What Works -- Part 7 -- Vascular Surgery Successes

This is one of the posts in which I simply brag about the excellent clinical work I see at this hospital.

We see many, many patients here with diabetes. Notwithstanding improved care of diabetic patients, one of the unfortunate problems they face is vascular disease, particularly in the lower extremities. So patients sometimes show up with the prospect of needing a foot or limb amputation.

It turns out that our vascular surgeons are extremely competent at fixing malfunctioning blood vessels, either by grafting new ones or inserting stents to reopen the original ones. There have been many cases where patients have learned that they could retain their foot after this surgery. I have had a chance to watch these procedures, and you really have to marvel at the ability of surgeons to repair extremely tiny blood vessels in the lower leg.

Here is a summary of activity in our Vascular Surgery division. Over 4000 revascularizations have been performed since 1990. The overall mortality rate is 1.1 %, which is substantially less than reported across the country at high volume centers (4.9%) .

The effectiveness of graft surgery is measured by patency, "the state or quality of being open, expanded, or unblocked." The first chart above shows the record for our hospital for bypass grafts to the foot. (On the chart, primary -- meaning no further intervention necessary -- is shown below; secondary -- meaning some revisit for clotting or another problem, is the line above above). Randomized trials elsewhere show one year patency of about 60%. We show similar results five years after surgery.

Another measure of success is the ability to save limbs over an extended period of time. The second chart above shows the results on this score for our surgeons. Many other institutions show 50 to 80% limb salvage after one year. Our place shows 78% after five years.

I think they are reading this . . .

While I know that lots of you out there from all over the world are reading this blog, I really don't know how many people inside BIDMC are. But, every now and then, I get word that someone is and has used what I have said to help motivate their own folks. As I have noted below, in an academic medical center, you are highly dependent on individual motivation to make improvements.

Here's the latest, from one of the leaders of the Emergency Department to every person working there:

From: Tracy,Jason A (BIDMC - Emergency Medicine)
Sent: Sunday, April 15, 2007 1:53 PM
To: Emergency Attendings; Emergency Residents; Emergency Techs; Emergency Nurses; Emergency Registration; Emergency UCO
Subject: Our CEO & "Dirty" tickets

Please note our CEO’s concern about hand washing & infection control at BIDMC: http://runningahospital.blogspot.com/2007/04/i-want-to-be-proud-but-i-am-not.html

Contaminating a vulnerable patient with a methicillin-resistant staph can result in a disastrous outcome. Hand washing is needed to keep our ED patients safe.

ED hand washing initiatives include:
- Improved signage & education – signs are posted throughout the ED (thanks Sue) and an educational campaign has started
- Peer-review and feedback – please help educate your peers, off-service rotators, students, support staff, etc.
- Spot checks & mystery observers (by ED team members and ID staff) – these “secret” checks are for statistics and feedback
- Cal-stat usage checks – the hospital tracks how much Cal-stat we use and analyzes usage based on patient encounter models
- “Dirty” tickets – these hand washing violations (tickets) will be given to violators to be signed by their supervisor

Yes, it is very difficult to wash/Cal-stat so much. Yes, it takes extra time. Yes, there are other safety issues to focus on. Yes, it’s fast-paced in the ED.

However, for all the reasons stated in our CEO’s blog, it’s not optional and we must do better.

Please send me any other ideas to improve compliance (short of a Cal-stat dispensing bedside turnstile) and/or interest in helping with this initiative.

What's in a number?

I have been searching for meaningful and effective ideas to present our central line infection rate that might supplement the one we use. We use the ratio of cases per thousand ICU patient-days. This is a good and accurate metric, but the problem that arises when you have a consistently low figure like 0, 1, or 2, is that there will inevitably be variation around it that may not be helpful in analyzing or explaining how you are really doing over time. Plus, is there another metric that gives just a bit more incentive to improve?

I am not talking about what our goal is. Our goal is "zero." Whether expressed as a rate or a simple number, the virtue of "zero" is that it is indeed "zero" in both cases. As Paul O'Neill has often noted, "Setting zero errors as a goal encourages breakthrough thinking, orients work cultures towards continuous improvement, and keeps people pushing toward the goal."

In factories, you often see a sign saying "x days since our last accident" that motivates people to pay attention to safety procedures and practices. We could do that for our hospital, i.e., "X days since our last central line infection," but I am not sure if it would be as effective. For one thing, we have several ICUs dealing with different kinds of patients and different degrees of difficulty in avoiding central line infections.

For example, we have heard an excellent report from folks in Pittsburgh championing a year without a line infection, but this was for their cardiac care unit only. In our CCU, they are past the 300 day mark without a line infection, but CCUs are lower risk than other ICUs.

Of course, this problem already exists for our composite ICU rate, too. And people will point out that factories have lots of different manufacturing sections with variation in risk. A company-wide figure creates both an overall sense of pride and community and internal peer pressure among the various corporate divisions to not let the whole group down by being the site of an accident.

Would that work within the setting of academic medicine? What's the verdict from those of you out there? Have any of you done this? Did it make an appreciable difference in how people behaved? In public perception of your institution?

