Learning healthcare: bringing 20 years of patient safety progress to COVID-19 at HCA Healthcare

KEY TAKEAWAYS:

1. Patient safety and quality are responsibilities, and not achieved by accident. At HCA Healthcare, we engineer them into our health system by design.
2. This is a defining moment: We can apply accelerated learnings from COVID-19 to improve quality and safety of healthcare in the next 20 years.
3. The need, the goal and the expectation is to provide the highest level of safe, quality care for every patient, every time.

In a challenge like no other – the COVID-19 pandemic – HCA Healthcare accelerated learning to support our healthcare workers in their high calling to deliver safe, high-quality and equitable care. Our long-term focus on patient safety and quality as a Learning Health System has driven us to operate and think differently throughout the coronavirus crisis, contributing to a 28% improvement in the survival rates of COVID-19 patients.

In celebration of our care providers and National Patient Safety Awareness Week 2021, Dr. Jonathan Perlin, president, clinical operations group and chief medical officer at HCA Healthcare, delivered the opening keynote at Modern Healthcare’s recent Patient Safety & Quality Virtual Briefing. Discussing key advancements and continuing challenges across the healthcare industry, Dr. Perlin honed in on how HCA Healthcare engineers patient safety and quality into our care processes. (Watch Dr. Perlin’s keynote here).

Without a doubt, any success we have had in managing and improving care for COVID-19 at HCA Healthcare would not have been possible without the resilience of frontline clinicians. Dr. Perlin rooted the keynote with a message of gratitude: “I join the leadership team at HCA Healthcare in thanking the frontline care providers – the heroes who’ve gone in to the battle against COVID each and every day – and are winning. Thank you for not only providing care in difficult times, but still doing everything you possibly can to advance safety, quality and equity.”

The 20-year evolution of modern safety and quality initiatives

The landmark 1999 report “To Err Is Human: Building a Safer Health System,” issued by the Institute of Medicine (IOM), suggested that up to 98,000 Americans die annually as a result of medical errors. The report sent shockwaves across the healthcare industry and country, and set forth a national agenda for healthcare institutions to break the silence surrounding such errors and to implement changes that would promote a culture of safety.

In a follow up report, IOM’s “Crossing the Quality Chasm” made an urgent call for fundamental change to close the quality gap, including a sweeping redesign of the American healthcare system.

“The care that we desired, was care that was Safe, care that was Timely, that was Equitable, that was Effective, that was Efficient and Patient-centered. Some of us used the acronym STEEEP to embrace these characteristics,” recalls Dr. Perlin.  “We always thought of safety as foundational.”

Now, more than 20 years later, we still have opportunity to continuously improve healthcare safety and delivery.

“We have to look more closely at equity as really the ultimate foundation on which we aspire to better attributes of care, including consistent safety and quality. Equity is fundamentally a safety problem.”

Dr. Jonathan Perlin

Addressing those who may claim that not enough progress has been made over the past 20 years, Dr. Perlin looks at it as a glass half full. “I think there’s a tremendous amount that’s been accomplished, and I want to thank all of my colleagues throughout healthcare and throughout the policy world who’ve helped to move the patient safety agenda forward.”

“So why do I think the glass is half full? Why am I not of the camp that that nothing has occurred in the last 20 years? Because I don’t believe the evidence would support that,” says Dr. Perlin. “Things have changed radically from 20 years ago and when I was a trainee.”

Quality measurement today is part of the national vocabulary. Dr. Perlin explains that, “bad outcomes today are not dismissed as just ‘bad luck’. We look at what the mechanisms are that lead to a particular outcome, good or bad, seek to understand that, and seek to make changes that lead to ‘good luck.’ And by good luck – I mean the consistent high-quality, reliable outcomes that your patient, my patient, your family, my family, your community, my community deserves.”

A number of important organizations have grown up around the patient safety movement:

• The Agency for Healthcare Research and Quality (AHRQ) – established 1989
• The National Quality Forum (NQF) – established 1990
• The National Committee for Quality Assurance (NCQA) – established 1990
• The Institute for Healthcare Improvement (IHI) – established 1991
• The National Patient Safety Foundation – established 1997
• The National Quality Forum – established 1999

All of these entities are forces in the policy environment that advance safety and quality. “It’s impossible to work in healthcare without appreciation for the extent of the federal interest in performance transparency. Whether it’s the Hospital Compare website, the Hospital Quality Improvement Program, the Hospital Readmissions Reduction Program, HCAHPS Patient Experience, incentive payments for physician improvement or alternative payment models, all of these entities put together the numerator terms (the outcomes, quality and safety) in relation to the cost of care – supporting a drive toward value as a motivator toward the attributes of care that we all want,” said Dr. Perlin.

Those ratings are endorsed by third parties entities like the National Committee for Quality Assurance (NCQA) and HEDIS Measures, which are broadcast through Leapfrog, Consumer Reports, U.S. News & World Report, Healthgrades and IBM Watson.

