Presentation on theme: "James H. Nichols, Ph.D., DABCC, FACB Associate Professor of Pathology"— Presentation transcript:
1Using Data to Reduce Error, Standardize Practice and Improve Patient Outcomes James H. Nichols, Ph.D., DABCC, FACBAssociate Professor of PathologyTufts University School of MedicineDirector, Clinical ChemistryBaystate Health SystemSpringfield, Massachusetts
3Baystate Health System Baystate Medical Center - tertiary care572 beds, 3rd largest acute care in NE40,000 discharges/200,000 inpatient days (4.7 mean LOS)600,000 ambulatory visitsWestern Campus of Tufts School of MedicineFranklin and Mary Lane HospitalsOver 40 Ambulatory Care Practices (1 million visits)Home nursing and assisted care (156,000 visits)Reference Lab (BRL) - 4 million tests/yearClin Chemistry - Core 1 Roche TLA (2500/day)
5Medical ErrorsInstitute of Medicine of the National Academies report 1999Medical errors kill 44, ,000 patients in US hospitals each year.“Number one problem facing health care” Lucien Leape, Harvard Professor of Public Health
6Medical Errors2002 Commonwealth Fund report estimated that 22.8 million people have experienced a medical error, personally or through at least one family memberReinforces the 1999 IOM report, “To Err is Human”Annual costs estimated at $17 – 29 billionUS Agency for Healthcare Research and Quality (AHRQ) estimate medical errors are the 8th leading cause of death in the US – higher than:Motor Vehicle Accidents (43,458)Cancer (42,297)AIDS (16,516)
7Laboratory Errors Typically think patient, tube or aliquot mix-up. Other, more insidious errors to considerOverutilization of testing – “fishing”Inappropriate use of testing – method selection or test for symptoms, screening vs managementMisunderstanding – wrong test, assume ‘test is a test’Delays – ordering, receipt of result, clinical action
8Laboratory ErrorsA minireview of the literature found the majority of errors occur in the pre and post analytical phases.Bonini P, Plebani M, Ceriotti F, Rubboli F. Clin Chem 2002;48:Many mistakes are referred to as lab error, but actually due to poor communication, actions by others involved in the testing process, or poorly designed processes outside the lab’s control.Medical errors occur in prevention, diagnosis and drug treatment occur. Among errors in diagnosis; 50% were failure to use indicated tests, 32% were failure to act on results of tests, and 55% involved avoidable delay in diagnosis. Leape LL, Brennan TA, Laird N, et al. N Eng J Med 1991;324:
9Man A creature made near the end of the week when God was tired. Mark Twain
10Medical Errors The Person The System Easier to blame a person than an institution for errors.In aviation, 90% of quality lapses are judged to be blameless.The SystemActive failures due to personal interaction with systemLatent conditions, weaknesses in system due to design flaws or heirarchical decisionsNeed to engineer systems that prevent dangerous errors and are able to tolerate errors and contain their effectsReason J. BMJ 2000;320:
11Automation Collects raw data and processes to information (trends) Reduces practice variability (device prompts)Consolidates operator interactions (barcoding)Assists decision-making (internal checks for QC pass, expiration dates, operator ID)When linked to information management and data algorithms can warn of possible errors (delta checks, device flags like inadequate sample, analyzer interferences)
13Hemolysis in the EDCoagulation specimens must be rejected if hemolyzed and recollectedInpatient rates of hemolysis are typically <1%ED had rates approaching 20% or moreRelated to implementation of a flexible catheter and practice of collecting blood through linesManufacturer even distributed a customer warning against collecting blood through this catheterYet, ED unwilling to change practice – customer satisfaction issue and comfort level of IV linesNumber of redraws and delays of ED patients led to elimination of practice.
