Thank you. Good day. Our next speaker is Dr. Mary Elizabeth Hanley. Dr. Hanley currently serves as our president. She was born and raised in greater Hartford area of Connecticut. She graduated magna cum laude from Salve Regina University in Newport, Rhode Island. After serving in the United States Army, she attended and graduated with honors from the University of New England, College of Osteopathic Medicine in Biddeford, Maine. She received several awards, including the award for clinical excellence and outstanding medical writing award. Dr. Hanley then did a transitional year internship at the Union Memorial Hospital in Baltimore. She then completed a residency and fellowship in anesthesiology and critical care medicine at the Johns Hopkins Hospital in Baltimore, where she was chosen to be chief resident. She joined the faculty at the Johns Hopkins School of Medicine and taught medical students, interns, and anesthesiology residents and fellows. In 2008, Dr. Hanley contracted necrotizing fasciitis in her right hand and arm. She lost most of the functional use of her right hand and underwent more than 10 surgeries to save her hand and arm. Her new disability made it difficult and unsafe for her to practice as an anesthesiologist. In 2009, Dr. Hanley began a new chapter in life as a resident in family medicine at Kent County Hospital in Warwick, Rhode Island. She was once again selected to be chief resident. Upon completion of her family medicine residency, she was offered a fellowship in Kent County Hospital with new undersea and hyperbaric medicine fellowship program. She completed her training in 2012 and has been practicing wound care and hyperbaric medicine since then. She became a fellowship program director at Kent County from 2013 to 2018. In 2018, Dr. Hanley accepted the position of medical director of the wound care and hyperbaric medicine program at Roper St. Francis Healthcare in Charleston, South Carolina. Dr. Hanley has numerous publications in scholarly journals and has written multiple book chapters and is editor-in-chief for a stat pearls board review program for undersea and hyperbaric medicine. She is the current president of the American Osteopathic College of Occupational and Preventative Medicine. She's on the faculty at Charleston Southern University, the Medical University of South Carolina and Edward Via College of Osteopathic Medicine at Virginia Tech University. She is a clinical associate professor at the University of New England College of Osteopathic Medicine. She is a national and international speaker in her field. Her greatest accomplishment is being the mother of two Eagle Scouts and one 2021 BS in biology graduate of the University of Rhode Island. She lives in Mount Pleasant, South Carolina with her family and an old English sheep dog. Dr. Hanley will not discuss any off-label uses of medications, nor does she have any conflicts of interest to disclose. Without further ado, Dr. Mary Elizabeth Hanley. Hello, everyone. I'm very happy to do this presentation for you today. I'm going to be speaking about embracing the aviation industry's culture of safety and post-pandemic healthcare systems. Can aviation standards help save patients? I'm Dr. Mary Elizabeth Hanley. I'm the president of the American Osteopathic College of Occupational and Preventive Medicine, and I'm very happy to be with you virtually today. My only disclosures is that I am a medical advisor to Hartman and Bioventus, and I won't be discussing any off-label use of their products or any products for that matter today. So basically, no disclosures. Our learning objectives, I will leave it for you to read these over afterwards, and hopefully I've met them. So on March 27th, 1977, a KLM Boeing 747 and a Pan American Airlines Boeing 747 collided on the tarmac at the Tenerife Airport on the Canary Islands, resulting in the deaths of 583 people. It was the single worst aviation accident in the history of commercial aviation. Tenerife is in the Canary Islands, which is a territory of Spain. It's located about 800 miles south of Portugal and about 500 miles to the east of the western African coast in the southeastern Atlantic. The two islands that are key in this whole story are Las Palmas and Tenerife. This was the KLM 4805, also known as the Rhine River. KLM 4805 was captained that day by KLM Captain Jacob Weltheusen-Van Zanten. Captain Weltheusen-Van Zanten at the time of the incident was 61 years old. He had over 1,500 hours in the 747, and he was the chief instructor in the 747 for KLM Royal Dutch Airways. PNAM Clipper 1706 was named the Clipper Victor, and ironically, this was the first 747 to be hijacked. Prior to this day, this exact plane had been hijacked on a flight from New York to Puerto Rico. It was hijacked to Cuba, and Fidel Castro came out to the airport to see it because he had never seen a 747 before. Joining the PNAM Clipper 1706 that day was Captain Victor Suggs. Captain Suggs was 57 years old at the time, and he had had over 500 hours on the 747, so both very experienced, capable pilots. This is Los Rodeos Airport. It has now been replaced by a new airport known as Tenerife North, but at the time in 1977, this was the