Improving Patient Safety: An Urgent 9/30/19 Imperative for ... · Improving Patient Safety: An...

ImprovingPatientSafety:AnUrgentImperativeforAllProviders

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Improving Patient Safety: An Urgent Imperative for All Providers

Patrick J. Dunne, MEd, RRT, FAARCFullerton, CA

[email protected]

Kentucky Society for Respiratory Care14th Annual Educational Symposium

Western Kentucky UniversitySeptember 25, 2019 w Bowling Green w KY

Disclosure

Professional relationship withw Monaghan Medical Corporationw Mylan Pharmaceutical

Career-long member/supporter ofw AARC (AARConnect)w State affiliates

Objectives

✦ State reasons why RTs should actively support and participate in efforts to improve patient safety;

✦ Describe the benefits of using patient-centered protocols, in conjunction with safety checklists, to ensure the delivery of appropriate and safe respiratory care, and

✦ List the prevalence and economic impact of post-operative pulmonary complications and the important role RTs can play to help address this significant patient safety issue.


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The Earliest Days”First, do no harm”

✦ Hippocratic oath written in Greek –“abstain from whatever is deleterious”

✦ The Latin phrase primum non nocerefirst appears mid-19th century medical texts

v Attributed to English physician Thomas Sydenham

Patient SafetyThe Modern Era

✦ Published1999byUSInstituteofMedicine

v BasedonHarvardMedicalPracticeStudy (NEnglJMed;1991)

✦ Estimated44,000to98,000preventabledeathseachyear

✦ Errorratehighestin

v Intensive/criticalcareunits,v Surgicalsuites,v Emergencytraumapatients

The Leapfrog GroupHospitalsafetyscore.org


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Wednesday, November 28, 2012

C-Suites Worst Nightmare!

Patient Safety2002-03

✦ 2002-03: Develops, releases National Patient Safety Goals

✦ 7 “major” NSPGs, with 16 subsetsv Identify patients correctly (2)

v Improve staff communication (1)v Use medication safely (3)

v Use alarms safely (1)v Prevent infection (5)

v Identify patient safety risks (1)

v Prevent mistakes in surgery (3)


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Patient Safety2011

“Checklists catch mental flaws in all of us – flaws of memory, of attention, and of thoroughness”

“Safety checklists, while a rather simple and decidedly low-tech intervention, have the potential to

significantly reduce iatrogenic harm”

B-10 B-17

Checklists Arrive in AviationOctober 30,1935

Patient Safety Checklists for Respiratory CareImproving Hand-off Communications

✦ Developed by AARC in 2012 (Grant from Masimo Corporation)✦ Employed evidence-based format✦ Available via open access on AARC.org


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Patient Safety2013

✦ Literature search 2008 – 2011✦ 210,000 to 400,000 preventable deaths per year✦ Non-lethal harm 10-to-20 fold higher✦ Near misses/non-reported incidents unknown✦ Preventable patient harm/injury an epidemic

Journal of Patient Safety. Vol 9; No 3: September 2013

Patient Safety2013

Established through support of Masimo Foundation for Ethics, Innovation to reduce preventable deaths to ZERO through development of actionable patient safety solutions

Convenes Annual World Patient Safety, Science & Technology Summit; Key feature – Personal Testimonials by family members of victims

AARC an active, engaged Partner

Patient Safety2015

✦ Implements Hospital-Acquired Conditions (HAC) Reduction Program

✦ Reduce payments 1% to worst-performing hospitals (25th percentile)

✦ 2019 Patient Safety Indicators – Rates of:

▶ Pressure ulcer ▶ Post-op respiratory failure▶ Iatrogenic pneumothorax ▶ Peri-op PE/DVT▶ In-hospital fall w/ Fx hip ▶ Post-op sepsis ▶ Peri-op hemorrhage ▶ Post-op wound rupture▶ Kidney injury requiring dialysis ▶ Abdomino-pelvic laceration


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Patient Safety2016

BMJ; May 2016

Patient SafetyDecember, 2018

Ed Salazar (father): Christopher Salazar (age 27)

Utah RTs: Shaylynn Uresk, Kim Bennion

Yvonne Gardner (mother); Madi (wife): Parker Stewart (age 21)

Patient SafetyApril, 2016 (AARCTimes)


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Patient SafetyJuly, 2018 (AARCTimes)

AARC members rally behind efforts to ensure pain medications don’t end up being a death sentence for people in their state

“Over 1 million PPCs occur each year resulting in 46,200 deaths and 4.8 million hospitalization days.”

