Quality Newsletter - September 2010

Sept. 20, 2010 - Focus on Quality at Texas Health

In this Issue

CQO Corner: Texas Health Hurst-Euless-Bedford's Dr. Susann Land

Blood clots are one of the leading causes of complications in United States hospitals, claiming an estimated 300,000 lives each year.

Dr. Susann Land, vice president and chief quality officer at Texas Health Harris Methodist Hosptial Hurst-Euless-Bedford, is leading a High Impact Performance Improvement (HIPI) project designed to prevent deadly blood clots from forming in both medical and surgical patients across the Texas Health system.

"We're choosing projects that will have a great deal of impact on improving patient care, and this is one of them," Dr. Land said.

Known in healthcare as "VTEs" or venous thromboembolic events — blood clots usually develop in the legs — either the calves or the thighs. Clots in the thighs have a much higher chance of travelling up to the lungs, causing inability to exchange oxygen from the lungs and, if the clot is large enough, death.

Though they can be very painful or even deadly, blood clots are often preventable.

"Patients need to be assessed to see if they are at risk," Dr. Land said. "If they are at risk, we need to put them on medication or use the mechanical compression devices that can help prevent them."
Much like a blood pressure cuff — though not as tight — a mechanical compression device is a sleeve that wraps around the leg and intermittently contracts to promote blood flow.

"They basically make your veins push blood back up towards the body," Dr. Land said. "It is like a continual massage around your calves and your legs."

The blood clot prevention HIPI initiative focuses on ensuring that one or both of these preventive measures are delivered to every patient who is at risk for developing clots.

"About four or five years ago, there was a national initiative to prevent blood clots in patients post-operatively, and we found that we had a major opportunity to become better at ordering and giving the preventive measures," Dr. Land said. "A group of us came together - doctors, nurses, pharmacists — and we decided we didn't want to only include surgical patients, but medical patients, as well, because many of them have a very high risk of developing blood clots."

The group worked to first determine which patients should receive the measures, then to adopt a risk assessment tool. They chose a tool developed by Dr. Joseph Caprini — an internationally renowned vascular surgeon and expert in preventing blood clots.

"Risk is determined by age, weight, how long you are going to be immobile," Dr. Land said. "If you have long surgeries, this adds additional risk. If you have certain diseases, you may have a higher risk. If you break a bone, especially a hip, it puts you at very high risk. So there are certain procedures and certain illnesses that give you a higher risk than others."

Dr. Land's group worked with educators to determine how to inform clinicians about which patients should be assessed for risk of developing clots and how and when the assessment should be done.

"The best time to give patients the medication or to put on the sequential compression device is within 24 hours of admission, or within 24 hours before surgery, or 24 hours after surgery," Dr. Land said. "The more immobile you are — the longer you are in bed, the higher the risk. So the sooner you start the prevention, the better."

Every member of the care team — the physician, the nurse, and the pharmacist — has a role to play in ensuring assessments are done and preventive measures are delivered, Dr. Land said.

"The doctors are responsible for ordering it, the nurses are responsible for giving it in a timely manner, and the pharmacists are responsible for monitoring drug-drug interactions and reminding the physician that a patient has been here awhile and may be due for an assessment."

The group has also leveraged CareConnect — Texas Health's electronic health record - by creating Best Practice Alerts that pop up on the screen while a physician or nurse is interacting with a patient's medical record.

"It pops up as a bright yellow banner," Dr. Land said. "And if a physician clicks on it, it says, 'Best Practice Alert - Please consider.' Then the physician can either click into the order set directly and do the orders immediately or click into the box to explain why he or she has opted not to order the preventive measures at this time."

This HIPI initiative also utilizes CareConnect as a risk assessment calculator. Dr. Ferdinand Velasco, Texas Health's chief medical information officer, developed the tool, which combines Dr. Caprini's risk assessment with certain information stored in CareConnect, such as age, weight, body mass index, and other risk factors.

