ImprovingPatientSafety:AnUrgentImperativeforAllProviders
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Improving Patient Safety: An Urgent Imperative for All Providers
Patrick J. Dunne, MEd, RRT, FAARCFullerton, CA
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
ImprovingPatientSafety:AnUrgentImperativeforAllProviders
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The Leapfrog GroupHospitalsafetyscore.org
The Leapfrog GroupHospitalsafetyscore.org
The Leapfrog GroupHospitalsafetyscore.org
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The Leapfrog GroupHospitalsafetyscore.org
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
Patient Safety in Respiratory CarePost-operative Pulmonary Complications (PPCs)
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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
Patient Safety in Respiratory CarePost-operative Pulmonary Complications (PPCs)
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