Critical Path Network

Early 100,000 Lives’ participant sees benefits

Facility sees dramatic reductions in ventilator use

One of the better known ongoing collaborations in the United States is the Cambridge, MA-based Institute for Healthcare Improvement’s (IHI) "100,000 Lives Campaign," whose goal is to save 100,000 lives through targeted QI interventions by June 14, 2006. The campaign, launched in January 2005, features "Six Changes That Save Lives":

  • Deploy rapid response teams (called when a patient seems to be losing ground but isn’t yet a true emergency).
  • Deliver reliable, evidence-based care for acute myocardial infarction (AMI).
  • Prevent adverse drug events (ADEs).
  • Prevent central-line infections.
  • Prevent surgical-site infections.
  • Prevent ventilator-associated pneumonia (VAP).

To date, more than 2,300 hospitals have enrolled in all 50 states, accounting for about 50% of all U.S. hospital beds, according to IHI. If all U.S. hospitals joined, says IHI, 183,000 lives could be saved every year.

One of the early adapters, Hackensack (NJ) University Medical Center (HUMC), a teaching hospital in northern New Jersey with nearly 700 beds, already has started reaping the benefits.

"It’s incredible," says Regina Berman, director of process improvement. "It goes to the concept that a group mind is better than a single thought. We have a brain trust — some of the best minds in the country — to sit down with to share. They include great scientists, operations people, and pharmacists. We are benchmarking and sharing collaborative data all over the place."

A good foundation laid

Berman notes that one of the reasons why the program has been effective so quickly is that HUMC already had laid a strong foundation. "We’ve been part of the IHI network for some time because we are a Pursuing Perfection’ [another IHI initiative] hospital," she explains.

"In December [2004], we were down at the annual forum and heard Don’s [Berwick, head of IHI] kickoff speech [on the campaign]. It was quite impassioned and very moving, so we signed up immediately," Berman adds.

HUMC already had worked at reducing AMI mortality and, in fact, had some of the lowest rates in the country, she reports.

"We focused on our systems for patient care by starting to work with first responders to transmit vital information even before the patient arrives," Berman relates. "Plus, thrombolysis used to be the gold [clot-busting] standard; now, we do angioplasty."

HUMC also was part of the [Centers for Medicare & Medicaid Services] demonstration project, "and we’re in the top decile in each category," she adds.

HUMC already has deployed its rapid response team. "Our understanding is that it should be the senior rehab nurse, a critical care person, who leads the team, because others feel more comfortable calling them," Berman observes. "In some cases, you can use physicians, but we feel nurses may be reluctant to call a physician-led team."

There are clear benefits to a rapid response team, she continues.

"Sometimes, you have an intuitive sense of a change in patients — they just do not look good; they are anxious, but you do not have objective data yet," Berman explains.

"A nurse may hesitate to call a doctor, but if they can call and say I’m worried’ and someone will come, it tends to help capture a downward spiral more quickly," she adds.

Berman says that typically, from the time a patient is perceived to have a change in status to the time he or she actually expires, there is about an 8- to 12-hour window. "So the idea is to catch that change as early as you can," she asserts.

One of the areas in which HUMC has seen dramatic improvement, and in which there is a slight overlap with the start of the 100,000 lives campaign, involves VAP infections.

"It’s what we call our ventilator bundle,’ says Berman — five steps every day at exactly the same time. "We’ve not only been able to prevent pneumonia, but we get our patients off the ventilator more rapidly."

When the initiative began in October 2004, she recalls, "We might have had 12 patients on ventilators in the ICU." Now, Berman points out, "There may be one or two."

A similar approach is being used regarding central lines and avoiding bloodstream infections — keeping patients connected for as short a time as possible.

"We want them connected as long as they need to be, but not one second longer," Berman notes. Success in this area involves proper technique and preparation of the site before the line is inserted.

"We’re creating a video for the staff to show them the best technique," she says.

Another evidence-based practice HUMC is adopting involves surgical infection prophylaxis.

"The evidence suggests that instead of shaving patients, you should use a clipper," Berman points out.

"Patients used to be shaved the night before surgery, and when they got nicks, bacteria got in them. Now, no one gets shaved until they are up in the OR and antibiotics have been started," she explains. Finally, HUMC is working on further improvements in medication reconciliation, to help prevent ADEs.

"The concept here is to do everything we can to include a call to the patient’s pharmacy for a complete and accurate list [of the medications the patient is on]," Berman says.

"Throughout their stay, changes are updated electronically, so we can ensure when they go home, they know exactly what to take, how often, and who to check with to make any changes," she notes.

Part of that effort, she adds, is to try to get patients to take more responsibility for compliance. "For our heart patients, we’ve created pillboxes and created a sample of what a day looks like," Berman adds. "We’ll take simple approaches to see what works to make things better."

Joining the 100,000 lives project involves no fee, and paperwork is minimal, according to IHI.