Unformatted Attachment Preview
The 100k Lives Campaign
150-200 words, intext citation and references
In the course text, read case 11-1, pages 338 (bottom) through 348. I have to respond to
Discussion question #3
Case 11–1
THE 100K LIVES CAMPAIGN: A VOLUNTARY CODE IN ACTION
BACKGROUND
In 2004, the Institute for Healthcare Improvement (IHI) put out a call for hospitals willing to
participate in its 100,000 Lives Campaign. Its goal was to prevent 100,000 deaths in U.S.
hospitals during an 18-month period (January 2005 through June 2006) by having hospitals
implement some or all of six quality-improvement changes that the IHI and its campaign partners
identified as evidence-based and potentially lifesaving.
The IHI developed the campaign in response to a 2001 Institute of Medicine report, Crossing
the Quality Chasm: A New Health System for the 21st Century, that concluded that 44,000 to
98,000 Americans die each year because of medical errors and adverse events (injuries caused by
medical management). This campaign provides an example of non-coercive alternatives to
command-and-control regulation—referred to by some as “voluntary codes.” To illustrate how
the campaign worked, this case discusses one of the six changes that the IHI put forward—
establishing a Medical Emergency Team (MET), also referred to a Rapid Response Team—and
describes one participating hospital’s efforts to implement that change.
THE 100K LIVES CAMPAIGN
The original campaign goal was to recruit 2,000 hospitals to implement at least one of the six
quality-improvement changes (see Table 11-4). The final number recruited exceeded 3,000,
representing about 75% of the nation’s hospital beds and 30 million discharges annually.
Because most hospitals chose to implement multiple changes—many implemented all six—the
campaign inspired 12,294 new quality-improvement efforts.
Each hospital had to set a target for the number of lives it would save. It had two options for
how to do this. The simplest way was to set a goal based on the campaign’s target of saving
100,000 lives. To do that, participating hospitals and hospital systems would have to avoid
slightly less than two deaths per thousand discharges per year. Thus, the calculation for arriving
at a hospital’s target for lives that would need to be saved would be as follows (IHI, n.d.):
(Number of discharges per year) × (18 months ÷ 12 months) × (2 lives saved ÷ 1,000
discharges)
The alternative was to look at what the literature suggested was the lifesaving potential of
each change and identify the population of patients whose care would be improved. From
339340that, a hospital could estimate the number of lives that would be saved if the program was
fully implemented for 18 months and then adjust that downward to account for months when the
program was not operational or in a “ramp up” phase.
The Institute for Healthcare Improvement and its partners identified six quality-improvement
changes to promote through the 100K Lives Campaign. They were as follows:
•
•
•
•
•
• Activate a Rapid Response Team at the first sign that a patient’s condition is worsening
and may lead to a more serious medical emergency (1,781 hospitals participating).
• Prevent patients from dying of heart attacks by delivering evidencebased care, such as
appropriate administration of aspirin and betablockers to prevent further heart muscle
damage (2,288 hospitals participating).
• Prevent medication errors by ensuring that accurate and continually updated lists of
patients’ medications are reviewed and reconciled during their hospital stay, particularly
at transition points (2,185 hospitals participating).
• Prevent patients who are receiving medicines and fluids through central lines from
developing infections by following five steps, including proper hand washing and
cleaning the patient’s skin with “chlorhexidine” (a type of antiseptic) (1,925 hospitals
participating).
• Prevent patients undergoing surgery from developing infections by following a series of
steps, including the timely administration of antibiotics (2,133 hospitals participating).
• Prevent patients on ventilators from developing pneumonia by following four steps, including
raising the head of the patient’s bed between 30 and 45 degrees (1,982 hospitals participating).