"The information that CareConnect can't pull requires a doctor's or nurse's input, but if you're not sure or if you think you might be underestimating a patient's risk, you can do a quick calculation."

Dr. Land, along with the nursing and quality staff, are currently leading a pilot project in the intensive care unit at Texas Health HEB to deliver preventive measures for blood clots to all patients.

"The feeling is that anyone who is admitted to an ICU is at high risk and needs medication and the compression devices," she said. "That has not traditionally been done everywhere, and so we took upon ourselves to do a pilot."

Nurses in the ICU at Texas Health HEB have taken leadership roles in the pilot, using whiteboards, magnets, and reminders to physicians to either deliver preventive measures or document why they are not being done.

"We found that last year, 2009, we were doing it about 84 percent of the time," Dr. Land said. "For the last three months, we've been at 100 percent."

Dr. Land and her team are working to roll out the ICU pilot to other Texas Health hospitals and hope to eventually roll it out to the remainder of the patient population across the hospital system.

"Our goal is for patients to get appropriate prophylaxis against blood clots while they are in the hospital. We'd like to see 100 percent," she said.

Dr. Land acknowledged that the blood clot prevention HIPI has demanded an enormous amount of time, but said the work has been a labor of love.

"I've really enjoyed doing it because I have a passion because there's just so much evidence out there that it's important, and if you look at our numbers, if you look at all the hospitals across THR, you can actually see that we have quite a low rate of pulmonary emboli or blood clots to the lungs, and we also have a fairly low rate of hospital acquired blood clots to the legs.

"To me, that's the most important thing: Keep patients safe and give them what they need."

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Improving Quality through EHR

A conductor's success is dependent on his orchestra's collaboration. One wrong note can ruin a performance. The same holds true for patients at a hospital — a physician's ability to avoid medication errors is dependent on the collaboration of clinical staff at the hospital.

At Texas Health Resources we work continuously to provide the physicians on the medical staff and the hospital's clinical staff the tools they need to fine-tune their performance and catch mistakes before they happen. And just as an orchestra is composed of many musical instruments, there are many instruments to help physicians, nurses, pharmacists, techs and others create a safe environment for patients.

Computer Physician Order Entry
Our Computerized Physician Order Entry (CPOE) uses standardized order sets and Clinical Practice Model (CPM) clinical practice guidelines as the foundation. CareConnect, Texas Health's electronic health record, has made a significant contribution to quality care at Texas Health hospitals. Medication errors have decreased an average of 54 percent and the estimated CPOE preventable adverse drug events have decreased an average of 33 percent.

According to Dr. Ferdinand Velasco, chief medical information officer for Texas Health, clinical decision support helps facilitate effective and safe medication use. It addresses the difficulty of keeping up with challenging drug interactions while preserving the physician's clinical judgment.

After the physician enters the prescription, drug and medication alerts are shown to the physician entering the order and to the pharmacist filling them. They check and verify the physician medication orders for drug-allergy; drug-drug interactions; route of administration; dosing; contraindications based on sex, weight, and age; diagnosis; lab and radiology results; duplicate orders, and corollary orders.

"We are making it easier to do the right thing and making it difficult to do the wrong thing," Velasco said. "More doctors are asking for added clinical decision support."

Barcoding
In addition to CPOE, Texas Health is in the process of adding a barcoding system across our hospitals. The system offers checks and balances for prescribed medications, drug interactions and documentation. When a patient is scheduled to receive medication, the nurse obtains positive patient verification by scanning the patient's wristband and the medication barcode. CareConnect will then verify the medication was ordered, the time for administering the medication is correct and no drug interactions are of concern. It reminds caregivers to follow the 5 Rs: right drug, right dose, right patient, right time, and right route.

"Barcoding not only makes the delivery of medications safer to our patients but it provides a safer practice for health care providers involved in delivering medications to our patients," said Marcie Williams, vice president of safety and risk management at Texas Health. "National research has proven that barcoding and scanning is the number one method of preventing medication errors. Texas Health is committed to innovative technology that will improve patient safety."

