MEDICAL NEWS & PERSPECTIVES

Initiative to Implement 6 Key Measures

in Hospital Care Called Lifesaving
Mike Mitka

N INITIATIVE TO IMPROVE PATIENT

care prevented about 122 300

avoidable hospital deaths over
an 18-month period, campaign leaders
said.
The initiative, the 100 000 Lives
Campaign, helped avert patient death
by instituting 6 evidence-based interventions among 3000 hospitals, representing an estimated 75% of all US hospital beds, explained Donald Berwick,
MD, president and chief executive officer of the Institute for Healthcare Improvement at the International Summit on Redesigning Hospital Care in
Atlanta last month. The institute, based
in Cambridge, Mass, launched the campaign in December 2004.
The campaign is a response to critics who have questioned whether the
health care system had made any significant changes to improve quality of
care and outcomes since an expert panel
convened by the National Academies
Institute of Medicine estimated that as
many as 98 000 patients die annually
due to medical errors (Kohn KT et al.
To Err Is Human: Building a Safer Health
System. Washington, DC: National
Academies Press; 1999).
Lucien Leape, MD, an adjunct professor of health policy at the Harvard School
of Public Health in Boston and a coauthor of the Institute of Medicine report,
hailed the campaigns results. Its a watershed event in that the big question
people kept throwing at us was, Is there
any evidence that health care is any safer
since our report came out? said Leape.
This is an unequivocal, Yes. What this
does is demonstrate these changes were
trying to make in our health care system can be done on a large scale.
To improve the quality of care, the
campaign helped implement 6 changes
in hospitals (Berwick DM et al. JAMA.
2006;295:324-327). These include

Deploying a rapid response team

at the first sign that a patients condition is worsening and may lead to a
more serious medical emergency (1781
hospitals participating).
Delivering reliable evidencebased care for acute myocardial infarction, such as appropriate administration of aspirin and -blockers (2288
hospitals).
Preventing adverse drug events by
ensuring review and reconciling accurate and continually updated lists of patients medications during their hospital stays (2185 hospitals).
Preventing central line infections
by following 5 steps, including proper
hand washing (1925 hospitals).
Preventing surgical site infections
by following a series of steps, including the timely administration of antibiotics (2133 hospitals).
Preventing ventilator-associated
pneumonia by following 4 steps, including raising the head of the patients bed (1982 hospitals).
To calculate the number of lives
saved by implementing these measures, researchers used hospital deaths
in 2004 as a baseline, then tallied deaths
(adjusting for age and illness severity)

for the following 18 months after hospitals had implemented their various
quality-improvement initiatives. Lower
numbers of deaths in each hospital were
considered lives saved.
While the changes implemented by
these hospitals may appear obvious
and fairly straightforward, they
required teamworka foreign concept in many health care institutions,
Berwick said.
Health care was built in fragments;
we suboptimized institutions or professions, Berwick said. These entities are
regulated and trained separately, producing a system in which efforts to provide patient care have been poorly coordinated, he added. But now were
seeing a convergence of teamwork, of
vertical integration, from hospital boards
right down to those on the front lines.
For Barbara A. Blakeney, MS, RN,
president of the American Nurses Association, the campaign validated teamwork across disciplines.
We do train in silos, we do teach in
silos, and that has been part of the problem, Blakeney said. We need to break
away from that. We need to actually
teach our clinicians what each other can
do. It is amazing what one discipline

Locations of Hospitals Participating in the 100k Lives Campaign

Source: Institute for Healthcare Improvement. http://www.ihi.org/IHI/Programs/Campaign

/Campaign.htm. Accessed June 23, 2006.

2006 American Medical Association. All rights reserved.

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Using 6 evidence-based
interventions, health
care professionals at
more than 3000 care
sites in the United
States averted more
than 100 000 patient
deaths over an
18-month period.

(Reprinted) JAMA, July 19, 2006Vol 296, No. 3 269

MEDICAL NEWS & PERSPECTIVES

in health care does not know about the

skill sets and the abilities of others.
If hospitals and clinicians remain reluctant to change, change will come to
them, because payers like Medicare and
private health insurance use findings on
improving outcomes to justify rate
changes based on quality performance, Leape said.

