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Hospitalized patients experience a wide range of preventable harms despite significant efforts to provide safe and effective healthcare. This project seeks to identify and predict stressed clinical environments – or "risky states" that predispose patients to preventable harms – initially in the intensive care unit, and then in the emergency department. This approach goes beyond the clinical specifics of any individual patient and any category of harm. It represents a departure from the historical "silo" approach of hospitals addressing specific harm categories such as falls or infections. This project is funded as a Career Development Award by the Doris Duke Charitable Foundation.
Inpatient consultation is the primary mechanism by which specialists provide care to hospitalized patients. For example, more than 90% of Medicare patients have at least one consultation during an impatient admission. Previous research has demonstrated that the scope of variation in inpatient consultation use across U.S. hospitals is substantial. This project seeks to advance knowledge of inpatient consultation in three ways: by defining the characteristics of beneficial consultations from multiple perspectives, including those of patients and families; by investigating novel non-clinical factors that drive consultation for reasons other than patient or family need; and by quantifying the relationship between inpatient consultations and patient outcomes and costs. This project is funded by the Agency for Healthcare Research and Quality. This work was preceded by research focused on consult quality in the critical care setting funded by the Gordon and Betty Moore Foundation.
Inter-hospital transfers (IHTs) are risky transitions of care and may be associated with worse outcomes for patients. This project identified best practices for IHTs nationally, assessed current practice within the Beth Israel Deaconess network member hospitals (Boston, Milton, Needham, and Plymouth), and then defined and implemented best practices for IHTs coming to the Cardiology service at Beth Israel Deaconess Medical Center, Boston. This work helped standardize the transition of care for IHTs during off-work hours and has provided valuable information for BIDMC’s Transfer Center. This project was funded by the Risk Management Foundation.
Alcohol withdrawal syndrome (AWS) carries a significant risk of morbidity and mortality. In the hospital setting, up to 40% of patients have alcohol-use disorders that put them at risk for developing AWS. Benzodiazepine administration remains the mainstay of current AWS care. This project sought to establish the prevalence and trends in inpatient AWS-related admissions using data from the National Inpatient Sample (NIS), while also identifying patient- and hospital-level determinants of outcome and utilization. The project examined the effectiveness of phenobarbital in treating AWS in the intensive care unit
(ICU). This was done through a quasi-experimental intervention conducted in the Beth Israel Deaconess Medical Center medical ICUs. This project was funded by the National Institute on Alcohol Abuse and Alcoholism.
Improvements in the acute care of critically ill patients have led to new challenges in the management of patients who survive with persistent, severe organ failure after critical illness. One such
intervention is the decision to place a gastrostomy tube to allow for provision of long-term artificial nutrition in patients who are unable to safely take in sufficient nutrition on their own due to new deficits in functional status, mental status, and respiratory function. This project seeks to quantify the incidence of gastrostomy tube placement across age groups in critically ill patients in the United States from 1993-2012,
describe patient and hospital drivers of practice variation in the placement of gastrostomy tubes, and describe the determinants of patient-level outcomes after gastrostomy tube placement. The overall goal of this project is to provide the necessary foundation for a future shared decision-making tool for critically ill patients, their surrogate decision makers, and clinicians to help decide whether the likely outcomes of a gastrostomy tube are in line with the patient's wishes and values. This project is funded by the National Institute on Aging.
Despite the progress that hospitals have made in reducing harm in specific areas, some preventable harm events still occur. These can result from faulty decision-making, perceptions or situational awareness gaps, communication deficiencies and other system failures. This project focused on how hospitals identify and respond to harms to patients, particularly incidents resulting from complex system failures. Work included detailed discussions with experts on risk – including a leading clinical safety researcher from England and safety leaders at JetBlue airlines. Quality and Safety Leaders are using these findings as a basis for implementing a small test of change in the management of high-risk medications. This project was funded by the Patrick and Catherine Weldon Donaghue Medical Research Foundation.
Procedure areas are high-volume, diverse, fast-paced units that are rapidly growing due to advances in technology and the increased demand for outpatient and non-surgical treatments. Traditionally, these areas are administered and managed by individual departments, with no central coordination and limited multidisciplinary oversight in the hospital. This can make review of unanticipated events, shared learning, and implementation of improvement, or corrective action, extremely challenging. This project developed approaches to standardize safety in interventional procedure settings, such as cardiac catheterization labs, and GI and radiology departments. The project conducted root cause analyses (RCA) focused specifically on interventional procedure settings, recommended changes to online reporting systems to make the information collected more accurate and comprehensive, and developed best practices around specific interventional procedure-focused areas. The project was funded by The Risk Management Foundation.
