The IHI's 100,000 Lives Campaign reminds us that patient safety is a life-or-death matter. How can we maintain the momentum now that we're beyond the initiative's established timeframe? Just ask the experts-nurses involved in success stories for each of the Campaign's six interventions. Here, review a cross-section of hospitals-large, small, and in-between; urban and rural-that show the Campaign interventions can be applied anywhere. There was one ground rule for the nurses we spoke with: frank talk not only about how interventions were working, but also barriers encountered and how they overcame them.
1. Deploy rapid response teams
Every intervention is important, but none has received more media attention than rapid response teams. Rapid response teams deliver the expertise of a critical care unit to the bedside of patients outside the unit. The team doesn't usurp the patient's nurses and physicians, but rather supports them with years of clinical expertise.
* Advisor. Sharon Garretson, RN, BSN, manager, ICU and step-down
* Hospital. University Hospitals Health System (UHHS), Richmond Heights Hospital, Richmond Heights, Ohio, a 225-bed urban hospital
* Highlights. The rapid response team includes an ICU nurse, a respiratory therapist, a hospitalist, and a resident. Traditionally nurses on any unit have placed the call for a rapid response team, but the team at Richmond Heights has expanded that. After the rapid response team was functioning smoothly, it was opened up so that any employee could call the team for anyone-patients, visitors, or staff. In fact, 17% of calls now come from the ICU. The next step is to allow visitors and patients to call the team. Garretson says that patients can call 911 at home, so why can't they do it in the hospital?
* Outcomes. Measurements of rapid response team effectiveness include codes per 1,000 discharges, codes outside of the ICU, and utilization of rapid response teams. From April 2005, when the rapid response team was implemented, to April 2006, Richmond Heights reduced the number of cardiac arrests per thousand discharges by 44% and the overall hospital mortality by 14%. The number of arrests outside of the ICU fell by 67%. Interestingly, 71% of patients were managed on the unit without being transferred to a higher level of care.
* Best practices. Garretson attributes their sustained success to staff education. Attendance at rapid response team education sessions was mandatory and tailored to the audience, with one 45-minute session for the ICU nurses, physicians, and respiratory therapists, and a 35-minute session for floor nurses. Garretson and education manager Mary Beth Rauzi conducted 35 sessions, every hour of the day and night.
* Barriers. Many ICU nurses resisted rapid response teams because no additional full-time equivalents (FTEs) were hired. Garretson tackled resistance in three ways. First, she was adamant in telling staff members that rapid response teams would be implemented and become part of their job description, so if they wanted to work in the ICU, they needed to be a team member. Second, she shared research showing that 6 to 8 hours before the arrest there are clinical signs that indicate a patient may be in trouble, thus allowing nurses to address the care challenge more efficiently. Third, Garretson committed to reevaluating the program at 6 weeks and again at 3 months to determine effectiveness and to see if it was realistic not to allocate additional FTEs to the program. Some medical/surgical nurses took offense, interpreting rapid response teams as a sign that management was saying they didn't know how to do their jobs. It was important to help nurses understand that wasn't the case. Barriers soon fell as the nurses in the ICU and on the medical/surgical units saw that patients were being helped. In fact, Garretson reports 1 day brought seven calls in a single 8-hour shift.
* Comment. "In 5 years, we're going to look back at healthcare, and everyone is going to have a rapid response team. We'll say, 'Remember the days when we thought rapid response teams were an alien concept? Remember when we had all those codes?' If your hospital isn't doing it now, you need to because it's not going away."
2. Improve care of acute myocardial infarction
With cardiovascular disease the leading cause of death in the United States, it's not surprising that one Campaign intervention focuses on acute myocardial infarction (MI). The intervention consists of several evidence-based components (e.g., thrombolysis within 30 to 60 minutes of arrival to the ED) as a "bundle" that can effectively reduce mortality.
* Advisor. Christi McCarren, RN, MBA, administrator, cardiovascular services
* Hospital. MultiCare Health System, Tacoma General Hospital, Tacoma, Washington, a 521-bed urban hospital
* Highlights. Tacoma General Hospital wanted to benchmark itself against the best heart centers in the country. The time to treatment at those centers was 60 minutes, and Tacoma lagged behind at 110 minutes. After implementing several interventions, McCarren and her team reduced the time to 70 minutes and are still going strong.
* Outcomes. The time from admission to ECG dropped from 10 to 4.4 minutes. Mortality from MI fell from 9% to 10% in 2004 to 5.5% as of April 2006.
* Best practices. Team members created a process map for the initial care of the MI patient, which allowed them to refine the process. Sometimes the change was simple. As in most hospitals, the time to treatment varied widely because the cath lab staff had to be called in during evening and night shifts. The ED staff would wait for the cardiologist to arrive before making the call, adding 30 to 40 minutes to the time. This process was changed so that the ED physician could decide whether or not the cath lab staff was needed.