“The most compelling message for the last 20 years is that improvement isn’t impossible. The message is that improvement is very possible and it can occur at a number of scales.”

Dr. Jonathan Perlin

Continuing breaches in patient safety

As chair of the National Quality Forum, Dr. Perlin called upon healthcare leaders everywhere to chart the path for improving the quality of care in America for every person, in every community.

One recent study claimed that 250,000 people in the United States die every year because of medical misadventures, including healthcare-associated infections, making it the third leading cause of death after heart disease and cancer.

Dr. Perlin shares that harm may take a number of different forms, and with COVID-19, “The landscape has certainly changed in the last year, and that’s the burden of the pandemic,” he said.

As we arrive at the anniversary of one year living with COVID-19, we’ve crossed a grim milestone of half a million – 500,000 – deaths attributed to COVID-19 in the United States. “And those are only the deaths that we know are related to COVID-19,” Dr. Perlin details. “When we think about these number of deaths, I think we owe ourselves, our country, our world, our humanity the humility to look back and ask the questions, ‘What could we have done differently? What lessons from patient safety might’ve changed outcomes?’”

The National Academy of Medicine and The National Quality Forum have put forth agendas on safety and quality that address the nation’s biggest healthcare challenges, many of which converge with HCA Healthcare clinical strategic priorities.

NAM details the grand challenges in healthcare as:

1. Early childhood and maternal health
2. Mental health and addiction
3. Better health for older adults
4. Infectious disease threats
5. Health equity

NQF builds upon this list outlining notable challenges in:

1. Measure architecture
2. Health equity
3. Patient and family engagement
4. Value-based care
5. Digital health
6. Quality gaps

In his keynote, Dr. Perlin offers insight into HCA Healthcare’s key quality and safety initiatives as a Learning Health System to improve maternal health, address infectious disease quality gaps, and ensure health equity.

“The privilege of scale isn’t being large, it’s accelerating learning. And accelerated learning is what we need to advance the patient safety agenda.”

Dr. Jonathan Perlin

HCA Healthcare is comprised of 185 hospitals and 2,000 sites of care, 275,000 colleagues and 47,000 active and affiliated physicians.* We have the privilege of over 32 million annual patient encounters that allow us to study vast amounts of patient data, learn rapidly, and in the process partner with others to advance and improve the entire healthcare system.

We’re currently partnering with public, private and academic institutions to better understand COVID-19, using data from our treatment of 122,000 COVID-19 inpatients in 2020, more than any other health system in the country.

Our scale also enables us to accelerate learning in a very important and immediately generalizable manner. “HCA Healthcare has a variety of sites of care that range from community hospitals to the most sophisticated medical centers, providing tertiary and quaternary care, as well as teaching for medical residents, nurses and others. What we learn generalizes broadly. We believe this because the population within HCA Healthcare is not just as diverse as the rest of the U.S. population, it’s actually more heterogeneous,” explains Dr. Perlin.

Changing the way the world thinks about maternal safety

Our network of hospitals welcomes more babies than any other U.S. healthcare provider in the country — more than 215,000 babies were delivered in 2020. And, for two decades, HCA Healthcare has been committed to improving maternal outcomes. We are leading the nation in perinatal patient safety practice by significantly lowering mortality rates, addressing racial disparities and discovering scientific breakthroughs that have paved the way for a healthier future.

In 1999, HCA Healthcare funded the Perinatal Risk Management Initiative, which aimed to identify and evaluate adverse maternal and fetal outcomes. This initiative led to a partnership with the March of Dimes in which HCA Healthcare conducted a landmark study of non-medically necessary deliveries prior to 39 weeks gestation. Using data from 27 hospitals and 18,000 deliveries over three months, HCA Healthcare found increased risk of illness for infants delivered at 37 and 38 weeks, compared to 39 weeks or later.

The study prompted HCA Healthcare to create and implement its evidence-based perinatal protocols in 2003, which included prohibiting elective delivery prior to 39 weeks across all HCA Healthcare facilities. This best practice has been adopted worldwide as a standard of care, including in non-HCA Healthcare hospitals. The research was also a cornerstone of the Centers for Medicare and Medicaid Services’ Strong Start for Mothers and Newborns initiative.

HCA Healthcare perinatal safety standards have been promoted by organizations like The American College of Obstetricians and Gynecologists (ACOG), The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) and March of Dimes (MOD).

Maternal mortality in the United States is a public health crisis. More women in America die from pregnancy-related complications than in any other developed country in the world.

The problem is so pronounced that USA Today, in an investigative series entitled “Deadly Deliveries,” called the United States the “most dangerous place in the developed world” to give birth.

