October 2013 Volume 1, Issue 2
One of the things that's most exciting and most rewarding about working at a major academic medical center like Boston Medical Center (BMC) is all of the different ways that our clinicians and scientists work to discover, develop and implement innovative new approaches to health care. Our researchers develop new treatments and cures, we find new ways to teach tomorrow's physicians, we test and deploy new techniques to improve patient safety, and we refine new models of care delivery that are better for our patients' health, and also use scarce resources more efficiently.
In this issue of BMC Innovations, you'll read about some great examples of all of these efforts: our Center for Regenerative Medicine scientists and the novel work they are doing with stem cells to tackle lung disease; our Project RED, which is a national model for reducing unnecessary hospital admissions and was just awarded the prestigious Drucker Prize; patient safety innovations that are combating alarm fatigue and breaking new ground in simulation training; and new ways to teach physicians-in-training to prepare them to effectively manage the range of factors affecting their patients' health.
All of this work is what we mean when we talk about delivering Exceptional Care without Exception. I hope you'll enjoy learning more about it.
Boston Medical Center has received the prestigious Peter F. Drucker Award for Nonprofit Innovation. The judges recognized BMC’s efforts to ease patients’ transitions from hospital to home through Project RED (Re-Engineered Discharge), a program created by Brian Jack, MD, chief and chair of BMC Family Medicine, and his team.
Reducing hospital readmissions is a national priority in the effort to shrink health costs and improve care. As many as 20 percent of Medicare patients are readmitted to the hospital within 30 days of discharge, accounting for an estimated $17 billion annually in Medicare spending, and another $17 billion in non-Medicare spending. Project RED, a step-by-step discharge solution that has proven to reduce readmissions, is considered a national model, with hundreds of hospitals in the U.S. and more in 11 countries worldwide currently using the program.
The Drucker Award is given annually to a nonprofit organization that demonstrates management icon Peter Drucker’s definition of innovation: change that creates a new dimension of performance. This year a record 864 nominations were submitted from nonprofit enterprises in 49 states and the District of Columbia, and BMC emerged the winner.
Project RED launched in 2003 with the goal of discharging patients in a way that promotes patient safety and reduces readmission rates. The team developed and tested 11 components that define a high-quality hospital discharge. A nurse or a computer-based avatar named “Louise,” a virtual patient advocate, works one-on-one with patients while they are in the hospital to deliver the components of the Project RED program. Each patient receives an individualized, easy to understand color booklet that contains information on how to care for themselves once back in their homes. Included in the booklet is information on medications, a color coded calendar of upcoming appointments and tests, an illustrated description of the discharge diagnosis and an explanation of what to do if a problem arises. Together these tools help patients navigate the time period between the hospital discharge and the first outpatient doctor visit, the interval where poor communication and inadequate information can trigger new medical problems and hospital readmissions.
Proof of Project RED’s efficacy first emerged in a trial performed in 2009 with 749 patients. The study found a 30 percent lower rate of hospital utilization in the RED intervention group compared with usual rates within 30 days of discharge. One readmission or emergency department visit was prevented for every seven participants who received the intervention. Beyond this clear benefit to the patients themselves, costs among the RED intervention group were nearly 34 percent lower.
BMC received high praise from Rick Wartzman, Executive Director of the Drucker Institute. “Among the things that most impressed the judges was the effectiveness of the discharge booklet,” he said. “One of Peter Drucker’s core principles was that ‘innovations have to be handled by ordinary human beings. … Anything too clever, whether in design or execution, is almost bound to fail.’ Boston Medical Center has captured this idea perfectly with the simple elegance of its innovation and its impressive results.”
Project RED has been so successful at preventing readmissions in the general patient population that new program enhancements are being developed for patient specific populations, for example patients suffering from depression. Among the many federal and other health care agencies promoting the benefits of Project RED are the Agency for Healthcare Research and Quality, the nation's leading federal agency for research on health care quality, costs, outcomes and patient safety; the Joint Commission; and the Centers for Medicare & Medicaid Services (CMS).
“Project RED is an example of the creative and innovative work we do at BMC to provide safe, effective care to the whole patient. We are honored to have our work to decrease hospital readmissions recognized by the Drucker Institute,” said Kate Walsh, BMC President and CEO.
For the 24 million Americans living with impaired lung function from diseases such as asthma, chronic obstructive pulmonary disease or pulmonary fibrosis, having their damaged lung tissue restored to normal function would be considered a miracle.
Researchers at the Center for Regenerative Medicine (CReM), a collaborative effort between Boston Medical Center and Boston University, are working to make that miracle happen.
