Inpatient Practice

Variability Creates Vulnerability

As I mentioned in a previous post, we just had our every-3-year JCAHO site survey. One of the surveyors made a comment that “variability creates vulnerability” and that phrase really stuck with me. So what does this mean? Let me give you an example. If you get on a plane, the pilot is going to go through a series of pre-flight checks and the flight attendants are going to give you a short speech about how to fasten your seatbelt and what do do in the event of a water landing. I’ve heard it dozens of time from dozens of flight attendants and it is always the same. I’ve also flown with dozens of pilots and each time, the pilot’s check list is also the same.

Not everything in the hospital can be standardized but the more you can reduce variability in practice, the less variability in outcome that you will have. Let me give you three examples.

The best outcome in CPR happens if you do chest compressions 100-120 times per minute. In order to ensure that this happens, our doctors and nurses have to go through BLS (basic life support) or ACLS (advanced cardiac life support) every 2 years. However, in the excitement of a true cardiac arrest, it can be hard to avoid going either too fast or too slow. At our medical center, we have recently started to use devices attached to the patient during CPR so we can analyze the compression rate during the code after the fact. When we first started auditing codes, I was surprised how commonly the chest compression rate either exceeded 120 or fell below 100. It turns out that this is pretty common at every hospital in the world – one’s sense of time becomes very altered when one’s adrenal glands are pumping out adrenaline at an ounce a minute during a cardiac arrest situation. We found 3 strategies to ensure correct timing of compressions – 2 that are expensive and 1 that is cheap. There are now automatic CPR compression devices that will compress the chest at a set rate and these are pretty fool-proof; we have one of these in our ER. The newer generation of the CPR monitoring devices don’t just record the compression rate but they can give a real-time read-out of compression rate during CPR. The least expensive option is to down-load a free metronome app to your smartphone and set it at 110 beats a minute and then turn it on during CPR to synchronize your chest compressions.

Our hospitalists are expected to place central venous catheters (“central lines”) and most of them learn how to do it during their residency. But there can be a lot of variability of the quality of training from one residency to another and hospitals will use different central line kits with different supplies in those kits. So 2 new hospitalists may use very different technique to put a central line into the same right internal jugular vein. To solve this, we developed a checklist for each of the steps that we expect during a central line placement and we have our hospitalists get proctored placing central lines during their first 6 months of employment to be sure that no matter where and how they were trained in central line placement, that they place it using the same procedural steps at our hospital.

Making sure you have the correct patient in your operating room and that you perform that operation on the correct anatomic part of that patient seems like a pretty straight-forward thing but every week in the U.S., there is a wrong-site surgery. Imagine waking up after anesthesia to find out that your good hip just got replaced instead of your bad hip or that you got your gallbladder taken out rather than your appendix. One way to prevent this is the “time-out” where everyone involved in the procedure stops what they are doing and confirms the patient, the sedation plan, the anatomic location, the specific procedure, etc. But time-outs only work if everyone is paying attention and you don’t miss any steps in the time-out. Therefore, the time-out should be scripted and just as predictable as the flight attendants’ pre-flight speech, no matter if you are in an OR or an endoscopy suite and no matter who is assisting during the procedure.

You can’t standardize everything in your hospital but you can standardize a lot of things. So look around you and see what you can do to reduce variability in order to reduce your vulnerability to bad outcomes.

September 13, 2016

By James Allen, MD

I am a Professor Emeritus of Internal Medicine at the Ohio State University and former Medical Director of Ohio State University East Hospital

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