only airport on Tenerife. As you can see, it's a single runway next to a taxiway. PNAM 1706 took off from New York City en route to Las Palmas in the Canary Islands. KLM 4805 took off from Amsterdam en route to Las Palmas. A terrorist bomb exploded in the terminal in Las Palmas, and there was fear that more bombs had been placed inside the airport, so the terminal at Las Palmas was closed indefinitely to all air traffic. Los Rodeos was a much smaller airport. It was staffed by a single air traffic controller because it was a Sunday, a normally very quiet day at this airport. At the time, they had no ground radar, no runway lighting, and this airport was plagued by frequent dense fog. So this is just a schematic showing the route in blue of KLM 4805 coming down from Amsterdam. Grand Canaria was the intended airport for both flights, but as you can see, they were then both diverted to Los Rodeos on Tenerife. And this is a schematic of the airport. As you can see, the single runway, and there are four exits off of the runway leading to and from the taxiway. This also shows at the far left of the picture where the two planes were parked waiting for clearance to leave. The KLM plane was parked in front of the Boeing, I'm sorry, in front of the PNM plane. And this irked the PNM flight crew tremendously because if the KLM plane had moved over four feet, they would have been able to get out and leave before them because the PNM passengers remained on board so that they would be ready to depart as soon as they got clearance. So there was a bit of bad blood between the two flight crews. This is an actual photo taken from under the wing of KLM 4805 with the PNM Clipper 1706 parked on the taxiway on 27 March 1977. The KLM captain was very worried about time. There were new mandatory rest requirements that the Dutch government had enacted, which were rather draconian, in that if he went over his allotted flight time, he would have to find accommodations for himself, the flight crew, and all the passengers to overnight in Tenerife. Tenerife at the time was a very small tourist destination, not a lot of hotel rooms. The Dutch regulations also specified he could be subject to a $20,000 fine, and he could also lose his license or even have jail time for a flight time violation. The PNM Clipper, as I stated previously, was parked behind KLM and could not get past them. So the KLM captain decided to refuel fully in Tenerife so that when he was cleared to depart, he could fly to Las Palmas, deplane his passengers, reboard, and then turn and burn back to Amsterdam without taking further time to refuel. This further delayed the PNM 1706 crew and further stirred their ire against the KLM crew. Las Palmas reopened around 1430 that afternoon. Air Traffic Control told the KLM crew to back taxi down Runway 12 and then do a complex 180 degree turn and hold at the end of the runway. Air Traffic Control told PNM 1706 to taxi down Runway 12, but take the third exit to the left to the taxiway to allow KLM 4805 to take off first. In the meantime, dense fog had rolled in and visibility was down to 300 meters in some spots. Now all along this whole afternoon, there were three languages being spoken, Spanish, English, and Dutch. The KLM crew went back and forth in the cockpit and on the radio in English and Dutch. The Air Traffic Controller spoke Spanish with a thick accent. The PNM crew was speaking English. PNM has difficulty finding the third exit off the runway. Part of the reason for this was that the Air Traffic Controller was not used to directing 747 jumbo jets, and he gave them directions to make some turns that were almost 90 degree angles that are almost impossible for a plane that big to make in an airport this small. So they go past the third exit and they realize their mistake. They radio the Air Traffic Controller that they missed the exit and are still taxiing on Runway 12. Meanwhile, KLM 4805 captain begins to push his thrusters for takeoff, and his first officer spoke up and said, sir, we don't have clearance for takeoff. So he sat back and became even more irritated at the delays. Air Traffic Control gave them KLM clearance for a departure route, but not takeoff clearance. KLM 4805 never heard the Air Traffic Control conversation with PNM stating that PNM was still taxiing down the runway due to static. And at the time, radio communications, it was kind of like a walkie talkie where if two parties were speaking, another party couldn't hear what their conversation was. So the KLM captain once again throttles up and begins rolling down the runway. This time the first officer says nothing to the captain, but radios Air Traffic Control and says we're at takeoff as they're gaining speed down the runway. Air Traffic Control tells them to hold, thinking that they're waiting for clearance and says to them, okay, I'll call you. The KLM captain likely just heard okay and figured he was cleared. So there was complete communication breakdown between Air Traffic Control and these two flights. And this is the point of impact. This occurred at 1706 and 50 seconds on Sunday afternoon. The last comment heard on the PNM cockpit data flight recorder is from Captain