'100,000 Lives' campaign hits its target ahead of deadline
IHI sought participation; more than 3,000 have signed up
The Institute for Healthcare Improvement (IHI), based in Boston, has reported that U.S. hospitals taking part in an 18-month effort to prevent 100,000 unnecessary deaths by dramatically improving patient care have exceeded that goal. Hospitals enrolled in the "100,000 Lives Campaign" have collectively prevented an estimated 122,300 avoidable deaths, according to IHI and, as importantly, have begun to institutionalize new standards of care that will continue to save lives and improve health outcomes into the future.
The campaign, initiated by IHI in December 2004, has enrolled more than 3,000 hospitals — representing an estimated 75% of U.S. hospital beds, and far surpassing the original enrollment goal of 2,000. About 86% have sent in mortality data.
How did IHI determine how many lives were saved? Campaign workers examined 2004 data for the participating hospitals to determine how many people were expected to die during the 18 months of the campaign. Then they checked the count of actual deaths reported. They also made mathematical adjustments for severity of illnesses and for volume of cases, to make a fairer comparison of the two time periods. They also made estimates for participating hospitals that did not report data.
"We get the data directly from the reports supplied by the participating hospitals," says Joe McCannon, IHI's campaign manager for "100,000 Lives." "We refer to that as the baseline data — the year before the campaign. Then, we look at data [hospitals provide deaths over discharges on a monthly basis] from January 2005 to June 2006, compare the performance, aggregate the data nationally, apply acuity adjustment to the hospital data, and create an aggregate estimate."
Mortality rates drop
It's a little trickier for hospitals to individually determine lives saved, he says, because they lack the acuity information needed. "However, individual hospitals may be looking at their mortality rates over time," he notes.
One campaign participant, Contra Costa Regional Medical Center in Martinez, CA, has seen a significant drop in mortality rates, according to Steve Tremain, MD, senior medical director for the Contra Costa Health Services system and director of system redesign for Contra Costa Regional Medical Center.
"By using ChartRunner, which IHI taught us how to use, the data show the mortality rate has dropped from 0.85% to 0.67%. That's truly significant; it's a 21% reduction," Tremain observes.
Tremain went to IHI's first annual meeting on redesigning hospitals in 2005. "They focused on systems solutions — helping people not make mistakes they did not want to make," he recalls. "We brought their ideas back to our organization, and we very quickly got support of the medical staff-run PI committee to sponsor our participation in all six initiatives."
The six "100,000 Lives" initiatives are:
- Activate a rapid response team (For more on rapid response teams, see the cover story in our July 2006 issue.)
- Prevent patients from dying of heart attacks by delivering evidence-based care.
- Prevent medication errors by ensuring that accurate and continually updated lists of patients' medications are reviewed and reconciled during their hospital stay.
- 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).
- Prevent patients undergoing surgery from developing infections by following a series of steps, including the timely administration of antibiotics.
- 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.
The first initiative implemented was medications reconciliation, and the others followed shortly thereafter, says Tremain.
In addition to lowered mortality rates, Contra Costa can point to a number of other successes. For example, it has lowered its ventilator associated pneumonia (VAP) rate significantly. "On patients on ventilators 48 hours or more, it dropped from about 20% to 1.8%; that's a 90% drop," says Tremain. The main reason the CCU gave for its success, he says, was that it was using the entire bundle of steps recommended, not just individual pieces. "One of the things IHI talks about is there is no 'partial credit,'" Tremain explains. "This is not a smorgasbord; the impact of each step is synergistic when you use them all."
A number of the successes at Contra Costa were achieved without the aid of technology, Tremain notes. "For example, our nurses were puzzled as to exactly what a '30% head of bed elevation' looked like [one of the interventions in the bundle]," he recalls. "They measured where it was, brought in a roll of red tape, and put it on the wall behind the head of the bed. If you could see the red line, the bed was not at the right level. So, for $3 [the cost of the tape] they identified the correct level on all potential ventilator rooms."
The last thing the staff did, he adds, was to put up a poster in the unit explaining the red line to family members, and asking them to inform the staff if they could see the line.
In another instance, the director of respiratory therapy made a clear model to represent the trachea, put a tube in it, inflated the cuff, and put pea soup in the tube. "They showed the staff that everything gets past the cuff," Tremain relates. "So, the staff realized they couldn't put all their trust in the cuff."
Involving the community
Another facility that has been a successful participant in the campaign, Brattleboro (VT) Memorial Hospital, is looking to improve on its success by involving the local community.