Participating hospitals had to agree to submit monthly raw mortality data for January 2005
through June 2006 and baseline data for the 18 months preceding the campaign (July 2003
through December 2004). To account for variations in 340341the acuity of the patient load, the
IHI calculated the “case mix ratio” (CMR) using national acuity data. The ratio compared
expected deaths per discharge for each month during the campaign period with expected deaths
per discharge for the comparable month in 2004. Thus, for February 2006, the formula for
calculating the case mix would be as follows:
(February 2006 CMR) = (February 2006 expected deaths per discharge) ÷ (February 2004
expected deaths per month)
The IHI then calculated the expected deaths per month if there had not been any quality
improvements by multiplying the number of discharges each month by the mortality rate for the
same month during 2004 and then adjusting for acuity by multiplying the anticipated number of
mortalities by the CMR. It then arrived at the number of lives saved by subtracting the actual
number of deaths from the expected number of deaths. The formula for calculating lives saved in
February 2006, therefore, would look like this:
(February 2006 lives saved) = ([February 2006 CMR] × [February 2004 mortality rate] ×
[February 2006 number of discharges]) − (February 2006 number of deaths)
These calculations were made using national numbers and aggregated data from all of the
reporting hospitals. Confounding factors would make it difficult for most hospitals to calculate
their individual lives saved with much accuracy.
VOLUNTARY CODES
There was no immediate financial return or other significant direct benefit to participating
hospitals and no monetary reward for reaching their goals, although some participants issued
press releases touting their involvement and put information about the campaign on their Web
sites. No law—either administrative rule or statute—was forcing them to 341342participate.
Indeed, the campaign fits the model referred to as a “voluntary code.” Webb (2004, p.11) defined
voluntary codes as follows:
•
Commitments not required by legislation or regulations
•
Agreed to by one or more individuals or organizations
•
Intended to influence or control behavior
•
To be applied in a consistent manner or to reach in a consistent outcome
“Unlike conventional command and control regulatory approaches,” wrote Webb, “voluntary
codes harness market, peer and community energies to influence behaviour, and draw on the
infrastructure of intermediaries such as industry associations, standards organizations and nongovernmental organizations for rule development and implementation” (p. 11). Webb considered
voluntary codes to be part of a concept called private governance, a term “intended to encompass
the full range of ways that organizations not directly affiliated with the State attempt to organize
their affairs” (p. 12). Other terms used to describe private governance include informal
regulation, private regulation, voluntary regulation, self-regulation, co-regulation, and
communitarian regulation, as well as soft law, self-management, and corporate social
responsibility.
The 100,000 Lives Campaign seems to fit Webb’s definition of a voluntary code. The
intermediaries in this case are the IHI and its partners, including the Joint Commission on
Accreditation of Health Care Organizations (JCAHO), the American Medical Association, the
American Nurses Association, the National Patient Safety Foundation, the Leapfrog Group, the
U.S. Center for Disease Control and Prevention, and the U.S. Centers for Medicare & Medicaid
Services.
Perhaps the best known types of voluntary codes are principles for responsible corporate
behavior promoted by nongovernmental, environmental, health and welfare, and social justice
organizations and adopted by corporations. There are many examples of such campaigns, one of
which is the 342343“No Dirty Gold” campaign started by Earthworks, with industry leadership
from Mike Kowalski, Chairman and CEO of Tiffany & Company, which encourages the gold
mining industry to adopt sustainable practices and the jewelry industry to use “clean” gold.
Voluntary codes are not new, and they may or may not be in the public interest. In the Middle
Ages, guilds controlled almost every aspect of commercial activities. The Better Business
Bureau grew out of “vigilance committees” formed in the late 1800s, and the National
Consumer’s League inspected working conditions at apparel factories as early as 1899,
authorizing those that met its standard to use its white label.
Webb (2004) suggested that the current interest in voluntary codes may be due in part to the
limitations of traditional government regulations:
Regulatory regimes pertaining to consumer, environmental, worker, and health and safety
protection, and many other areas, have made considerable progress in improving the lives of
millions. But for all their strengths, the command-and-control regulatory approach is not without
its limitations, including expensive and protracted development and enforcement processes;
jurisdictional constraints on subject matter, approach and scope; vulnerability to inconsistent and
inadequate enforcement, due to staff resources and cutbacks, and associated downturns in
government and public attention; and a tendency toward inflexibility and overformality (p. 4).
