Transcript Standardizing communication and treatment of shock

The Imperative to
Improve Quality
Virginia A. Moyer, MD, MPH
Baylor College of Medicine
Texas Children’s Hospital
Disclosures
I have no relevant financial relationships
with the manufacturers of any commercial
products and/or provider of any
commercial service discussed in this CME
activity.
 I do not intend to discuss an unapproved
or investigative use of a commercial
product or device in my presentation.

What are we trying to accomplish?

Right care for the right patient at the right
time in the right way

Better health outcomes for children,
families, and communities
A true story
RCT of treatment of hypertension on the
jobsite (a steel mill) vs. referral for
treatment to primary care practitioner
 No difference in compliance between the
groups
 Exploration of factors relating to therapy
revealed:

Determinants of the clinical
decision to treat hypertension:
1.
2.
3.
4.
The level of diastolic blood pressure.
The patient’s age.
_
The amount of target-organ damage.
Determinants of the clinical
decision to treat hypertension:
1.
2.
3.
4.
The level of diastolic blood pressure.
The patient’s age.
The physician’s year of graduation
from medical school.
The amount of target-organ damage.
More true stories



A term baby was born with sluggish respirations. During
labor, the mother had received meperidine (Demerol,
half-life 2.5-4.0 hours in adults and 12-39 hours in
neonates.) The physician started resuscitation and
ordered naloxone. Shortly after administration of the
medication, his condition began to deteriorate further.
Prompted by the proximity of the deterioration to the
administration of the naloxone, the physician checked
the packaging of the drug. The syringe had inadvertently
been filled with Lanoxin. The packages of both drugs,
made by the same manufacturer, were almost identical.
ECG revealed bi-directional ventricular tachycardia,
consistent with digoxin toxicity.
Approximately 1 hour later the baby died. A post-mortem
digoxin level was 17 ng/ml (therapeutic range 0.8 to 2
ng/ml).
From the AHRQ Web M&M files
A previously healthy 10-month-old girl was diagnosed with irondeficiency anemia. One of the nurses explained in broken
Spanish that the child had “low blood” and needed to take a
medication. The pediatrician wrote the following prescription
in English:
“Fer-Gen-Sol iron, 15 mg per 0.6 ml, 1.2 ml daily (3.5 mg/kg)”
The pharmacist attempted to demonstrate proper dosing and
administration. The prescription label on the bottle was written
in English. Within 15 minutes of receiving the first dose, the
child vomited twice and appeared ill. In the emergency
department, the serum iron level 1 hour after ingestion was
365 mcg/dL (therapeutic = 60-180 mcg/dL). She was
admitted, was asymptomatic for the remainder of the
hospitalization, and was discharged the following day with no
apparent sequelae. Upon questioning, the parents stated that
they had administered a household tablespoon of the
medication, approximately 43 mg/kg (a 12.5-fold overdose).
From the AHRQ Web M&M files

Jim T developed fever and cough while in Maryland at
his grand-daughter’s graduation. Didn’t get care until
he got back to Houston breathless and hypoxic, and
was hospitalized for 5 days for pneumonia. Widely
accepted guidelines for CAP recommend levoquin
alone, he got levoquin and vancomycin. Vanc takes
hours to infuse and causes considerable phlebitis. He
refused to eat, did his best not to cough, and didn’t get
an incentive spirometer until his wife asked for
something to make him try to breathe deeply. He had
a CT scan for elevated liver enzymes, the results of
which were AWOL for 2 days. He was ready for
discharge on Sunday, but his own doctor was not on
call, so he stayed until Monday. He was unhappy with
his care because the trash cans were rarely emptied,
even when they were full of vomitus and smelled bad.
IOM Domains of Quality
Safe
 Effective
 Patient Centered
 Timely
 Efficient
 Equitable

Determinants of the clinical
decision to treat hypertension:
1.
2.
3.
4.
The level of diastolic blood pressure.
The patient’s age.
The physician’s year of graduation
from medical school.
The amount of target-organ damage.
Determinants of the clinical
decision to treat hypertension:
1.
2.
3.
4.
The level of diastolic blood pressure.
The patient’s age.
The physician’s year of graduation
from medical school.
The amount of target-organ damage.



