Safer Hospital Stays



Hospital-Acquired and Surgical Complications

Hospitals are where you go to get better, not worse. Surgery is intended to correct problems, not cause them. Yet in too many instances, unintended consequences leave patients and their doctors battling new, even greater hazards.

Diagnostic errors, infections, blood clots and the over-prescription of medications can turn what should be a relatively routine event into a life-threatening incident. IHPI members are working to make surgery and hospitalization less risky propositions. Through numerous cross-disciplinary initiatives, many of which are garnering state and national attention and adoption, they are designing ways to anticipate and counteract human error, ensure improved communication and better prepare both doctors and patients to succeed.

In my area of focus, surgery, the issue that keeps me up at night is the variation in quality, safety and performance between hospitals.
Justin Dimick, M.D., M.P.H., whose research is focused on ways to measure and improve the quality of surgical care and patient outcomes

What can be done to lower the risk of hospital-acquired complications?

Intravenous catheters (IVs) are used in more than a billion cases each year in the U.S., making IV placement the most commonly performed procedure in hospitalized patients. U-M hospitalist and IHPI member Vineet Chopra, M.D., M.Sc., is working to help physicians decide when to place an IV device and which device to use.

Through engagements like the Michigan Hospital Medicine Safety Consortium (HMS), a collaborative of 52 Michigan hospitals and Blue Cross Blue Shield of Michigan (BCBSM) focused on IV catheter and PICC (peripherally inserted central catheter) line use, Chopra and his colleagues are focused on bringing research into daily practice. “We found that up to a quarter of patients who receive PICCs have them placed for five or fewer days and may not need them, “ says Chopra, “and that the same proportion of patients may develop clots or infections as a result. So it’s far from a harmless decision.”

The recently-issued ‘Choosing Wisely’ recommendations from the Society of General Internal Medicine reflect the HMS findings regarding IV catheter use, cautioning physicians against routinely using PICC lines – and leaving them in place for longer than necessary – simply for provider or patient convenience.. “Based in part on our work, they have echoed that IV device selection should be a key ‘stop and think’ signpost for physicians,” Chopra adds.

While inappropriate IV use may lead to bloodstream infection and other complications, the use and potential overuse of urinary catheters can increase patients’ risks of developing urinary tract infections (UTIs).

Sanjay Saint, M.D., M.P.H., Chief of Medicine at the VA Ann Arbor Healthcare System, and U-M assistant professor of internal medicine Jennifer Meddings, M.D., M.Sc., are guiding doctors and nurses in deciding which hospital patients may benefit from a urinary catheter and which ones won’t. One recent outcome of their extensive ongoing research is the publication of the Ann Arbor Criteria for Urinary Catheter Appropriateness, a detailed guide to help hospital practitioners choose between three different catheter types, consider non-catheter strategies, and address common bedside challenges that give rise to catheter overuse.

There are currently 2 large national collaboratives currently focused on reducing catheter-associated urinary tract infection and central line associated blood stream infection. Saint, Meddings, and Chopra are part of the national project team (supported by funding from the Agency for Healthcare Research and Quality) that is developing, implementing and evaluating interventions to reduce common bloodstream and urinary tract infections, with step 1 including education and tools to reduce inappropriate use of both urinary and vascular catheters.  

Antibiotic utilization is another area garnering the attention of IHPI members, “We need to challenge the most basic ‘first steps’ we take when patients are admitted to the hospital,” explains Chopra. “For example, patients presenting with a fever are usually prescribed antibiotics right away, to treat a possible infection.  But we’re beginning to see that the decision to prescribe a barrage of antibiotics might not be the best approach for every patient.” 

Overuse of antibiotics has led to the rise of antimicrobial resistance and clostridium difficile. Starting in 2017, hospitals will be required by the Joint Commission to have antibiotic stewardship programs that combat these issues. Valerie Vaughn, M.D., clinical lecturer in internal medicine, and her colleagues are taking this a step further through the Michigan Hospital Medicine Safety Consortium (HMS) to combat antibiotic overuse in pneumonia and urinary tract infections. “The big problem is that providers feel that if a little bit of antibiotic is needed, more must be even safer. We found that over half of patients with pneumonia are prescribed antibiotics for longer than necessary,” says Vaughn. “But broader, stronger and longer means more resistance and a higher chance of adverse events. We have to fundamentally change the way we think about antibiotics and prescribe the minimum amount that’s effective.”

“Our work with urinary catheters, PICC lines and antibiotic use has impacted care in Michigan, across the U.S. and internationally,” adds Saint. “We’re actively collaborating on these issues with clinicians and researchers in Australia, Italy, Thailand, India, Switzerland and Japan.”

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What role should the hospital and the doctor play in ensuring the best possible outcome from a planned surgical procedure?