Suggs who stated, there he is, look at him, that son of a bitch is coming. PNM 1706 sees the KLM barreling at them. Captain Suggs desperately tried to make a hard left onto the grass median, but it's not very easy to move a 400,000 plane that nimbly. Captain Van Zanten sees the PNM clipper is still on the runway and pushes full throttle in an attempt to gain lift. However, his fully fueled plane is far too heavy. He ends up dragging the tail for several meters, gain some lift, but the belly of KLM 4708 shears off the top of PNM 1706, gets airborne for a brief period and then plummets to the ground in a huge fireball. All of the passengers and crew on the KLM flight are killed. There are 61 survivors from the PNM clipper, including the flight crew. This is a cartoon, if you will, of what happened. You can see how KLM is briefly airborne, but it's fully fueled. He's too heavy and just can't get enough lift to get over the PNM clipper. And this is the aftermath. I can remember, I was a little kid when this happened, but I remember seeing these pictures on the cover of Time Magazine and thinking, wow, that looks really awful. You know, to me, it was a world away. I had no real understanding or idea of what happened, but these pictures just sort of were etched into my memory. And the ironic part of this one is that the gentleman on the far left, as you can see, is one of the 61 survivors and he's got his carry-on bag with him. And this is all that was left of KLM. This is the hanger that was used as a temporary morgue at Los Rodeos. So lessons learned from the most horrific commercial aviation accident in recent history. It brought about the development of the concept of crew resource management, which we'll talk further about. It was sort of the birth of the whole concept of just culture, but we weren't calling it just culture back then. It brought the standardization of procedures and processes in commercial aviation and the acceptance of English as the international language. And it also caused us to take mindful pause, analyze success and failure, and anticipate problems and have a plan. So crew resource management is the concept that if you look back in the 1970s, airline pilots, especially 747 captains, there were very few of them. They were pretty much exclusively male and they were like gods. You never questioned the captain. It went back to the old doctrine of the sea captain where the captain is always right. So they were never questioned or challenged. This led to a culture of dangerous deference where people were too afraid to speak up, even if they felt the captain was doing something wrong or dangerous. There was that level of intimidation. So the concept of crew resource management sort of implies if you see something, say something. And it doesn't matter who sees it or who says it. Anybody from the baggage handler to the captain to the flight attendant to the caterer is encouraged to speak up if there's some type of a safety concern. You're not judged for bringing something up to the forefront. There's no punitive measures for speaking up. And the emphasis is on teamwork, mutual respect, collaboration, and provision of good safe service to the consumer. Just culture now is being adopted in many workplaces. And it's very similar to the crew resource management model. Anyone who has ever gone to a morbidity and mortality rounds in a teaching hospital, especially in the surgical service, can remember how awful it feels to sit there and see some poor surgical resident just torn to shreds by attendings and professors and even their fellow residents for a mistake or a misadventure in the operating room. And as an anesthesiology resident, I used to go to these M&Ms and I would sit there and just thank God I wasn't a surgery resident and I couldn't be pulled into this feeding frenzy. And we called it the ABCs, accuse, blame, and criticize. We're trying to move away from that, thankfully, because nobody learns in that environment and it's more punitive than it is constructive. So the focus now with Just Culture is on teamwork and having the entire team embrace a culture of safety for everyone, for customers, our patients, our staff, their families, and everyone, no matter whether it's someone in engineering or housekeeping or the chief of surgery is encouraged to speak up. So another thing that came out of this event is standardized procedures and checklists. The airlines have always been very into checklists. There's the pre-flight checklist, there's the post-flight checklist, and you have to go through your checklist before you can leave the gate. The practice of a sterile cockpit or flight deck also came out of this event, and that is the practice where extraneous conversation and personnel in the flight deck is strongly discouraged. Talking about your kids and your vacation plans is a big distraction as are extraneous personnel. So all of those are discouraged in the commercial aviation industry now. Hospitals are now beginning to embrace checklists more. One of the reasons behind it is that sometimes your most mundane procedures or things that you do every day are the ones that are messed up because it's so rote to you