December 28, 2016
U.S.A.F. Innovation Shows Promise in Fighting Veteran Suicide and Cancer Mortality While Reducing Sepsis
The High Reliability Organization Counsel (HROC) and Sepsis Alliance are partnering to deploy the Military Acuity Model (MAM), which helps save patient lives by reducing task saturation in hospitals. Studies have shown that MAM reduces the incidents of sepsis, and public-private partnerships that implement MAM may be able to significantly lower veteran suicide and cancer mortality rates.
The High Reliability Organization Council (HROC) and Sepsis Alliance are joining forces to call for expanded deployment of a U.S. Air Force innovation called Military Acuity Model (MAM) into civilian, Veterans Administration (VA) and Military Health System (MHS) hospitals.
MAM is a data-driven early warning system designed to help patients by preventing task saturation within the hospital. The result of a public-private partnership that was awarded the Military Healthy System Innovation Award in 2013, MAM has been shown to reduce incidents of sepsis.
Initially proven at Wright-Patterson Air Force Base in helping reduce failure to rescue, or preventable deaths, by 87% through process and team changes, the MAM is credited in "force-multiplying" teams toward the treatment of veterans seeking healthcare services.
The U.S. Centers for Disease Control and Prevention (CDC), which is always exploring ways to reduce patient risks and preventable deaths, analyzed hospital discharges between 2000-2010. Over that 10-year span, the top eight deadliest diagnoses all had double-digit declines in inpatient mortality except for one: sepsis. In fact, sepsis actually had a double-digit increase during that same period of time.1
“Sepsis is the tip of the spear, and we’re racing against the clock to raise sepsis awareness and help lower sepsis mortality,” said Thomas Heymann, Executive Director of Sepsis Alliance. “The MAM is a vital tool in combatting sepsis. We believe implementation, particularly in partnerships between public and private health organizations, can lead to higher recognition of sepsis as a medical emergency, which can significantly improve patient safety.”
Past studies suggest there is a need to go beyond the four walls of the VA to engage civilian and community partners.2 Passage of the Veterans Access, Choice and Accountability Act of 2014, more commonly known as the “Choice Act,” has led to more veterans going to civilian hospitals for treatment, Yet, even with The Choice Act in place, the unacceptably high rate of suicide among veterans suggests that access to care outside the VA system afforded by The Choice Act may not be enough.
Sepsis Alliance and HROC are calling for Federal and civilian healthcare providers to partner in implementing MAM, given advantages each organization brings to the partnership. For instance, the Military and VA possess specialized knowledge and techniques that could be paired with the readily-available electronic data provided by civilian providers. Such partnerships could also include developing MAM-based cognitive resource-versus-risk models to lower suicide rates within the veteran community.
“Suicide among veterans is a FTR, similar to sepsis, as it is a preventable death where time is of the essence,” added Lieutenant Colonel Jared Mort, an expert in the MAM. “MAM can help identify specific tasks at risk of failure, further upstream, instead of waiting for a patient to become thoroughly at risk at a late stage. This includes earlier interventions addressing more comprehensive quality of life issues that would otherwise create burdens. It is these burdens that can lead to 'moments of vulnerability', or trigger events, which then have deadly consequences for our veterans and active duty servicemembers."
In a 2016 brief titled, “Facts About Veteran Suicide,” the VA estimated that sixty-five percent (65%) of veterans who commit suicide are aged 50 or higher who have not taken part in recent combat.3 MAM studies suggest that age may play a large role in these suicides, and that both physical and cognitive declines play significant roles in task saturation, creating moments of vulnerability that leave this retirement-age population more at risk of preventable death. “This is because task saturation may impair an individual's ability to overcome challenges they face,” added Lt. Col. Mort, “which can lead to two of the most significant interpersonal risk factors -- feelings of burdensomeness and hopelessness -- not frequently verbalized prior to veteran suicide.”4
In addition to task saturation, PSS may also contribute to higher suicide rates. A 2010 study published in the Journal of American Medical Association showed that PSS can increase cognitive impairment and cloud judgment, which also increases moments of vulnerability that can lead to suicide. Attacking the underlying incidents of sepsis will eliminate PSS, reducing the likelihood of these moments of vulnerability from happening in the first place.
“Without question, MAM can have a positive impact on our veterans and servicemembers, even before they begin experiencing such personal and emotional anguish,” added Lt. Col. Mort. “Based on MAM's reductions in similar preventable patient safety issues studied, HROC estimates that implementation of MAM can help reduce suicide rates by 30%, a factor which is incredibly significant.”