"We are moving medication reconciliation to another level," explains Jan Puchalski, quality specialist. "We have information on our web site, we've done newspaper articles, and educational programs," she shares. "In our quarterly report, which goes out to 'the world,' we are really trying to get the patients to make these lists and check their accuracy while they are at home and well, and to get used to taking them with them. We hope to [improve things] at the front end."
Brattleboro Memorial also has been involved with the campaign for more than two years. "We were in on surgical site infection prevention at the ground level, and we've also done rapid response teams," Puchalski relates.
For myocardial infarctions, the facility now gives aspirin on arrival and at discharge 100% of the time, she reports. "Discharge instructions for CHF [congestive heart failure] were at 31% last year; now they are at 100%. We've had similar improvement in adult smoking cessation classes," she adds.
CHF, she says, probably represents their greatest area of success. "We've worked out things so it's part of the process," she explains. "The nurse has a discharge summary sheet, which cues her as to the discharge instructions. Before, it was just by reminder or memory."
The same is true with pneumonia vaccinations, she says. "We were quite low with giving it — about 18%," she recalls. "We included it on our sheet and incorporated a standing order so nurses do not have to rely on docs; they can give it on their own." The protocol, she says, is based on CDC recommendations.
In the area of preventing surgical-site infections, antibiotics are given within one hour 100% of the time. "Before, we 'knew' we were giving it, but we weren't really sure — because there was no documentation," Puchalski explains. "We added it to the flow sheet that the anesthesiologist actually uses, so it cues him to put in 'antibiotic given' and 'time given,' so we now have that documented."
Use all the initiatives?
In order for a hospital to participate in the "100,000 Lives" campaign, it only has to agree to implement one of the six initiatives. However, according to IHI statistics, most of the hospitals appear to have implemented more than one. Here are their figures, broken down by initiative:
- Rapid response teams: 1,781 hospitals participating.
- Heart attacks: 2,288 hospitals participating.
- Medication errors: 2,185 hospitals participating.
- Central line infections: 1,925 hospitals participating.
- Surgical infections: 2,133 hospitals participating.
- VAP: 1,982 hospitals participating.
Roughly one-third of the facilities said they were implementing all six measures, and more than half committed to at least three, the IHI notes.
"It's an important question," says McCannon. "Our assumption is [they will save more lives] if they do more, and participate in more of the initiatives." However, he notes, some initiatives, like the rapid response teams, have really great potential to save lives. "The thing is, you can look at each of the interventions in your hospital, and that would give you a very strong sense of the changes happening on the hospital level," McCannon notes.
"I think there's real value in using all six of the initiatives," says Tremain. "After all, the concept is called opt out, not opt in. When we have the science that tells us what's best for the majority of patients, you have to turn it around."
He offers the example of providing patients with aspirin. "You would opt not to give aspirin to someone with a bleeding ulcer, but everyone gets the proven care unless the patient brings something unique to the situation, where the best care is not best for them. We learned that this methodology is transportable to any specific set of interventions."
Did the IHI exceed its goal, at least in part, because it enrolled more hospitals than anticipated? "That could be a factor," McCannon concedes. "We've tapped into a lot of energy and frustration among providers of care who are anxious to make improvements — and have done so in a proactive way. Also, it's easy to get involved; there's a low goal of entry, and it's pretty straightforward."
The IHI is definitely not going to rest on its laurels, he continues. "Our feeling is there is still a great deal of room for improvement; our work is still in its early stages," says McCannon. "We will encourage hospitals to completely do all six initiatives, show them how to sustain them broadly, and in December we will announce a new level of the campaign — likely some new interventions."
Won't things be a bit anticlimactic, now that the goal has been met? "Part of the charisma of the campaign has definitely been associated with its aims," McCannon admits, "So we will be mindful of that in the new phase."
The IHI has hinted that the new phase may include the goal of having all hospitals participating in all of the initiatives by the end of 2007.
For more information, contact:
Joe McCannon, Institute for Healthcare Improvement, 20 University Road, 7th Floor, Cambridge, MA 02138 USA. Phone: (617) 301-4836.
Steve Tremain, MD, Senior Medical Director, Contra Costa Health Services, Director of System Redesign, Contra Costa Regional Medical Center, Martinez, CA. Phone: (925) 370-5122. E-mail: [email protected].
Jan Puchalski, quality specialist, Brattleboro Memorial Hospital, Brattleboro, VT. Phone: (802) 257-8244.
The Institute for Healthcare Improvement (IHI), based in Boston, has reported that U.S. hospitals taking part in an 18-month effort to prevent 100,000 unnecessary deaths by dramatically improving patient care have exceeded that goal.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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