Medication Best Practice Advisories (BPA)
Different from drug alerts that are highly preconfigured by the vendor, medication best practice advisories are more structured and flexible.  They are process driven based on a complicated work flow. For example, Metformin is a drug taken for diabetes that can be very toxic to the kidneys. When given within a certain time frame of having had a dye injected for a CT scan or something similar, the drug can be even more toxic. If a patient has a diagnostic study that requires dye and they are on Metformin, then an alert pops up to inform the radiology tech to ask the nursing staff to hold off the Metformin administration. When the physician tries to order Metformin, then an alert will show that a diagnostic test was performed and remind the doctor to schedule the administration of the drug 48 hours after the dye was administered. The advisory is one more way to minimize potential adverse events. 

Because the advisory is workflow driven, it puts the responsibility of preventing the administration of Metformin to everyone on the care giving team, not just the physician and nurse.

Patient need-based medication profile
Beginning with Obstetric order sets, Texas Health is in the process of structuring pain management according to recent Joint Commission requirements. Physicians used to prescribe a "laundry list" of pain medications for the nurse to choose from; they are now required to build a medication profile based on patient needs. This means that physicians must prescribe specific pain medications for mild pain, moderate pain and severe pain.

The order set is a safer way to order medication. Nurses no longer have to choose from many medications; they are limited to three specific ones that are given to patients based on their pain scale. Texas Health began with the OB set and plans to go through other order sets in Care Connect to structure all pain management the same way. Physicians have the opportunity to really take a look at the patient and target the types of pain the patient is likely to experience.

And there's more
Texas Health has incorporated additional ways to help prevent medication errors through the hiring of clinical pharmacists, structured order-sets for certain high-alert medications, dual sign-off on certain high-alert medications, smart-infusion pumps, and other technology and processes.

"What's most important is not one tool, but the idea that we have a shared platform for medication management," said Dr. Velasco. "With this shared platform, we can collaborate together to provide patients quality, safe care."

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Accolades

QUEST
Improving quality and patient safety is the number one priority at Texas Health Resources hospitals. Our nonprofit hospitals use multiple tools to measure and improve quality, including our participation in QUEST, a voluntary, three-year quality improvement collaborative.

Texas Health joined QUEST to compete against the best of the best. Many of the other QUEST participants were high performing hospitals from the Hospital Quality Incentive Demonstration who wanted to expand their improvement efforts into additional areas.

The collaborative has given Texas Health the opportunity to benchmark our progress, improve quality, and see how we compare to 144 other hospitals across the country.

In Year 2 of QUEST, three Texas Health hospitals performed in the top 25 percent of the collaborative for eliminating avoidable hospital mortalities, safely reducing the cost of care, and delivering evidence-based care to patients:

• Texas Health Azle
• Texas Health Cleburne
• Texas Health HEB

Seven additional Texas Health hospitals achieved top performance thresholds for two of the three measure sets:

• Texas Health Arlington Memorial
• Texas Health Dallas
• Texas Health Fort Worth
• Texas Health Kaufman
• Texas Health Plano
• Texas Health Southwest Fort Worth
• Texas Health Stephenville

One of the most significant improvements we have made since beginning QUEST was to integrate core measures into Care Connect, our electronic health record. This has enabled us to "hardwire" quality improvement processes into the care we provide to each patient.

As a healthcare system that is dedicated to continuous quality improvement, we have been encouraged by the rapid improvement outcomes of hospitals participating in the QUEST collaborative.  For instance, in 2008 - the first year of QUEST - only 25 participants achieved top performance thresholds. In 2009, that number jumped to 76 participants - nearly half of the entire collaborative. This is clear evidence that the improvements being made across the QUEST collaborative are working.

Innovation award for Texas Health Arlington Memorial
Texas Health Arlington Memorial's interdisciplinary huddle process received the 2010 Doyle Award for Innovation and Leadership in Healthcare from Milliman Care Guidelines. The company produces annually updated, evidence-based clinical guidelines and selects Doyle Award winners using an independent panel of judges. The huddle process will also be presented at the American Case Management Association's national conference this year.