Cancer mortality may also benefit through greater adoption of MAM. Expansion of application of the MAM to monitor veterans fighting cancer, given their high frequency of VA or civilian hospital stays, while reducing other risks, can help hospitals lower preventable deaths in the veteran community.
Studies conducted by the National Institutes of Health (NIH), as well as the VA, showed that exposure to carcinogens, such as herbicides during the Vietnam War and contaminants from oil-well fires during the Persian Gulf War, left veterans with significantly higher rates of certain types of cancer than the general population.5,6,7 One NIH study published in 2004 revealed that cancer patients are at almost 4 times greater risk8 to be hospitalized with severe sepsis -- which has at least a 28% mortality rate9 -- than the general population, with factors such as age, weakened immune systems, and emerging antibiotic-resistant bacteria contributing to these staggering numbers.
Initial research on the MAM focused on its application in treating cancer patients. Dr. Shereef Elnahal, a radiation oncologist and physician expert who has researched MAM extensively, has published two peer-reviewed articles on MAM’s implementation at Johns Hopkins and Wright-Patterson AFB. In these articles, he revealed that his goal was to help diagnose and treat more cancer patients quickly, yet safely, using the MAM methodology. Elnahal noted that during his Hopkins study, “The busiest clinic days [average] increased from 5.3 patients per day to 10 per day during implementation, a 1.9-fold increase." 10,11
“Dr. Elnahal's implementation of MAM led to higher 'safe throughput' -- the clinic’s team could manage more patients at a higher level of safety, and without adding to staff headcount,” explained Terry Rajasenan, co-inventor of MAM who sits on the Executive Board of HROC. “In preventing task saturation, select team members became more reliable. The same team was then seeing essentially twice as many patients -- yet still safely. This was surprising at first glance, but quite logical once it was fully understood by our research. The end result is that better screenings and preventions, whether for sepsis, cancer deaths, or suicides, are possible for more patients – without the need to add staff or overwhelm existing staff with more and more work."
Organizations interested in learning how to reduce task saturation, and the circumstances where MAM techniques can help, are encouraged to visit HROC at:About HROC
HROC (http://www.thinkhro.org) is a registered non-profit committed to scientific study and public safety, and serves as a platform for education and collaboration, supporting and assisting in the implementation of High Reliability Organizations (HRO) in healthcare, government, and nonprofit entities. It arose from over 2 years of pro bono work by ProcessProxy Corp. with the U.S. Air Force in a Cooperative Research And Development Agreement. HROC members are clinicians, researchers, veterans, and HRO practitioners on the frontline of educating the public on the need for healthcare to adopt HRO principles in the interest of significantly improving both patient and public safety.About Sepsis Alliance
Sepsis Alliance is the nation’s leading sepsis advocacy organization, dedicated to saving lives by raising awareness of sepsis as a medical emergency. A 501(c)(3) organization, Sepsis Alliance was founded by Dr. Carl Flatley after the sudden, unnecessary death of his daughter Erin to a disease he had never even heard of. Sepsis Alliance produces and distributes educational materials for patients, families and health providers on sepsis prevention, early recognition and treatment. The organization also offers support to patients, sepsis survivors, and family members through its sepsis.org website which receives more than 1 million visits each year. The organization founded Sepsis Awareness Month in 2011, and works with partners to host community outreach events across North America. Since Sepsis Alliance began its mission, sepsis awareness has increased almost threefold, from 19% to 55%. For more information on Sepsis Alliance, a GuideStar Gold-rated charity, please visit http://www.sepsis.org.Footnotes
1 https://www.cdc.gov/nchs/data/databriefs/db118.pdf (CDC/NCHS, National Hospital Discharge Survey, 2000-2010)
3 http://www.dcoe.mil/Content/Navigation/Documents/SPC2012/2012SPC-Kronick-facts_about_veteran_suicide.pdf; https://www.va.gov/opa/publications/factsheets/Suicide_Prevention_FactSheet_New_VA_Stats_070616_1400.pdf
4 Kumar, Updesh. "The Wiley Handbook of Personality Assessment"; http://www.wiley.com/WileyCDA/WileyTitle/productCd-1119173442.html
9 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1065011/ ; Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR, Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care https://www.ncbi.nlm.nih.gov/pubmed/11445675 Crit Care Med 2001;29(7):1303–1310
11 Improving Safe Patient Throughput In A Multi-Disciplinary Oncology Clinic, physicianleaders.org March/April 2015; http://bit.ly/2hL6kMh