Device Related HAI Prevention1/17/2012 13 Champions • Knowledge Market • Ownership • Influence • Perseverance Measurement Feedback TRIP • Summarize evidence into checklists

1/17/2012

1

Device Related HAI Prevention:the three “Cs”

Julia Slininger RN, BS, CPHQ

VP Quality and Patient Safety

HASC

Device Related HAI

CLABSI

CAUTI

VAP

All of which can lead to SEPSIS

1/17/2012

2

Prevention Bundles

• National Quality Forum endorsed Researched

Statistically Measured, and

Trialed in Local Facilities

Based on Science:

1/17/2012

3

5

A picture is worth a thousand words

CLABSI Bundle

• Wash Hands• Sterile gloves, hat, mask, gown, and completely drape the patient• Avoid placing the catheter in the groin• Clean the insertion site with chlorhexidine•Remove catheters when no longer needed

1/17/2012

4

CAUTI Bundle

• Avoid unnecessary urinary catheters.

• Insert urinary catheters using aseptic technique.

• Maintain urinary catheters based on recommended guidelines.

• Review urinary catheter necessity daily and remove promptly.

VAP Bundle

•Elevation of the Head of the Bed 30 degrees

•Daily "Sedation Vacations" and Assessment of Readiness to Extubate

•Peptic Ulcer Disease Prophylaxis

•Deep Venous Thrombosis Prophylaxis

•Daily Oral Care with Chlorhexidine

1/17/2012

5

The First “C”

CHECKLISTS

Standardization

“The nurse practitioner came to me distraught and said ‘Peter, can you help me? I am trying to learn how to place central lines. One resident showed me one way, but when I worked with a second resident, he said it was completely wrong and that I should only do it his way. Which one is correct?’

This lack of standardization is entirely unacceptable and dangerous to patients, yet it happens every day, across the country, and around the world.”

Peter Pronovost, MD

1/17/2012

6

Standardization

“The idea of a checklist really started to make sense to me when I was preparing to attend a seminar on patient safety and medical errors in Salzburg, Austria. Among the long list of experts on safety, I saw that James Reason would also be attending the seminar. On the flight over, I read Reason’s book Managing the Risks of Organizational Accidents, which contained detailed information about aviation safety programs- specifically the use of checklists to improve safety.”

Peter Pronovost, MD

Standardization

“Though familiar with the idea of using checklists in aviation, I had never really examined the theory. I was captivated. The parallels between aviation and medicine were striking. Decision, control, and inevitably the safety of passengers and patients were relegated to one individual- in aviation, pilots; in medicine, doctors. Both professionals were expected to master complicated equipment and science that was constantly evolving and changing. And in both arenas, errors could easily result in death.”

Peter Pronovost, MD

1/17/2012

7

Standardization

“But there were also significant differences between medicine and aviation. In aviation the general acceptance that humans are fallible was fundamental to the checklist’s success.”

“The healthcare community, however, has difficulty admitting that well meaning, highly trained, competent doctors predictably and continuously make mistakes. So, when errors inevitably happen, the event and everyone involved are shrouded in guilt, shame, denial and secrecy.”

Peter Pronovost, MD

Standardization

“Also, medicine is infinitely more complex than aviation. The amount of information that a doctor must retain to practice medicine is mind-boggling. To put this in perspective, what a pilot needs to know to fly a specific aircraft, say a Boeing 747, is the equivalent of what a doctor must remember to perform one single procedure. However, in a given week, a physician will likely be called upon to perform hundreds of different procedures”

Peter Pronovost, MD

1/17/2012

8

Standardization

“Every patient is different, and as such requires different treatment, knowledge, and skills, yet all 747s are pretty much identical. Also, the number of new medical research studies far outweigh the number of new aviation studies published each year.”

“Finally, the aviation industry also keeps better records than we do in medicine, making it easier to monitor performance, standardize practice, and learn from mistakes.”

Peter Pronovost, MD

Preventability

“In aviation all crashes are deemed preventable.”

“In hospitals, people come to us already sick, many on the edge of death. If they don’t survive, it is difficult to determine whether it was the result of an error or inevitability. Some patients are going to die, no matter how hard doctors and nurses try to save them. Separating preventable from inevitable harm requires science.”

“In spite of these challenges, I was intrigued by the similarities between aviation and medicine and I was convinced checklists in aviation were a good model for medicine.” Peter Pronovost, MD

1/17/2012

9

Science

“To test my theory, we chose to use checklists to reduce the number of central line infections.”