* Barriers. McCarren says that staff members believed they were doing a good job. She and the team had to prove that although staff members weren't doing a "bad" job, they could do better. McCarren developed a checklist to track time segments (e.g., time to ECG, time to transport, time to perfusion) to establish baselines, and then added specific time goals. She reviews the checklist after each use and provides immediate feedback. McCarren says she encountered less resistance from the cardiologists than she expected, noting that once the focus is on patients and "doing the right thing," control becomes less of an issue and barriers start tumbling down.
* Comment. "Timing is everything. The reality is that you need to understand that with performance improvement, you have to get past the initial inertia by creating an emergency or a need. We were seeking chest pain center accreditation. You're looking for common motivations that people can wrap their arms around; the IHI's Campaign is one of those central initiatives to improve care that people can embrace."
3. Prevent adverse drug events
One of the best ways to prevent adverse drug events is by reconciling medications at patient admission, transfer, and discharge. The good news is that it's an initiative everyone can readily support. The bad news is that the system is complicated, with many different people involved, making it perhaps the hardest intervention to put into place.
* Advisor. Anna Roth, RN, MS, assistant director, redesign
* Hospital. Contra Costa Regional Medical Center, Martinez, California, a 164-bed county hospital with seven ambulatory care centers
* Highlights. Unlike many hospitals, Contra Costa Regional chose a non-clinician, who supervised the pharmacy, to lead the medication reconciliation team. Roth says the advantage was the team leader had to learn all the current processes and look at them from a systems instead of a user perspective. The team leader worked closely with the physician in leading the medication reconciliation team. Roth was able to provide support when the team encountered barriers, including acting as a liaison between the team and nurse executives.
* Outcomes. In September 2005, medications were recorded on admission 53% of the time; that's now up to 93%. The goal was to increase the number of patients who had medications reconciled within 3 months of rollout by more than 50%, and they were able to do that. The goal is 98% reconciliation on admission, discharge, and transfer; they're now at 84%.
* Best practices. Roth says the team looked at processes that already existed and built necessary changes into actions that were already occurring. One example was obtaining a medication history. The team elected to start low-tech. The clinician writes the patient's medications on admission, and then this form is turned into a computer-based one. The team also convinced administrators to free up a nurse manager who knew about electronic data entry; she's now part of systems redesign and is manager of informatics. Because she managed medical/surgical units, she knows the daily work and is articulate in clinical and electronic data transmission-a key contribution to the team.
* Barriers. Roth reports one barrier common to most hospitals: freeing up floor nurses to attend team meetings. They wanted these nurses to participate since they're the experts, the ones who work with the patient MAR and the physician. An added challenge was the California staffing ratios. The team adapted in a number of ways. Charge nurses are included on the team because once or twice a month they have days when they can work on special projects. The team also relies on e-mail but soon learned that they had to let the floor nurses know this would be an avenue of communication because the nurses rarely used it. Also, reports are posted, not e-mailed, because they found that nurses don't print them out.To overcome barriers, Roth points out the need to have the difficult conversation when a provider or unit isn't meeting the goals. It can be hard for a non-clinician like the team leader to tell a clinician, "That's not acceptable." Roth says, "You have to use data and the literature to counter when they play the clinician card."
* Comment. "Tell staff members up front whether making the change will require additional time, and tell them why and the benefits, particularly how it will benefit the patient."
4. Prevent central line infections
The "bundle" of evidence-based components to reduce these infections include maximum barrier precautions, appropriate choice of site, daily assessment as to whether the line can be discontinued, and calling on the nurse to stop an insertion if the proper procedure isn't being followed. As of June 2006, 11 hospitals in the Campaign reported they hadn't had a central line infection in over 1 year.
* Advisor. Jill Patak, RN, BSN, CPHQ, quality engineering specialist
* Hospital. Our Lady of Lourdes Memorial Hospital, Binghamton, New York, a 267-bed rural hospital
* Highlights. The team developed a central line pack kit that the hospital's distribution center puts together and stocks in the patient units. All the necessary supplies are in the kit, including the checklist the nurse completes to ensure that proper procedure is followed.
* Outcomes. Use of the bundle cut the infection rate from 15.3% in 2004 to 5.8% in 2005-a 62% reduction.
* Best practices. Patak reviews all the checklists and works closely with the infection control coordinator. The coordinator alerts her when an infection occurs. Patak notes the importance of continual monitoring, emphasizing the need to "drill down" to determine the reason for each infection. Unfortunately, four infections have occurred since January, so the team is working on identifying possible reasons, focusing on encouraging physicians to use the appropriate site (subclavian instead of jugular), and securing the catheter correctly. Nurses have been reeducated on the proper management of central lines, with emphasis on strict aseptic technique.