that you don't think about it. So if you miss something, you don't even realize it. So that's why checklists are sometimes the most beneficial for the most common procedures because it reminds you to follow the steps sequentially. Dr. Peter Pronovost was a brand new surgical intensive care unit attending when I was an anesthesiology and critical care medicine fellow at Johns Hopkins. He was one of my first attendings in the SICU, and he's a great guy. He was a wonderful attending. He's very passionate about critical care and patient safety. That's why he developed his checklist for central line insertions in the SICU at Johns Hopkins. The rate of CLABSIs, which stands for central line associated bloodstream infection, plummeted when we began to use this checklist. And Dr. Pronovost then went on to work with the World Health Organization on checklists that are used all over the world now in the operating room. So lessons learned from Tenerife, standardization of communication, no ambiguous terms like okay or takeoff, acceptance of English as the international language, the going back and forth between Dutch, German, English, Spanish just led to more confusion and frustration. Crew resource management, and also there was finally the Spanish government agreed to install ground radar and then ultimately to build a second larger, more modern airport at Tenerife. But that wasn't until about 20 years later. So do we have a safety problem now with commercial aviation? All these years after 1977. Well, according to the FAA, there were almost 16 and a half million flights handled by the FAA last year. That means a flight having any contact whatsoever with a tower or filing a flight plan. 45,000 average daily flights are handled by the FAA, about 1,875 per hour in a 24 hour period. And 2.9 million passengers fly every day in and out of United States airports. The annual risk of being killed in a plane crash for the average American is about one in 11 million. The annual risk of being killed in a motor vehicle crash for the average American is about one in 5,000. So the most dangerous part of any flight is your trip driving to and from the airport at this point. So this is the cockpit of a Boeing 747. Lots of technology, lots of buttons, gadgets. There are cup holders. And this is the standard ICU bed in hundreds of surgical and medical ICUs all over the country. I don't know about you, but I'm much more comfortable in this setting than I would be in the cockpit of the 747. I know these machines, I know these buttons, I know these monitors. So it's all our different areas where our comfort level lies. But this begs the question, do we have a safety crisis in US healthcare? Well, the number of patients admitted to US hospitals in 2020 was about 33.3 million. And that's from the American Hospital Association. The number of deaths associated with hospital acquired infection in the United States is about 100,000 per year. And a third of those are due to CLABSIs or central line associated bloodstream infection. The number of deaths associated with HAPIs, which is a hospital acquired pressure injury in the US is about 60,000 a year. And that's according to the Joint Commission. So these two unfortunate misadventures that happen to far too many patients during the course of hospitalization, are these diagnoses, is this our Tenerife in healthcare? Is this our wake up call to do something to make our healthcare system safer? Do we have a safety crisis in US healthcare? Well, the cost to the hospitals ranges between 18,000 and 90,000 per patient if they acquire a hospital acquired infection. It significantly increases the length of stay, which also increases the cost. And central lines are no longer just in the ICU setting. One study found that 55% of ICU patients had central lines and 24% of non-ICU patients had them. And we tend to forget that a PICC line is a central line. One in 31 hospitalized patients and one in 43 skilled nursing facility patients have a hospital acquired infection. So put that against your one in 5,000 chance of dying in a car accident, and you're far more likely to be injured or killed in a hospital. This is Dr. Pronovost. So by utilizing the checklist that Dr. Pronovost developed at the Johns Hopkins Hospital in Baltimore, the SICU rate of CLABSI infections dropped from 33%, about a third of the patients in the surgical ICU, to less than 2%. So what is this radical checklist that was developed by my friend, Dr. Pronovost? It's really not that radical. Step one, wash your hands with soap and water. Step two, clean the patient's skin with chlorhexidine antiseptic. Step three, use sterile drapes. Step four, wear a sterile mask, gown, and gloves. And step five, put a sterile dressing over the catheter site. It's kind of like, you know, central line insertion 101, but how many times have you seen a line going in in the ICU by someone who wore the same scrubs into work in the parking lot that day, and they're now in the ICU putting in a sterile line and they're not draped? And maybe they just squirted some Purell on their hands before they started. We've all seen it. So this is the surgical safety checklist that Dr. Pronovost developed