Transcript Improving Patient Safety in Hospitals | Thomas Dongilli, A.T

Improving Patient Safety in Hospitals
Thomas Dongilli A. T.
Director of Operations
Peter M. Winter Institute for Simulation,
Education and Research (WISER)
Administrator
Department of Anesthesiology
University of Pittsburgh School of Medicine
American Society of Anesthesiologist Endorsed Simulation Center
Overview of WISER
University of Pittsburgh Medical Center
University of Pittsburgh
WISER Support
School of
Medicine
School of
Nursing
University of
Pittsburgh
School of
Pharmacy
Undergrad –
Medical Biology
Dental School
21 Hospitals
UPMC
57,000
Employees
SDS and Out
Patient Clinics
Satellite Centers
University
of
Pittsburgh
School of
Nursing
ISMETT
Hospital
UPMC East
WISER
Children’s
Hospital
Passavant
Hospital
McKeesport
Hospital
Demographics of Participants
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Medicine
– Medical Students (MS 2-4)
– Residents
• Anesthesiology
• Emergency Medicine
• ENT
• Internal Medicine
• OB/GYN (course work in
development)
• Pediatrics
• Surgery
• Dental
– Fellows
• Critical Care
• Pediatric Intensivists
– Faculty Members and Community
Physicians
• Anesthesiology
• Critical Care Medicine
• Emergency Medicine
Nursing
– Undergraduate Nursing Students
– Practicing Nurses
• Med / Surg
• ICU
• OR
– Nurse Anesthetists
– Student Nurse Anesthetists
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Pharmacy Students
 Pharmacists
 Occupational Therapy
 Paramedics, EMTs
 Respiratory Therapists
 Other Simulation Centers /
Educators
 Many Others
Simulation for Students
– Providing a Consistent Experience
– Build Base Knowledge
– Repetitive Deliberate Practice
to Increase Retention
– Introduce Clinical Variability
– Start Psychomotor Skills Development
– Introduce Team Concepts
Simulation for Post Graduates and Residents
– Preparing To Begin Real Work
– Standardizing the Experience
• Clinical Supplement + + +
– Procedural Mastery
– Continue to build base knowledge
– Increase Team Functions
Simulation for Practicing Professionals
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Maintenance of Competence
Base Knowledge
Currency of Knowledge
Therapeutic advances
Skills / Procedures
Base On Experience ???
Clinical Track Record (Quality
Assurance)
How Does Healthcare Compare to Other Major
Industries
NASCAR… Is this how your team functions?
Questions?
• Why can’t we shock someone within 2 minutes of
a crisis but the pit crew can complete all of their
tasks within 20 seconds?
• Are we not as educated as the pit crew?
• Are they better at their jobs?
The answer is:
They are better organized.
They practice their jobs!
They practice as a team!
Silos of Work and Training
RNs
MDs
PharmDs
RRTs
Technicians
Support Staff
Silos contribute to medical errors!
Medical Error Data
• The IOM defines medical error as “the failure to
complete a planned action as intended or the use
of a wrong plan to achieve an aim.”
• Approximately 1.3 Million patients are injured
annually in the United States as a result of a
“Preventable Medical Errors”
The National Coordinating Council for Medication Error Reporting and Prevention
• Top 2 causes of preventable medical errors or
adverse events:
1. Equipment Errors. Failure to utilize or
malfunction of equipment
2. Diagnosis Errors. Failure to diagnose or
recognize
The Need for Simulation
• 1999….Between 44,000 and 98,000 Americans die each
year in U.S. hospitals due to preventable medical errors
(Institute Of Medicine)
• 2004…. 195,000 Americans die a year due to preventable
errors (HealthGrades)
• An estimated 15,000 Medicare patients die each month in
part because of care they received
• 99,000 patients die as a result of hospital-acquired infections
(HAI) each year (AHRQ, 2009).
• Hospital errors rank between the fifth and eighth leading
cause of death, killing more Americans than breast cancer
and traffic accidents (IOM).
• Just one type of error—preventable adverse drug events—
causes one out of five injuries or deaths per year to patients
in the hospitals
Medical Errors
Occurrences per 1000 patients admitted
Healthcare Industry Results
“If a 747 jetliner crashed every day, killing all 500
people aboard, there would be a national uproar
over aviation safety and an all-out mobilization to
fix the problem.
In the nation's hospitals, though, about the same
number of people die on average every day from
medical "adverse events," many of them
preventable errors such as infections or incorrect
medications.”
USA Today
Why Simulation????
Why Simulation for the Healthcare Provider?
Psychomotor Skills
Decision Making
Base Knowledge
Communications Skills
Teamwork Skills
Professionalism Skills
MULTIPLE CHOICE TEST DOES NOT EQUAL CLINICAL
PERFORMANCE!