Webb and other authors, however, are quick to acknowledge the limitations of voluntary
codes—for example, a “free rider” who chooses not to participate may gain a cost advantage
over competitors who are “doing the right thing.” Voluntary codes and conventional government
regulations are not mutually exclusive. In Canada, the use of bicycle helmets is required by law,
but safety standards for their manufacture are voluntary; meanwhile, hockey helmets
manufacturing standards 343344are federally mandated, but the use of helmets during hockey
games is discretionary in most of the country (Morrison & Webb, 2004).
When JCAHO, an independent, nonprofit organization, sets a standard for health care
organizations and then evaluates and accredits them, it is engaging in a form of private
governance. State agencies that regulate hospitals may grant “deemed status” to hospitals that
meet JCAHO’s standards, accepting accreditation in lieu of a visit by state inspectors or
requiring less frequent state inspections.
State regulations and voluntary efforts to reduce medical errors may co-exist. As of September
2005, 23 states had passed legislation or regulations requiring adverse event reporting for
hospitals (Rosenthal & Booth, 2005).
THE CASE FOR METS
Cardiac arrest teams that respond to the bedside of a patient who suddenly has no palpable
pulse or detectible blood pressure, is unresponsive, or requires the initiation of life support are
common features in hospitals. These teams, despite access to increasingly sophisticated
technology and increasingly refined protocols, have had limited impact on survival. In the United
States, the percentage of patients who suffer in-hospital cardiac arrest and survive long enough to
be discharged has remained at around 15% for almost 3 decades.
The IHI has noted that there is wide variability in hospital survival rates. The IHI attribute
this variability to three factors: (1) failures in planning, (2) failures in communication, and (3)
failure to recognize deteriorating conditions. Cardiac arrest teams appear to illustrate the third
factor. In the hours preceding arrest, patients typically show signs of distress. If those signs are
recognized and appropriate steps taken, the arrest can often be prevented. One study found that
76% of patients who unexpectedly coded or had to be admitted to intensive care showed
symptoms of respiratory, 344345airway, or circulatory deterioration an hour or more beforehand
(Buist et al., 2002). Patients may be dying from respiratory or cardiac failure and related
complications, but hospitals’ “failure to rescue” may be a contributing factor.
In February 1990, Liverpool Hospital in Sydney, Australia introduced a variation on the
cardiac arrest team, something it called the MET. The difference between the cardiac arrest team
and a MET was that hospital staff could summon the MET to treat anyone who was noticeably
deteriorating or acutely unwell. Initial results, published in the mid 1990s, were highly favorable.
In 2002, a team of Australian researchers published a study that found that establishing a MET in
their hospital resulted in a 50% decrease in the incidence of unanticipated cardiac arrests, even
after making adjustments for variations in case mix (the acuity of its patient population).
Mortality declined from 76% to 55% (Buist et al., 2002).
Although there was broad agreement that METs made intuitive clinical sense, appeared to
work, were relatively simple and inexpensive to implement, and did not seem to produce any
clinical adverse outcomes, hospitals were slow to deploy them. Kerridge and Saul (2003)
suggested that this “institutional inertia” might be traced to a continuing quest for data that
would meet the “gold standard” of evidence-based medicine, and Buist et al., many argued, had
not met that standard.
Then Bellomo et al. (2003) published more robust results. They studied a MET team
established at a major Melbourne, Australia teaching hospital. The relative risk of experiencing a
cardiac arrest, while a patient, declined 65% during the 4-month study period when compared
with a 4-month period before the MET began operating. The relative risk of dying from an inhospital cardiac arrest declined 56%. The number of days survivors spent in the intensive care
unit declined 80%, and the total days they spent in the hospital declined 88%. Strikingly, the
hospital’s overall mortality rate dropped 25%. The IHI cited this experience as evidence
345346when it put Rapid Response Teams on its menu of qualityimprovement changes. To meet
its goal of 100,000 lives saved, the campaign estimated that it would need to prevent about two
deaths per 1,000 discharges. The data out of Australia suggested that METs alone could prevent
three deaths per 1,000 discharges.