* Barriers. At first some physicians balked when nurses brought out the checklist, and the nurses found it difficult to tell the physicians that the procedure couldn't proceed because of lack of adherence. Patak went to the unit to support the nurses, and the team had the support of the vice president of medical affairs, whom the nurses could call if necessary.
* Comment. "When you're ready to try an evidence-based intervention, you need to work with the staff to determine the best way to test it. It's important to follow IHI's recommendation of testing with one nurse, one patient. Don't go too fast. Learn from each test and revise as necessary until you've tested it with all the patients. By then, it should be very clear what's effective and will accomplish your goal."
5. Prevent surgical site infections
Reducing infection isn't just good patient care, it's good business. Pending Medicare legislation would reduce payment for patients who get an infection, and consumers are watching closely as more states mandate public reporting of infection rates.
* Advisor. Jan Fitzgerald, RN, director of quality and medical management
* Hospital. Baystate Medical Center, Springfield, Massachusetts, a 698-bed urban hospital
* Highlights. The team at Baystate Medical Center (BMC) started working on reducing surgical site infections in 2002. In 2004 they signed on for the 100,000 Lives Campaign as a way to validate the work they had been doing. A major challenge was to determine how to consistently and reliably administer the antibiotic within an hour before the start of surgery. After trying different options, they determined the anesthesiologist is in the best position to give the antibiotic, and it takes only an extra few minutes. This success was key in spreading the change to all practicing anesthesiologists. Further tasks, such as keeping patients warm and well oxygenated, followed.
* Outcomes. Baystate already had low rates of infection, and the IHI Campaign helped to focus BMC on implementing the surgical site infection intervention, decreasing the infection rate to less than 1%.
* Best practices. The team preprinted the antibiotic information on the anesthesia flow sheet to act as a visual prompt and to provide a standardized way to document. Fitzgerald emphasizes the need to be able to talk authoritatively to physicians about the science of what they do. They also used variable compensation models for selected providers to encourage interest and foster competition, along with positive feedback to the entire perioperative team for reduced infection rates.
* Barriers. Fitzgerald says some surgeons ordered antibiotics for too long a duration, which contributes to the emergence of resistant organisms. The team worked with the surgeons to get them to shorten the course of therapy.
* Comment. "You have to be empowered to change the process without going through multiple approvals. Identify the key people, such as informal leaders who are willing to change, and use real-time data so staff members know how they're doing. That will keep them engaged and interested to sustain their effort and energy."
6. Prevent ventilator-associated pneumonia
Ventilator-associated pneumonia (VAP) is deadly, yet often preventable. Some of the key prevention strategies are directly under nurses' control, including elevating the head of the bed between 30 and 45 degrees, and proper use of sedation. As of February 2006, at least 25 hospitals participating in the Campaign reported that they had no cases of VAP for more than 1 year.
* Advisors. Joyce Fisher, RN, nurse manager, ICU; Shannon Page, RN, BSN, ICU case manager and data coordinator; Jennifer Dunscomb, RN, MSN, CCRN, clinical nurse specialist
* Hospital. Columbus Regional Hospital, Columbus, Indiana, a 325-bed rural hospital
* Highlights. The team has multiple strategies, including mouth care and hand sanitation, which they integrated into standard physician orders. Like many hospitals, however, keeping the head of the bed elevated was a major challenge. They integrated checking for bed elevation into morning rounds and added it to the information that the respiratory therapists collected during their ventilator checks.
* Outcomes. At baseline, the head of the bed was elevated 63% of the time; it's now at 100% adherence. Amazingly, the hospital went 2 years and 9 months without a VAP, despite a higher number of ventilator days. They also saw an 83% reduction in variation of the care provided, and decreased length of stay and mortality for ICU patients. Unfortunately, when they did have a case of VAP in October 2005, the young patient died. This experience was a strong motivator for the staff to follow all of the elements of the intervention.
* Best practices. The three advisors represent the philosophy of the vice president of nursing-a triad approach to patient care. Each person fulfills a specific role. The CNS evaluates the evidence, the manager provides the leadership and support of policy, and the third person, in this instance the case manager, drives practice at the bedside and uncovers barriers to change. In addition, managers such as Fisher are paid for performance based on a scorecard. One of the items on Fisher's scorecard is VAP.
* Barriers. Some nurses were afraid of the physiological changes that might occur with bed elevation, and worried about self-extubation by the patient. Team members used education to overcome these fears. They brought in physical therapists and occupational therapists to show the nurses how to best position a patient in the bed. The therapist had a staff nurse volunteer to play the patient role so nurses could see exactly how to implement the therapist's suggestions. Other education topics included adequate management of a patient's pain and anxiety. To address staff fears about adding more nursing time for the VAP and other interventions, the team emphasized that preventing complications will save nurses time.
