Directly from the article: "Dan Meyer, president of the Sword Swallowers Association International, cited sword swallowers’ contributions to the development of the endoscope, a device used by physicians in some instances to peer down a patient’s throat to examine esophageal disorders."
Not sure if I would call it a lost art, but a fascinating read none the less. You never know where important medical contributions will come from.
Lean healthcare advocates realize that improving healthcare is not just about the hospital. In fact, 50% of the problem or opportunity (glass half empty or full) is at the home. Some interesting technologies for the home to help us improve our lives. Though, most of these are just for geeks, they will work they way down to a very usable level for regular folk too.
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Brigham and Women's Hospital surgeon Atul Gawande, MD, is on the road talking up one of his favorite topics: Checklists. You could say he wrote the book on them, "The Checklist Manifesto."On Wednesday Gawande talked at a Scripps Quality Summit in San Diego about how the 19-point system he and others developed is proving every day that its use can reduce surgical deaths, complications, surgical site infections, and unplanned reoperations.
Death rate dropped from 1.5% to .8%; complication rate from 11% to 7%; surgical site infections, from 6.2% to 3.4% and unplanned reoperations, 2.4% to 1.8% as measured within the first 30 days in eight hospital sites globally, after his surgical checklists were adopted, he said.
He also talked about how hard it is to get providers to adopt those checklists, that they are controversial, and listed some of the reasons many providers are resistant, even with so much evidence that they improve care. Gawande told his audience that providers largely think they alone are responsible for the treatments they administer to one patient, but in fact, it takes 19.5 full-time equivalent positions to make that process happen.
Gawande recounted one bone-chilling example of how the failure to perform one thing – the administration of a simple vaccine that should have been part of routine medical procedure – caused the system to disastrously fail for one young man.
It was the story of Duane Smith, a 34-year old grocery store worker from Texas, who got in a terrible vehicle collision while driving in Boston.
"He'd had a broken leg, broken pelvis, broken arm, bilateral lung collapse and internal bleeding from an unknown source. The team that took care of him worked like clockwork. The EMTs got on the scene immediately. They extracted him, gave volume resuscitation, and kept him alive. They transported him rapidly to the nearest level one trauma center.
"There in the emergency room, they enumerated and found every injury, identified bilateral lung collapse and needed chest tubes, confirmed the bleeding was not coming from his chest and moved him to an operating room so that his ruptured spleen (could be) removed."
Its important to understand the underlying reasons hospitals are not using a simple technique of checklists in order to improve patient safety. This is not a problem alone in hospitals. As checklists are implemented in any industry, in any company, there is always initial resistance. People tend to think that checklists wont work in their environment. Everyone always thinks their environment is different. Sometimes, people think it will make the work rote. Sometimes, its as simple as, change is hard. People never used checklists before, and now you are asking them to make a behavioral change. The important thing to do (and I learned the hard way at Mobile Aspects) is just to keep reiterating the point over and over, and lead by example. You need to talk to your leaders and get them to get aboard and lead by example. But changing culture is hard work, and not for the weary. It is done through diligent, consistent work each and every day. I continue to applaud all those in the healthcare field trying to make a difference in the culture of healthcare delivery for the better.
A Johns Hopkins-led safety checklist program that virtually eliminated bloodstream infections in hospital intensive-care units throughout Michigan appears to have also reduced deaths by 10 percent, a new study suggests. Although prior research showed a major reduction in central-line related bloodstream infections at hospitals using the checklist, the new study is the first to show its use directly lowered mortality.
“We knew that when we applied safety science principles to the delivery of health care, we would dramatically reduce infections in intensive care units, and now we know we are also saving lives,” says Peter J. Pronovost, M.D., Ph.D., a professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine and leader of the study published in BMJ, the British Medical Journal. “Thousands of people are believed to have survived because of this effort to reduce bloodstream infections.”
Pronovost’s previous research has shown that coupling a cockpit-style, infection-control checklist he developed with a work environment that encourages nurses to speak up if safety rules aren’t followed reduced ICU central-line bloodstream infections to nearly zero at The Johns Hopkins Hospital and at hospitals throughout the states of Michigan and Rhode Island. Experts say an estimated 80,000 patients a year with central lines get infected, some 31,000 die — nearly as many as die from breast cancer annually — and the cost of treating them may be as high as $3 billion nationally.
For the new study, Pronovost and his team, using Medicare claims data, studied hospital mortality of patients admitted to ICUs in Michigan before, during and after what is known as the Keystone ICU Project, which features the checklist. They compared the Michigan information to similar data from 11 surrounding states. While data from both Michigan and the other states showed a reduction in hospital deaths of elderly patients admitted to ICUs over the five-year period from October 2001 to December 2006, the patients in Michigan were significantly more likely to survive a hospital stay during and after the Keystone project.