VIRGINIA MASON’S EXPERIENCE
Virginia Mason Medical Center, a 100,000 Lives Campaign participant situated in Seattle,
launched its MET in July 2005 (Virginia Mason Medical Center, 2006). The goal was to prevent
avoidable codes by intervening before patients developed cardiopulmonary arrest or other
adverse events. Each specially trained team included a critical care charge registered nurse, a
respiratory therapist, and a hospitalist. To manage the program, Virginia Mason established a
team made up of a project manager, the medical director for the critical care unit and respiratory
therapy, the hospitalist service director, a respiratory therapy manager, a preceptor coordinator,
the chief of nursing services for the intensive care unit, an administrative director, and a
communications consultant.
The hospital nursing staff was instructed to call immediately both the MET (by dialing a special
phone number) and the managing physician whenever any of the following occurred:
•
•
•
•
•
• Care providers were worried about the patient
• The patient’s heart rate suddenly went below 40 or above 130 beats per second
• The patient’s systolic blood pressure suddenly dropped below 90
• The patient’s respiratory rate suddenly dropped below eight or climbed above 30
breaths per minute
• The pulse oximetry saturation rate of a patient receiving oxygen dropped below 90%
346347
•
•
• There was an acute change in the patient’s state of consciousness
• The patient’s urine output suddenly dropped to less than 50 ml during a 4-hour period
For outcome measurement, the team chose to monitor the number of MET calls per week, the
number of cardiopulmonary resuscitation or intubation events inside and outside the intensive
care unit each month, and the rate of potentially preventable codes. Initially, calls for the MET
were fewer than hoped for. The project team then undertook a series of steps to increase
utilization:
•
•
• It improved its communications tools and its documentation.
• It had the operator convert all STAT (immediate response) calls that were still coming
in to MET calls.
•
•
•
•
•
• It partnered with the STROKE team, conducting another round of education and
focusing more on at-risk populations.
• It “advertised” the MET’s existence by paging the team through the overhead intercom
in addition to personal pagers.
• It required all registered nurses to sign a form documenting that they knew when and
how to call the MET.
• It audited high-volume units and provided feedback on how the MET could be better
used.
• It looked for opportunities to celebrate the program and recognize nurses who made use
of it.
Over time, the number of MET calls increased, averaging 70 per month (55/1,000 discharges).
The hospital observed a decline in the number of cardiopulmonary and respiratory arrests
occurring outside of the critical care unit, although given the hospital’s low mortality rate, the
numbers are too small to determine whether the intervention had a significant impact on
mortality (Westley, 2007).
347
348
OVERALL 100K LIVES CAMPAIGN RESULTS
On June 14, 2006, the IHI released the results of the 100,000 Lives Campaign at its 2nd
Annual International Summit on Redesigning Hospital Care. Across 18 months, the participating
hospitals combined prevented an estimated 122,300 avoidable deaths. Perhaps more important,
said IHI President and CEO Donald Berwick, is the fact that so many hospitals had
institutionalized new standards of care as a result of the campaign. He noted that more than 20
hospitals have reported no deaths from ventilator-assisted pneumonia over an entire year. This
form of pneumonia is the leading cause of deaths from hospital-acquired infections.
“When we decided to launch the campaign we didn’t know if hospitals could take on another
challenge,” Dr. Berwick said. “But the campaign has exceeded our highest expectations. The
participating hospitals have not only prevented an estimated 122,300 unnecessary deaths, but
they’ve also proven that it’s possible for the health care community to come together voluntarily
to make significant changes in patient care. I have never before witnessed such widespread
collaboration and commitment on the part of health care leaders and front-line staff to move the
system giant steps forward” (Berwick et al., 2006).
DISCUSSION QUESTIONS
1.
Purchase (2004) argued that industry groups develop voluntary codes to enhance their
commercial interests, typically:
a.
To gain consumer confidence and trust
b.
To forestall collective actions by consumers
c.
To forestall adverse political interventions
d.
To promote desire of political interventions
e.
To restrain trade.
1
How does well does the 100,000 Lives Campaign fit with those constructs?
2.
What does the experience of Virginia Mason Medical Center say about the
implementation of voluntary codes in health care?
3
If you wanted to conduct future policy research based on the experiences of the 100,000
Lives Campaign hospitals, what would you measure and why?
4. What are other examples of voluntary codes used in the health care environment? Why are
they so prevalent in this industry? What seems to determine the mix of voluntary and
government regulations in health care settings?