This project developed a process to share information under the protection of a patient safety organization (PSO). This process can help facilities better understand the service lines at multiple locations, provide accurate quality information, and to drive effective improvement work. The team used the bariatric surgery service line as the basis for developing a model for such exchange that could be transferred to other service lines. The toolkit developed as a part of this of this project is available below. This project was funded by CRICO / The Risk Management Foundation.
The opioid epidemic has reached a new level of crisis that requires a national approach to developing safe strategies to care for patients with
overdose in the intensive care unit (ICU). There is a national need to provide coordinated outpatient addiction care resources for patients with opioid use disorder and their families. This project devised a national survey of institutions to assess the prevalence and agreement between ICU opioid-related substance abuse disorder protocols. These findings provide an opportunity for a new standard of care for this vulnerable population.
Nurses play a key role in the functioning of a hospital and its individual departments, and their role is particularly critical in intensive care units (ICUs). In Massachusetts, acute care hospitals are generally required to adhere to a 1:1 or 1:2 nurse-to-patient ratio in ICUs. To achieve this, hospitals are required under state regulation to develop and operationalize an acuity tool that measures the stability of ICU patients.
The goal of this project was to determine whether this regulatory requirement has been associated with an improvement in patient outcome. The team focused on mortality rates for patients in Massachusetts ICUs before and after the mandate. The team then compared these findings to mortality rates in out-of-state hospitals.
Neuromuscular blocking agents (NMB) are used in the intensive care unit (ICU) for patients with severe acute respiratory distress syndrome (ARDS), dyssynchrony during mechanical ventilation, open chest, and shivering post cardiac arrest. Studies have found that the early use of NMB on patients with severe ARDS decreased mortality, and this project identifies specific ICU characteristics associated with a higher score of "perfect care" for these complex patients.
Optimizing ICU Safety through Patient Engagement, System Science and Information Technology, a Beth Israel Deaconess Medical Center (BIDMC) project funded by the Gordon and Betty Moore Foundation, addressed three fundamental, interrelated barriers to the elimination of preventable patient harm on a broader scale: (1) unreliable systems of care, coupled with a lack of
sophistication in healthcare as to how to improve those systems; (2) failure to adequately engage patients and families in their own care; and (3) failure to spread successful innovation into non-academic settings, where the majority of healthcare is actually delivered in the United States. Through the work described below, BIDMC leveraged health information technology, system science and patient and family engagement to
improve quality and safety in the critical care environment.
Managing Risky States to Prevent Harm
"Risky states" refers to the environmental drivers in a unit that can put that unit at risk for patient harm to occur. This project identified correlations between states and harms to present a risk level for a unit and developed a model that calculates the risk levels of by unit.
Intensive care units (ICUs) use checklists of core quality measures during clinical rounds to ensure evidence-based care is provided to all patients. Typical checklists incorporate a range of quality measures but remain agnostic to the patient. This project developed an electronic decision-support tool, the Patient-Specific Checklist (PSC), to individualize patient care by providing clinicians a patient-specific view of pertinent data and daily care needs. This interface has assisted clinicians in delivering high quality care while also improving workflow.
Being a patient or having a family member in a hospital intensive care unit (ICU) can be a disorienting and confusing experience. This project developed a mobile-friendly application that promotes bi-directional
communication between the patient and family, and the ICU care team. The application helps families learn more about the unit their family member is in, learn about their family member's daily plan, connect directly to support services, and maintain a private journal of the ICU stay. In bridging the gap between the family and the ICU care team, MyICU engages patients and families in preventing physical and emotional harm in the ICU.
Stemming from the foundational work of MyICU, MyNICU was created to help improve families' experiences in the Neonatal Intensive Care Unit (NICU). MyNICU is a mobile-friendly application that further engages parents in their infant's care by providing them with information and resources that extend beyond the NICU stay. Parents receive a CribNews update each morning with information on their infant's last 24 hours including weight, feedings, medications, and times the infant was held. CribNews also includes members of the team who have provided care to the infant in the last 24 hours. Family members can also request services, track their infant's progress in a private journal, and review additional hospital resources.
During multidisciplinary rounds in the intensive care unit (ICU), healthcare professionals work collaboratively towards providing comprehensive patient care. This project designed a toolkit that standardized and structured daily rounds based on a unit's culture. Working with clinicians and refining the toolkit, the project increased nursing participation in team discussions and decreased miscommunication among team members. This project demonstrates that implementation of a simple toolkit, incorporated into existing workflow and rounding culture in different types of ICUs, can improve engagement of nursing staff and
Being a patient in the intensive care unit can be disorienting and unsettling, with a number of clinical team members entering and exiting the patient's room to provide care. The aim of this project was to improve
patient and family satisfaction, and create an environment that drives correct workflow. The team recognized that hand hygiene is a single step in a substantially more complicated process of room entry. They applied Lean engineering techniques to develop a standard process that included both physical steps and standard communication elements from provider to patients and families.
