, we were probably in the 60% range in terms of compliance with the 90-minute door-to-balloon metric, so we knew we had a problem," explains Allen. Consequently, an improvement team, consisting of members of the EMS staff, emergency physicians, nurses, cath lab staff, and quality personnel, devised a solution that includes a "tackle box" containing all the supplies and forms needed whenever a STEMI (ST segment elevation myocardial infarction) patient presents to the ED, complete with a checklist of all the required materials and steps so that the case is handled thoroughly and efficiently.
Data from 2013 show that the hospital’s median door-to-balloon times are now down to 46.5 minutes, exceeding both state and national median times, and Allen observes that a process for quality improvement is ongoing with every STEMI case that presents.
The STEMI improvement team now meets every month to review data and ideas for further improvement, but perhaps even more important than this meeting is a standard policy to review every STEMI case right away. "Every door-to-balloon gets an immediate debrief by EMS, nursing from the ED, and nursing from the cath lab in terms of what went right and what went wrong," explains Allen.
"We have a sheet that outlines each of the major time [intervals] such as door to EKG or EKG to cath lab and [the meeting participants] write down each of those times. Then they are reviewed at the monthly meetings. However, if there is something that doesn’t work, and it is a serious issue, then we are able to address it right then and there in real time."
The idea for the tackle box approach grew out of the observation that standardization could resolve multiple hold-ups throughout the process of care for STEMI patients, observes Allen. "The tackle box mentality was just that we wanted everything in one place. We didn’t want to have to think about where the consent form is or where the medicines we need are," he says. "Everything that is needed is portable and in one place."
With this approach, the patient doesn’t even physically need to stop when he or she presents to the ED, says Allen. "The cardiac team is meeting the patient at the door, and they are literally walking with the patient," says Allen. Further, the ED primary nurse takes charge of the tackle box, and he or she stays with the patient as well. "As long as the patient is stable and ready to go, everything is happening en route to the lab," adds Allen.
To ensure that every important step takes place as patients are quickly transported to the cath lab, a checklist with seven "must have" items is posted on the top of the tackle box for quick reference.
• ID bracelet on the patient;
• defib pads on the patient;
• ED primary nurse with the patient — RN to RN report;
• copy of ED chart, including all ED paper work, EKG, stickers, etc;
• IV(s) intact;
• patient is undressed;
• patient on oxygen.
One other step the improvement team has made to speed STEMI patients to care is having EKGs sent to the ED by EMS prior to the patient’s arrival. Allen notes that the hospital was among the last in the region to implement this practice, but with that process now in place, the cath lab team is activated before the patient arrives. "If we have any sense that there is a STEMI patient in the field, our cath lab is activated, so we encourage the EMS crew to call in a STEMI alert even if they are not entirely sure," says Allen.
Further, nursing supervisors are now instructed to go to the cath lab to turn on the equipment whenever a STEMI alert is called. "The computers and the equipment are now turned on and warmed up before the cath lab team arrives," says Allen. "That has shaved off a few minutes from the process."
There were multiple challenges involved with implementing the new STEMI process, but getting buy-in from the cath lab was a particularly important step. "Eventually I got the director of the cath lab to attend the [monthly] meetings, and that is when the process really gelled," says Allen. "At that point, we had buy-in from all the key stakeholders: ED physicians, cardiologists, and all the staff in both of those areas."
Key to winning the support of cardiologists was getting them to realize what was in this improvement effort for them, notes Allen. Consequently, having the data on hand to demonstrate that the hospital really needed to make improvements was critical. "You have to make the case as to why this is important. Clearly this is a patient safety issue, it’s an outcomes issue, and it is a financial issue as well, with this being a core measure," says Allen. "Once the cardiologists bought into the idea that they could really get their times down by critically looking at the process, we made significant strides."
The improvement in door-to-balloon times is part of a larger, organization-wide initiative aimed at improving quality and safety that began more than five years ago, when Connecticut’s Department of Public Health put the hospital on probation because of a series of incidents that led to patient harm. At that point, Ann Marie Capo, RN, MA, an associate vice president and chief quality and patient safety officer at Dempsey Hospital, led a successful two-year effort to get the hospital off probation.
