Teams reduce avoidable hospital deaths

Tami Good, a respiratory therapist at Bay Park Community Hospital, listens to the lungs of William Dunn, while registered nurses Cathy Thorn, right, and Sarah Grant read his chart. Ms. Good and Ms. Grant are on the Rapid Response Team.

Listen to your gut.

That's pretty good advice, but too many doctors and nurses have been reluctant to second-guess their colleagues. The result? An estimated 100,000 people die every year in U.S. hospitals from preventable medical errors.

Ignoring that nagging feeling that something is wrong - wait a minute, are we supposed to cut off this guy's left leg or his right leg? - is just one basic mistake hospitals make, according to Dr. Donald Berwick, a health-care quality expert in Boston.

Not giving every heart-attack patient an aspirin or forgetting to wash your hands and spreading infections are other examples.

Last year, Dr. Berwick and his Institute for Healthcare Improvement began an effort called the "100,000 Lives Campaign." The goal was preventing 100,000 avoidable hospital deaths by June 14, 2006.

About 3,100 hospitals, including many in northwest Ohio and southeast Michigan, signed up and adopted some or all of six initiatives.

Yesterday, Dr. Berwick said his goal was not only reached, but exceeded - the campaign prevented 123,300 avoidable deaths.

"These achievements are unprecedented," he told reporters during a telephone news conference yesterday from Atlanta. "And there are more gains to make ahead."

Locally, Bay Park Community Hospital is one of many hospitals that adopted one of the toughest initiatives, a "rapid response team." This small team of nurses and respiratory therapists drops everything and rushes to a patient once alerted by an employee who has a hunch something is not quite right with the patient.

"Listen to your gut is what we tell our nurses," said Kendra Contreras, a nurse and lead coordinator of Bay Park's rapid response team.

The results have been astounding, she said. From 2005 to 2006, the number of Bay Park patients "coding" - having their heart or breathing stop, or developing some other major emergency - has plummeted 35 percent.

When nurses, or anyone else at the hospital, suspect something is just not quite right with a patient - maybe their pulse is erratic or they just don't "look" right - someone triggers an alert that signals the rapid response team. Within two minutes, members of the team rush to the patient to quickly assess the patient and see if further attention is needed.

That is different than a "code" team that all hospitals have. Those respond once a patient's heart has already stopped or some other serious problem has arisen. The goal here is to prevent the heart from stopping in the first place, Ms. Contreras said.

"It's an extra set of eyes," she said. "A new nurse might not be able to tell the difference between low blood sugar and a cardiac problem. A seasoned nurse - all rapid response members have years of experience - will know."

Bay Park, which is owned by ProMedica Health System, is one of many local hospitals to embrace the 100,000 Lives Campaign effort. Other ProMedica hospitals also have, as well as Mercy Health Partners' facilities.

"I think this is a remarkable initiative, and I really applaud Don Berwick," said Dr. David Franzblau, chief medical officer at Mercy, which includes St. Vincent Mercy Medical Center, St. Anne Mercy Hospital, and St. Charles Mercy Hospital.

"There was some skepticism about Dr. Berwick's boldness, but this has really caught on," he said.

Mercy hospitals have formed rapid response teams and already had started with some of the other campaign ideas. He declined to give specific results of the adoption of some of the efforts, but said it's "safe to say we have dramatically impacted" and reduced medical errors and preventable deaths.

How exactly Dr. Berwick calculated his 122,300 number is complicated. During the news conference yesterday, reporters expressed some skepticism and were frustrated that results for individual hospitals were not available.

But Dr. Berwick said once all the data from participating hospitals were entered into a database and adjusted for mortality and other factors, the results were clear: There were fewer avoidable deaths during the campaign than before.

When asked by a Blade reporter why the voluntary efforts that prevented 122,300 deaths aren't made mandatory, Dr. Berwick said that day may come.

"There will reach a point where patient expectations are that these [efforts] will become the standard of care, and hospitals will have a duty to deliver," he said.

Dr. Berwick's 100,000 Lives Campaign is endorsed by the American Medical Association, federal health officials, insurance companies, and others.

Contact Luke Shockman at:

lshockman@theblade.com

or 419-724-6084.