The care team huddle involves a daily meeting with case managers, nurses, social workers, therapists, and other caregivers to discuss the patient's care and progress. Using evidence-based care guidelines, the team identifies necessary changes to the patient's treatment plan to help prevent complications and prepare streamlined plans for discharge. The process has improved the quality of patient care, decreased the length of stay and increased patient satisfaction.

Texas Health Plano receives Cycle III Chest Pain accreditation
Texas Health Plano received Cycle III Chest Pain Center with Percutaneous Coronary Intervention accreditation, the highest level of distinction currently available for the treatment of chest pain and heart failure.  To become accredited, hospitals must undergo a rigorous evaluation process and meet multiple criteria established by a formal accreditation committee.

Texas Health Plano joins Texas Health Arlington Memorial, Texas Health Dallas, Texas Health Fort Worth, and Texas Health Southwest Fort Worth in receiving the accreditation.

Texas Health Dallas physician leader honored for infection prevention
Dr. Ed Goodman, medical director of infection prevention at Texas Health Dallas and Texas Health Resources' physician advisor for infection prevention, has been honored as a "2010 Who's Who in Infection Prevention" by Infection Control Today.

The national magazine, considered one of the country's leading sources of infection-control news for clinicians and scientists, recognizes Dr. Goodman for his longtime leadership in the field in North Texas and across the state.

Texas Health Denton receives Nuclear Medicine accreditation
Texas Health Denton has been awarded a three-year accreditation in nuclear medicine. The accreditation is the result of a survey by the American College of Radiology (ACR).  The hospital voluntarily chose to pursue the accreditation, further demonstrating its commitment to quality, patient care and safety.

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Technology Round Up

SpineAssist^TM surgical robot now available at Texas Health Plano
Texas Health Plano is one of only three hospitals in the United States to offer the SpineAssist^TM surgical robot, a new technology that enables physicians to plan the optimal surgery ahead of time using a computed tomography (CT)-based 3D simulation of the patient's spine.

Accurate to less than half a millimeter, the robot also dramatically increases surgical precision.

"Like a pilot in a flight simulator, I can map out the patient's spinal anatomy and perform the entire procedure before the patient even arrives for surgery," said Dr. Isador Lieberman, a fellowship-trained orthopedic and spinal surgeon on the medical staff at Texas Health Plano. "It allows me to be more efficient and more precise, and to anticipate potential complications before they occur."

Dr. Lieberman, an internationally renowned spine surgeon, helped develop the idea for the technology in 2001.

In addition to increasing precision, the robot reduces the amount of radiation exposure during surgery. Patients typically have less likelihood of infection, report less pain after surgery, fewer complications and fewer hospital stays. The technology has been used in just over 1,000 cases worldwide with no instances of nerve damage as a result of surgery.

SpineAssist® technology has two key components: A workstation that enables surgeons to pre-plan procedures in 3D based on the patient's individual anatomy, creating a "surgical blueprint," and a robotic arm that guides the surgeon during the procedure using the preoperative plan.

During surgery, the robot's extension arm guides the surgeon to the pre-planned location with utmost accuracy, allowing the surgeon to operate through small incisions in the skin and underlying muscles in order to reach the exact pre-planned location on the spine. Most procedures utilizing the robot are minimally invasive.

SpineAssist® technology can be used in biopsies, to treat thoracic-lumbar fusion and vertebral compression fractures, and to correct scoliosis.

Texas Health HEB offers da Vinci® SI
Texas Health HEB now offers the da Vinci® SI robotic surgical system, which enables surgeons to make small, one centimeter incisions to perform total laparoscopic hysterectomies. Because the procedures are done with such small incisions, patients tend to recover faster and with less pain.

In addition to gynecological surgeries, the da Vinci® Surgical System can be used to treat endometriosis, fibroid tumors, and a variety of cancers, such as gynecologic cancer. The da Vinci® system is controlled by surgeons seated at a console next to the patient's bedside.

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