Johns Hopkins lab puts systems engineering to work on ICU safety

BALTIMORE  -  The Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine has partnered with the Johns Hopkins University Applied Physics Laboratory (APL) to design and deploy a set of interventions to reduce medical errors in intensive care units.

Funded by an $8.9 million grant from the Gordon and Betty Moore Foundation, the two- year project will take place at three sites: the Surgical Intensive Care Unit at Johns Hopkins Hospital (JHH); the Bayview Medical Center, a JHH-affiliated community hospital; and the University of California, San Francisco Medical Center.

Alan Ravitz, program manager for biomedical systems at APL, who is leading the lab's involvement in the initiative, says it is designed to "demonstrate that a systems approach to the management of patient care can improve both the processes of care and the outcomes of patients, and facilitate the meaningful engagement of patients and families."

Healthcare IT has improved mortality and morbidity rates in hospitals, but the increasing use of technology has also led to challenges with regard to quality and patient safety, say Johns Hopkins officials. Studies show that at least one in every five of the estimated four million patients treated in intensive care units (ICUs) every year is harmed during their hospital stay.

These adverse events range from ICU-acquired weakness and delirium to ventilator-associated infections such as pneumonia, adult respiratory distress syndrome, blood stream infections, deep vein thrombosis and pulmonary embolus.

Noting that most medical devices commonly used in ICUs  -  infusion pumps, ventilator systems, defibrillators, electrocardiogram (ECG) analyzers  -  are not integrated or interoperable, resulting in systems that do not share data or functionality across the healthcare enterprise, Ravitz says the APL team will develop a systems approach and apply systems engineering principles and best practices to improving care and reducing adverse effects.

"Healthcare technology is grossly under-engineered," said Peter Pronovost, MD, director of the Armstrong Institute. "Devices don't talk to each other, treatments are not specified and ensured, and outcomes are largely assumed rather than measured. This project will seek to change that by enlisting systems engineers to ensure patients always get the treatments they should, by engaging patients in every aspect of their care and creating a healthcare system that continuously improves."

Pronovost also recently led the Comprehensive Unit-based Safety Program (CUSP), a federal initiative that cut bloodstream infection in ICUs by 40 percent.

Carolyn M. Clancy, MD, director of the Agency for Healthcare Research and Quality, praised the results.

"CUSP shows us that with the right tools and resources, safety problems like these deadly infections can be prevented," she said.

At Johns Hopkins, for each type of harm, the lab will create an approach that incorporates three levels of theory: clinical epidemiology culture and supporting social structure, and organizational, team and human factors, officials say.

In addition to managing the project, APL  -  which will receive roughly $3.2 million of the grant  -  will lead the systems engineering component, including the incorporation of human factors engineering to ensure that technologies developed support improving patient outcomes and enhance the effectiveness and efficiency of clinicians.

APL and Johns Hopkins Medicine have collaborated on other healthcare improvement projects that employed a systems engineering approach  -  including an effort to improve the design and operations of medical treatment facilities and a safety initiative aimed at improving the safety of infusion pumps.

"Through these efforts, we've learned key lessons that we intend to apply to the patient safety ICU demonstration project," says Ravitz. "System devices need to be more tightly integrated with the larger IT enterprise and more aligned with workflow and the needs of the patient and family to reduce the risks inherent in the design of some the medical devices."

Work on the pilot is scheduled to start this fall, officials say. In addition to managing the project, APL  -  which will receive roughly $3.2 million of the grant  -  will lead the systems engineering component, including the incorporation of human factors engineering to ensure technologies developed support improving patient outcomes and enhance the effectiveness and efficiency of clinicians.