“From emphysema and asthma to lung cancer, diseases of the lung cause a tremendous burden of human suffering and health care costs in the U.S. today,” says CReM Co-director Darrell Kotton, MD, a physician in the department of Pulmonary, Allergy, Sleep, and Critical Care Medicine at BMC, who also serves as Professor of Medicine and Pathology at BU School of Medicine. “Unfortunately, treatments for many of these diseases are inadequate.”
The Center’s work includes a focus on patients whose lungs do not heal effectively due to disease and who usually require intensive treatments, lengthy hospital stays, or even the daily use of supplemental oxygen to stay alive. The CReM team generates stem cells from these patients through a technology called reprogramming, where they take a small sample of skin or blood from these individuals and reprogram these cells into “induced pluripotent stem (iPS) cells,” which function similarly to embryonic stem cells.
“By developing the methods needed to coax those stem cells into new lung cells, we can use them to model the patient’s disease,” says Kotton. “Because each patient’s stem cells are unique, we can also use these cells to develop individualized treatments for each patient in the future. One day, we even hope to engineer new bioartificial lungs from these cells."
CReM scientists have already defined the steps required to cure some lung diseases resulting from inherited gene mutations. Using a blood sample from a patient with one of these diseases,--cystic fibrosis, for example--the CReM team reprograms the sample into iPS cells employing a stem cell cassette they developed. Next, the team performs “gene editing,” a technique whereby the disease-causing gene mutation in those cells is changed back to normal. These “gene-corrected” stem cells are then exposed to certain proteins or growth factors, akin to following a recipe. The cells slowly differentiate into lung cells that are used to better understand a patient’s disease, screen drugs that might work in that particular patient or build new function lung tissue for the patient.
Much of CReM’s current work focuses on making these steps routine and affordable so that one day these lung diseases, which are currently incurable, become a thing of the past.
The team also has created a disease-specific stem cell bank for a variety of inherited lung ailments from cystic fibrosis to sickle cell anemia. The stem cell bank, which holds 100 lung-disease specific stem cell lines, is paving the way for other researchers to start exploring the use of stem cells as a viable treatment option. Most importantly, the CReM’s “open-source” approach to biological research means the databases, knowledge and any tools or stem cells generated from the Center’s studies can be shared with other scientists without restriction or exclusivity and are free of charge.
“We believe this type of sharing is the quickest and most effective way to develop novel therapies for future patients,” says Kotton.
Hospitals around the country are grappling with the issue of alarm fatigue. The concern is that the constant noise of equipment alarms on hospital inpatient floors is so overwhelming that nurses can become desensitized, thereby creating potential patient safety risks. This issue is so pervasive that the Joint Commission--the accrediting body for hospitals nationwide--is implementing a new national standard aimed at reducing alarm fatigue.
BMC is tackling the issue head on, where a multidisciplinary team of BMC physicians, nurses and clinical engineers has designed a new approach to increase patient safety by reducing the number of clinically insignificant alarms. Their work is already getting national attention.
The approach was piloted on a unit that cares for cardiac patients and uses telemetry equipment to monitor heart rate, blood pressure, oxygen level and other vital signs. The alarm noise on the unit was constant. Many of the alarms indicated clinically insignificant events that required no action by staff, yet they competed with alarms indicating life-threatening conditions like critical heart rhythms.
“The warning alarms for clinically insignificant events were constantly going off and creating unnecessary background noise, causing us to struggle with alarm fatigue,” says Deborah Whalen, NP, BMC Clinical Service Manager, Cardiology.
The team reviewed alarm data and developed a list of safe changes that would decrease the total number of alarms, while still ensuring that alarms continued for all events that required immediate attention.
During the six-week pilot, the number of alarms dropped from 87,823 to 9,967 per week; a stunning 89 percent decrease in audible alarms. Patient satisfaction rose. Staff satisfaction increased, too, with many nurses remarking on the quietness of the unit and noting that they could spend more time caring for patients than answering clinically insignificant alarms. Physicians indicated that patient alarm histories now were more meaningful and there was unanimous agreement that care was safer and better. The results were so successful that the program has been implemented in all inpatient adult general medical surgical units at BMC.
“We observed that while the number of alerts dropped drastically, we also had greater response to alerts because those that sounded were all actionable, and now the staff were keenly listening for alarms,” says James Piepenbrink, director of the department of clinical Engineering at BMC.
Meanwhile, the novel approach of the pilot and the significant improvement in both patient care and patient and staff satisfaction is proving of interest to care providers nationwide, and in May, the BMC team presented their work in a Joint Commission webinar viewed by more than 1000 health care institutions with more than 5000 participants.