A term baby was born with sluggish respirations. During
labor, the mother had received meperidine (Demerol,
half-life 2.5-4.0 hours in adults and 12-39 hours in
neonates.) The physician started resuscitation and
ordered naloxone. Shortly after administration of the
medication, his condition began to deteriorate further.
Prompted by the proximity of the deterioration to the
administration of the naloxone, the physician checked
the packaging of the drug. The syringe had inadvertently
been filled with Lanoxin. The packages of both drugs,
made by the same manufacturer, were almost identical.
ECG revealed bi-directional ventricular tachycardia,
consistent with digoxin toxicity.
Approximately 1 hour later the baby died. A post-mortem
digoxin level was 17 ng/ml (therapeutic range 0.8 to 2
ng/ml).
From the AHRQ Web M&M files



A term baby was born with sluggish respirations. During
labor, the mother had received meperidine (Demerol,
half-life 2.5-4.0 hours in adults and 12-39 hours in
neonates.) The physician started resuscitation and
ordered naloxone. Shortly after administration of the
medication, his condition began to deteriorate further.
Prompted by the proximity of the deterioration to the
administration of the naloxone, the physician checked
the packaging of the drug. The syringe had inadvertently
been filled with Lanoxin. The packages of both drugs,
made by the same manufacturer, were almost identical.
ECG revealed bi-directional ventricular tachycardia,
consistent with digoxin toxicity.
Approximately 1 hour later the baby died. A post-mortem
digoxin level was 17 ng/ml (therapeutic range 0.8 to 2
ng/ml).
From the AHRQ Web M&M files
A previously healthy 10-month-old girl was diagnosed with irondeficiency anemia. One of the nurses explained in broken
Spanish that the child had “low blood” and needed to take a
medication. The pediatrician wrote the following prescription
in English:
“Fer-Gen-Sol iron, 15 mg per 0.6 ml, 1.2 ml daily (3.5 mg/kg)”
The pharmacist attempted to demonstrate proper dosing and
administration. The prescription label on the bottle was written
in English. Within 15 minutes of receiving the first dose, the
child vomited twice and appeared ill. In the emergency
department, the serum iron level 1 hour after ingestion was
365 mcg/dL (therapeutic = 60-180 mcg/dL). She was
admitted, was asymptomatic for the remainder of the
hospitalization, and was discharged the following day with no
apparent sequelae. Upon questioning, the parents stated that
they had administered a household tablespoon of the
medication, approximately 43 mg/kg (a 12.5-fold overdose).
From the AHRQ Web M&M files
A previously healthy 10-month-old girl was diagnosed with irondeficiency anemia. One of the nurses explained in broken
Spanish that the child had “low blood” and needed to take a
medication. The pediatrician wrote the following prescription
in English:
“Fer-Gen-Sol iron, 15 mg per 0.6 ml, 1.2 ml daily (3.5 mg/kg)”
The pharmacist attempted to demonstrate proper dosing and
administration. The prescription label on the bottle was written
in English. Within 15 minutes of receiving the first dose, the
child vomited twice and appeared ill. In the emergency
department, the serum iron level 1 hour after ingestion was
365 mcg/dL (therapeutic = 60-180 mcg/dL). She was
admitted, was asymptomatic for the remainder of the
hospitalization, and was discharged the following day with no
apparent sequelae. Upon questioning, the parents stated that
they had administered a household tablespoon of the
medication, approximately 43 mg/kg (a 12.5-fold overdose).
From the AHRQ Web M&M files
A previously healthy 10-month-old girl was diagnosed with irondeficiency anemia. One of the nurses explained in broken
Spanish that the child had “low blood” and needed to take a
medication. The pediatrician wrote the following prescription
in English:
“Fer-Gen-Sol iron, 15 mg per 0.6 ml, 1.2 ml daily (3.5 mg/kg)”
The pharmacist attempted to demonstrate proper dosing and
administration. The prescription label on the bottle was written
in English. Within 15 minutes of receiving the first dose, the
child vomited twice and appeared ill. In the emergency
department, the serum iron level 1 hour after ingestion was
365 mcg/dL (therapeutic = 60-180 mcg/dL). She was
admitted, was asymptomatic for the remainder of the
hospitalization, and was discharged the following day with no
apparent sequelae. Upon questioning, the parents stated that
they had administered a household tablespoon of the
medication, approximately 43 mg/kg (a 12.5-fold overdose).
From the AHRQ Web M&M files
Jim T

