Hospital reduces neonatal fatalities by 50%

By Kim Smiley

Infant mortality rate is often used as an indication of a nation’s health and social condition.  When reviewing the data for different countries, it becomes obvious that for a wealthy, developed country, the United States has a high infant mortality rate. According to the CIA World Factbook, the US infant mortality rate is 6.2 deaths per 1,000 births, which is nearly twice that of France, Italy and Spain. Additionally, the US ranked 60 for maternal deaths in a study for the Institute for Health Metrics and Evaluation.

The good news is that healthcare providers are working to improve care and help reduce preventable injuries and deaths during childbirth.  Obviously, access to prenatal care, overall health of the mother and other factors play a role in birth outcomes, but some relatively simple solutions targeting labor and delivery care have proven to dramatically increase birth outcomes.  A new report “Solutions in Sight” by the nonprofit Public Citizen lists some of the successes in improving birth outcomes.

One particularly impressive case is that of Ascensions Health, which reduced its neonatal fatality rate by 50% across its 43 hospitals by implementing relatively cheap, common-sense solutions.  Ascension did a number of things to help improve birth outcomes such as improving training and communications.  Drills were done to practice how staff should respond in a variety of emergency situations to help medical personnel identify and quickly respond to potentially dangerous scenarios.  There was also focus on communication between personnel to help ensure there were no misunderstandings in high pressure situations and to encourage all staff members to speak up if they perceived a dangerous situation.

Additionally, they worked to develop “bundles” of services, which are packages of procedures that have been shown to produce the best results.  Bundles are essentially guidelines for how staff should respond in a variety of situations.  There was also an emphasis on reducing C-section deliveries that weren’t medically necessary because these types of births are associated with a higher rate of complications. None of these solutions were earth-shattering, but they have proven effective when consistently implemented.

In additional to the clear benefit of saving lives and reducing the number of potentially life-long injuries, improving birth outcomes has economic benefits.  Better birth outcomes reduce the likelihood of expensive lawsuits. This example is a classic win-win where doing the right thing actually saves money in the long run as well.

Many of us do not spend our days delivering babies, but this example has many lessons that can be applied across industries.  Learning how to provide effective, realistic training can dramatically improve performance.  Empowering employees at all levels to speak up when something doesn’t look right can save lives, whether it’s in a factory or a hospital.  Formally documenting and using best practices so employees can benefit from others’ experience can streamline many processes and reduce preventable errors.  Sometimes the simple solutions really are the most effective.

Typically, a Cause Map is built when something has gone wrong, but it can also be used as a proactive tool to help understand why something has gone right.  To view a high level Cause Map of this example, click on “Download PDF” above.  Another example of a proactive, positive Cause Map is the Miracle on the Hudson, where all passengers survived a plane landing on a river.

After Patient Death, CMS Surveyor Declares “Immediate Jeopardy” To Patient Safety

By ThinkReliability Staff

From the moment a patient arrived at an endoscopy clinic in New York on August 28, 2014, things didn’t follow the usual procedure.  The patient brought her own ear, nose and throat physician (ENT) to accompany her into surgery for an esophagogastroduoudenoscopy (EGD), though the ENT did not have privileges at the facility.  The patient signed a consent form for anesthesia, and the EGD and her vital signs were taken, though it appears her weight was either not taken or not recorded.

After a time out that was initiated by the endoscopy technician (as opposed to the anesthesiologist, as required by policy) for the EGD, the patient was administered Propofol for sedation.  After the patient was sedated, the ENT attempted to perform a nasolaryngoscopy, despite not having facility privileges or a record of patient consent, but the initial attempt appears to have been unsuccessful.  After the EGD was completed, the ENT performed another nasolaryngoscopy beginning at 8:28 AM and ending (per interview records) at 8:30 AM.

By that time, the patient’s condition was quickly deteriorating.  Her blood pressure had dropped from its pre-procedure level of 118/80 to 84/40, her pulse from 62 to 47, and oxygen saturation from 100% to 92%.  Both the Cardiac Arrest Record and the Endoscopy Code Blue Record indicate that at 8:28 AM (the same time the second nasolaryngoscopy was beginning) the patient went into cardiac arrest/ ventricular tachycardia and measures were taken for resuscitation (including assisted ventilation, chest compressions, and administration of epinephrine and atropine).

The record of the surgery note that the laryngoscope was withdrawn at 8:30 AM, at which time cardiopulmonary resuscitation (CPR) was undertaken.  The patient was resuscitated and transferred to a hospital, where she died on September 4, 2014.  The cause of death from the autopsy report was anoxic encephalopathy (brain damage) caused by hypoxic cardiac arrest (oxygen deprivation).

The day prior to the patient’s death, a surveyor from the Centers for Medicare and Medicaid Services (CMS) declared “Immediate Jeopardy” due to “significant findings . . . which compromised patient safety”.  Specifically, the surveyor noted that the facility had risked patient safety by allowing a doctor without privileges to be allowed in the operating room and perform a procedure, and not obtaining consent or performing a time out for a procedure that was performed.

The facility quickly submitted a corrective action plan that revised procedures allowing visitors to the facility, ensuring informed consent and time out procedures are used before every procedure, and providing training on these updated procedures to staff.  Immediate jeopardy was removed on 9/5/14, although the facility was still considered out of compliance with CMS requirements, and was given until March 2 to maintain its certification.  (CMS has not released whether the facility has been successful.)

A lawsuit is underway that may provide more detail as to how the CMS findings caused (or didn’t cause) the patient’s death.  At this point, what is known can be captured in a timeline (for a chronology of events) and a Cause Map (to capture the cause-and-effect relationships that led to the impact to the goals) to start organizing and presenting information logically.  As more information is available, the Cause Map can be updated.

