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Dartmouth Medical School Dartmouth-Hitchcock Medical Center

Vital Signs

Training center doesn't make change, but it makes change possible

By Jennifer Durgin

Nurse Christina Graves, left, goes through a training exercise in the PSTC under the watchful eye of its director, Frances Todd.

Correlation doesn't equal causation. That's why the director of DHMC's Patient Safety Training Center (PSTC) hesitates when asked for specific examples of how the center has improved care.

Path: Proving that training improves care "is one of the most difficult things to do," says Frances Todd, director of the PSTC, "because there are so many factors" involved in any aspect of patient care. Yet if one examines safety improvements at DHMC in recent years, the path often leads back to the PSTC.

For example, consider how often patients need to be transferred to a higher level of care—a sign that their condition is worsening. In 2008, when a new PSTC opened, the number of transfers per 1,000 patient days at DHMC was 6.5. Since then, the rate has dropped steadily. As of early 2011, it had fallen to 3.8. Much of the credit for the decline, says Todd, goes to nurses.

"It's up to the bedside nurse to detect if there's a problem," says Todd. "It may seem like a no-brainer that you would recognize that somebody is in respiratory distress, but that's not always the case. They present differently. You have to look at a lot of different factors."

Learning those assessment skills is "number one" in training nurses how to keep patients from worsening. And, says Todd, "number two is, 'Okay, now that I see they are in trouble, what do I do?' "

Improving the skills of nurses is a major focus of the PSTC. In 2005, it became a key component of orientation for new nurses. After three years, nursing turnover had dropped from 19% to 10%, and DHMC had saved $3.4 million in training time and recruitment costs.

All sorts of other clinicians—including faculty physicians, resident physicians, medical students, and medical assistants—also use the PSTC. In the first three quarters of FY2011, the center logged 15,000 encounters. Users practice interventions, run through various scenarios, and learn communication skills.

PSTC training even extends to secretaries, security personnel, and janitorial staff. If someone collapses in a waiting room, for example, a secretary might be the first responder. By knowing who and how to call for help, explains Todd, the secretary can streamline a response in which every second matters.

Suite: The 8,000-square-foot facility, one of the largest on-site simulation training centers in the nation, features six inpatient rooms, one operating suite, a three-bay emergency room, skills and procedural labs, three debriefing rooms, and specialized audiovisual equipment to help users assess their performance. The center also houses 12 high-tech, lifelike manikins that respond to interventions just like real patients. Their blood pressure, heart rate, temperature, and respiration can change, and they sweat, bleed, drool, and cry. One can even give birth.

Manikins: Many articles about the PSTC focus on the manikins, says Todd. But the high-tech equipment is just a tool, she says, to help people develop communication, teamwork, and technical skills, with the ultimate goal of delivering safe, effective, efficient care.

After three years, nursing turnover had dropped from 19% to 10%

"You've got to empower your staff," says Dr. George Blike, an anesthesiologist who is the medical director of the PSTC and DHMC's patient safety officer. "That's where safety lives."

"We are the change agent that helps people . . . get to that place where we want to be," says Todd. For DHMC, "that place" is in the top 5% of academic medical centers nationally in terms of patient safety, effective care, and affordability.

So far, the organization is on track to meet that goal by 2014. DHMC has already made substantial improvements on several indicators, including health-care-associated bloodstream infections and readmissions within 30 days of a discharge.

Sounding like a BASF commercial, Todd says the PSTC doesn't make a lot of the changes in patient safety throughout the hospital, but it makes a lot of those changes possible.

"That's the impact," she says.


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