Developed fever and cough while in Maryland at his
grand-daughter’s graduation. Didn’t get care until he
got back to Houston breathless and hypoxic, and was
hospitalized for 5 days for pneumonia. Widely
accepted guidelines for CAP recommend levoquin
alone, he got levoquin and vancomycin. Vanc takes
hours to infuse and causes considerable phlebitis. He
refused to eat, did his best not to cough, and didn’t get
an incentive spirometer until his wife asked for
something to make him try to breathe deeply. He had
a CT scan for elevated liver enzymes, the results of
which were AWOL for 2 days. He was ready for
discharge on Sunday, but his own doctor was not on
call, so he stayed until Monday. He was unhappy with
his care because the trash cans were rarely emptied,
even when they were full of vomitus and smelled bad.
Jim T

Developed fever and cough while in Maryland at his
grand-daughter’s graduation. Didn’t get care until he
got back to Houston breathless and hypoxic, and was
hospitalized for 5 days for pneumonia. Widely
accepted guidelines for CAP recommend levoquin
alone, he got levoquin and vancomycin. Vanc takes
hours to infuse and causes considerable phlebitis. He
refused to eat, did his best not to cough, and didn’t get
an incentive spirometer until his wife asked for
something to make him try to breathe deeply. He had
a CT scan for elevated liver enzymes, the results of
which were AWOL for 2 days. He was ready for
discharge on Sunday, but his own doctor was not on
call, so he stayed until Monday. He was unhappy with
his care because the trash cans were rarely emptied,
even when they were full of vomitus and smelled bad.
Jim T

Developed fever and cough while in Maryland at his
grand-daughter’s graduation. Didn’t get care until he
got back to Houston breathless and hypoxic, and was
hospitalized for 5 days for pneumonia. Widely
accepted guidelines for CAP recommend levoquin
alone, he got levoquin and vancomycin. Vanc takes
hours to infuse and causes considerable phlebitis. He
refused to eat, did his best not to cough, and didn’t get
an incentive spirometer until his wife asked for
something to make him try to breathe deeply. He had
a CT scan for elevated liver enzymes, the results of
which were AWOL for 2 days. He was ready for
discharge on Sunday, but his own doctor was not on
call, so he stayed until Monday. He was unhappy with
his care because the trash cans were rarely emptied,
even when they were full of vomitus and smelled bad.
Jim T

Developed fever and cough while in Maryland at his
grand-daughter’s graduation. Didn’t get care until he
got back to Houston breathless and hypoxic, and was
hospitalized for 5 days for pneumonia. Widely
accepted guidelines for CAP recommend levoquin
alone, he got levoquin and vancomycin. Vanc takes
hours to infuse and causes considerable phlebitis. He
refused to eat, did his best not to cough, and didn’t get
an incentive spirometer until his wife asked for
something to make him try to breathe deeply. He had
a CT scan for elevated liver enzymes, the results of
which were AWOL for 2 days. He was ready for
discharge on Sunday, but his own doctor was not on
call, so he stayed until Monday. He was unhappy with
his care because the trash cans were rarely emptied,
even when they were full of vomitus and smelled bad.
Jim T

Developed fever and cough while in Maryland at his
grand-daughter’s graduation. Didn’t get care until he
got back to Houston breathless and hypoxic, and was
hospitalized for 5 days for pneumonia. Widely
accepted guidelines for CAP recommend levoquin
alone, he got levoquin and vancomycin. Vanc takes
hours to infuse and causes considerable phlebitis. He
refused to eat, did his best not to cough, and didn’t get
an incentive spirometer until his wife asked for
something to make him try to breathe deeply. He had
a CT scan for elevated liver enzymes, the results of
which were AWOL for 2 days. He was ready for
discharge on Sunday, but his own doctor was not on
call, so he stayed until Monday. He was unhappy with
his care because the trash cans were rarely emptied,
even when they were full of vomitus and smelled bad.
No, really, how are we doing?
Failure to provide appropriate care
 Provision of unnecessary care
 Variations in care not explained by patient
characteristics
 Inequities by race/ethnicity

Quality of Care Received by
Children and Adolescents in the US



Comprehensive study of care for children and
adolescents
242 indicators developed by consensus of
experts and practicing pediatricians
16 clinical areas
4

preventive, 6 acute, 6 chronic
1,536 patients from 12 metropolitan areas
studied by medical record review and interview
Quality of Care Received by
Children and Adolescents in the US