Improving the Usability and Quality of Critical Care Policies, Procedures and Guidelines
Nursing policies and procedures are designed to guide and inform standardized care based on evidence-based best practice, consistent with regulatory and accreditation standards. At BIDMC, policies, procedures and guidelines are maintained in the Critical Care Practice Manual; a resource for all critical care clinicians in the intensive care units (ICUs). Based on concerns about the quality and usability of the existing policies and
procedures, the project team created a new electronic format that incorporated the best evidence-based research available and standardized the presentation of all policies and procedures. Not only did this work
ensure that clinical practice was aligned with the best evidence but it incorporated a process for systematic review and updating of policies, procedures, guidelines and directives over time.
Communication, Apology, and Resolution (CARe) is BIDMC's transparent and honest approach to unanticipated clinical outcomes and adverse events. Prompt recognition of and response to medical injury, along with appropriate compensation to the patient or family if the harm was preventable, has demonstrated the potential to improve patient safety, reduce medical costs, and enhance fairness and transparency in health care. It is simply the right thing to do. The CARe program was piloted in 2012 through the Center for Healthcare Delivery Science. Grant funding helped launch the program at BIDMC, BID-Needham, BID-Milton, and several hospitals in the Baystate Health network, and supported the development of a statewide alliance to assist in implementation of CARe across Massachusetts through education, resources, and training called the Massachusetts Alliance for Communication and Resolution following Medical Injury (MACRMI). The pilot study demonstrated that after three years of using CARe to resolve adverse events, there was no increase in the number of claims, and providers were satisfied with the approach.
Respect is a critical element of safety, patient-centered care, and fostering a trusting patient-provider relationship. Most healthcare organizations' efforts to reduce harm focus on physical harm, but other
forms of harm are both prevalent and important. These "non-physical" harms can be framed using the concepts of respect and dignity. In healthcare, these concepts can be defined as follows: dignity is the intrinsic, unconditional value of all persons, and respect is the sum of the actions that honor or acknowledge a person's dignity. Disrespect is an affront to dignity and can cause harm, and organizations and providers should strive to eliminate disrespect. Due to its importance, our team has dedicated various projects to improve this aspect of healthcare delivery.
A Roadmap for Advancing the Practice of Respect in Healthcare
In 2016, leaders at Beth Israel Deaconess Medical Center convened a group of experts from around the world to strategize about expanding the definition of preventable harm to include non-physical harm, and to develop a more reliable approach to the "practice of respect." These discussions, funded by the Gordon and Betty Moore Foundation, were the starting points for the development of a consensus statement to serve as a model for institutions implementing this work. A team at BIDMC then developed a consensus statement and invited all convening attendees to participate in a modified Delphi process to finalize its language. This process included five rounds of surveys, by which participants identified key strategies. Strategies included hospital leadership championing a culture of respect and dignity; promoting accountability in this area; engaging and supporting the healthcare workforce; partnering with patients and families; establishing systems to learn about and improve the practice of respect; and expanding
the research agenda and measurement tools, and disseminating what is learned.
Development of a Framework for Health Care Organizations to Describe Patient and Family Harm form Disrespect and Promote Improvement: A Scoping Review
This project used the current literature to develop a practical, improvement-oriented framework to recognize, describe, and prevent non-physical harm events that result from disrespectful interactions with
the healthcare system. The team described a framework designed to expand organizations' ability to recognize, describe and understand non-physical harm events using the concept of disrespect. The components of this framework include care processes, contributing factors, professional/organizational behaviors, and modifying factors and consequences, including consequences affecting patients and families, professionals,
organizations and society. This project was funded by the Arnold P. Gold Foundation.
The primary goal of the Harvard Medical School Fellowship in Patient Safety and Quality is to train a cadre of physician-scholars prepared to lead quality, safety and operational improvement efforts. This two-year postgraduate program is for physicians who are in or have completed a residency or fellowship program.
Healthy Lives is a pioneering Brookline Community Mental Health Center program that treats adults with serious chronic medical conditions and a behavioral health comorbidity. The Program was first piloted in Health Care Associates at Beth Israel Deaconess Medical Center and later spread to Bowdoin Community Health Center. The Healthy Lives team received a Massachusetts Health Policy Commission Investment Award in 2017 to implement their approach within the BIDCO care management structure integrating behavioral health, primary care and community services.