The 100k Lives Campaign
150-200 words, intext citation and references
In the course text, read case 11-1, pages 338 (bottom) through 348. I have to respond to
Discussion question #3
Case 11–1
THE 100K LIVES CAMPAIGN: A VOLUNTARY CODE IN ACTION
BACKGROUND
In 2004, the Institute for Healthcare Improvement (IHI) put out a call for hospitals willing to
participate in its 100,000 Lives Campaign. Its goal was to prevent 100,000 deaths in U.S.
hospitals during an 18-month period (January 2005 through June 2006) by having hospitals
implement some or all of six quality-improvement changes that the IHI and its campaign partners
identified as evidence-based and potentially lifesaving.
The IHI developed the campaign in response to a 2001 Institute of Medicine report, Crossing
the Quality Chasm: A New Health System for the 21st Century, that concluded that 44,000 to
98,000 Americans die each year because of medical errors and adverse events (injuries caused by
medical management). This campaign provides an example of non-coercive alternatives to
command-and-control regulation—referred to by some as “voluntary codes.” To illustrate how
the campaign worked, this case discusses one of the six changes that the IHI put forward—
establishing a Medical Emergency Team (MET), also referred to a Rapid Response Team—and
describes one participating hospital’s efforts to implement that change.
THE 100K LIVES CAMPAIGN
The original campaign goal was to recruit 2,000 hospitals to implement at least one of the six
quality-improvement changes (see Table 11-4). The final number recruited exceeded 3,000,
representing about 75% of the nation’s hospital beds and 30 million discharges annually.
Because most hospitals chose to implement multiple changes—many implemented all six—the
campaign inspired 12,294 new quality-improvement efforts.
Each hospital had to set a target for the number of lives it would save. It had two options for
how to do this. The simplest way was to set a goal based on the campaign’s target of saving
100,000 lives. To do that, participating hospitals and hospital systems would have to avoid
slightly less than two deaths per thousand discharges per year. Thus, the calculation for arriving
at a hospital’s target for lives that would need to be saved would be as follows (IHI, n.d.):
(Number of discharges per year) × (18 months ÷ 12 months) × (2 lives saved ÷ 1,000
discharges)
The alternative was to look at what the literature suggested was the lifesaving potential of
each change and identify the population of patients whose care would be improved. From
339340that, a hospital could estimate the number of lives that would be saved if the program was
fully implemented for 18 months and then adjust that downward to account for months when the
program was not operational or in a “ramp up” phase.
The Institute for Healthcare Improvement and its partners identified six quality-improvement
changes to promote through the 100K Lives Campaign. They were as follows:
•
•
•
•
•
• Activate a Rapid Response Team at the first sign that a patient’s condition is worsening
and may lead to a more serious medical emergency (1,781 hospitals participating).
• Prevent patients from dying of heart attacks by delivering evidencebased care, such as
appropriate administration of aspirin and betablockers to prevent further heart muscle
damage (2,288 hospitals participating).
• Prevent medication errors by ensuring that accurate and continually updated lists of
patients’ medications are reviewed and reconciled during their hospital stay, particularly
at transition points (2,185 hospitals participating).
• Prevent patients who are receiving medicines and fluids through central lines from
developing infections by following five steps, including proper hand washing and
cleaning the patient’s skin with “chlorhexidine” (a type of antiseptic) (1,925 hospitals
participating).
• Prevent patients undergoing surgery from developing infections by following a series of
steps, including the timely administration of antibiotics (2,133 hospitals participating).
• Prevent patients on ventilators from developing pneumonia by following four steps, including
raising the head of the patient’s bed between 30 and 45 degrees (1,982 hospitals participating).
