Optimizing Trauma Quality Improvement

Transcription

1 Harborview/ALNW EMS & Trauma Conference Optimizing Trauma Quality Improvement Gregory J Jurkovich, MD FACS Donant Professor of Trauma Surgery Vice-Chair for Clinical Affairs and Quality Department of Surgery UC Davis Health, Sacramento, CA William Stewart Halsted Safe Surgery Antisepsis Rubber gloves Hemostasis Re-establish tissue planes Tissue handling Silk sutures Hospital Chart Ernest Amory Codman Graduate of Harvard Medical School 1895 (age 25): Surgeon at the MGH Developed X-ray imaging techniques Wrote first English language textbook on x-ray imaging Passion was in hospital reform Ernest Amory Codman Ernest Codman born the year that Stanley went to find Dr. Livingston (1869) and died as Hitler was overrunning much of Europe (1940). During his lifetime, Xrays were discovered and anesthesia became a reality, and he died just as the antibiotic era was born. Ernest Amory Codman 5 x 8 cards on each patient Advocated year follow-up End Result Program Advocated publicizing results Developed the M & M conference 1

2 Codman s End Result concept The common sense notion that every hospital should follow every patient it treats, long enough to determine whether or not the treatment has been successful, and then to inquire, If not, why not? with a view to preventing similar failures in the future. 1918: Founded ACS Hospital Standardization Program 1951: Joint Commission on Accreditation of Healthcare Organizations Codman s End Result Resigned his fulltime position Opened a competing hospital of 12 beds on Beacon Hill Reported a complication rate of 1 in displayed this cartoon at Suffolk District Surgical Society Fired from MGH The American College of Surgeons has advocated for patient safety since its establishment in all hospitals are accountable to the public for their degree of success If the initiative is not taken by the medical profession, it will be taken by the lay public American College of Surgeons The worst doctors will point out the errors of their colleagues; the best will tell you about their own. Thus you can differentiate them. Tweeted: 03:16 AM - 12 Mar from Mark Reed Fast forward 88 years after the establishment of the ACS The Nature of Adverse Events in Hospitalized Patients. Results of the Harvard Medical Practice Study II Lucian L. Leape, et al NEJM 1991; ,000 patients; 1,131 (3.7%) disabling medical complications, 27% due to errors Suggested our health care system design accounts for almost all of the problems that lead to errors, poor quality, and unsafe care. Professor of Surgery Tufts and Chief, Division of Pediatric Surgery Joined Harvard with TA Brennan two NEJM articles 1994 Error in Medicine Co-author IOM report To Err is Human Father of Modern Patient Safety movement Lucian L. Leap 2

3 Institute of Medicine, 1999 MEDICAL ERRORS 100,000 PREVENTABLE DEATHS/YEAR Are there really 100K prentable deaths? Prospective study of a university surgical service (general, trauma, cardiothoracic, vascular) Complications meticulously analyzed, including disease related and error related. Total complication rate of 32.1% Minor complications 49% avoidable Major complications 49% avoidable Of the 128 deaths, 38 (30%) were felt to be avoidable Conclusion: complication rates in surgical patients are 2-4 times greater than those identified in the IOM report. *Healey MA, Shackford SR, Osler TM et al. Arch Surg/Vol 137, May WTA 2011 Thanks to Gage Ochsner ( ) Background: Despite advances in assessing quality and safety surgical M&M has not changed. Goal is to compare traditional M&M results to the data collected using the ACS-National Surgical Quality Improvement Program(NSQIP) techniques How accurate is that data collected in our weekly M&M? Hutter MH et al., J Am Coll Surg 2006;203: Morbidity and Mortality and the ACS-NSQIP Study Design Retrospective study from M&M conference at MGH. Data collected by residents and faculty over one year A nationally audited nurse reviewer collected the NSQIP data Morbidity and Mortality and the ACS-NSQIP Results: Mortality rates for traditional M&M were 0.9% vs.1.9% for the NSQIP nurse reviewer 50% of deaths were not being reported at M & M Complication rates in M&M were 6.4% vs. 28.9% for the NSQIP group Hutter MH et al., J Am Coll Surg 2006;203: Hutter MH et al., J Am Coll Surg 2006;203:

4 Morbidity and Mortality and ACS NSQIP Conclusions Traditional M&M under reports both in-hospital and post-discharge complications and deaths Approximately 50% deaths and 75% complications did not get reported in M&M Perhaps we are not as good as we say we are in reporting our mistakes completely We have a way to go with reporting our complications The tables show the dramatic difference in numbers by the two techniques Hutter MH et al., J Am Coll Surg 2006;203: Hutter MH et al., J Am Coll Surg 2006;203: Medicine vs. Surgery Morbidity and Mortality Conference Medicine vs. Surgery M & M American College of Surgeons All Rights Reserved Worldwide. Ø 50% of medical service errors vs. 95% of surgical service errors were presented at M & M Ø Error discussion occurred in 10% of medicine cases and 34% of surgical cases Ø Errors in medicine conference were ignored more that surgical conference. Ø Errors in the medicine conference were less often attributed to the team Ø In surgery 64% of errors included the team or system and 33% were attributed to the individual Pierluissi et al., JAMA 2003;290: Quality Assurance in Trauma Started with outcomes assessment in femur fractures s (Ernest Codman, MD) Led to JCAHO (1951) and now Joint Commission (2007) Early goals were system improvement and preventing unnecessary deaths Landmark Preventable Death studies of 1960 s What is the standard paradigm of a preventable death in trauma? Torso/Extremity Bleeding (Non-CNS) No surgery or delayed surgery Perforated Intestine No intervention or delayed intervention If the patient dies because of no intervention = preventable death 4

5 Preventable Trauma Deaths 1955: R. Zollinger, President of SUS, wrote in Arch Surg on preventability of death following MVC 1989: Trunkey reviewed 29 studies in a JAMA article; more published subsequently Research contributed to regionalized trauma care Causes include: Failure to evaluate abdomen Delays to treatment Critical care errors Estimated preventable death rates: 2% to 70% Preventable Death Studies 50 + Studies since 1961 article by Von Wagoner (J Trauma 1:401, 1961) Most from the late 1970 s s Orange County, San Diego, Wisconsin, Florida Panel Process varied Independent review - majority decision Panel consensus review - discussion Unanimous decision review Orange County - Non CNS Pre-system (assessed twice, 4 years apart) /30 15/21 Clearly preventable (37%) (71%) (Preventable death rate) 9 14 Bleeding 1 Sepsis 10/30 11/21 No Operation Orange County - Non CNS After System TC NTC 2/23 4/6 Clearly Preventable (9%) (67%) 1/14 1/2 No Operation West & Cales, 1979, 1983 San Diego County (CNS & Non CNS) 1979: 17/83 (20%) Preventable (Autopsy) 1982: 12/90 (13.3%) Preventable deaths System (MAC - regional council) : 3/112 (2.7%) Preventable deaths 1986: 1/62 (1.6%) Preventable (Autopsy) TC NTC 11/541 17/224 (2%) (7.6%) Shackford,1986 Guss, 1989 Preventable Death Studies - Limitations Not a substitute for: CQI or CPI Error analysis Morbidity Assessment Outcomes Assessment Measuring experiences and volume performance Preventability: moving target as care standards change 5

6 Preventable death assessment struggles with: Potentially preventable: Great variability - may assess quality not preventability Judging complex phase of care: e.g.: fluid effects on respiratory function Attributing controversial care to preventability e.g.: DVT prophylaxis and P.E. Accuracy of Preventable Death Assessments NP/POSS vs. PROB/DEF Intra-panel Agreement Non CNS Cases 66-88% Inter-panel Agreement Non CNS Cases 86-95% Good for determining the obvious MacKenzie, 1992 Institute of Medicine Reports Quality and Safety Safety is the avoidance of a negative outcome. Quality is the achievement of a positive outcome. Safety Quality Quality and Safety Safety can drain provider morale. Quality builds provider morale. Safety Quality Never Events 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF) CMS and AHRQ definitions Adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable NQF initially defined 27 such events in 2002 and revised and expanded the list in 2006 Six Categories: surgical, product/devise, patient protection, care management, environmental, criminal Cliff Ko, ACS NSQIP 6

7 Sentinel Events Joint Commission definitions Events that result in an unanticipated death or major permanent loss of function, not related to the natural course of the patient s illness or underlying condition Fewer (12; 2012) Sentinel Events than Never Events Child death or abduction Suicide, Homicide, Rape, Assault Death, paralysis, coma, loss of function - Meds Transfusion hemolytic reaction Prolonged fluoroscopy/radiation exposure Wrong site surgery Surgical Never Events Surgery performed on the wrong body part Surgery performed on the wrong patient Wrong surgical procedure performed Unintended retention of a foreign object Intraoperative or immediately postoperative death in an ASA Class I patient Artificial insemination with the wrong sperm or donor egg Sentinel and Never Events mer.aspx?primer Why is the error rate so high? Occur relatively infrequently in individual practices and institutions, but occur simultaneously at 5000 locations. Perceived by health care workers as isolated events or outliers Most errors do no harm Most healthcare providers have difficulty in dealing with human error Enabling factors Explosion of technological advances in the 2 nd half of the 20 th century New drugs New operations Specialization of healthcare providers Healthcare is a very complex system The greater the complexity of the system, the greater is the propensity for chaos In open, interacting systems, unpredictable events will happen. Healthcare providers have difficulty in dealing with human error Culture of medical practice Error free practice Mistakes are unacceptable Infallible Error = failure of character How can there be an error without negligence Sense of responsibility of the patient Responsible for any errors that occur Infallibility cover up mistakes, shift blame 7