14Phlebotomy Hemolysis Rates Implement Practice Change
15Middleware Data server sits between an analyzer and LIS/HIS POCT servers are a form of MiddlewareAllows data processing before sending results LIS, also functions as data repository for report searchesCommon current uses – autoverification, insertion of data flags for H/I/L indicesMore sophisticated functions are limited only by imagination of the lab
16Clinical AlarmsCritical pathway ordering practices and variant ordering practicesHct level and POCT glucose testingMedication (propofol) and potential test interference (i-Stat)Insulin dose, individual response and prediction of future doseDisease/medication (high blood pressure/loop diuretics) vs predicted lab result (low K) vs questionable lab results (high K)Medical devices (flexible catheters) and potential for hemolysis and laboratory interference
17POCT Error ManagementPOCT – diagnostic testing conducted close to the site where clinical care is deliveredPOCT error rates are not known in literaturePOCT conducted by nursing but managed by labRequires considerable interdisciplinary communication to deliver effectivelyPOCT QI can be a tool to uncovering ongoing errors and addressing system weaknesses
18Reducing Errors through Automation Newer POCT devices have data managementPrompts operator to perform testing same way every timeLock-outs act as internal “fail-safes” to prevent a patient result if QC fails, not performed or operator is not certified for testing.Feb 2004 CLIAC meeting discussion of possible changes to CLIA waived category suggested that waived tests havefail-safe or failure alert mechanisms whenever possibleinclude QC materials with kitsspecimens requiring significant manipulation not be waived
19Medical Errors The Person The System Easier to blame a person than an institution for errors.In aviation, 90% of quality lapses are judged to be blameless.The SystemActive failures due to personal interaction with systemLatent conditions, weaknesses in system due to design flaws or heirarchical decisionsNeed to engineer systems that prevent dangerous errors and are able to tolerate errors and contain their effectsReason J. BMJ 2000;320:
20Patient Identification Errors POCT results are transmitted to the POCT manager when devices are downloadedThe data manager orders and results the test in the LISIf the test does not match an active patient account the data manager holds the result for resolutionCompliance problems as test cannot be billed, and some results transmitted to incorrect patient record and inappropriate medical management
21Failure Mode and Error Analysis FMEA identifies an errorOutlines possible steps that could lead to the error.Identifies the reasoning behind the various pathways, why they exist and ways that paths can be improved.Establishes quantitative monitors and the means of measuring improvement.FMEA improves motivation by seeking route causes of errors rather than placing blame.
22ICU FMEAIncidence of patient ID errors in our ICU led to an administrative demand for improved compliance or loss of privileges (3 strike rule)Conducted FMEA analysisID errors due to multiple issues:Long number entry (9 digits), transposition of numbersSome devices can’t accept leading zerosPatient wristbands are not legible (clin engineering)Need for patient care, share operator IDs (retraining)Barcoding seen as optimum solution
23BarcodingIn practice, one of the more challenging projects to implement in an institution:Devices only read specific barcode languagesWristbands vary in durabilityInk isn’t permanent (thermal vs inkjet)Devices don’t require barcode entry!Try to engineer around manual entry by adding special characters or digits to IDThese work-arounds lengthen the barcode and increase read failure if barcode not flat on wrist.How to print? Wristbands only or labels that an operator can stick onto device or paper towel? What about neonates?