Participating hospitals had to agree to submit monthly raw mortality data for January 2005
through June 2006 and baseline data for the 18 months preceding the campaign (July 2003
through December 2004). To account for variations in 340341the acuity of the patient load, the
IHI calculated the “case mix ratio” (CMR) using national acuity data. The ratio compared
expected deaths per discharge for each month during the campaign period with expected deaths
per discharge for the comparable month in 2004. Thus, for February 2006, the formula for
calculating the case mix would be as follows:
(February 2006 CMR) = (February 2006 expected deaths per discharge) ÷ (February 2004
expected deaths per month)
The IHI then calculated the expected deaths per month if there had not been any quality
improvements by multiplying the number of discharges each month by the mortality rate for the
same month during 2004 and then adjusting for acuity by multiplying the anticipated number of
mortalities by the CMR. It then arrived at the number of lives saved by subtracting the actual
number of deaths from the expected number of deaths. The formula for calculating lives saved in
February 2006, therefore, would look like this:
(February 2006 lives saved) = ([February 2006 CMR] × [February 2004 mortality rate] ×
[February 2006 number of discharges]) − (February 2006 number of deaths)
These calculations were made using national numbers and aggregated data from all of the
reporting hospitals. Confounding factors would make it difficult for most hospitals to calculate
their individual lives saved with much accuracy.
VOLUNTARY CODES
There was no immediate financial return or other significant direct benefit to participating
hospitals and no monetary reward for reaching their goals, although some participants issued
press releases touting their involvement and put information about the campaign on their Web
sites. No law—either administrative rule or statute—was forcing them to 341342participate.
Indeed, the campaign fits the model referred to as a “voluntary code.” Webb (2004, p.11) defined
voluntary codes as follows:
•
Commitments not required by legislation or regulations
•
Agreed to by one or more individuals or organizations
•
Intended to influence or control behavior
•
To be applied in a consistent manner or to reach in a consistent outcome
“Unlike conventional command and control regulatory approaches,” wrote Webb, “voluntary
codes harness market, peer and community energies to influence behaviour, and draw on the
infrastructure of intermediaries such as industry associations, standards organizations and nongovernmental organizations for rule development and implementation” (p. 11). Webb considered
voluntary codes to be part of a concept called private governance, a term “intended to encompass
the full range of ways that organizations not directly affiliated with the State attempt to organize
their affairs” (p. 12). Other terms used to describe private governance include informal
regulation, private regulation, voluntary regulation, self-regulation, co-regulation, and
communitarian regulation, as well as soft law, self-management, and corporate social
responsibility.
The 100,000 Lives Campaign seems to fit Webb’s definition of a voluntary code. The
intermediaries in this case are the IHI and its partners, including the Joint Commission on
Accreditation of Health Care Organizations (JCAHO), the American Medical Association, the
American Nurses Association, the National Patient Safety Foundation, the Leapfrog Group, the
U.S. Center for Disease Control and Prevention, and the U.S. Centers for Medicare & Medicaid
Services.
Perhaps the best known types of voluntary codes are principles for responsible corporate
behavior promoted by nongovernmental, environmental, health and welfare, and social justice
organizations and adopted by corporations. There are many examples of such campaigns, one of
which is the 342343“No Dirty Gold” campaign started by Earthworks, with industry leadership
from Mike Kowalski, Chairman and CEO of Tiffany & Company, which encourages the gold
mining industry to adopt sustainable practices and the jewelry industry to use “clean” gold.
Voluntary codes are not new, and they may or may not be in the public interest. In the Middle
Ages, guilds controlled almost every aspect of commercial activities. The Better Business
Bureau grew out of “vigilance committees” formed in the late 1800s, and the National
Consumer’s League inspected working conditions at apparel factories as early as 1899,
authorizing those that met its standard to use its white label.
Webb (2004) suggested that the current interest in voluntary codes may be due in part to the
limitations of traditional government regulations:
Regulatory regimes pertaining to consumer, environmental, worker, and health and safety
protection, and many other areas, have made considerable progress in improving the lives of
millions. But for all their strengths, the command-and-control regulatory approach is not without
its limitations, including expensive and protracted development and enforcement processes;
jurisdictional constraints on subject matter, approach and scope; vulnerability to inconsistent and
inadequate enforcement, due to staff resources and cutbacks, and associated downturns in
government and public attention; and a tendency toward inflexibility and overformality (p. 4).