“I chose the SICU for this study because I worked there- I knew the systems, I knew the procedures, and I knew the culture. More importantly, I had established strong relationships with this team, and I knew they were devoted clinicians that would do their best to support this effort. Furthermore, the SICU was struggling with central line infections. If we were successful, we would not only prove our system was effective, we would also save lives.”

Peter Pronovost, MD

CLABSI Bundle

• Wash Hands• Sterile gloves, hat, mask, gown, and completely drape the patient• Avoid placing the catheter in the groin• Clean the insertion site with chlorhexidine•Remove catheters when no longer needed

1/17/2012

10

First Test of Change

• “38% compliance”

• “dismal”

• “Putting 2 of 3 patients at greater risk of infection and death”

What to do?

• Education?

• Persuasion?

• Inquiry!

1/17/2012

11

Lessons Learned

PDSA“Peter, in a perfect world that would be fine, but it takes time to find all the things I need to perform those [5] steps. And I don’t have the time to run around the hospital looking for them.”“So I ran a little test… I had to go to eight different places…”

Peter Pronovost, MD

The Approach

“When barriers are identified, the team should not just encourage clinicians to “try harder”. Instead, they should make changes in the way the work is being performed and organized that make it easier to comply with the checklist”

Peter Pronovost, MD

1/17/2012

12

Second Test of Change

•70% compliance

• not good enough

• It had been 4 years since Josie King died. “Peter, can you tell me Josie would be any safer at Hopkins now than she was four years ago?”

The Second “C”

CHAMPIONS

1/17/2012

13

Champions

• Knowledge Market

• Ownership

• Influence

• Perseverance Measurement

Feedback

TRIP

• Summarize evidence into checklists

• Identify and mitigate local barriers

• Measure performance

• Ensure all patients reliably receive the intervention

A year later infection rates in the SICU dropped nearly to zero. We saved an estimated 8 lives and $2 million.

1/17/2012

14

One of the key components of TRIP…

“is to identify procedures that have the highest benefit to the patients and condense them into a checklist. However, what we ultimately learned was that to ensure that patients actually received these improvements, a culture change was required. Good culture is the lubrication that allows us to redesign systems- without it sparks fly”

Reliability and Perfection- What we have learned from You !

Getting past 95% to 100% requires

• More physicians to “buy in”

• Leadership to drive the program

• Accountability of individuals

• Effective teams in the everyday environment

So if we have Checklists and Champions, what else do we need?

1/17/2012

15

The Third “C”

CUSPComprehensive Unit-based

Safety Program

For Culture Change

Culture is Local

“Studies have shown that variations in culture between units in a hospital are four times greater than the variations in culture between hospitals”

“Our safety team reviewed the liability claims and errors that resulted in substantial harm to patients at a number of hospitals, and in nearly 90% of these events, one of the care team members knew something was wrong and either kept silent or spoke up but was ignored.”

“Patients pay an awfully high price for dysfunctional teamwork.”

Peter Pronovost, MD

1/17/2012

16

The Goals of CUSP

• Focus on small or large problemsHow fax’d orders are receivedReducing CLABSI

• Improve teamwork cultureEngage staff in the research

• Learn from mistakesRather than accepting them

• Create positivity and hopeBringing joy and pride to the unit

Choosing the first project

• Survey the unit:

• “How could the next patient be harmed?”

• “What do you think can be done to minimize patient harm or prevent the safety hazard from happening?”

1/17/2012

17

CUSP implementation

1) Involve MD champions in initial CUSP trials.

2) Refine your approach. 3) Demonstrate improvement4) Then focus on device related HAI (or other

initiatives5) Involve more MDs6) Appoint a C-level administrator to

“sponsor” the effort

CUSP Results

• Specifically (Processes): Transport teams implemented Med reconciliation form at the bedside Daily goals form for MDs/RNs

• Generally (Outcomes): Safety Culture scores went up 50% LOS for ICU patients dropped by half Med errors dropped from 94% to 1% Nursing turnover went from 9% to 2%

1/17/2012

18

CUSP Results

When Dr. Pronovost and Chris Goeschel took the CLABSI checklist through CUSP for the entire state of Michigan, in three months the CLABSI rate went from 2.7 infections per 1000 cath days to zero, and stayed there for the 18 months of the study, saving an estimated 2000 lives and $200 million a year.

Peter Pronovost, MDSafe Patients, Smart Hospitals p. 142

The 4th “C”

Checklists +

Champions +

CUSP =

Culture Change!

C4 =

Patient Safety!