"We accomplished that through the use of multidisciplinary teams that homed in on specific issues that were outlined in the report that the Department of Public Health brought forward to us," explains Capo. However, she adds that this was just the beginning of what became a much more comprehensive mission.
Dempsey Hospital is now plugged into a three-year, statewide effort, led by the Connecticut Hospital Association (CHA), to adopt high-reliability practices and eliminate medical errors. With all of the hospitals in the state pushing in the same direction, there is ample opportunity for administrators to learn from each other’s mistakes and share best practices. "All 29 hospitals in the state have pledged to participate in this initiative, and we are a small enough state for this kind of collaborative effort to work," observes Capo, who has taken a leadership role in the CHA collaborative.
For instance, most of the hospitals now hold daily safety huddles, an innovation aimed at keeping the focus on safety and continuous quality improvement while also ensuring that if an error occurs on one floor, the other floors will hear about this error and take the same corrective actions to prevent it as the floor on which it occurred.
At Dempsey Hospital, the daily safety huddles started in March of 2013. Capo usually presides over the huddles, but they include representatives from throughout the hospital. "We do a look back and a look forward," says Capo. "We start with the critical care areas, and we call out all of our service areas and they do a brisk report."
The safety huddles are designed to proceed swiftly, never taking more than 20 minutes, says Capo. "If someone has a situation occur today, the expectation is that they will tell us what the follow-up is going to be tomorrow," she says. For more difficult issues requiring system-level solutions, corrective teams are put in place to delve into the problems and devise corrective actions. Allen’s improvement team focused on shortening door-to-balloon times is one example.
"As we gather information during the week at our safety huddles, the information that needs to be distributed to staff goes quickly into a Friday flyer,’ and then that report gets posted and passed out to all the managers in all the areas," explains Capo. "Then, once a month we have a bigger safety newsletter that is published in which we highlight all the work that we have been doing."
For example, the newsletter will report on any safety stories about situations that occurred in the hospital that month, what corrective actions have been taken, and also how adverse events were prevented. The report also provides data on a range of safety-related metrics for the month.
In addition to the hospital-level safety huddles, there are unit-level huddles that occur at least once a day, and, in some cases, on every shift. The hospital has identified safety coaches from every department who actively participate in these huddles. "They bring information back to their units and meet on a monthly basis with the person in charge," explains Capo.
Getting hospital staff to identify and report errors is difficult, but it is essential to preventing repeat incidents of the same type. Consequently, hospital administrators have developed the "good catch award" as a way to highlight staff members who have identified an error before it reaches a patient, explains Capo. "Each time someone is nominated for a "good catch award," we give them a catcher’s mitt, and then after they have received four catcher’s mitts, we give them a more substantial award," she explains. "That has encouraged reporting."
As part of the CHA collaborative, more than 3,000 of the hospital’s staff members will undergo training focused on five key areas that administrators refer to by the acronym CHAMP:
• Communicating clearly;
• Handing off the care of patients safely;
• Attention to detail;
• Mentoring peers;
• Practice and accept a questioning attitude.
Campo stresses that it is not just the clinical staff members who are being held responsible for patient safety, but everyone in the hospital. In fact, she recalls one instance in which a housekeeper actually stopped a surgeon from going into the intensive care unit (ICU) while a central line was being placed. "Three or four years ago that employee might have been met with some harsh language, but that is no longer the case," says Capo. "What we are attempting to do here and what we are beginning to see the results of is a culture change that has to occur."
Capo notes that while the hospital used to rank below average on central-line associated blood stream infections (CLABSI), it has now gone for well over a year without a CLABSI in the ICU. Similarly, at press time, the hospital had gone for more than 80 days without a catheter-associated urinary tract infection (CAUTI) in the ICU. Capo adds that the hospital has gone from having poor scores on core measures to top percentile rankings in some areas. "This is a journey, and it is really an individual as well as an institutional commitment to put the patient first," she says.
To colleagues struggling with many of the same issues, Capo emphasizes that administrators at all levels of the organization need to be persistent. "You have to emphasize that the patient comes first always, and you have to keep reminding yourself because you will be challenged, especially in the beginning," she says. "There will be naysayers and there will be people who think they can opt out of the behaviors you are asking them to change."