Webb and other authors, however, are quick to acknowledge the limitations of voluntary
codes—for example, a “free rider” who chooses not to participate may gain a cost advantage
over competitors who are “doing the right thing.” Voluntary codes and conventional government
regulations are not mutually exclusive. In Canada, the use of bicycle helmets is required by law,
but safety standards for their manufacture are voluntary; meanwhile, hockey helmets
manufacturing standards 343344are federally mandated, but the use of helmets during hockey
games is discretionary in most of the country (Morrison & Webb, 2004).
When JCAHO, an independent, nonprofit organization, sets a standard for health care
organizations and then evaluates and accredits them, it is engaging in a form of private
governance. State agencies that regulate hospitals may grant “deemed status” to hospitals that
meet JCAHO’s standards, accepting accreditation in lieu of a visit by state inspectors or
requiring less frequent state inspections.
State regulations and voluntary efforts to reduce medical errors may co-exist. As of September
2005, 23 states had passed legislation or regulations requiring adverse event reporting for
hospitals (Rosenthal & Booth, 2005).
THE CASE FOR METS
Cardiac arrest teams that respond to the bedside of a patient who suddenly has no palpable
pulse or detectible blood pressure, is unresponsive, or requires the initiation of life support are
common features in hospitals. These teams, despite access to increasingly sophisticated
technology and increasingly refined protocols, have had limited impact on survival. In the United
States, the percentage of patients who suffer in-hospital cardiac arrest and survive long enough to
be discharged has remained at around 15% for almost 3 decades.
The IHI has noted that there is wide variability in hospital survival rates. The IHI attribute
this variability to three factors: (1) failures in planning, (2) failures in communication, and (3)
failure to recognize deteriorating conditions. Cardiac arrest teams appear to illustrate the third
factor. In the hours preceding arrest, patients typically show signs of distress. If those signs are
recognized and appropriate steps taken, the arrest can often be prevented. One study found that
76% of patients who unexpectedly coded or had to be admitted to intensive care showed
symptoms of respiratory, 344345airway, or circulatory deterioration an hour or more beforehand
(Buist et al., 2002). Patients may be dying from respiratory or cardiac failure and related
complications, but hospitals’ “failure to rescue” may be a contributing factor.
In February 1990, Liverpool Hospital in Sydney, Australia introduced a variation on the
cardiac arrest team, something it called the MET. The difference between the cardiac arrest team
and a MET was that hospital staff could summon the MET to treat anyone who was noticeably
deteriorating or acutely unwell. Initial results, published in the mid 1990s, were highly favorable.
In 2002, a team of Australian researchers published a study that found that establishing a MET in
their hospital resulted in a 50% decrease in the incidence of unanticipated cardiac arrests, even
after making adjustments for variations in case mix (the acuity of its patient population).
Mortality declined from 76% to 55% (Buist et al., 2002).
Although there was broad agreement that METs made intuitive clinical sense, appeared to
work, were relatively simple and inexpensive to implement, and did not seem to produce any
clinical adverse outcomes, hospitals were slow to deploy them. Kerridge and Saul (2003)
suggested that this “institutional inertia” might be traced to a continuing quest for data that
would meet the “gold standard” of evidence-based medicine, and Buist et al., many argued, had
not met that standard.
Then Bellomo et al. (2003) published more robust results. They studied a MET team
established at a major Melbourne, Australia teaching hospital. The relative risk of experiencing a
cardiac arrest, while a patient, declined 65% during the 4-month study period when compared
with a 4-month period before the MET began operating. The relative risk of dying from an inhospital cardiac arrest declined 56%. The number of days survivors spent in the intensive care
unit declined 80%, and the total days they spent in the hospital declined 88%. Strikingly, the
hospital’s overall mortality rate dropped 25%. The IHI cited this experience as evidence
345346when it put Rapid Response Teams on its menu of qualityimprovement changes. To meet
its goal of 100,000 lives saved, the campaign estimated that it would need to prevent about two
deaths per 1,000 discharges. The data out of Australia suggested that METs alone could prevent
three deaths per 1,000 discharges.