The mannequin, representing an 89-year-old woman, is lying on a stretcher in the preoperative area prior to surgical repair of a hip fracture. The anesthesia resident and preoperative nurse are conducting their final checks when the mannequin says, "I can't breathe." The “patient’s” heart rate more than doubles and her blood pressure drops dramatically. The resident and nurse must now quickly determine what has happened and how to respond.
The next 10 minutes are critical. As a simulation trainer watches through a one-way window, the nurse and resident respond to the patient’s severe drug reaction and cardiac arrest. For the participants, the scenario feels like a real emergency.
Welcome to BMC’s Alan D. Solomont and Susan Lewis Solomont Clinical Simulation and Nursing Education Center, where caregivers use computer-controlled equipment to develop and refine skills, learn new procedures and treatment protocols before using them on actual patients, and practice communication skills with their team. After rehearsing a scenario or procedure, the team debriefs to review their work and evaluate their communications under stress, while learning strategies to improve their care delivery with patients and families in high-risk scenarios and critical situations.
The center, named in honor of former vice chair of the BMC Board of Trustees Alan Solomont and his wife Susan, uses mannequins programmed with pre-defined scenarios and provides immersive experiential learning techniques for every BMC employee involved in patient care. This makes BMC the only medical center in Boston to run team simulation training that includes all of the hospital’s doctors, nurses, residents and other front-line patient care providers. Since the center opened in March 2012 more than 4,500 medical staff, including physicians, residents, nurses and other caregivers have rotated through the center to complete more than 20,000 hours of training.
“The experience is as real as it gets,” says Keith Lewis, RPh, MD, Chair, Anesthesiology and a driving force behind the Center’s creation.
“Simulation is not a technology, but a technique. It allows you to see the roles of various caregivers, prevent errors and problems before they occur, and define how to achieve the best possible outcome.
“This is transforming the way we take care of our patients at BMC,” adds Lewis. “Simulation at BMC prepares our entire staff to provide care as a team and not as individual providers. Practicing techniques and protocols, while working together in teams of various specialties, improves communication and facilitates effective handoffs of critical information. We want the best possible teams in every real situation, no matter how high pressure. The result is fewer medical errors, which typically come from lapses in communication, which helps us to continue to be a leader in patient safety.”
The center’s reach will broaden as simulation training is extended to additional staff roles, like pharmacy.
“Unlike most centers, everyone who works at BMC will touch our simulation center in some way as part of their employment at BMC,” said Lewis. “This state-of-the-art center is beginning to make simulation training an integral part of the BMC culture.”
Exemplifying the innovative programs and creative solutions that help meet the medical, psychological and daily life needs of its patients, four Boston Medical Center staff members recently were named Champions in Health Care by the Boston Business Journal (BBJ).
Every year in late June, hundreds of medical residents flock to new cities and unfamiliar hospitals to begin years of training in their medical specialty.
At Boston Medical Center, orientation for pediatric residents has a unique feature. They participate in a hands-on Poverty Simulation exercise and through role playing gain insight into the particular needs of low income patients.
For most of them, these are lessons that will last a lifetime. One in eight Americans has an income below the poverty level, and one in five children in America live in poverty. With millions of low income Americans getting better access to health care for the first time under national health care reform, tomorrow’s doctors are all the more likely to find themselves caring for underserved patients. The socio-economic issues these patients face can be just as important to their health as their medications and treatment.
“To competently treat our patients, we need to understand where and how they live and what their challenges are. The simulation shows that zip code matters as much as genetic code when treating patients,” says Megan Sandel, MD, associate professor of pediatrics and environmental health.
“People have described poverty as choosing the lesser of two evils. You’re faced with having bad choices and really bad choices, such as whether to spend your money on a prescription medication or food.”
At this year’s simulation session, 35 pediatric residents played the roles of father, mother, grandparent or child facing challenges typical to those living below the poverty line. Strapped for time and money, participants were forced to make the tough decisions their low income patients make every day.
The point of the exercise was soon made clear: No matter how hard you tried, it was all but impossible to overcome multiple obstacles.
”You learned quickly you couldn’t outsmart your way out of a problem; you just didn’t have enough resources,” said one participant. “I quickly came to the realization that staying afloat wasn’t even possible and that I had to focus on minimizing losses as opposed to even attempting to stay above water,” said another.
“This simulation teaches the residents something that medical school may have never covered. Learning to take into account outside factors in their patients’ lives will make them better doctors and help them to provide appropriate and comprehensive care for the patients who need the most help,” says Robert Vinci, MD, program director of the Boston Combined Residency Program, chief of pediatrics at BMC and the Joel and Barbara Alpert Professor and Chair of Pediatrics Chair at BUSM.