Only 44.3% of recommended care was
given:
 Preventive
43%; Acute 48%; Chronic 45.3%
 Diagnostic 33.8%; Treatment 67%
 OME 64.5%; Adolescent prevention 26.1%
Mangione-Smith R, et al. NEJM 2007
Use of non-recommended tests
during preventive health visits
The USPSTF recommends against
provision of UA, CXR and EKG for routine
screening
 National data show that at least one of
these tests is ordered at 43% of routine
preventive care visits for adults
 Not studied in children

Merenstein D et al, Am J Prev Med 2006
Variations in care among 14
neonatal centers
Intervention
% of 401-1000gm
infants receiving
0 – 59%
High frequency
ventilation
Early indomethacin 1 – 75%
Phototherapy at
Bili<5mg/dl
Steroids for CLD
0 – 100%
20 – 52%
Center Variability in Survivors
with BPD in NICHD Neonatal
Network
BW (g)
Affected (%) Center Range (%)
501 - 1500
17
4 - 26
501 - 750
42
15 - 61
751 - 1000
25
5 - 42
1001 - 1250
11
1 - 21
1251 - 1500
4
0-9
Fanaroff et al. Am J Obstet Gynecol 2007
Inequities in Care
Admissions for preventable conditions
Children with special health care
needs without family-centered care
Houston, we have a problem
How did we get here?

First Law of Improvement:
"Every system is perfectly designed
to achieve the results it gets”
Attributed to Paul Batalden
How do we go forward?

Redesign the system to get the results we want
 Doing
the same thing over and over again and
expecting different results does not make sense
 Problems are rarely with individuals, rather with
systems
 Health care can learn from industry how to
understand and redesign systems
 Improvement science is a legitimate academic pursuit
The role of academics/ academic
medical centers

Research
 CPG
Development
 Measure Testing

Education
 Faculty
Development
 Educational Program Development

Clinical Care
 Adopting
innovations in health care delivery
 Feedback to measure developers
Nedza SM Academic Medicine 2009; 84(12):1645-1647
The role of academics/ academic
medical centers

Research
 CPG
Development
 Measure Testing

Quality improvement is a science, not an
art
A
young science
 Much to be learned from other fields
 Golden opportunity to break new ground
Nedza SM Academic Medicine 2009; 84(12):1645-1647
The role of academics/ academic
medical centers

Education
 Faculty
Development
 Educational Program Development

Where will our future leaders come from?
Nedza SM Academic Medicine 2009; 84(12):1645-1647
The role of academics/ academic
medical centers

Clinical Care
 Adopting
innovations in health care delivery
 Feedback to measure developers

Integrate quality and safety governance
with medical schools
 Dedicated
time for clinicians to focus on
quality
Nedza SM Academic Medicine 2009; 84(12):1645-1647
The role of academics/ academic
medical centers

“…we need more academic physicians who are
ready to advance the science of performance
measurement, who are positioned to prepare
students to embrace the integration of
performance data into daily practice, and, most
importantly, who translate evidence-based
performance measurement into better clinical
care.”
Nedza SM Academic Medicine 2009; 84(12):1645-1647
Develop Expertise

IHI Open School
 Students

lead the way!
Advanced Training Program(s)
 Utah
 Now

many other local programs
Certification Programs
 American

Board of Medical Quality
Masters Degree in Quality
 Thomas
Jefferson University, others
The news is not all bad…
Reducing central line infections