with the World Health Organization. Now, before I came to beautiful Charleston, South Carolina, I practiced in Rhode Island. And for a while, Rhode Island had the dubious distinction of being the world headquarters for wrong site surgery. We were really good at taking off the wrong leg or operating on the wrong eye or the wrong arm. So something had to be done. So this checklist starts off with each member of the team. So the anesthesiologist and the circulating nurse go through and make sure that the anesthesia checklist has been completed, that the pulse oximeter is on the patient and working. Is there a risk of a difficult airway? Is that equipment available? And how much blood loss is anticipated? Do we need to get more from blood bank? Then the timeout is done by the entire team where everybody comes together, makes sure they have the correct patient, the correct procedure, the patient is positioned properly, consent is signed, surgical site is marked, antibiotics are given and DVT prophylaxis. And actually before any of this starts, the team assembles and introduces themselves to each other. So it's, hi, Jim, I'm the surgeon. On this case today, I'm concerned that I could run into some trouble with blood loss. So I wanna make sure that anesthesia is aware we may need an extra cooler of blood. And I'm Mary Beth, I'm the anesthesiologist. I've got plenty of blood and I'm worried about the airway. So everybody just kind of discusses what their role is, what their concerns are and what they're going to do about it to minimize the risk for the patient. So this has significantly decreased wrong site surgeries and unanticipated surgical misadventures where the proper equipment, the proper medications, the proper amount of blood was not available. So now we're gonna shift and talk a little bit about HAPIs, which is a misnomer because it's a hospital associated pressure injury. There's nothing happy about it or healthcare associated pressure injury. So about two and a half million patients develop pressure injuries in acute care settings. 60,000 die as a result of these. And the cost in the United States is estimated at 11 billion that's billion with a B annually. Those data are from JACO. So three hospitals in California identified 23 root causes of hospital associated pressure injuries in their daily work and implemented countermeasures to prevent it. They saw a 62% improvement in their HAPI rates and a savings of over $15.3 million to the systems. The Agency for Healthcare Research and Quality, AHRQ, found that despite a 13% decrease in all hospital acquired conditions from 2014 to 2017, HAPI rates have increased by 6%. Now I looked at data from 2020 and unfortunately COVID is going to skew some of these numbers because as we know, COVID can cause tissue necrosis and wounds and tissue injury. And so sometimes what we're calling a pressure injury is really a COVID related skin injury. So the data for the past two years during the pandemic are going to be sort of difficult to tease out. So these three hospitals that partnered to prevent HAPIs then instituted a robust process for improvement or an RPI. An RPI is a fact-based, systematic and data-driven problem solving methodology. It incorporates tools and concepts from Lean Six Sigma and change management. Lean Six Sigma was developed for companies and groups to manage waste, but it has since been transformed into a methodology that can be used for quality assurance and quality improvement. So HAPI, lessons learned. Identify at-risk patients at admission. That means the minute the patient hits the door, they get a full skin assessment in the emergency department or on the arrival to the nursing unit. They are assessed for their level of mobility or immobility, decreased activity, change in sensation and tissue tolerance. Is there a risk for moisture associated skin injury, shear with moving in bed or being pulled up in a bed? And age, perfusion and nutrition are all certainly risk factors that are taken into consideration. So we have the Braden scale, which is used to predict pressure injury risk. And it looks at sensory perception, moisture, activity, mobility, nutrition, friction and shear. The higher the score, the lower the risk for a HAPI. So it's inversely proportional. A total of less than 12 means a patient is at high risk for developing a hospital or healthcare associated pressure injury. A total of less than nine is severe risk. The scale is done daily by a registered nurse and documented in the EMR. They tried having medical assistants, certified nursing assistants, LPNs do the scoring. And they found that it was more accurate if there was an RN responsible for doing it every day. So early interventions, what do we do? We offload, we take pressure off, we turn, we reposition, we get patients up out of bed the night of surgery or a few hours after surgery, get them up and walking. Don't leave them laying in bed for days at a time. The use of specialty beds, specialty mattresses, barrier creams, foam dressings, offloading devices, Provolone boots for the heels to protect heels. Ongoing nutritional support and assessment. I had no idea how critical nutrition is to wound