Would it matter to you as a prospective patient? If you read a website saying "60 days since our last infection", would you say to yourself, "What an excellent hospital" or would you say "That's a long time -- there is bound to be an infection soon, and maybe it will be me"? Does it work better or worse than posting an infection rate of "1.2 cases per thousand ICU patient-days"?

I want to be proud, but I am not

I had hoped never to have to say such a thing. BIDMC is a wonderful hospital, full of warm, well-intentioned, and competent people who achieve excellent clinical results and even the occasional miracle. But I saw numbers recently that make me cringe. So it is time to let you know -- and to let my staff know -- that enough is enough.

I am talking about hand hygiene. I have raised this topic before and have referred to the national problem. Medical staff can't seem to remember that germs can be carried from one room to another, and one patient to another. OK, they know this, and they believe it. But they can't seem to toss off bad habits and adopt ingrained behavior to make sure they practice proper hand hygiene.

I like to think that things have improved from the 1840s:

Ignaz Philipp Simmelweis, while working as a doctor in Vienna from 1844 to 1850, determined that ... childbed fever was being spread in maternity hospitals by dirty hands. He proved that a chlorine hand wash reduced deaths from 18.27 percent to 1.27 percent. His superiors scorned his findings and eventually he lost his position. In the city of Pest, he repeated the hand washing measures, reducing mortality due to childbed fever to an average of 0.85 percent while elsewhere the death rate was 10-15 percent. Despite acceptance of his work by the young medical students and by the government of Hungary, and being published in medical journals of the time, his work was disdained by the academic authorities of the time.

But, maybe they have not improved. How else to explain the lack of compliance with well established principles of hand hygiene.?

So why am I upset? After months of intensive effort and various education and other campaigns, our compliance with hand hygiene has risen from 52% on our medical-surgical floors to 57%. Sure, it is great to see it rising, but does this result provide confidence to anyone out there that the message has sunk in? And, some floors remain at or below 40%. The results are better in the ICUs, rising from an average of 60% to 71%. But, in the words of our Quality and Safety staff, "opportunities remain for performance improvement and sustainability of improvement."

The results on one particularly noncompliant floor have prompted one of our Chiefs to write to his physicians:

THIS IS ABSOLUTELY INTOLERABLE!
It is bad patient care.
It increases our post op infection rate.
We should be setting the example for the students and nurses.
I have asked [the nurse manager] to have the nursing staff call attention to any physician, resident, staff, PA, med student, fellow, etc) on the ... service who does not wash his or her hands. This is meant to remind you. If I hear of anyone reprimanding a nurse for such a reminder, you will hear from me and it won't be a friendly call. I have no problem with you reminding the nursing staff if you see a lapse as well. Together we must achieve 100% compliance. There is no reason not to.

There is no reason not to. Dear BIDMC, please make me proud.

Falls

Hospitals do all they can to avoid patient falls. Falls can lead to minor cuts and bruises, but they can also cause serious injuries. It is a cruel irony to be injured in a fall when you are being cured in a hospital.

All falls are recorded to evaluate what happened and why. One of our folks was recently looking through our reports and noticed a pattern. Three people had recently suffered falls just as they were about to be discharged. No, not after they left their room and were heading home. But while they were sitting on the edge of their bed, fully clothed, ready to go.

What was happening here? We think that our staff members were receiving a subliminal message: They would see a healthy, dressed person in the room and might not have paid the same degree of attention to the patient as they would have an hour earlier when he or she might have been sitting on the edge of the bed in a hospital gown. Slight dizziness or instability of this person would then lead to the fall.

So, now we have circulated the word to the floors to be alert to this possibility, and we are hoping to see a difference. This takes no major effort, just an extra bit of attention at the right time.

Unexpected problem, good analytical pickup by one of our quality and safety staffers, and a simple solution. Not all safety improvements require a huge effort.

I'm curious whether other hospital folks out there have seen this particular phenomenon, too, and, if so, what you did about it. Ditto for other types of safety and quality observations

Central Line Infections, both better and worse

Here are our latest figures for central line infections, measured in cases per thousand ICU patient days. The average over the last several months remains better than for the previous year, but the rate for February comes from two actual cases, worse than January and with 100 fewer patient days. As always, we treat them as sentinel events and try to learn what went wrong and why.

Our folks are really serious about this and, in my opinion, deserve a lot of credit. A friend of mine was recently in the hospital and had one of these lines put in his chest for delivery of an anti-cancer drug. His wife, a medical professional, watched the doctor and nurse insert the line and was very impressed with their understanding of, and rigorous application of, the protocol. (And no, my friends did not mention to their providers that they had read all about this in my blog.)

Month ----- Infection Rate
Oct 05 ----- 1.67
Nov 05 ----- 1.28
Dec 05 ----- 2.43
Jan 06 ----- 3.07
Feb 06 ----- 1.40
Mar 06 ----- 1.07
Apr 06 ----- 0.00
May 06 ----- 0.59
Jun 06 ----- 1.15
Jul 06 ----- 0.57
Aug 06 ----- 3.03
Sep 06 ----- 2.50
Oct 06 ----- 0.00
Nov 06 ----- 2.38
Dec 06 ----- 1.87
Jan 07 ----- 0.00
Feb 07 ----- 1.15