VIRGINIA MASON’S EXPERIENCE
Virginia Mason Medical Center, a 100,000 Lives Campaign participant situated in Seattle,
launched its MET in July 2005 (Virginia Mason Medical Center, 2006). The goal was to prevent
avoidable codes by intervening before patients developed cardiopulmonary arrest or other
adverse events. Each specially trained team included a critical care charge registered nurse, a
respiratory therapist, and a hospitalist. To manage the program, Virginia Mason established a
team made up of a project manager, the medical director for the critical care unit and respiratory
therapy, the hospitalist service director, a respiratory therapy manager, a preceptor coordinator,
the chief of nursing services for the intensive care unit, an administrative director, and a
communications consultant.
The hospital nursing staff was instructed to call immediately both the MET (by dialing a special
phone number) and the managing physician whenever any of the following occurred:
•
•
•
•
•
• Care providers were worried about the patient
• The patient’s heart rate suddenly went below 40 or above 130 beats per second
• The patient’s systolic blood pressure suddenly dropped below 90
• The patient’s respiratory rate suddenly dropped below eight or climbed above 30
breaths per minute
• The pulse oximetry saturation rate of a patient receiving oxygen dropped below 90%
346347
•
•
• There was an acute change in the patient’s state of consciousness
• The patient’s urine output suddenly dropped to less than 50 ml during a 4-hour period
For outcome measurement, the team chose to monitor the number of MET calls per week, the
number of cardiopulmonary resuscitation or intubation events inside and outside the intensive
care unit each month, and the rate of potentially preventable codes. Initially, calls for the MET
were fewer than hoped for. The project team then undertook a series of steps to increase
utilization:
•
•
• It improved its communications tools and its documentation.
• It had the operator convert all STAT (immediate response) calls that were still coming
in to MET calls.
•
•
•
•
•
• It partnered with the STROKE team, conducting another round of education and
focusing more on at-risk populations.
• It “advertised” the MET’s existence by paging the team through the overhead intercom
in addition to personal pagers.
• It required all registered nurses to sign a form documenting that they knew when and
how to call the MET.
• It audited high-volume units and provided feedback on how the MET could be better
used.
• It looked for opportunities to celebrate the program and recognize nurses who made use
of it.
Over time, the number of MET calls increased, averaging 70 per month (55/1,000 discharges).
The hospital observed a decline in the number of cardiopulmonary and respiratory arrests
occurring outside of the critical care unit, although given the hospital’s low mortality rate, the
numbers are too small to determine whether the intervention had a significant impact on
mortality (Westley, 2007).
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OVERALL 100K LIVES CAMPAIGN RESULTS
On June 14, 2006, the IHI released the results of the 100,000 Lives Campaign at its 2nd
Annual International Summit on Redesigning Hospital Care. Across 18 months, the participating
hospitals combined prevented an estimated 122,300 avoidable deaths. Perhaps more important,
said IHI President and CEO Donald Berwick, is the fact that so many hospitals had
institutionalized new standards of care as a result of the campaign. He noted that more than 20
hospitals have reported no deaths from ventilator-assisted pneumonia over an entire year. This
form of pneumonia is the leading cause of deaths from hospital-acquired infections.
“When we decided to launch the campaign we didn’t know if hospitals could take on another
challenge,” Dr. Berwick said. “But the campaign has exceeded our highest expectations. The
participating hospitals have not only prevented an estimated 122,300 unnecessary deaths, but
they’ve also proven that it’s possible for the health care community to come together voluntarily
to make significant changes in patient care. I have never before witnessed such widespread
collaboration and commitment on the part of health care leaders and front-line staff to move the
system giant steps forward” (Berwick et al., 2006).
DISCUSSION QUESTIONS
1.
Purchase (2004) argued that industry groups develop voluntary codes to enhance their
commercial interests, typically:
a.
To gain consumer confidence and trust
b.
To forestall collective actions by consumers
c.
To forestall adverse political interventions
d.
To promote desire of political interventions
e.
To restrain trade.
1
How does well does the 100,000 Lives Campaign fit with those constructs?
2.
What does the experience of Virginia Mason Medical Center say about the
implementation of voluntary codes in health care?
3
If you wanted to conduct future policy research based on the experiences of the 100,000
Lives Campaign hospitals, what would you measure and why?
4. What are other examples of voluntary codes used in the health care environment? Why are
they so prevalent in this industry? What seems to determine the mix of voluntary and
government regulations in health care settings?