8 Paradox Standard of perfection, error free practice Errors are inevitable Examine and learn from mistakes Denied this by concept of infallibilty and fear Fear of embarrassment and censure Fear of patient reaction Fear of litigation Surgical M & M Conference Unknown origin Codman given credit for careful analysis of outcome (fracture healing) Long-standing surgical legacy and heritage Or: Blame, ABC Forgive : Accuse, and Blame, Remember Confess 2003 Forgive and Remember When the patient of an internist dies, the natural question his colleagues ask is, What happend? When the patient of a surgeon dies, his colleagues ask, What did you do? By the nature of his craft and his beliefs about it, the surgeon is more accountable than other physicians and he also has much more to account for. High Risk Behavior + High Risk Situations = Adverse Event High Risk Behavior + High Risk Situations = Adverse Event One of the report s main conclusions is that the majority of medical errors do not result from individual recklessness or the actions of a particular group--this is not a bad apple problem. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them. Institute of Medicine To Err is Human

9 Latent errors are defects in the design and organization of processes and systems that can lead to failures and errors. Latent errors are often unrecognized or just become accepted aspects of the work. Latent errors errors whose effects are delayed lead to active errors, whose effects are felt immediately. Examples Door handle vs. bar How is the time out certain to happen? Dr James Reason James Reason; Human Error, 1990 JAMA Surgery Aug cases, 7 years, National Center for Patient Safety, VHA JAMA Surgery Aug cases, 7 years, National Center for Patient Safety, VHA No time out 12 Consent form not specific 10 No skin marking 10 No imaging documentation 12 Leading to Ptx 4, Htx 3, and 2 DEATHS Current Approaches The statistics say that a surgeon will make a given mistake once every 200 times he or she performs a surgery... If the mistake is made the results range from terrible to lethal. The author shares what it feels like to be told that you will make the mistake, that doing the task 99.5% of the time without error can still cost a life. Patient Safety in 2015 Not Error --- Adverse event Error Tasks viewed as error prevention Stakeholder support enlisted Ongoing challenges include: Agreed targets of change Development of effective interventions Improved & standardized error monitoring Leape & Berwick JAMA

10 ACS COT New (2011) Definitions Old Preventable Non-Preventable Possibly Preventable New Unanticipated mortality with opportunity for improvement Mortality without opportunity for improvement Anticipated mortality with opportunity for improvement Contemporary Approaches Improving recognition & reporting Lessons Learned from M & M Standardizing classification Understanding predisposing factors Structural & systemic factors Defective information processing System fixes (build safety firewalls) rather than blame assignment Pursuing patient safety & error reduction Patterns of Errors Contributing to Trauma Mortality: Lessons Learned from 2594 Deaths American Surg Assc. Ann Surg, 2006 Russell L. Gruen MD PhD Gregory J. Jurkovich MD Lisa K. McIntyre MD Ronald V. Maier MD Department of Surgery Harborview Medical Center University of Washington Seattle, WA. 69 yo male s/p MVC with traumatic brain injury (TBI) and multiple extremity fractures. Tracheostomy placed on HD#14 for ventilator weaning. 6 hours after OR, leak noted from tracheostomy, necessitating constant manipulation by RT and bedside RN Physician notified. 10

11 See the patient; try to troubleshoot? Call anesthesia to orally intubate and remove tracheostomy? If patient stable, make note to discuss on am rounds? Promptly notify the attending surgeon of problem, regardless of whether the patient is stable or not? Air leaks from a fresh tracheostomy are urgent surgical problems that require attending notification. Most require urgent revision in the operating room. What lessons to take away from this? House physician saw patient, made note to discuss with surgeon in AM. Just before AM rounds, patient coughed trach out and desaturated. Attempts made to reinsert trach in addition to endotracheally intubating patient failed. Patient ultimately suffered respiratory arrest and died Identify the nurse, respiratory therapist, and house physician involved. Blame them, forgive them, hope they remember this forever. But make a note in their record that this occurred on their watch Or.... Write a hospital-wide policy for the management of fresh tracheostomies. Track problems. Revise policy. But... Thank you What to do about that 1%? Can surgery be perfect? Is that a reasonable expectation? Can planes never crash? Can cars never fail? Can oil rigs never leak? Can nuclear reactors never fail? American College of Surgeons All Rights Reserved Worldwide. 99% of the time all is fine 11