Critical Care Medicine. September 2011

Patient Safety in Respiratory CarePost-operative Pulmonary Complications (PPCs)

“Post-operative pulmonary complications are more of a financial burden than cardiovascular or infectious

complications after surgery, costing the US$3.4 billion annually.”

Surg Clinics N Am. Volume 95: April 2015



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“The development of at least 1 PPC, even those presumed mild (e.g. atelectasis, need for prolonged oxygen therapy) was associated with significantly increased early post-operative mortality, ICU

admission and prolonged LOS.”

Fernandez-Bustamante, A; et.al. JAMA Surg. Feb 2017


Postoperative Pulmonary ComplicationsOverview

✦ Relatively recent area of independent investigationv Typically “we treat it when detected”

✦ Prevalence following general surgery/anesthesiav Overall range: 2% to 40%

§ 2% (low risk patient/low risk procedure)§ 40% (high risk patient/high risk procedure)

✦ 10-fold higher risk in abdominal proceduresv Risk intensifies closer to diaphragm

✦ Increased LOSv 12 days vs. 3 days

✦ No additional provider payments

✦ Increases 30-day readmissions

✦ Major contributor to surgical morbidity, mortality v Higher in elderly population

✦ Part of Hospital Acquired Condition Reduction Program

Postoperative Pulmonary ComplicationsImpact


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Predictive Factors for PPCsSmetana GW. Ann Intern Med. 2006

✦ Patient Relatedv Age (≥ 65 yrs.)

v Low SpO2 (≤ 90%)

v Recent respiratory infection (2-3 weeks prior)

v Anemia

✦ Procedure Relatedv Surgical site/procedure (Abdomen, Thorax)

v Length of surgery (≥ 2.5 hrs.)

v Emergency vs. elective

Additional Risk Factors for PPCsBranson R. Respir Care; November 2013

✦ COPD

✦ CHF

✦ OSA (esp. undiagnosed/untreated)

✦ Cigarette smoker

✦ Other chronic conditions (i.e. diabetes)

✦ Functional dependence

✦ Impaired sensorium

✦ Drug/alcohol dependence

Adding insult to injuryv Pain control

v Sedationv Diminished cough

v Immobility

✦ Incentive Spirometry (aka Sustained Maximal Inspiration)

v A prophylactic bronchial hygiene technique§ 1970s - “cost-effective” alternative to IPPB

v Slow, deep inhalation followed by breath hold (2 – 6 seconds)

§ Ideally, from FRC to TLC

v IS devices widely used in many/most hospitals

What About Incentive Spirometry?What Does The Evidence Say?

✦ Cochrane Database Systematic Review; Feb 2014v 12 studies with useable data on 1160 subjects

v “There is low quality evidence regarding the effectiveness of incentive spirometry for prevention of postoperative pulmonary complications in patients after upper abdominal surgery.”


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Evidence for Incentive Spirometry?Respir Care; March 2018

✦ Published studies: inconsistent methodologies = inconclusive results✦ Lack of patient adherence data major confounder in IS studies✦ Standardized clinical approach for IS lacking

“Until evidence of benefit from well-designed clinical trials becomes available, the routine use of IS in postoperative care is not supported by high levels of

evidence . . .

Given their expertise in working to optimize patients’ postoperative pulmonary outcomes, respiratory therapists can play an integral role in educating providers

about the dearth of evidence supporting IS.”

Patient SafetyOur Responsibility – Our Time

✦ Medical mistakes:

v Are prevalent, harmful, deadly & costly§ An epidemic requiring immediate/continuous action

§ Excellent opportunity for RTs in ALL care settings

v Impact EVERY health care stakeholder§ Patients/family, purchasers, providers, payors

v Are largely preventable§ Demands “mindfulness” in a highly complex environment

§ Require a Culture of Safety

Patient SafetyOur Responsibility – Our Time

“Today’s clinicians have at their disposal some 6,000 drugs and

4,000 medical/surgical procedures to treat more than 13,000 different diseases, symptoms and types of

injuries.

Medicine has become the art of managing extreme complexity.”

Atul Gawande, MD

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