Less than a year after hiring a new president and chief executive officer, Sandra Coletta, Kent Hospital has hired new clinical leaders: Dr. Michael Dacey as senior vice president and chief medical officer, and Rene Fisher as senior vice president and chief nursing officer.
Dacey, of Warwick, has been at Kent since 2000, first as medical director of the intensive-care unit, then since last year, as chief of medicine. He was a key player in implementing Kent’s “rapid response system” and also developed a sepsis team in the ICU.
Dacey answered questions about his work and how he’s approaching his new position.
PBN: You were Kent’s point person for the statewide ICU Collaborative. How valuable do you think that project has been, and do you see it as a model for how to take on other major safety issues in hospitals?
DACEY: The ICU Collaborative began almost three years ago, and it was a concerted effort by all the hospitals to improve the care of patients in ICUs across the state. There are 22 ICUs in Rhode Island, and it was one of the first times that all of the hospitals had gotten together in a concerted way to improve the care of patients in a specific area. In that sense I believe that could be a model.
The thing to understand is that the collaborative is not just doctors, and that’s the strength of it. It’s doctors, it’s nurse leaders, staff nurses, respiratory therapists, pharmacists – it’s a multidisciplinary approach. In intensive care medicine, that flows naturally, because over the last 15 years, we’ve evolved as a multidisciplinary model … but the strength of having a statewide effort is that you get the opinions of people at other hospitals. They may be doing something at Rhode Island Hospital or Roger Williams or South County Hospital that I can learn from, or vice versa, and it’s not just doctors, but a multidisciplinary approach. …
Getting it organized was not easy, but once you have it in place, it takes on a life of its own.
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PBN: You also introduced rapid response teams at Kent. Can you tell us about them?
DACEY: It’s a model that was first developed at the University of Pittsburgh, which is where I trained. … That’s a team of a nurse, a respiratory therapist and a physician’s assistant that can be activated by a nurse on a medical floor. So if your father or your mother was in the hospital with pneumonia, and it was getting worse, traditionally, they would have paged the doctor and he would have had to order a chest X-ray. Now if the nurse is worried, she can activate the team, the team comes in and does any tests that are necessary, talks to the physician, develops a plan of care. It’s a more immediate way rather than let things go on until it becomes a real emergency.
That is now becoming the standard, for hospitals to have rapid response teams, and intervene early. It has impacts on quality – we saw a really dramatic, 60-percent decline in the number of patients who had cardiac arrests in the hospital – and a big improvement in survival, decreased ICU admissions. And that’s a quality measure, but it’s also a cost measure. If you can take care of patients before they get critically ill, then you can save the patient’s life and do it at a reduced cost. I think that’s one of the most novel things we’ve done outside the collaborative.
PBN: You also created the sepsis team within the ICU.
DACEY: That started outside of the ICU Collaborative but has now become an important part of it. Sepsis kills an enormous number of patients each year in hospitals: between 600,000 and 700,000 die each year of infections and low blood pressure because of those infections, and shock, and respiratory failure. It’s the same concept of early intervention: if you can give the patients IV fluids and antibiotics early, it’s been proven that you can make a real difference. But you know how busy emergency departments can be; we see about 60,000 patients a year here – it’s the second-busiest emergency department in the state. One hour can lead into the next … so what we did is we created a system where the intensive-care unit can come to the patient at the discretion of the emergency department staff. The nurse can say this is a patient who clearly has septic shock, and he’s going to need a nurse to take care of just him for the next couple of hours, and the ICU can send a nurse with a team. …
We’ve seen some very substantial improvements, both in terms of mortality – from a national average of about 26 percent, to about 17 percent – and with that, the length of stay, which used to average 12 to 15 days for severe septic shock, has now decreased to about eight days. So that’s a cost benefit as well. There are upfront costs – you have to take an ICU nurse and not give her an assignment … and it can cost a few hundred thousand dollars a year to staff that team, but from it we’ve gotten improvements in patient outcomes and cost improvements.
PBN: How do you extend that kind of approach to the whole organization, and avoid problems like Kent recently had with its interventional radiology unit?
DACEY: I think the secret to that is to empower the people on the front lines and make it part of their culture. One of the things we did was to empower the nurses to say, “I don’t feel comfortable with how we’re doing this procedure.” The ability for nurses to speak up is very important. To go through a big, complex organization like a hospital, you have to empower people on the front lines in all departments and encourage them to raise their hands and speak up. It’s a cultural change, and we’ve undertaken a lot of that at Kent Hospital. But like a lot of places, you do find an occasional non-adherent. But I think there’s been a major improvement in our culture of safety in the last several years.
PBN: You plan to continue working in the ICU at least once a week. Why?
DACEY: Yes, once a week and one out of every three weekends or so. I think that’s important, because first of all, I don’t want to lose my skills. I like practicing medicine – I’ve spent the last 20 years preparing and practicing it. But you also need to lead by example, and you need to understand what’s going on. I think that’s very important from a leadership perspective.
