Nearly 15 years after the patient-safety
movement started, deaths and injuries from poor care continue to be all too common in U.S. hospitals. For example, studies show that between 21% and 63% of urinary catheters, which frequently cause painful infections that are costly to treat, are placed in patients who do not need them.
A set of strategies to prevent catheter-associated urinary-tract infections is one of 10 patient-safety practices being strongly recommended by the federal Agency for Healthcare Research and Quality
in its report issued earlier this year, Making Health Care Safer II: An Updated Critical Analysis of Patient Safety Practices.
The practices that made the AHRQ list were found to show evidence of effectiveness in real-world use. Despite the evidence, however, experts say compliance is far from universal. Instead, compliance
varies greatly from one hospital to another—and within each hospital.
“Even if you are talking about an individual organization, there will be certain areas where it's practiced beautifully, some where it's practiced pretty well, and some that may not be practicing it at all,” says Carol Haraden, a vice president at the Institute for Healthcare Improvement. It's “an issue everywhere around the world.”
The only antidote to poor compliance with safety practices is leadership from the executive ranks, and there hasn't been enough of that. “The more sophisticated groups understand that this is a job for leadership because no individual can make this happen,” she says. “It really has to emanate from the top.”
Some of the practices on AHRQ's top 10 list—proper hand hygiene and checklists to avoid wrong-site surgery, for example—seem so basic that outside observers may assume that compliance is universal. Those who understand patient safety the best say that's not so.
“It's easy to be a quarterback from the sidelines and think, 'For goodness sake, why is this happening?' ” Haraden says. “It's a lot harder than people think it is. That doesn't give anybody a pass, but I do think (patient safety) is much more challenging than it appears.”
AHRQ's report, issued in March, updates an earlier study that analyzed the strength of evidence for various patient-safety practices. The original report was released just two years after the Institute of Medicine's To Err is Human: Building a Safer Healthcare System published in 1999 estimated that 98,000 Americans die each year from medical errors in hospitals.
Since then, most hospitals have poured considerable money and effort into improving patient safety—with mixed results. According to this year's report, “evidence indicates that progress has not matched the efforts and investment.” Indeed, patient-safety advocate John James reviewed four recent studies of patient harm and estimated that between 210,000 and 400,000 deaths per year are associated with poor hospital care. His research was published in the September 2013 issue of the Journal of Patient Safety.
AHRQ's original report revealed there was scant evidence to support some practices that were believed to improve patient safety. As the patient-safety movement has matured, researchers have evaluated many practices, creating a vast pool of literature available to determine what really works.
Thus, AHRQ commissioned its Evidence-based Practice Centers—RAND Corp., University of California at San Francisco/Stanford, Johns Hopkins University and the ECRI Institute—to review 41 patient-safety practices. The researchers considered the evidence about whether a practice actually improves patient safety. Unlike the previous review, AHRQ's latest report also examined the evidence that a practice will work in a real-world setting rather than in a controlled experiment.
“That is a new twist on evidence-based reports,” says James Battles, AHRQ's social science analyst for patient safety.
Of the 41 practices reviewed, 20 practices were deemed to have at least moderate evidence that they are effective, and 25 practices had at least moderate evidence that they could be successfully implemented in a typical hospital. The researchers combined that information to identify 10 practices that had sufficient evidence of both effectiveness and implementation to warrant being “strongly encouraged” for adoption, while another 12 practices were classified as those that should be “encouraged” (See chart).
In general, no one tracks hospital compliance with patient-safety measures. One exception is the CMS' core measures program, which has required hospitals since 2003 to report their compliance with certain practices for heart attack, pneumonia, heart failure and surgery patients.
Over time, however, the CMS has shifted its focus to outcomes measures such as readmission rates and hospital-acquired conditions. For example, the CMS tracks the number of catheter-associated urinary-tract infections in a hospital rather than the compliance with strategies to avoid them.
Private payers, meanwhile, are generally silent on patient-safety measures, says Dr. Sheldon Stadnyk, chief medical officer for Banner Health's Western Region. “My guess is that it may still be hard for them to measure,” he says.
That is because, except for core measures, U.S. hospitals are not working on a standard patient-safety agenda that requires them to track—or even to work on—the same patient-safety initiatives. Just because AHRQ's list shows the practices are proven to be effective, that does not automatically make them top priorities, Haraden says.
“You may think reducing mortality is the No. 1 priority, but some of those high-evidence practices really have very little effect on mortality,” Haraden says. “You can't do every single thing at once, so you have to look at your population and think about which practices are going to help your patients the most.”
Sarah Krein, a researcher at the VA Ann Arbor (Mich.) Healthcare System and the University of Michigan Health System, has studied the adoption of patient-safety practices for nearly a decade.
She says most hospitals are making a good-faith effort to improve patient safety, but as more is learned about how to improve safety, the number of safety initiatives keeps growing. “People are trying to respond,” she says. “But it becomes difficult when you're trying to use the limited resources that you have to address all of these different issues.”
In a survey of hospital infection prevention specialists in 2009, Krein found that at least 90% of hospitals are using some practices to prevent central line-associated bloodstream infections and ventilator-associated pneumonia. But only one practice—bladder ultrasound—to prevent catheter-associated urinary tract infections was used by at least 50% of the hospitals responding to the survey.
Krein's work documented a significant increase in the use of patient-safety practices to reduce hospital-acquired infections between 2005 and 2009, and she expects to find another increase when she analyzes data from a follow-up survey being conducted this year. She is encouraged by increasing compliance but points out that systemic change takes time.
“It really involves working with multidisciplinary teams and a broader perspective to patient-safety issues,” she says.
Many of the practices on AHRQ's list are hardwired into leading health systems, Stadnyk says. “Some of these are so old that, if I were to encounter another (chief medical officer) in my network that says 'We're not doing all those,' I would probably raise my eyebrows and say 'Did you guys miss the boat?' ” he says.
Banner considers many of AHRQ's recommended practices to be a base on which to build. For example, it developed a systemwide standard that changed the way patients with total knee replacement surgery are treated: Catheters are avoided and weight-bearing ambulation starts on the day of surgery.
“Our orthopedists were not very pleased when we unrolled this. They hit us with, 'That's not in the literature, show me,' ” Stadnyk says. “And what we say is, 'We know that early ambulation and avoiding catheters whenever possible are two themes that run through all these safety things. Let's put them together and create our own initiative.' ”
In some cases, major campaigns that focus on a specific safety issue seem to work. More than 30% of all U.S. hospitals are participating in AHRQ's Comprehensive Unit-based Safety Program to reduce bloodstream infections and catheter-associated urinary-tract infections. AHRQ provides tool kits, implementation guides and educational sessions to help staff members on specific units improve patient safety.
By September 2012, participating intensive-care units had reduced rates for urinary-tract infections by 40%; interim results for the initiative are to be released later this year.
The central-line and catheter-associated infection programs “have reached the tipping point,” Battles says. “For the areas that we have organized technical assistance, we are feeling pretty good.”
Lola Butcher is a freelance writer based in Springfield, Mo. Reach her at firstname.lastname@example.org.