Small changes, big results: How five hospitals are drastically improving care

Relatively small actions at these academic medical centers have led to significant successes, from increasing the use of generic medicines to lowering the risk of in-hospital cardiac arrests.
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The numbers can seem overwhelming. 

Each year in the United States, 90,000 people die from hospital-acquired infections, according to a 2018 report from The Leapfrog Group. More than 17,000 malpractice lawsuits are filed annually, and doctors can expect to be sued once every seven years. Estimates of pharmaceutical spending in the United States ranged from $323 billion to as much as $477 billion in 2016, a 2018 analysis from Health Affairs found.

The problems are large, but small measures can have big impacts, whether it’s tweaking electronic health records (EHRs) to increase generic drug use or apologizing to patients for medical errors. Here are five ways that academic medical centers are improving patient care, saving lives, and reducing costs.

1. Increasing generic drug use

The strategy: Change default options in EHRs

Using generic drugs sounds like an easy way to cut costs. The problem? Most doctors don’t have time to review long lists of drugs for generic options. To simplify the process, Mitesh Patel, MD, and his team with the Penn Medicine Nudge Unit, which uses behavioral economics and psychology to guide medical decisions, changed the default medication options in EHRs to generics for its 75 most-prescribed medications. The switch increased generic prescribing rates from 75% to 98%, leading to $32 million in savings, a 2016 Penn Medicine pilot study found.

“Setting the default to [generics] saved clinicians time,” says Patel. “There is also evidence that patients are more likely to adhere to generic medications than brand medications because they are more affordable.”

The Nudge Unit has introduced more than 30 improvements at Penn Medicine, including a secure text messaging system for health care workers (poor communication can lead to delays and errors, and so far, the system has decreased patients’ length of stay by 14%) and a program that reduced unnecessary lab tests in the ICU by displaying their cost when doctors placed the order. Other steps have led to higher influenza vaccination rates for patients and fewer opioid prescriptions for acute pain. You can find the unit’s full portfolio here.

2. Reducing sepsis risk in children

The strategy: Take three key steps in 60 minutes

Starting antibiotics. Administering intravenous fluids. Taking blood cultures. These three actions, completed within an hour of identifying possible sepsis in children, can save lives. That was the result of a recent study published in the Journal of the American Medical Association (JAMA), which examined the outcomes of 1,179 children with sepsis at 54 hospitals in New York. The state toughened its sepsis rules following the 2012 death of Rory Staunton, a 12-year-old boy who died from undiagnosed sepsis five days after a cut on his arm became infected. Known as “Rory’s regulations,” the rules require hospitals to follow several protocols, including the key steps involving blood cultures, antibiotics, and fluids. In the JAMA study, completing these three steps within 60 minutes of suspected sepsis reduced the odds of death by 40% compared to children who did not receive all three steps.

Researchers have yet to determine the cost benefits for hospitals, but each action is inexpensive, says the study’s senior author, Christopher W. Seymour, MD, associate professor in the Department of Critical Care and Emergency Medicine at the University of Pittsburgh School of Medicine. And most important, they can prevent the needless deaths of children like Staunton.

“Implementing and following pediatric sepsis protocols may improve outcomes for the highest-risk children with sepsis,” says Seymour. “No child should die from a treatable infection.”

3. Preventing malpractice litigation

The strategy: Apologize and explain what happened

“I’m sorry.” Those can be powerful words for dealing with hospital errors and preventing lawsuits, as research published in Health Affairs shows. The 2017 study focused on six Massachusetts hospitals that use a program called CARe (Communication, Apology, and Resolution). The program has four main components: Communicating with patients and families when adverse outcomes occur, investigating and explaining the reasons, implementing systems to prevent recurrences and improve patient safety, and apologizing and offering compensation (when appropriate).

Of the 989 adverse events involving CARe in the study, only 5% led to lawsuits or malpractice claims. That’s because apologizing and explaining what happened can soothe patients’ anger, says study author Michelle Mello, JD, PhD, professor of health research and policy at Stanford University. In roughly 75% of the cases, adverse events were not even caused by errors, but when patients feel that health care providers are being evasive or concealing negligence, it can lead to malpractice claims, she says.

At Boston’s Beth Israel Deaconess Medical Center (BIDMC), one of the hospitals in the study, an attending physician and a patient relations employee usually attend meetings with patients and families. Attorneys rarely attend until the discussions involve compensation. If in-person meetings can’t be arranged, communication occurs by letter or phone.

“The decision to meet in person or to apologize in writing is generally driven by the preference of the patient or family,” says Patricia Folcarelli, RN, PhD, vice president of health care quality at ‎BIDMC. “Asking ‘what would be most helpful for you at this time’ is a good guide to help decide who, when, where, and how these conversations should happen.”

4. Decreasing in-hospital cardiac arrests

The strategy: Use data to predict heart attacks

More than 200,000 in-hospital cardiac arrests occur annually in U.S. hospitals. The survival rate is around 25%, the American Heart Association reports. To improve those numbers, two assistant professors at the University of Chicago Medicine (UCM), Matthew Churpek, MD, PhD, and Dana Edelson, MD, have used hundreds of thousands of EHRs to develop an algorithm called eCART, which uses vital signs, lab results, and demographic data to calculate a cardiac arrest risk score. The idea? To predict cardiac arrest within hours, even days. 

“eCART incorporates dozens of variables from a patient in real-time — age, blood pressure, white blood cell count, for example — and calculates the probability that a patient will develop a cardiac arrest or need to go to the intensive care unit,” says Churpek. 

A patient’s score is updated constantly, and nurses review it on a dashboard. When the score becomes too high, the system notifies a rapid response team. The results? Between 2014 and 2017, eCART reduced the ward cardiac arrest rate by nearly 50%. eCART is now running in over 10 hospitals around the country, and at Alexian Brothers Medical Center in Elk Grove Village, Illinois, the cardiac arrest rate dropped by 57% in 2017.

eCART has been shown to predict outcomes for additional conditions, such as sepsis and pulmonary embolisms. This not only saves lives but increases staff efficiency. “It decreases wasted work associated with sepsis screening on low-risk patients and improves MD/RN communication by empowering nurses to speak up when their ‘worry’ sensor goes off,” says Edelson. “It gives them a language that physicians can hear. It’s truly a culture change.”

5. Increasing hand washing

The strategy: Install an electronic monitoring system

Want your staff to follow proper hand-washing procedures? Denver Health Medical Center improved its adherence rates from 40% to 70% by implementing an electronic hand-hygiene monitoring system. The CenTrak system uses sensors and employees’ badges to track their location and monitor their use of waterless hand sanitizers and soap dispensers. Health care workers are required to clean their hands 60 seconds before they enter a room and within 60 seconds after they leave. The badges then track their adherence rates.

“Our ultimate goal has been to use it as a performance improvement tool,” says Heather Young, MD, medical director of infection prevention at Denver Health. “We do not punish staff with low adherence, but work with them and their managers to identify barriers, educate, and determine a strategy for improvement.” Such efforts have proven effective: In a 2016 study, health care workers at the Santa Clara Valley Medical Center in California were twice as likely to comply with hand hygiene guidelines when they knew they were being watched.

The program is part of Denver Health’s Target Zero safety effort, which has reduced infections, patient falls, and medication errors. Next up: Young and her team are studying the link between electronic hand-hygiene monitoring and reducing hospital-acquired Clostridium difficile infections.