48% of ICU patients have central venous catheters,
accounting for 15 million central venous catheter-days
per year in ICUs.
Between 500-4000 U.S. patients die annually due to
blood stream infections, costing $3,700 to $29,000 and
prolonging hospitalization by a mean of 7 days.
What if a series of interventions could markedly reduce
the risk of BSI, were already readily available in
hospitals, and were done all of the time on each patient?
Institute for Healthcare Improvement 2007
0
2003 - Qtr1
2002 - Qtr4
2002 - Qtr3
2002 - Qtr2
2002 - Qtr1
2001 - Qtr4
2001 - Qtr3
2001 - Qtr2
2001 - Qtr1
2000 - Qtr4
2000 - Qtr3
2000 - Qtr2
2000 - Qtr1
1999 - Qtr4
1999 - Qtr3
1999 - Qtr2
1999 - Qtr1
1998 - Qtr4
1998 - Qtr3
1998 - Qtr2
1998 - Qtr1
Rate per 1000 cath days
Reducing Central Line Infections
ICUs that have implemented multifaceted interventions similar to the
central-line bundle have nearly eliminated CR-BSIs.
25
20
15
10
5
0
2003 - Qtr1
2002 - Qtr4
2002 - Qtr3
2002 - Qtr2
2002 - Qtr1
2001 - Qtr4
2001 - Qtr3
2001 - Qtr2
2001 - Qtr1
2000 - Qtr4
2000 - Qtr3
2000 - Qtr2
2000 - Qtr1
1999 - Qtr4
1999 - Qtr3
1999 - Qtr2
1999 - Qtr1
1998 - Qtr4
1998 - Qtr3
1998 - Qtr2
1998 - Qtr1
Rate per 1000 cath days
Reducing Central Line Infections
ICUs that have implemented multifaceted interventions similar to the
central-line bundle have nearly eliminated CR-BSIs.
25
20
15
10
5
Family Centered Rounds
Time of Day of Discharge
Muething, S. E. et al. Pediatrics 2007;119:829-832
Copyright ©2007 American Academy of Pediatrics
Family Centered Rounds
Time of Day of Discharge
Muething, S. E. et al. Pediatrics 2007;119:829-832
Copyright ©2007 American Academy of Pediatrics
Standardizing communication
and treatment of shock




Guidelines for resuscitation of patients with
septic shock. Brierley J, et al, Crit Care Med
2009 Vol. 37(1), 1-23.
Early recognition of compensated shock
Rapid initiation of early goal directed therapy
Optimize communication handoffs between EC
and PICU
Binita Patel, Section of Emergency Medicine
Eric Williams, Section of Critical Care
Baylor College of Medicine, Texas Children’s Hospital
Standardizing communication
and treatment of shock
Standardizing communication
and treatment of shock
350
Time in minutes
300
250
200
2009
2010
150
100
50
0
Triage to 1st Triage to 1st Door to PICU
bolus
Abx
Binita Patel, Section of Emergency Medicine
Eric Williams, Section of Critical Care
Baylor College of Medicine, Texas Children’s Hospital
Standardizing communication
and treatment of shock
“I have to say that this “SHOCK” treatment was the most amazing ER
experience we have ever had at Texas Children’s Hospital. As a
parent of a child with a very long, complicated medical history, it is
very comforting to know that my child, will be treated so rapidly and
effectively. The minutes or hours saved by this aggressive treatment
could be the difference in my daughter avoiding a very serious
illness or complications with her transplanted organs…
…Thank you, again, to you and whoever else shares the credit for the
creation of this protocol. I have no doubt that its implementation
saved my daughter from a more complicated course and enabled
her to get discharged, this afternoon, only 3 days after being
admitted.”
Unsolicited comment from the parent of a patient
treated on the shock protocol.
Standardizing communication
and treatment of shock
“I have to say that this “SHOCK” treatment was the most amazing ER
experience we have ever had at Texas Children’s Hospital. As a
parent of a child with a very long, complicated medical history, it is
very comforting to know that my child, will be treated so rapidly and
effectively. The minutes or hours saved by this aggressive treatment
could be the difference in my daughter avoiding a very serious
illness or complications with her transplanted organs…
…Thank you, again, to you and whoever else shares the credit for the
creation of this protocol. I have no doubt that its implementation
saved my daughter from a more complicated course and enabled
her to get discharged, this afternoon, only 3 days after being
admitted.”
Unsolicited comment from the parent of a patient
treated on the shock protocol.
Intensive Family Centered Care at
the end of life
Sweeney L et al. Am J Manag Care.
2007 Feb;13(2):84-92.
Intensive Family Centered Care at
the end of life
Sweeney L et al. Am J Manag Care.
2007 Feb;13(2):84-92.
Access to a Usual Source of Care
100
80
60
Before SCHIP
After SCHIP
40
20
0
White
Black
Hispanic
Shone LP, et al.
Pediatrics. 2005 Jun;115(6):e697-705.
Access to a Usual Source of Care
100
80
60
Before SCHIP
After SCHIP
40
20
0
White
Black
Hispanic
Shone LP, et al.
Pediatrics. 2005 Jun;115(6):e697-705.
How do we go forward?
We CAN improve quality
 WE can improve quality

 Never
doubt that a small group of thoughtful,
committed citizens can change the world.
Indeed, it is the only thing that ever has.

Margaret Mead
 What

IHI
can we do by next Tuesday?