In today’s economy and healthcare environment, most hospitals and other healthcare organizations are struggling to stay above water. All are cutting resource expenditures in one area or another. We are always concerned that such cuts may imperil patient safety. But there are numerous areas where such cuts can be undertaken while preserving patient safety and in the last few weeks there have been numerous examples.
One good example is after-hours ultrasound. Whether your organization is in an urban or a rural setting, you know that there is a shortage of ultrasound technicians. Hiring and retaining good ultrasound technicians is an uphill battle for many organizations. The biggest impediment to retaining them is the on-call schedule. Many balk at being called in at all hours of the night to do ultrasound scans, especially when such calls may take place 1-3 times each night at many hospitals. There is a very high rate of negative scans and many of those scans don’t have to be performed after-hours. In many cases, bridging therapy can be instituted overnight and the scan can be performed in the morning during usual working hours.
The University of Pittsburgh recently studied this issue (Chaer et al 2009). They developed a policy/guideline for after-hours performance of venous duplex ultrasound studies looking for DVT. A multidisciplinary group (surgery, internal medicine, emergency medicine) developed a structured algorithm using a modified Wells score and D-dimer testing. Patients who had a low probability of DVT (modified Wells score = 0 and D-dimer negative) were discharged and referred for outpatient followup the following day. Those at moderate risk (modified Wells score >1 or D-dimer positive) were treated with LMWH overnight and were scheduled for venous duplex ultrasound in the morning. For moderate- or high-risk patients in whom anticoagulation was contraindicated or declined for other reasons, the ultrasound tech was called in and the study performed. In the first year the number of after-hours ultrasound studies dropped from 59 per month to 19 per month without any clinically adverse events. There was also a substantial increase in the rate of positive after-hours studies. And job satisfaction for ultrasound techs improved significantly.
A second example is the use of daily chest x-rays, a practice commonly used in intubated, mechanically ventilated patients. A French study (Hejblum et al 2009) compared the routine daily chest x-ray strategy against an “on-demand” strategy (where chest x-rays are ordered based on clinical questions). They found that the on-demand strategy resulted in 32% fewer x-rays being done with no obvious adverse clinical consequences. Fewer x-rays should translate to lower costs, fewer x-rays of limited clinical utility, lower radiation exposure, and theoretically even less exposure to microbial pathogens on the portable x-ray equipment. Fewer portable x-rays also translates to more technician time available for imaging studies on outpatients. So hospitals really should look at their current policies (whether truly policy or just traditional practice) and see whether the on-demand approach better suits them. The authors and the accompanying editorialist appropriately note that local factors will weigh heavily into such decisions. Changes in workflow (eg. the on-demand strategy really requires early rounding daily to see whether chest x-rays are needed that day) may be necessary.
A third example is use of clinical “rules” that help guide the decisions whether to pursue imaging or not in patients seen in the emergency department. For years, we have used the Ottawa knee and ankle rules in our ED’s and seen the number of knee and ankle x-rays diminish without adversely affecting patient care. Similarly, there are several “rules” that aid the decision about performing CT scans of the head in patients with minor head trauma. Use of such rules not only saves costs but it also streamlines ED throughput and helps avoid lengthy waits by patients.