* Comment. Dunscomb says, "Organizations often have the 'flavor-of-the-month' change and that causes lots of confusion. With this Campaign everyone knows this isn't going away; it's the standard of care. Everyone is focused, particularly since leadership has set the expectation that this is what's going to be done."
Support, support, support
Are you ready to join the 100,000 Lives Campaign, but worried that you'll be unable to do it? Are you already participating and implementing one or more of the six interventions, but want to do more? In either situation, you have access to many support systems. (See "Resources.")
One of the IHI's goals for the Campaign was to establish an infrastructure that not only supports hospitals in implementing current interventions, but future ones as well. It includes IHI faculty experts and 55 nodes, or field offices, in 45 states and two territories. The nodes provide networking support and reflect types of current hospital systems-academic, pediatric, public, and rural. Over 130 node organizations, including nurses' associations, large health systems, and state hospital associations, also support the effort.
IHI faculty experts and Campaign field staff make site visits to Campaign hospitals and host discussion groups on http://www.IHI.org. Kathy Duncan, RN, is the expert for rapid response teams, and Fran Griffin, RRT, MPA, is the expert for the other five interventions. Duncan and Griffin also respond to e-mails and phone calls. Because they're familiar with so many hospitals, they serve as a clinical "clearinghouse." If, for example, a hospital needs a checklist, the faculty member can pull five or six examples for the hospital to determine what will work for them. They can also give tips. For example, Duncan says a hospital in South Dakota shaved off 20 minutes of response time when cath lab employees who called in for off-shift procedures were allowed to park in the administrative lot instead of the more remote employee lot.
Get onboard
The 100,000 Lives Campaign is a national initiative that you might want to be a part of if you aren't already. You can turn to the IHI and your colleagues for support as you begin, or continue, the effort to save lives.
Resources
The IHI has created a number of resources, available at no charge, to support hospitals participating in the Campaign. All resources can be downloaded at http://www.IHI.org.
Getting Started Kits. Each kit includes three items: a "How-to Guide," a customizable slide presentation, and an annotated bibliography for a particular intervention. The comprehensive How-to Guides describe the intervention and its benefits, explain how to perform the necessary analyses, and provide information on how to implement the intervention and evaluate outcomes. The guides cover the smallest detail. For example, the rapid response team How-to Guide lists the criteria for when to call the team and discusses possible mechanisms for calling.
The How-to Guides aren't designed to be followed without question, but rather serve as the base on which to build. For example, the IHI doesn't recommend a specific beta blocker for the patient with an acute MI, but rather calls for a beta blocker to be given and gives tools to help hospitals work with the cardiologists to make a decision on what would work best. Kathy Duncan, RN, the IHI faculty expert for the rapid response team intervention, says, "That's been the magic of the Campaign. What works at a big academic hospital won't work in a rural one." The emphasis is on not reinventing the wheel, so you can download sample tools and checklists and adapt them to your own facility.
Recent additions to the How-to Guides include sections on:-Tips and tricks. A sample tip from the rapid response team How-to Guide: "Design and encourage the development of opportunities for the rapid response team staff to 'connect' to additional staff within the hospital-for example, follow-up visits to patients who remain on the medical/surgical floor, debriefing opportunities after a call, etc."-Frequently asked questions-Patients and families fact sheet
The annotated bibliography for each intervention has also been updated (each new entry is marked with an asterisk).
How-to Guide for Sustainability and Spread. This guide outlines specific tactics for building on the progress you've already made (sustainability) and disseminating best practices to other care settings (spread).
How-to Guide for Running a Successful Campaign in Your Hospital.. This guide harvests lessons from the first 18 months of the Campaign, describing the best practices the IHI has observed for each stakeholder group in hospitals participating in the Campaign.
Model for Improvement. This model, developed by Associates in Process Improvement, is used to drive improvements in the hospital. It consists of two parts: 1. Three fundamental tasks for improvement teams: set clear aims, establish measures that will tell if changes are leading to improvement, and identify changes that are likely to lead to improvement. 2. The Plan-Do-Study-Act (PDSA) cycle to conduct small pilot tests of a specific change in the designated test setting. Rapidly testing changes on a small scale promotes buy-in and modification of the interventions. Once the change is tested and fine-tuned, it's ready for implementation. Broaden the implementation of the change within the organization by first including all the patients in a unit, then all units in a division, then other parts of the organization, and so on.
Campaign Mentor Hospitals. If you need help with planning and implementing an intervention, you can turn to the Mentor Hospitals. The staff at these hospitals has volunteered to provide support, advice, clinical expertise, and tips to those who need it. How do you choose which hospital to contact? You might want to pick a hospital similar to your own. The Mentor Hospital list makes it easy by specifying which intervention(s) each hospital is working on and includes information on the number of licensed beds, whether it's a teaching hospital, whether it's a rural or urban setting, and some additional information about the hospital's experience with implementing the intervention.