WE NEED TO KNOW MORE!
Simulation Applications
Individual Psychomotor Skills
Monitoring and
Intervention Skills
Assessment
Clinical
Problem Solving
Communication and
Teamwork skills
Clinical Reasoning
Central Line Training
(Patient Safety and Risk Management)
Health System Integration
Crisis Team Training (Improve Responses)
Improvement is Rapid and Measurable
Position Task Completion
100%
Completion Percentage
75%
Airway
Airway Assistant
Chest compressions
Floor RN
50%
ICU RN (Cart)
Procedure MD
Recorder ICURN
Team Leader
25%
0%
1
2
Session
3
Crisis Team Data
100.00%
90.00%
80.00%
Mortality
70.00%
Simulator “Mortality”
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
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2
Session number
3
Activation of Response Teams
Braithwaite et al. Use of medical emergency teams to detect medical errors.
QUAL SAFETY HEALTH CARE, 2004.
So Where to Start?
Patient Safety Initiatives….
• Training?
• Risk Management?
• Financial?
• Competencies?
• Operational Efficiency?
• Clinical Preparedness?
Assessment of a Current Site Efforts
Picked 1 topic to review…Medical Crisis
•  utilization of Rapid Response Team
• Training Emphasis on “The Team”
– Utilizing highly trained personnel
– Bringing critical care to the patient bed side
– Promoting early intervention
• Mock Codes were initially used to assess the
“Team” and System Responses
• Initial responders were unclear of role and
treatment protocols
• Minimal to no training for the true
“1st Responders” (except BLS)
Criteria for Activation of Response Team
We had one…..
Methodology for Training
• Identified Key Areas for Improvement
– Recognition of Crisis
• Do they actually identify a crisis?
– Initial treatment of patients in crisis by non
ICU / Code Team members
• What can they do before the code team
arrives?
Rationale for Course Development
We want to:
• Enhance critical thinking and motor skills of initial
providers
• Improve early problem recognition
• Eliminate inconsistent initial interventions
• Standardize key responses
• Empower decision making
• Improve communication
• Complement the MET team
• Assessment of current site training and policies
Brief Survey…. Are You / They Ready??
• How many of you are instructors for students?
• How many clinical sites do your students rotate
through?
• How many of you work and rotate units or at clinical
sites?
• Are you / they prepared for an emergency at each
site?
– What is the correct number to dial for a code at
each site?
– Where is the Code Cart located?
– Is there equipment in my patients room (O2, BVM,
etc).
– What are you expected to do in the first 5 of a
crisis?
“The First 5 Minutes” Course
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Can be Mobile
Sessions can last as little as 30 minutes
Rotate through while on duty
Use as preparation for clinical rotations
Curriculum
• Discuss why participants are there
• Statistics about initial responders
(local policies)
• Carry out scenario focusing on initial
assessment and management
• Provide comprehensive debriefing session
with questions and answers
• Provide time to practice skills
Simulated Experience
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Identify a crisis is occurring
Assess ABCs
Call for appropriate help
Utilize local staff and equipment
Work together as a team
Perform key common tasks prior to MET arrival
“Package” the patient for the MET team
Initial Scenario
Evaluation Criteria
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ABCs
Calling for help
Crash cart arrival
HOB and Backboard
Pad placement
Proper use of AED
O2 and Airway management
IV verification
Communication
Documentation
Initial Outcomes (Scenario 1)
• Greater than 9 minutes to shock patient (Avg.)
• BVM less than 10% of patients
• 40% of the participants did not know the correct
number to dial to activate the Rapid Response
Team
• Report was inconsistent
• 80% of the nurses did not set the defib to the
appropriate setting (all defibs had AED
functionality)
Debriefing Session
• Scenario Reviewed
• Time to practice equipment and skills
• 2nd Scenario run
– 2nd Scenario Averages:
• Less than 1:50 Seconds to complete key
tasks
• 96% of top 20 tasks completed within
time frame
• Report standardized
• Equipment utilized
Implementation Process
• Mandatory training for all non-ICU staff
• Opposite BLS recertification
• Part of initial BLS certification and training day
• Roll out program to nurses throughout health
system
•RT and PCT are also invited to sessions
• SON Utilization
•Utilized for students prior to first clinical
• Include new equipment, policies
Future Plans
• Pursue other possibilities for using the initial response
structure:
• Trauma Patient Entering the
Emergency Room
• When New Admission Enters Unit
• Crisis in Radiology
•ICU Application
• Continue to assess actual responses
• Create a Critical Care adaptation
• Include other disciplines
• Continue movement into outpatient areas
What is Driving This at Your Facility??
Sometimes things just don’t go according to plan!!