Around Opelika, AL, a city of about 26,000 an hour's drive from Montgomery, 36 people are alive today who otherwise would have died after receiving suboptimal care at East Alabama Medical Center.
That's a harsh admission. But executives with the 314-bed hospital say they know this is true because three years ago, they joined a project with 156 other health systems to share quality data for comparison. The data revealed that patient mortality rates at EAMC were higher than expected, acknowledges hospital CEO Terry Andrus.
"That was obviously something we did not want on our marquee," he says. "But working with other hospitals, we found that care of septicemia was the thing we needed to work on."
EAMC discovered what some other hospitals in the Premier Quest collaborative already knew: It needed to have the emergency department team be much more attentive to a combination of symptoms: high fever, high heart rate, mental status changes, and high blood pressure.
By the third year of the program in 2010, Andrus says, the hospital identified "36 lives [that] were saved because we took this sepsis initiative and put in this bundle. That is, 36 people that probably would otherwise have died did not die."
Premier is a quality improvement and healthcare purchasing alliance. The groups says that nationwide, 157 member hospitals saved $4.5 billion and 24,820 lives under the Quest program.
Steve Hubbard, MD, a retired thoracic surgeon who now consults on quality for the hospital, says that "Even though we had read the articles, it didn't really occur to us how important it was to get the antibiotics in within an hour or two, and we didn't understand that it was important to give enough IV fluids that certain blood levels would change or other measurements would change."
"The Quest project put us in touch with other hospitals who had successfully given a lot of IV fluids towards a targeted goal, and when we started doing that, that's when we saw our mortality rate come down," he said.
Hubbard says hospitals with low mortality rates had procedures in place so that when patients came in through the ED, they were promptly asked a series of questions. "If two or three are positive, it turns on the light bulb that this patient might have a life-threatening infection," Hubbard says.
The hospital launched an "early sepsis bundle" which includes a key ingredient, serum lactate screening.
"In the 'old days,' those same questions would have been asked, and recorded, and the patient would have waited until a physician came around to see them," Hubbard says. "And eventually they would have gotten a series of tests and then someone would say, 'Gosh, maybe this patient is infected because they have a high fever,' and the patient would have been sent to a hospital floor and gotten sicker and sicker."
Andrus estimates that even if the patient didn't die right away, he or she would be "in the hospital four or five weeks, a lot of it in the ICU. And that probably cost the healthcare system $100,000 to $150,000."
East Alabama was one of three Quest-collaborative hospitals that presented case studies of their improvement to help Premier publicize the success of the program. Other hospital systems that presented case studies about the progress they made during the three-year project were McLeod Health Regional Medical Center in Florence, SC and Inova Health of Fairfax, VA.
In addition to reductions in observed-to-expected mortality rates and costs, Premier President and CEO Susan DeVore says improvements in this Quest hospital cohort came across the board in improved patient experience scores, better compliance with evidence-based guidelines, and greater reduction in harmful events.
Compared with Medicare data for other non-Quest hospitals in the nation for 2009, Quest hospitals had a 29% lower mortality rate, Premier officials said. And compared with U.S. Bureau of Labor Statistics, Quest hospital inpatient costs rose only 2% above inflation over the 2008-2010 year period, while non-participating hospitals' costs rose 17%.
DeVore said the project realized a $1,025 decrease in the average inpatient cost per discharge compared with the baseline of the project, which equated to a 17% decrease.
The program measured 24 specific types of harmful events similar to initiatives led by the Center for Medicare and Medicaid Innovation's Partnership For Patients and the Affordable Care Act's value-based purchasing program.
Richard Bankowitz, MD, Premier's chief medical officer, says the project accepted hospitals only if they agreed to several key points:
- Senior leadership needed to pledge commitment through the process and remove barriers
- To be transparent with their data, which meant all 157 hospitals could see each others' performance
- To which measures to use and to define what success would look like
- To share best practices with each other
It wasn't easy. EAMC's Hubbard says that in talking with other hospitals, he learned some "didn't join Quest because they were afraid they would look bad on paper and didn't want anybody to know. So it was a real leap of faith by our administration to let us be a part of this. It helped physicians learn to look at results that always as good as we would like."
"Change is more difficult for some people than others, particularly if we're convinced that the way we have always done it is just fine and we don't see the needs in our own patient population, because we haven't stepped away to look at the big picture," he says.
Premier is continuing the project for another three-year period, calling it Quest 2.0, and is raising the benchmarks for many of the quality measures needing improvement. It is encouraging hospitals to sign up.