26 June 2006

Protocols Save Lives

While individual acts of negligence can be linked to particular deaths, most medical mistakes are attributable to bad systems. Colorado hospitals are part of a national effort to institute some of the simplest and most important protocols that make the difference between good care and bad, or even life or death. The results, predictably, are good.

3,100 hospitals (out of more than 5,000) are participating in an unprecedented national campaign led by Harvard professor Dr. Donald Berwick to reduce fatal hospital errors. After 18 months, some 122,300 lives had been saved as a direct result of improved care and reduced errors . . . . Berwick launched the program after a startling 1999 study found that as many as 98,000 Americans die each year from preventable hospital errors
. . . . Sixty-two of Colorado's 71 acute care hospitals took part in implementing some of the changes proposed . . .


How many lives saved again? About two per hospital per month.

Key practices include:

(1) Rapid response times for patients outside ERs whose vital signs deteriorate.
(2) Encouraging less experienced staff to call for help.
(3) Double checking patient medications.
(4) Using pre-operative antibiotics.
(5) Washing hands and a patient's skin prior to IV insertions.
(6) Giving asprin and beta-blockers to potential heart attack patients.
(7) Raising the heads of people on ventilators.

The real pioneer in a systems approach to preventing medical mistakes was the professional association of anesthesiologists, which has worked to identify key systems and improve them with impressive results:

One medical specialty, anesthesiology, has already made significant improvements in its safety record. Mortality resulting from errors in anesthesia has been reduced by 95 percent over the past 15 years.


In the same time frame, a focus on protocols has dramatically improved the quality of care at Veterans Administration hospitals.

[H]ere's a curious fact that few conservatives or liberals know. Who do you think receives higher-quality health care. Medicare patients who are free to pick their own doctors and specialists? Or aging veterans stuck in those presumably filthy VA hospitals with their antiquated equipment, uncaring administrators, and incompetent staff? An answer came in 2003, when the prestigious New England Journal of Medicine published a study that compared veterans health facilities on 11 measures of quality with fee-for-service Medicare. On all 11 measures, the quality of care in veterans facilities proved to be “significantly better.”

Here's another curious fact. The Annals of Internal Medicine recently published a study that compared veterans health facilities with commercial managed-care systems in their treatment of diabetes patients. In seven out of seven measures of quality, the VA provided better care. It gets stranger. Pushed by large employers who are eager to know what they are buying when they purchase health care for their employees, an outfit called the National Committee for Quality Assurance today ranks health-care plans on 17 different performance measures. These include how well the plans manage high blood pressure or how precisely they adhere to standard protocols of evidence-based medicine such as prescribing beta blockers for patients recovering from a heart attack. Winning NCQA's seal of approval is the gold standard in the health-care industry. And who do you suppose this year's winner is: Johns Hopkins? Mayo Clinic? Massachusetts General? Nope. In every single category, the VHA system outperforms the highest rated non-VHA hospitals.


Veteran's Administration hospitals do this with some of the lowest paid doctors in the profession.

Another major breakthrough along the same systems oriented lines has been the development of the "trauma center", a specialized hospital unit with systems tailored to maximizing trauma patient survival, an idea largely attributable to R. Adams Cowley, M.D. of Maryland, which has produced great improvements in patient care. In metropolitan Denver, the most visible effect of this reform can be found at Denver Health our level one trauma center. Swedish Medical Center and St. Anthony's Hospital in Denver are also level one trauma centers.

Studies in Boston and Scandinavia have shown similarly promising results in having specialty centers with the proper systems in place to treat heart attacks and strokes.

2 comments:

Kyle said...

Wow, you could have never convinced me VA hospitals would be so good. I wonder if this is because they are really good, or most hospitals are just really bad.

Interesting post.

Kyle said...

I've been thinking about this post a lot, and something occurred to me - probably the most interesting part about Berwick's program, besides how successful it is, is how cheap it is. Those seven things on the list are all virtually cost-free.

If only it had been expensive not to have them in the first place, they'd have been done long ago.