Evidence from the U-M-led Michigan Bariatric Surgery Collaborative (MBSC), indicates that the risk of complications including dangerous blood clots is lower when the procedure is performed by a high-volume surgeon in a high-volume hospital. The MBSC, another BCBSM partnership involving IHPI researchers and clinicians from 38 statewide bariatric surgery programs, focuses on improving quality of weight loss surgeries by collecting and analyzing clinical data, sharing of performance feedback with surgeons, and disseminating best practice guidelines.

Further study, including research led by IHPI member Justin Dimick, M.D., M.P.H., Chief of the Michigan Medicine Division of Minimally Invasive Surgery and an MBSC leader, sheds more light on the potential for harmful complications stemming from a surgeon’s operating skills. That research included conducting peer reviews and scoring of videotaped surgical procedures, revealing that doctors with low skill scores had surgical complications nearly three times higher than high-skill surgeons.

MBSC surgical guidelines stem from these and other studies led by IHPI members. Their research has also led three major U.S. hospitals including Michigan Medicine, to set minimum-volume standards their surgeons must maintain in order to perform common procedures including bariatric staple surgery, mitral valve repair and hip or knee replacement.

What role should the patient play?

It’s no surprise that when it comes to major surgical procedures, doctors and hospital staff aren’t the only ones who determine success – patients have an equally important role to play.

When it comes to major surgical procedures, it’s not just the doctor and the hospital staff who determine success – patients have an important role to play. Research conducted by U-M surgeons led by transplant surgeon and IHPI member Michael Englesbe, M.D., shows that patients who make even modest positive lifestyle changes prior to their scheduled procedures show impressive gains in how well they bounce back.

“Historically, we tend to operate when it’s convenient for the patient and for us,” says Englesbe. “That’s a paradigm we’re trying to change. Now, for major procedures like transplants, we’ve instituted a program of ‘pre-habilitation’ – to train patients and their families, both physically and mentally, in advance of the procedure.” The Michigan Surgical Home and Optimization Program, launched within Michigan Medicine in 2012, offers education, guidance and motivation to make changes including quitting smoking, increasing physical activity and reducing stress. “Our initial findings have been impressive,” says Englesbe. “Patients showed a 30 percent reduction in costs and marked improvements in their recovery time.”

As a young surgeon, it was heartbreaking to tell a patient that he was too sick to be a candidate for transplant. That experience motivated me to better understand surgical risk and who will or won’t do well after surgery. That led me to health services research, and to finding ways to help patients prepare themselves for surgery – physically and mentally – to improve outcomes.Michael Englesbe, M.D., who directs the Michigan Surgical & Health Optimization Program

Thanks in part to additional statistical and data analysis support from IHPI, Englesbe and his team earned a $6.4 million grant to the program out in 40 Michigan hospitals and practices. “The evidence we’ll be able to gather will measure not only the clinical relevance of ‘prehabilitation’,” says Englesbe, “but its economic and social value as well.”

How well are we preparing tomorrow’s doctors to prevent errors and counteract unpredictability in the hospital environment?

One IHPI-led research team is looking at the role unpredictability plays in physician training. The team, which includes investigators from both the Medical School and the Center for Healthcare Engineering and Patient Safety (CHEPS), is focusing on the training of residents in transplant surgery. Taking a systems approach, they are examining diagnostics and training protocols in order to build processes and simulation tools that anticipate and counteract human error in both teaching and practice.

The biggest issue I saw when I began my career is still the most important one – routinely providing care that represents the best scientific evidence.Sanjay Saint, M.D., whose pioneering efforts toward reducing catheter-associated urinary tract infections, one of the most common and costly hospital infections in the world, have translated into improved outcomes nationally and internationally

Recently, this and related IHPI projects were recognized with a grant from the Agency for Healthcare Research and Quality (AHRQ) to fund the M-Safety Lab, a unique pairing of medical and engineering practitioners charged with finding new ways to improve communication and reduce hospital-acquired complications.

Learn more here: M-Safety Lab

How does hospital care intensity affect outcomes?

The rate that patients die from major complications (also known as the failure-to-rescue rate) is an indicator of how well a hospital recognizes and manages post-surgery complications; a low rate suggests that patients are less likely to die. An IHPI research team reviewed Medicare data to uncover the connection between high hospital care intensity (HCI), a measure of the aggressiveness of an institution’s approach to treatment, and the length of hospital stays and rates of dying from major complications.

The team’s analysis indicated that patients who had surgery at high HCI institutions had longer hospital stays and more major complications, but were somewhat less likely to die of a major complication than those treated at low HCI facilities.

The biggest driver of how well patients do after surgery is our ability to rescue them when a serious complication arises. Improving outcomes for surgical patients by addressing that concept drives my clinical practice and my interest in health services research. It has become my life’s work.Amir Ghaferi, M.D., M.S., whose research explores the mechanisms underlying variations in surgical mortality

Overall, care intensity, which has been implicated in rising healthcare costs, explained little about differences in post-operative outcomes, which has important implications for understanding how resources and effort are related to patient benefit. 

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