The Big Picture

Error reduction, patient safety, risk reduction and quality improvement are hot topics of discussion in the medical community.  Commercial aviation, with all the potential risks, is classified as one of the safest industries today.  What can the medical community learn from their success?

Here is a challenge for the medical community.  Eliminate patient harm due to mechanical ventilation.  Patients are routinely harmed by the process of mechanical ventilation, an unacceptable situation.

Jean-Louis Vincent, MD, ICU Management 6:1:2006 said it best. “Over the years, healthcare services have developed a ‘cover-up‘ culture where mistakes have been hidden … However, this traditional attitude is beginning to change as we learn from other industries where great harm is possible, e.g. aviation and nuclear power, which approach the concept of safety with a no-fault or limited fault approach.“

In 1999, the American Hospital Association reported that there were somewhere between 44,000 and 98,000 deaths every year due to medical errors.  Compare this to National Transportation Safety Board statistics for 2004, where there were 11 fatalities due to commercial aviation.  Despite the recent focus safety statistics, experts assure that the health system in the United States is safe. But its safety record is a far cry from the record of the similarly complex aviation industry, which is being held up as an example for the medical community. The Institute of Medicine has stated that health care is at least a decade behind aviation in safeguarding consumers' lives and health. 

Human error is still the leading cause of accidents.  Aviation professionals receive Crew Resource Management (CRM) training, and aircraft-type specific training, conducted with advanced simulations.  The health care industry offers little, if any, of this kind of training.   The Federal Aviation Administration requires any pilot flying a turbojet aircraft to have type-specific training and certification before they may act as the pilot in command.  How many different types of medical instrumentation does the average healthcare professional come in contact with on a given day?  The Joint Commission on Accreditation of Healthcare Organizations published a Sentinel Event Alert 26.2.2002, “Root Cause Analysis of 23 deaths or injuries related to long term ventilation”, where inadequate orientation/training was found to be a factor in 87% of these cases.  The second leading factor in this study was “communication breakdown among staff members”.  These are risk issues that can improve with effective training.

Hospitals can no longer afford the costs of medical errors and increased lengths of stay due to improper actions by staff.

The Future for the ICU Ventilator:

Safety is predicated upon three basic elements: the operator, the machine and the environment.  If any one of these elements is weak then the entire system can fall apart. 

The Operator (pilot or clinician) needs to be in both physical and mental condition to perform safety.  Errors are much more likely when the Operator has worked long hours or needs to function with a team that has little standardization.  Operators must maintain, what pilots refer to as “situational awareness” (SA).  Situational awareness is defined as, “the degree of accuracy by which one’s perception of his current environment mirrors reality”.  Manipulation of the flight controls is often the easiest aspect of good piloting skills.  Getting a pilot to the point where they exhibit a high degree of situational awareness skills and can anticipate what will happen next is what separates the average pilots from those most able to conduct safe flight operations under all conditions.  This also applies to health care within the ICU.  The clinician must keep the big picture of appropriate care, patient safety, and effectiveness while responding correctly to minor deviations.  Those teams, who do this with consistency, generate the best patient outcomes.

There have been plenty of aviation accidents that could have been prevented if the cockpit crew had communicated more effectively.  In fact, an NTSB study of 37 accidents found that 31 could have been prevented if one or more crewmembers had spoken up about errors and/or situational awareness concerns.  This holds true in clinical practice as well.  This is exactly why the Joint Commission listed “communication breakdown” as the number two reason for ventilator injuries or deaths in the report cited earlier.

The second element to safety is the Machine (aircraft, ventilator or other instrumentation).  Modern mechanical ventilators are all very manual devices.  Equipment is designed to protect the patient in the event of a failure.  But Ventilator Induced Lung Injury does not normally result from an equipment failure, but rather from incorrect ventilator settings that were set by a human operator.  The modern mechanical ventilator, with rare exception is like having the pilot flying the airliner by hand all the time, in all kinds of weather.  Not the best prescription for safety. 

Pilots have one huge advantage over the clinician in the ICU.  They rely on cockpit automation to maintain situational awareness and divide duties between the team.  The autopilot has dramatically improved the safety of airline travel.  We are just now seeing independent thinking medical device companies offering “autopilots” on their medical devices as well. 

Mechanical ventilators, that do not employ advanced technology like an autopilot, offer almost no safety net for the clinician.  It is impossible for a clinician to be at the bedside all the time.  There are common problems with mechanical ventilators however that the industry is ignoring.  There are too many modes.  Clinicians are rarely experts at all the modes on modern ventilators, not to mention the differences between how these modes operate between various models of ventilators.  There is far too much complexity in the operation of a ventilator.  There is a multitude of controls that all must be set by the clinician often using “best clinical judgment”.  These settings are static, while the patient and the environment are dynamic. 

Aircraft instrumentation has come a long way and safety has improved in line with those advances.  The airliner cockpit used to be filled with dials and gauges, and progressed to digital displays.  But, because situational awareness is so critical to the safety of the passengers on board a modern airliner, the aviation community is always exploring new ways to help pilots maintain it.  The modern “glass cockpit” uses pictures rather than dials and numbers to help pilots make intelligent decisions. Such displays can put contingency plans at a pilot’s fingertips, while greatly simplifying many of the aspects of the flight.  In stressful circumstances, the cockpit offers “intelligent” displays that all the pilot to focus only on what is important to the task at hand.

We can see evidence that the medical community is venturing down this pathway as well, but with mixed results.  Fancy “boxes” and displays only can help the clinician if they know how to use them effectively.  Little time is spent with the clinician in training on this area of operation of each particular device.  High tech toys can sometimes lull pilots and clinicians into losing situational awareness.  Serious concentration on these displays can distract from other required tasks.  The respiratory therapist or physician will agree that waveform interpretation is not a simple task.  The latest trend in the presentation of ventilator data is to provide an easy to understand picture of patient status rather than numbers and waveforms, this is known as the “ventilation cockpit”. 

Imagine a completely modern graphical user interface that provides what a pilot would call, an “artificial horizon”.  Imagine being able to see what is actually happening to the lungs.  Soon a clinician will be able to actually see a patient weaning from the ventilator, not by studying a list of data for various monitored parameters but with easy to understand graphics that interpret the data based upon established clinical principles.  One researcher, involved in this project said, “A picture is worth a thousand numbers.”

Training programs would make extensive use of advanced simulators so that scenario based training could reinforce the critical care protocols. 

The third key factor related to safety is the Environment (the weather or the patient and facility).  The modern ICU is a flurry of activity.  The patient is dynamic.  The patient care team is diverse, dynamic and not allows working as a team.  The clinician is presented with a situation that is difficult or impossible to control.  Pilots learn to develop contingency plans to manage elements beyond their control.  The clinician needs better tools to not only let them manage what is happening real time, but all them to anticipate the elements that are not in their control.  The goal is to anticipate not simply react.  Here again the “autopilot” can reduce workload so that clinicians can focus on the environment and most importantly, the patient safety and quality of care.

Risk managers and clinical teams have realized that ventilating patients in the ICU without these new technologies is bad for the patient and bad for business.  The new standard of care in mechanical ventilation is here.  Are you ready to make those changes for patient safety and quality of care that our patients deserve?