24BarcodingDuring implementation, operators continued to manually enter patient IDs due to the scanner failing on the 1st attemptAn investigation was conducted into why scanners faili-Stat scanners failed more frequently than glucoseOperator interaction with the POCT device was the primary determinant in scanner failure
31BarcodingBarcode acceptance and difficulties in implementation lead to <100% effectiveness:Manual entryBarcoding patient with the wrong account or patient IDPatients with multiple wristbandsScanning the wrong barcode (lot number instead of patient)From the AACC listserv, those successful institutions communicate the value of barcoding and have operators who have acknowledged the advantages and implement strategies to enhance success
33Communication How best to reach clinicians? Errors are a system weakness and require an interdisciplinary system fix, one person is not responsible.Utilize available resources:Hospital Quality Improvement TeamsPeer-Reviewed LiteraturePractice GuidelinesLearn to speak ‘clinicalese’ – Use Clinical Protocols
34Portland ProtocolExamined glucose levels and surgical complications in 1,585 cardiac surgery patients with diabetes (990 preprotocol and 595 postprotocol)Implemented protocol of postoperative intravenous insulin to maintain glucose <200 mg/dL.Intensive monitoring and insulin therapy on hospitalized inpatients lowers blood glucose levels in the first 2 postoperative days with concomitant decrease in proportion of patients with deep wound infections (2.4% vs 1.5%, p<0.02)Zerr KJ et al. Ann Thorac Surg 1997;63:
35Portland Protocol ACC/AHA Guidelines for CABG Surgery “Another patient characteristic that has been associated with postoperative mediastinitis is the presence of diabetes, especially in patients requiring insulin. In addition to the microvascular changes seen in diabetic patients, elevated blood glucose levels may impair wound healing. The use of a strict protocol aimed at maintaining blood glucose levels 200 mg/dL by the continuous, intravenous infusion of insulin has been shown to significantly reduce the incidence of deep sternal wound infection in diabetic patients.”Eagle KA, Guyton RA. JACC 1999;34:
36Portland Protocol Blood Glucose Insulin Unit/hr <125 125-175 1 12>2253q1hr until glucose with <15 mg/dL change and insulin rate unchanged x4 hrs. Then q2hr.Weaning vasopressors (Adrenalin) check q30min until stableStop q2hr testing on POD #3Test q2hr during the night on telemetry if glucose <200
37Portland Protocol Operational Issues Which method to utilize? [TAT, Accuracy]Glucose meter – glucose oxidaseBlood Gas glucose – glucose oxidaseCore laboratory glucose - hexokinasePreferred sample? [Method, Line Contamination]Whole blood or plasmaFingerstick, line draw or venipuncture
381.18 0.94 1.11 Unmodified direct-reading biosensor result ”relative molality” of glucosein plasma or whole blood(not recommended)1.180.94Concentration ofglucose in plasma(recommended)Concentration ofglucose in whole blood(not recommended)1.11Fig. 1. Conversion factors for different quantities of glucose.
40Quality Specification Modeling Monte Carlo simulation to generate random “true” and “measured” glucose based on mathematical model of meters having defined imprecision and bias. (N=10, ,000 pairs)Analytical error Insulin dose errors5% %10% %2x or greater insulin dosage errors >5% of time when analytic error exceeded %Total error < % required to provide intended insulin >95% of time.Boyd JC. Bruns DE. Quality specifications for glucose meters: Assessment by simulation modeling of errors in insulin dose. Clin Chem 2001;47:
41Portland ProtocolGlucose meters may or may not be applicable for tight management, as can vary by +/-20% in the 100–200 mg/dL range.Blood gas and some analyzers perform better than glucose meters, may be more appropriate in these cases.Should be a clinical not a laboratory decision, role of laboratory to inform not dictate method
44Clinical ProtocolsClinical protocols provide a pathway of care to manage patients with specific disorders in the most effective manner for optimum patient outcome.Incorporating laboratory testing into clinical protocols standardizes practice, reduces practice variability, ensures appropriate ordering of tests and can assist the interpretation of test results.Clinical protocols are a good means of communicating with clinicians and providing reminders or important components of decision-making
452004 National Patient Safety Goals - JCAHO Improve the accuracy of patient identificationImprove the effectiveness of communication among caregiversImprove the safety of using high-alert medicationsEliminate wrong-site, wrong patient, wrong-procedure surgeryImprove the safety of using infusion pumps.Improve the effectiveness of clinical alarm systems.Reduce the risk of healthcare-acquired infections.
