Interventions gaining ground as next phase for patient safety research

Nancy C. Elder, MD, associate professor at the University of Cincinnati's Dept. of Family Medicine, said she turned down an invitation to speak on evidence-based patient-safety interventions last year because there wasn't enough to discuss.

Now, however, her prediction that interventions would be the next phase of patient safety research appears to be coming true. One sign: A report on evidence-based guidelines for preventing ventilator-associated pneumonia published in the Aug. 17 Annals of Internal Medicine. Another example experts cite is research at Boston's Brigham and Women's Hospital on computerized physician order entry systems designed to protect patients and reduce redundant tests.

The interventions are not limited to hospitals. The Kentucky Medical Assn. Patient Safety Task Force has developed a test-tracking system for primary care doctors.

"I think there are other areas in patient safety where we still don't know enough to say, 'This intervention works,' " Dr. Elder said. "But the lab test process -- getting the right test done and getting the results handled properly -- that's an up-and-coming area that holds a lot of potential for improving patient health."

The KMA unveiled its test-tracking tips Aug. 14, and while they may not fit a classic definition for "evidence-based" development, Task Force Chair Greg Cooper, MD, said he believes the end result is a system that will improve quality and safety.

"We've taken the foundation from evidence-based systems that have shown to be functional and information from practical applications has been added," said Dr. Cooper, a family physician in a three-physician practice based in Cynthiana, Ky. "We didn't have to reinvent the wheel, and it was interesting to sit at the table and get input about what's worked in individual practice and what hasn't."

Some warnings

For example, the KMA strongly recommends against a standard procedure of telling patients "If you don't hear from us, your test results are fine." However, it also warns that its suggestions are not adoptable for everyone.

That was music to the ears of John Hickner, MD. "Research and experience has shown that guidelines off the shelf don't always work well and it's a lot easier to develop guidelines than to implement them," the professor of family medicine at the University of Chicago Pritzker School of Medicine said.

Nevertheless, Dr. Hickner added that it appears "everyone is starting to creep forward and make changes." He said slow progress is fine with him because the effects of safety-related changes need to be tracked for unintended consequences.

"There's danger in this sense of urgency we have as Americans where we want it done and we want it done now," he said. "That's not always the best way to go about making system improvements. There is a great danger in doing worse than we're doing. That's my own opinion based on life experience -- not on research."

Drs. Elder and Hickner said one common finding emerging from primary care patient safety research is that technology cannot solve all problems. Other research trends include refining error reporting, looking at problems with patient "hand-offs" between physicians and getting patients involved in error prevention.

Training teams, building coalitions

Lucian L. Leape, MD, patient safety pioneer and adjunct professor of health policy at the Harvard School of Public Health in Boston, said "tremendous change is afoot" and trends include systemwide team training and regional coalitions that bring competing hospitals together to reduce infections, medication errors and wrong-site surgeries.

"This is the patient safety movement," Dr. Leape said in an e-mail. He added that the struggle to find evidence that interventions work is not what's holding patient safety back.

"The problem is getting implementation of what we already know works," he said. "Take hand hygiene. What do we have to do to get that to work? We have to change the culture.

"In any case, three cheers for evidence of effectiveness -- may we see much, much more," he said. "Meanwhile, it's time to get on with doing what we already know works -- now."

The ventilator-associated pneumonia guidelines published in the Annals of Internal Medicine were developed by Canadian researchers who reviewed relevant studies conducted before April 2003 and scored identified strategies on factors such as homogeneity of results, safety, feasibility and economic issues.

Annals of Internal Medicine editor Harold C. Sox, MD, said practice guidelines have been a regular feature of the journal for 15 to 20 years, but this report took the concept in a new direction. "This one represents something different in that it is not a study about treating something, it's about trying to prevent a common complication of care," he said. "It's an application of a time-tested technique, but it may also be the start of a trend."

Getting in on an emerging trend was not the intent when the report was chosen for publication. Dr. Sox said the criteria for publishing an article are: Is it true? Is it new? Is it likely to be directly applicable to patient care? "This fits all three," he said. "We're hopeful that it's going to make a great difference."