Utilizing our scale, HCA Healthcare employed our rich data to identify perinatal risks and develop solutions to combat these risks. We found that the top three causes of maternal mortality were preeclampsia, deep vein thrombosis (DVT) and pulmonary embolism (PE) in C-Section deliveries, and post-partum hemorrhage.

Preeclampsia

• HCA Healthcare developed initial hypertensive crisis medication algorithms, now ACOG published standards of care
• Progressing into hypertensive crisis demands timely activation to prevent severe morbidity and mortality

DVT/PE in C-Section Deliveries

• HCA Healthcare implemented prophylactic utilization of sequential compression devices on all C-section patients after 2008 mortality review to mitigate venous thromboembolism (VTE) risks
• HCA Healthcare became NQF measure steward in 2013 when the evidence indicated practice made significant impact

Post-partum hemorrhage

• HCA Healthcare began work in 2008, updated with algorithm in 2018
• Hemorrhage risk assessments completed on all patients
• Hemorrhage drills in all facilities in 2018 and ongoing

Infection (and drug-resistance) prevention

For more than a decade, HCA Healthcare has been a leader in the national effort to reduce healthcare-associated infections and provide a safer hospital environment for our patients.

So when the medical community was looking for new ways to prevent deadly MRSA infections, we implemented a study involving nearly 75,000 patients across 43 of our hospitals. In a study published by the New England Journal of Medicine in 2013, we shared a new standard that has significantly reduced MRSA infections in our facilities and around the world.

The REDUCE MRSA study, conducted in conjunction with investigators at Harvard University and several other academic institutions, as well as programs at the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, and the Centers for Disease Control and Prevention (CDC), found that using antimicrobial soap and ointment to decolonize all ICU patients reduced bloodstream infections by 44% and MRSA by 37%. The CDC has since adopted this practice.

While the REDUCE MRSA trial focused on ICU patients, the follow-up ABATE Infection Trial, published in 2019 by The Lancet, focused on patients outside the ICU. Conducted exclusively at affiliate hospitals over a 21-month period, the study identifies that a nasal infection-control technique and patient bathing with chlorhexidine drastically reduces bloodstream infections in non-ICU patients with devices by 31%, and reduces infection with antibiotic-resistant bacteria by 40%.

Non-ICU patients with devices – such as central venous catheters, midline catheters and lumber drains – saw great benefit from chlorhexidine bathing and nasal application of the antibiotic mupirocin.

The ABATE trial was conducted at 53 HCA Healthcare hospitals, engaging 667,000 patients in 194 non-ICU units.

Predictive Healthcare: Sepsis Prediction & Optimization of Therapy (SPOT)

One great example of how we deliver safe, high-quality care is with our Sepsis Prediction and Optimization of Therapy (SPOT) tool, an algorithm-based alerting system for the early detection of sepsis. Approximately 270,000 Americans die from sepsis each year, making it deadlier than breast cancer, prostate cancer and AIDS combined. The symptoms of sepsis are similar to those of many other illnesses, making diagnosis challenging. Studies have shown that early recognition followed by aggressive treatment increases chances of patient survival significantly.

Our clinical and data science experts created SPOT using data from millions of hospitalizations. SPOT continuously monitors vital signs, lab results, nursing reports and other data that can inform treatment, and recognizes critical data points in patients’ electronic health records to quickly alert care teams to important, often subtle, changes in a patient’s condition so they can take appropriate action.

Accelerating learning during COVID-19 and beyond

Building on the capabilities of the SPOT technology, HCA Healthcare’s data science team developed the powerful and flexible NATE (Next-gen Analytics for Treatment and Efficiency) platform. So, when our teams needed new tools to respond to COVID-19, we were able to deliver.

NATE delivers data-rich views of a facility using real-time analytics and machine learning solutions. With an urgent need to treat acute respiratory distress syndrome (ARDS) we developed an overlay for NATE named C-ARDS (COVID ARDS). C-ARDS brings real-time analytic insights to assist clinicians in applying the appropriate clinical protocol for mechanically ventilated patients, specifically COVID-19 patients.

The impact of C-ARDS was tremendous on several fronts. For physicians and care teams, C-ARDS helped illustrate the effectiveness of the treatment for ARDS, which had been known for years, and these insights helped decrease anxiety within the physician and nursing communities. Additionally, C-ARDS enabled communication and collaboration between respiratory therapists, intensivists, and nurses to support high quality patient care. The ability to monitor closely key data points for COVID-19 patients resulted in decreasing their lengths of stay and helping to increase survival for COVID-19 in our facilities by 28%.

Overcoming the pandemic will not occur easily or all at once. We will need to continue to build, adjust and apply lessons learned in patient safety, including contemplating equity as a fundamental safety issue, to ensure healthier tomorrows for our patients. As we move beyond this pandemic, we will be entering a new world, and we have an opportunity and the obligation to do better, together.

*Statistics current as of Dec. 31, 2020