47NACB Laboratory Medicine Practice Guidelines – Evidence Based Practice for POCT Clinicians, staff and laboratorians need guidance to apply POCT in the most effective manner for patient benefit.This guidance should be based on a concurrence of the scientific evidence to date.This need for evidence-based practice was the concept behind the NACB Laboratory Medicine Practice Guidelines for POCT
48Evidence-Based Practice for POCT POCT is an increasingly popular means of delivering laboratory testing.When used appropriately, POCT can improve patient outcome by providing a faster result and therapeutic intervention.However, when over-utilized or incorrectly performed, POCT presents a patient risk and potential for increased cost of healthcare.This LMPG will systematically review the existing evidence relating POCT to patient outcome, grade the literature, and make recommendations regarding the optimal utilization of POCT devices in patient care.Develop liaisons with appropriate professional, clinical organizations: ACB, ADA, ACOG, CAP, etc.
49Evidence-Based Practice for POCT Focus Group Chairs Cardiac – Robert H. Christenson, Ph.D.Diabetes – Christopher Price, Ph.D.Reproduction – Ann M. Gronowski, Ph.D.Infectious Disease – Robert Sautter, Ph.D.Coagulation – Marcia Zucker, Ph.D.Parathyroid – Lori J. Sokoll, Ph.D.Drugs – Ian Watson, Ph.D.Bilirubin Screening – Steven Kazmierczak , Ph.D.Critical Care – Greg Shipp, Ph.D.Renal – William A. Clarke, Ph.D.Occult Blood – Kent Lewandrowski, M.D.pH – James Nichols, Ph.D.Introductory Comments – Ellis Jacobs, Ph.D.
50Evidence Based Practice for POCT pH Guidelines I Does the use of pH paper for assisting the placement of nasogastric tubes, compared to clinical judgment (air, pressure) improve the placement of tubes on inpatient, endoscopy, home care and nursing home patients?We recommend the use of pH testing to assist in the placement of nasogastric tubes. The choice of measuring pH with an intragastric electrode or testing tube aspirates with a pH meter or pH paper will depend on consideration of the clinical limitations of each method, and there is conflicting evidence over which method is better. (Class II – prospective comparative trials and expert opinion)
51Evidence Based Practice for POCT pH Guidelines I Assuring correct NG or NI tube placement:Measure length of tubeDirect visualization of oropharynxAuscultation of stomach by air insufflationAspiration of gastric contentsIrrigation of tube with 10 to 50 mL waterDirect palpation of tube within stomach during intra-abdominal proceduresGold Standard - Abdominal roentgenogram to confirm positionpH may be faster, safer and more economical
52Evidence Based Practice for POCT pH Guidelines I Gastric contents more acidicNeuman – pH < 4 can reduce need for x-rays (PPV 100%, Sens 100%, Spec 88% for N = 46 patients and 78 placements.) pH>4 not useful – respiratory or duodenal.Acid suppressors increase gastric pH and 6.0 may be a better cutoff (81% pH 1 – 4, 88% intestinal >6.0, pulmonary >6.5). Confounds aspirate pH 4 – 6.pH of gastric fluid may replace 85-95% of x-ray cases. Significant decrease radiation exposure
53Evidence Based Practice for POCT pH Guidelines I Method to determine pH controversialContinuous monitor or pH tipped NG tube preferred for those patients that are equipped, but expensive.Question whether pH probes are measuring gastric contents or cell surface pHAspirate pH may not generate sufficient volume, may differ from intragastric pH, as antacid, drug salts, protein and bile may interfere with some methods.pH meter more accurate than pH paper, but paper simpler (0.5 – 1.0 increments), cheaper, easier to use and quality assure, and can be performed bedside.X-ray confirmation still the “gold standard” and recommended in indeterminate cases.
54Question Five: Can gastroccult testing of gastric fluid from a nasogastric tube be used to detect gastrointestinal bleeding in high-risk intensive care unit patients receiving antacid prophylaxis?