To see the timeline and initial Cause Map, click on “Download PDF” above.


This year’s flu vaccine only about 23% effective

By Kim Smiley

According to the Centers for Disease Control and Prevention (CDC), the flu vaccine for the 2014-2015 flu season is only about 23% effective among people of all ages.  While the flu vaccine is not perfect, the effectiveness is generally closer to 60% percent.

So what made this year different?  Why is the flu vaccine so much less effective than what has been previously observed?  The short answer is that creating a flu vaccine is not an exact science and that the experts’ best guess of which flu strains would be the most common wasn’t as good this year.

One of the reasons that a flu vaccine is needed each year while many vaccines (like the MMR vaccine) aren’t is that the flu virus changes relatively quickly.  The strains of flu that are circulating generally morph from year to year and a new vaccine is needed to protect against them.  The lag time inherent in developing a new vaccine also makes attacking this moving target  difficult.  It just takes time to develop a new vaccine that needs to be tested, manufactured and distributed to millions of people.  Companies need about six months to manufacture vaccines in the quantities required so the process of developing a new flu vaccine begins long before the predicted start of the flu season.

Every year there are hundreds of different strains of flu circulating and flu vaccines contain antigens for only 3 or 4 specific strains. Deciding which strains to include in the vaccine each year is not a simple cut and dry decision. Scientists monitor which strains of flu are circulating worldwide and use that data to select which strains to include in the vaccine, but it is difficult to predict how the virus will change months out.  The button line is that sometimes the flu virus changes unexpectedly and the vaccine ends up being less effective, as it did this year when the specific type of H3N2 virus included in the vaccine morphed after the development of the vaccine.

The question of how to prevent a similar problem in the future is tricky and doesn’t have simple answers.  There are scientists working to develop antigens that would respond to a part of the flu virus that doesn’t change, which could potentially lead to a longer lasting flu vaccine.  Until then the best way you can protect yourself is to get the flu vaccine each year. The CDC still recommends people receive the vaccine this year, even with the lower effectiveness, because it does offer some protection against the flu.

And wash your hands often with soap…that is always the simplest way to reduce the spread of disease.

To view a high level Cause Map, a visual root cause analysis, of this issue, click on “Download PDF” above.

VA works to save nurses’ backs

By ThinkReliability Staff

More than 35,000 nursing employees suffer back and other injuries every year that impact their ability to perform their jobs.   Their rate of musculoskeletal injuries is about three times that of construction workers.

The commonly taught “proper” lifting techniques and sharing the lift with other employees doesn’t help.  Says William Marras, director of The Ohio State University’s Spine Research Institute, “The bottom line is, there’s no safe way to lift a patient manually.  The magnitude of these forces that are on your spine are so large that the best body mechanics in the world are not going to keep you from getting a back problem.”

Armed with these findings, and some studies of their own, the Department of Veterans Affairs (VA) is leading the way in preventing these types of injuries.  The VA discovered that at least $22M (believed to be underestimated) was spent treating employees’ injuries every year.  There are other indirect costs – patient care suffers when nurses are unable to perform their jobs.  At least 2,400 nursing employees at the 153 hospitals operated by the VA suffer injuries every  year that interfere with their ability to work.

Says the VA, “In recent years, a patient body weight of 35 pounds was established as the maximum weight that providers can safely lift when lifting and moving patients without the risk of injury.  This limit requires a new approach to lifting and moving patients.”

To determine what that new approach should be, the VA looked at what was causing the injuries, and why.  (To see the cause-and-effect relationships leading to the nurse injuries at the VA in the Cause Mapping format, click on “Download PDF” above.)  As part of their routine tasks, nurses regularly lift more than 35 pounds.  (The weight of a 200-pound patient’s leg is about 40 pounds.)  Not only moving patients, but repositioning them was a problem.

The availability of equipment that provides lifting (or repositioning) assistance to nurses was a big issue.  Many hospitals purchase just a few pieces, which are frequently unavailable (or incredibly inconvenient) when needed.  The VA is working to install ceiling lifts in all patient rooms and everywhere else patients need to go (clinics, imaging departments, etc.).  They’re also using “floating” mattresses, which use an air stream to “float” patient mattresses from bed to gurney.

Even having readily available equipment didn’t completely solve the problem.  The VA is working to ensure that staff, who were accustomed to manually handling patients, would actually use the equipment.  Rather than minimal and occasional training, the VA trains on lifting constantly.  At least one employee on duty at all times is responsible for ensuring safe lifting technology is used.  Injuries that can be sustained from manual lifting are emphasized.  Additionally, each hospital has a “safety champion”.  This is a full-time position that ensures that other employees have what they need to ensure safe lifting and that the hospital as a whole puts in the time and money to protect worker’s backs.

These programs come at a cost, but appear to be very successful in reducing injury rates (and associated costs) at these hospitals.  The VA as a whole has spent more than $200 million since 2008 on its “safe patient handling program” and has reduced nursing injuries from moving patients 40%.  One California VA hospital has spent $2 million to install lifts across the hospital.  Before the program, it spent $1 million over four years hiring replacements for injured employees.  Last year, nobody got hurt badly enough to miss work.  Says Tony Hilton, the hospital’s safe patient handling and mobility coordinator (“safety champion”), “Remember, I’m your guardian angel.  You know I’ve got your back.”

Click on “Download PDF” to see an overview of the cause-and-effect relationships for which the VA is implementing solutions to reduce nursing injuries.  Or, click here to learn more about the VA’s program.