healing until I got into wound care and also the use of checklists. So primum non nocere, first do no harm. We all took an oath to do no harm. Nobody goes into medicine or healthcare because they wanna hurt people. We all go in with lofty goals of helping people and helping our fellow humans. So patients come to us, to our hospitals or our healthcare facilities looking for high quality, safe care. And we need to be constantly vigilant to protect them and to protect our staff and the patients, visitors, and families. So fostering a culture of safety where everybody has equal input, a just culture is a difficult paradigm shift for many systems who have relied on the old ABC system of accused, blamed, criticized for a long time. So we need to start to look at events as learning opportunities and not blame festivals. And we need to have leaders, administrators, medical directors, physicians, nurses who lead by example. And so this is my mandatory cartoon that I have to put one form or another of in every talk. And this is from one of my favorite stories by Lewis Carroll, Alice in Wonderland. And this is actually a misrepresentation because it's the mad hatter who says to Alice, have I gone mad? And Alice says to him, I'm afraid so, you're entirely bonkers, but I'll tell you a secret, all the best people are. So these past two years have really driven us completely bonkers. We've just made it through the first pandemic of most of our lifetimes. There might be some people here who remember the Spanish influenza of the 1920s, maybe Dr. Silberman. But the thing that we need to remember now is we're coming back to life and it's slow and it's painful and we want this so desperately to be over, but we need to be patient with one another. You never know what someone else is dealing with internally. And the bottom line is we're all just walking each other home. Thank you so much for your attention. I hope you enjoyed the presentation. And if anybody can identify this body of water in this area of land, I will give you $10. Thank you very much. Thank you. Good day. Our next speaker is Dr. Mary Elizabeth Hanley. Dr. Hanley currently serves as our president. She was born and raised in greater Hartford area of Connecticut. She graduated magna cum laude from Salve Regina University in Newport, Rhode Island. After serving in the United States Army, she attended and graduated with honors from the University of New England College of Osteopathic Medicine in Biddeford, Maine. She received several awards, including the award for clinical excellence and outstanding medical writing award. Dr. Hanley then did a transitional year internship at the Union Memorial Hospital in Baltimore. She then completed a residency and fellowship in anesthesiology and critical care medicine at the Johns Hopkins Hospital in Baltimore, where she was chosen to be chief resident. She joined the faculty at the Johns Hopkins School of Medicine and taught medical students, interns and anesthesiology residents and fellows. In 2008, Dr. Hanley contracted necrotizing fasciitis in her right hand and arm. She lost most of the functional use of her right hand and underwent more than 10 surgeries to save her hand and arm. Her new disability made it difficult and unsafe for her to practice as an anesthesiologist. In 2009, Dr. Hanley began a new chapter in life as a resident in family medicine at Kent County Hospital in Warwick, Rhode Island. She was once again selected to be chief resident. Upon completion of her family medicine residency, she was offered a fellowship in Kent County Hospital with new undersea and hyperbaric medicine fellowship program. She completed her training in 2012 and has been practicing wound care and hyperbaric medicine since then. She became a fellowship program director at Kent County from 2013 to 2018. In 2018, Dr. Hanley accepted the position of medical director of the wound care and hyperbaric medicine program at Roper St. Francis Healthcare in Charleston, South Carolina. Dr. Hanley has numerous publications in scholarly journals and has written multiple book chapters and is editor-in-chief for STAT Pearl's board review program for undersea and hyperbaric medicine. She is the current president of the American Osteopathic College of Occupational and Preventative Medicine. She's on the faculty at Charleston Southern University, the Medical University of South Carolina and Edward Valley College of Osteopathic Medicine at Virginia Tech University. She is a clinical associate professor at the University of New England College of Osteopathic Medicine. She is a national and international speaker in her field. Her greatest accomplishment is being the mother of two Eagle Scouts and one 2021 BS in biology graduate of the University of Rhode Island. She lives in Mount Pleasant, South Carolina with her family and an old English sheepdog. Dr. Hanley will not discuss any off-label uses of medications, nor does she have any conflicts of interest to disclose. Without further ado, Dr. Mary Elizabeth Hanley.

aviation safety protocols

healthcare systems

Tenerife disaster

standardized procedures

crew resource management

just culture

medical education

COVID-19 pandemic