55Recommendation Five:We cannot currently recommend for or against the use of gastroccult to detect gastric bleeding in intensive care unit patients receiving antacid prophylaxis.Grade of Evidence: III – small study, clinical evidence
56Gastroccult TestsFOBT should not be used to measure occult blood in gastric fluid because of interferences from low pH, certain medications and metal ions.The presence of occult blood in gastric fluid can be useful to detect stress ulcer syndrome, so specific gastroccult tests are utilized.Fecal occult blood tests should not be used to measure occult blood in gastric fluid because of interferences from low pH, certain medications (antacids and vitamin C lead to false negative results) and metal ions (iron and copper salts lead to false positive results). The presence or absence of occult blood in gastric fluid is useful in emergency department or intensive care unit settings for the detection of bleeding due to trauma or a deteriorating gastric condition (stress ulcer syndrome). Gastroccult tests are employed for this purpose. The pseudoperoxidase in hemoglobin reacts with guaiac and a buffered, stabilized hydrogen peroxide solution producing a blue color in the presence of blood. Two in-vitro studies have illustrated that gastroccult is a simple, rapid and convenient method for the evaluation of patients with suspected occult blood in gastric fluid. Gastroccult, unlike hemoccult, is not influenced by pH or sucralfate.(58, 59)
57Bleeding in ICU Patients A small study with 41 patients showed that 13/14 patients with positive gastroccult tests had a source of upper GI bleeding as seen by upper endoscopy.Study suggest gastroccult testing may aid in detecting occult bleeding in critically ill patients.However, patients with negative gastroccult tests did not undergo upper endoscopy which may have documented false negative results.Derrida et al(60) used gastroccult every four hours to identify blood in gastric juice of 41 ICU patients at risk for gastrointestinal bleeding (patients with overt gastrointestinal bleeding were excluded) and receiving antacid prophylaxis. 27% (14/41) had at least one positive gastroccult reading and received an upper endoscopy. No endoscopy was performed in patients with negative gastroccult findings. In 13/14 patients a source of gastric bleeding was detected. This study suggests that gastroccult testing may aid in detecting occult bleeding in critically ill patients. However, this small study did not perform upper endoscopy on negative patients, which may have documented false negative results obtained with the gastroccult test. Conclusions - Currently data is insufficient to recommend the use of gastroccult for ICU patients to detect upper gastrointestinal bleeding. Although this practice is widespread, more studies will be necessary to document the utility of gastroccult testing for this application.
58Baystate Gastroccult Testing Discontinued without incidentApproached Chief of GI and Division of Healthcare Quality with clinical utility.Researched literatureDeveloped recommendation and justificationDraft letter to medical staff reviewed by select cliniciansGeneral announcement and test removal
59Gastroccult Discontinuation No peer-reviewed literature indicating improved outcomes based on GastroccultUse of test after NG tube placement leads to positive results solely due to trauma of tube insertionOvert bleeding is a medical concern and doesn’t require test to detectpH is medically useful, pH paper is a better alternative because it’s easier to QC, already available on units and lower costElimination would reduce hospital burden of training and POCT documentation on nursing staff and reduce risk of developer mixup with hemoccult.
60Gastroccult Cost Savings Reagent: (12,000 tests/year)Cards $21,000Developer $ 5,000LaborNursing (5 min/test, 45K= 125d) $22,000Competency (1100 x 15 min) $ 6,000Lab oversight (4hr x 8 units x 12 mo) $ 8,500Total Annual Savings Estimate $62,500Total billed previous yearCost estimate for pH replacement $
62SummaryMedical errors are a significant problem and the laboratory should be aware of the many opportunities to reduce errorsInterdisciplinary teams and positive attitudes are important factors in achieving successful outcomes and changes to practiceNeed to engineer systems (not people) that prevent dangerous errors and are able to tolerate errors and contain their effectsAutomation, information management and communication are effective strategies to reduce errors.The next challenge for laboratorians is to better integrate the data we have at hand and condense the literature into standard practice pathways that assist clinicians in appropriate decision-making for optimal patient care