These findings cannot definitively attribute the mortality reduction to the Keystone project, Pronovost says, but no other known large-scale initiatives were uniquely introduced across Michigan during the study period. “This is perhaps the only large-scale study to suggest a significant reduction in mortality from a quality-improvement initiative,” Pronovost says
The Keystone ICU Project, developed at Johns Hopkins, includes a much-heralded checklist for doctors and nurses to follow when placing a central-line catheter, highlighting five cautionary and basic steps from hand-washing to avoiding placement in the groin area where infection rates are higher. Along with the checklist, the program promotes a “culture of safety” that comprises safety science education, training in ways to identify potential safety problems, development of evidence-based solutions, and measurement of improvements. The program also empowers all caregivers, no matter how senior or junior, to question each other and stop procedures if safety is compromised.
Central lines are thin plastic tubes used regularly for patients in ICUs to administer medication or fluids, obtain blood for tests, and directly gauge cardiovascular measurements such as central venous blood pressure. But the tubes are easily contaminated
In 2009, U.S. Health and Human Services Secretary Kathleen Sebelius called for a 50 percent reduction in catheter-related infections nationwide by 2012. To that end, in partnership with a branch of the American Hospital Association and the Michigan Hospital Association, the Johns Hopkins model is being rolled out state-by-state across the country. Forty states have launched the program, and preliminary data from some of the early adopters is very encouraging, Pronovost says.
The original Keystone project was funded by HHS’s Agency for Healthcare Research and Quality.
Other Johns Hopkins researchers involved in the research include Allison Lipitz-Snyderman, Ph.D.; Donald Steinwachs, Ph.D.; Dale M. Needham, M.D., Ph.D.; Elizabeth Colantuoni, Ph.D.; and Laura L. Morlock, Ph.D.
Dr. Pronovost, at my alma mater, Johns Hopkins has been leading the way, along with Atul Gawande, MD, for the movement of checklists in healthcare. This is another story about how changing the delivery of medicine (not the clinical procedures) is yielding tremendous safety and efficiency results in healthcare. If you look at it, checklists are really a "Lean" process. They are created by examining a problem, understanding it, getting data, and putting together an initial attack plan. Then over time, that attack plan is honed and honed to be made better and better.
Checklists in hospitals can save lives, eliminate redundancies, and transform healthcare. It is not about make a procedure rote - you cant replace the doctor and the nurse or their expertise in practising a knee replacement, etc. However, you can help them ensure they remove potential infection point happen rarely to them, but over a large population (300 million people) create significant numbers of occurrences in the 100's of thousands per year. Its about transforming the delivery and logistics of healthcare, not transforming the actual care itself.
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Marketing campaigns that promise "satisfaction guaranteed or your money back" are risky, but often effective. I saw this first-hand in college delivering pizzas for Domino's, which had recently launched a campaign that guaranteed customers would get their pizza for free if it wasn't delivered within 30 minutes. People rarely got a free pizza but everyone knew about the promotion and business thrived.
Now, a group of specialty hospitals in Texas is using a similar program to promote emergency care. Emerus Hospital Partners, a five-hospital network with facilities in the Houston and Dallas areas, has a program that guarantees free care for emergency department patients if they don't see a doctor within 15 minutes. The clock starts ticking as soon as patients complete their paperwork to check in.
"So far, there have been only 17 occasions where we didn't meet the deadline and those patients were low-acuity because we still operate on a triage system," said Randy Park, MD, chief medical officer for Emerus. "So we've failed to meet the deadline in less than one percent of our cases and those patients were very happy to receive their care for free."
Emerus operates specialty hospitals that provide a full suite of emergency care, including CT scans, ultrasounds, x-rays and on-site lab and pharmacy services. The 24-hour emergency hospitals are staffed with experienced emergency department physicians, which Park says makes a difference in delivering results.
No doubt that our hospitals in the US still deliver the best clinical care in the world. But, as the main theme of my blog continues, the biggest problem we have is the logistics in delivering the care. From administrative paperwork processes, to inefficient workflows, to overburdened supply chains, almost every part of the care delivery system needs an overhaul.
The great thing I am seeing is that Hospital executives are getting the "Lean" bug. As I travel from hospital to hospital, I see mini-experiments happening every day where hospitals are trying new techniques to make themselves leaner (and consequently, safer). In this instance, Emeritus Hospital system in Texas is providing a guarantee that when you visit the ER, you will be seen within 15 minutes from when you check-in. If you take a look at how they did it, it wasnt through some incredible technology change. It was simply a change in culture. By offering the guarantee, all the great employees there new they had to operate differently. This created a new culture in which people come in quickly and leave quickly. Incentives matter - there was no incentive to hurry people through the process. Now there is.
I am incredibly encouraged to see all the experiments going on across the country in our hospitals. Its only making the situation better for both the patient and the hospital.