In our current system, we pay

people more when they do moreso
they do more, Leape said. Payers are
very interested in how to link the
whole scheme of reimbursement to
quality, to pay for outcomes and not
just good work.
Berwick hopes the campaign can
get all participating hospitals to

adopt all 6 quality improvement initiatives by 2007. Leape would like to

see the effort expand even further.
Im very excited by the campaign,
but why only 3000 hospitals and
6 quality improvements? Leape
said. Why not get all 5000 hospitals
and institute 30 tools for quality
improvement?

Novel Targeted Cancer Drugs Highlighted

Tracy Hampton, PhD
ATLANTAIn their continued search
for new and effective treatments for cancer, scientists investigating the potential of novel targeted therapies reported results of several early trials at
the recent annual meeting of the American Society of Clinical Oncology held
here in June.
The research . . . is exciting not only
because it shows how far we have come
in understanding the disease itself, but
because it demonstrates the success in
translating this knowledge into practice, said Bruce Johnson, MD, of the
Dana-Farber Cancer Institute, in
Boston.
AGENTS OF APOPTOSIS

In a phase 1 trial, an agent that binds

to receptors on cancer cells that trigger apoptosis, or cell death, halted cancer growth in more than half of the patients whose tumors could be assessed.
This recombinant, or genetically engineered, human Apo2L/TRAIL (Apo2L)
targets two cell death receptors called
DR4 and DR5.
In this trial, 58 patients with different types of advanced cancers received multiple doses of intravenous
Apo2L. Among 37 patients whose tumors could be assessed, 21 (56%) had
stable disease at 8 weeks, and 1 patient experienced significant tumor
shrinkage. This is reasonably good for
a phase 1 study, but still this needs to
be confirmed in other trials, said lead
270

author Roy Herbst, MD, PhD, of the MD

Anderson Cancer Center, in Houston.
Its very hard to make much of efficacy, and I stress that this is a very early
trial, he added.
Another new agent called YM155
promotes apoptosis through a novel
mechanism: inhibiting survivin, a protein that suppresses cell death. Survivin is selectively expressed in most
solid tumors and hematologic malignancies but not in normal tissues, and
YM155 is the first drug designed to inhibit this protein.
Researchers from the San Antoniobased Institute for Drug Development
at the Cancer Therapy and Research
Center and other institutions observed some antitumor activity following treatment with intravenous YM155
in 5 of 41 patients with advanced cancers that were not responding to chemotherapy. Antitumor activity was not
seen in the majority of patients. Larger
studies should help determine YM155s
anticancer potential; it is being evaluated in phase 2 studies of advanced
prostate cancer and melanoma and will
soon be assessed in patients with nonHodgkin lymphoma.
ERBB2 STATUS STUDIES

Researchers from Genentech Inc, in

South San Francisco, and other institutions have obtained early results
from a study in patients with advanced
ovarian cancer who received the
first member of a new class of agents
called HER dimerization inhibitors.

JAMA, July 19, 2006Vol 296, No. 3 (Reprinted)

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This drug, pertuzumab, prevents the

ERBB2 receptor protein from binding
(dimerizing) to other receptors in the
HER family. When ERBB2 proteins are
bound in this way, they are also activated by phosphorylation, which
begins a chain of events in cancer cells
that blocks cell proliferation and
tumor growth.
In the study, 28 fresh tumor biopsies were evaluated from patients with
relapsed ovarian cancer who were
treated with pertuzumab; and 8 (28.6%)
were positive for phosphorylated
ERBB2. Time to disease progression was
20.9 weeks for the 8 patients with
cancers with phosphorylated ERBB2
compared with 5.8 weeks for the 20 patients with cancers featuring unphosphorylated ERBB2.
The investigators also tested archived tumor tissue obtained during a
patients initial surgery or biopsy for expression of genes involved in the ERBB2
receptor signaling pathway to determine if the gene expression patterns
could point to which patients had tumors that expressed phosphorylated
ERBB2an indication that the patient would be a good candidate for pertuzumab therapy. The gene expression patterns predicted phosphorylated
ERBB2 status in 75% of more than 60
samples.
An ongoing randomized phase 2 trial
will evaluate whether these gene expression patterns are biomarkers that
are predictive of potential clinical benefits from pertuzumab.

2006 American Medical Association. All rights reserved.