The Canadian C-spine rule was developed almost 10 years ago and during validation studies demonstrated a sensitivity for significant spinal injury of 99%. It was postulated that implementation of this clinical rule could reduce unnecessary cervical spine films by almost 50%. Now, the results of a well-done randomized trial at Canadian hospitals has been published (Stiell et al 2009). The study showed that cervical spine imaging at the intervention hospitals had a relative decrease of 12.8% whereas there was a relative increase of 12.5% at the control hospitals. The relative reduction in imaging rates was greater in community hospitals than teaching hospitals. Using fairly sophisticated methods to detect any significant missed injuries, they found no missed fractures nor adverse clinical outcomes at the intervention hospitals. Note that rates of imaging at all hospitals were considerably lower than at typical US hospitals, suggesting that many physicians in Canada may have already begun adopting the rule even before this study. Implementation of the rule was fairly simple. A one hour educational session and distribution of pocket guides, posters, and the supporting literature were used. In addition, there was the requirement that physicians complete the rule at the time the imaging requisition was submitted. (Our note: As hospitals implement computerized physician order entry or CPOE, one can easily incorporate the rule into the order entry process and provide help at ensuring the rule is interpreted correctly). Though the degree of benefit in the Canadian hospitals was modest, the opportunity in US is much higher, given the higher baseline cervical spine imaging rates in the US. Perhaps the litiginous nature of the US legal system may be preventing adoption of the Canadian C-spine rule in the US. However, if it becomes the “standard of care” there should be fewer concerns about lawsuits and less studies ordered “defensively”. Again – without compromising patient safety the opportunity from reducing unnecessary cervical spine imaging impacts not only costs but also reduces radiation dose, frees up radiology resources for other endeavors, and improves wait times in the ED.
And we still see other practices that are both costly and potentially threaten patient safety. Many hospitals still do not have automatic review of all oxygen orders (see our Patient Safety Tips of the Week for April 8, 2008 “Oxygen as a Medication” and January 27, 2009 “Oxygen Therapy: Everything You Wanted to Know and More!”. How often have you made rounds and seen patients with their oxygen face mask or nasal prongs hanging down around their neck? If they don’t need or use the oxygen, why would you put them (and the institution) at risk for adverse events such as fires. Most hospitals have now incorporated protocols in which respiratory therapy or nursing have the ability to discontinue oxygen if parameters like degree of oxygen saturation are met. But at a minimum you should have protocols and reminders that force the question be asked about continued need for oxygen at least every few days.
But there are other examples where you do not want to cut and where investment in resources may save money in the long run. Housekeeping is one of those areas. We have seen hospitals faced with budget deficits cut housekeeping staff, only to encounter increased nosocomial infection rates. Note that two of the articles in our November 2009 What’s New in the Patient Safety World column (“Ten Ways to Prevent Healthcare-Associated Infections” and “BMA: Tackling healthcare associated infections through effective policy action”) mention the need for increased attention to cleaning “near-patient high-touch” sites (eg. bed rails, bedside lockers, infusion pumps, door handles, switches, etc.). Well, another study from the UK (Dancer et al 2009) suggests that hiring an additional cleaner who focuses on these sites has the potential to save a hospital £30,000 to £70,000 ($50,000 to $116,000 US) annually even after accounting for the salary for the extra cleaner. In this study, the hospital hired an extra cleaner to perform “enhanced” cleaning (focusing on the near-patient high-touch sites) 5 days a week. Two wards were compared in a crossover design. They demonstrated a 33% reduction in microbial contamination at the hand-touch sites and a 26.6% reduction in new MRSA infections on the wards receiving the enhanced cleaning. When the enhanced cleaner crossed over to the other ward, the reduction was seen on the new ward. And both wards had clusters of new MRSA infections 2 to 4 weeks after the enhanced cleaner left both wards. Though the study makes some assumptions and has some other limitations, our guess is that there is real savings to be had with this approach.
The bottom line: in hard times think your decisions about resource reallocation through wisely. Do those that you can do without diminishing patient safety. And sometimes spending a little extra in some areas can improve both patient safety and your budget.
Chaer RA, Myers J,
Pirt D, et al. The Impact of a Systemwide Policy for
Emergent Off-Hours Venous Duplex Ultrasound Studies. Annals of Vascular Surgery 2009; Corrected Proof, 11 September 2009
Comparison of routine and on-demand prescription of chest radiographs in mechanically ventilated adults: a multicentre, cluster-randomised, two-period crossover study. The Lancet 2009; Early Online Publication, 5 November 2009
Stiell IG, Clement CM, Grimshaw J, et al. Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial. BMJ 2009;339:b4146 (Published )
Dancer SJ, White LF, Lamb J, Girvan EK, Robertson C. Measuring the effect of enhanced cleaning in a UK hospital: a prospective cross-over study. BMC Medicine 2009, 7:28 doi:10.1186/1741-7015-7-28