the science of improving patient safety

The Science of Improving Patient Safety

On the CUSP: Stop CAUTI

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Sean Berenholtz, MD MHSJohns Hopkins UniversityQuality and Safety Research Group

The Problem is Large

• In U.S. Healthcare system

– 7% of patients suffer a medication error 2

– On average, every patient admitted to an ICU suffers an adverse event 3,4

– 44,000- 98,000 people die each year as the result of medical errors 5

– Nearly 100,000 deaths from HAIs 6

– Estimated 30,000 to 62,000 deaths from CLABSIs 7

– Cost of HAIs is $28-33 billion 7

• 8 countries report similar findings to the U.S.

Bates DW, Cullen DJ, Laird N, et al., JAMA, 1995 Donchin Y, Gopher D, Olin M, et al., Crit Care Med, 1995. Andrews L, Stocking C, Krizek T, et al., Lancet, 1997. Kohn L, Corrigan J, Donaldson M., To Err Is Human, 1999. Klevens M, Edwards J, Richards C, et al., PHR, 2007 Ending Health Care-Associated Infections, AHRQ, 2009. 2

ConditionCondition % of Recommended Care Received

Low back pain 68.5

Coronary artery disease 68.0

Hypertension 64.7

Depression 57.7

Orthopedic conditions 57.2

Colorectal cancer 53.9

Asthma 53.5

Benign prostatic hyperplasia 53.0

Hyperlipidemia 48.6

Diabetes mellitus 45.4

Headaches 45.2

Urinary tract infection 40.7

Hip fracture 22.8

Alcohol dependence 10.5

RAND Study Confirms Continued Quality Gap

McGlynn EA, Asch SM, Adams J, et al., N Engl J Med, 2003. 3

Healthcare-Associated Infections: A Preventable Epidemic

• Focus on 4 HAIs: VAP, SSI, CRBSI, UTI• $5 billion per year excess costs• 1.7 million patients per year

– 1 out of 20 patients

• 98,000 deaths per year– As many deaths as breast cancer and HIV/AIDS put

together– 6th leading cause of preventable deaths

http://oversight.house.gov/story.asp?id=18654

Case- Is this death preventable?

• 65 year-old male admitted to ICU with HAP• Requires intubation for ARDS• Zosyn 19 hours after admission• Culture sent, day 2 grew MRSA• Dx CA-BSI and DVT/PE• Died ICU day 21

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System is a set of parts interacting to achieve a goal

“Every system is perfectly designed to achieve the results it gets”

Caregivers are not to blame

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Rather than being the main instigators of an accident, operators tend to be the inheritors of system defects….. Their part is that of adding the final garnish to a lethal brew that has been long in the cooking.”

James Reason, Human Error, 1990

On the CUSP: Stop CAUTI

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System Failure Leading to This Error

Catheter pulled withPatient sitting

Communication betweenresident and nurse

Lack of protocol For catheter removal

Inadequate trainingand supervision

Patient suffers

Venous air embolism

Pronovost PJ, Wu Aw, Sexton, JB et al., Ann Int Med, 2004.Reason J, Hobbs A., 2000. 9

Principles of Safe Design

• Standardize – Eliminate steps if possible

• Create independent checks• Learn when things go wrong

– What happened– Why– What did you do to reduce risk– How do you know it worked

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Eliminate Steps

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Create Independent Checks

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Healthcare-Associated Infections: A Preventable Epidemic

• Focus on 4 HAIs: VAP, SSI, CRBSI, UTI• $5 billion per year excess costs• 1.7 million patients per year

– 1 out of 20 patients

• 98,000 deaths per year– As many deaths as breast cancer and HIV/AIDS put

together– 6th leading cause of preventable deaths

http://oversight.house.gov/story.asp?id=186513

EVIDENCE-BASED BEHAVIORS TO PREVENT CLABSI

• Remove Unnecessary Lines

• Wash Hands Prior to Procedure

• Use Maximal Barrier Precautions

• Clean Skin with Chlorhexidine

• Avoid Femoral Lines

MMWR. 2002;51:RR-1014

Standardize

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CR-BSI Checklist

• Before the procedure, did they: – Wash hands – Sterilize procedure site

– Drape entire patient in a sterile fashion

• During the procedure, did they:– Use sterile gloves, mask and sterile gown– Maintain a sterile field

• Did all personnel assisting with procedure follow the above precautions

• Empowered nursing to stop the procedure if violation occurred

Crit Care Med 2004;32(10):2014. 16

Daily Goals

J Crit Care 2003;18(2):71-75

• What needs to be done for the patient to be discharged?

• What is the patients greatest safety risk?

• What can we do to reduce the risk?

• Can any tubes, lines, or drains be removed?

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Impact on Catheter-Related BSI

VAD Policy Checklist

Empower Nursing

Line Cart

Daily goals

Crit Care Med 2004;32(10):2014. 18

Time periodMedian

CRBSI rateIncidence rate ratio

Baseline 2.7 1Peri intervention 1.6 0.76

0-3 months 0 0.624-6 months 0 0.567-9 months 0 0.4710-12 months 0 0.4213-15 months 0 0.3716-18 months 0 0.34

Michigan Keystone ICU

N Engl J Med 2006;355:2725-32 19

Michigan Keystone ICU

Time period Median VAP Rate Incidence Rate RatioBaseline 5.5 1.0 (reference)

Intervention 0 0.590 – 3 months 0 0.674 – 6 months 0 0.477 – 9 months 0 0.47

10 – 12 months 0 0.3913 – 15 months 0 0.4816 – 18 months 0 0.5119 – 21 months 0 0.4422 – 24 months 0 0.3225 – 27 months 0 0.3428 – 30 months 0 0.28

Infect Control Hosp Epidemiol. 2010 (in press) 20

Principles of Safe Design Apply to Technical and Team Work

On the CUSP: Stop CAUTI

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Basic Components and Process of Communication

Dayton E, Henriksen K, Jt Comm J Qual Patient Saf, 2007.

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48% 48%54% 59%

83% 88% 90% 93%

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60

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L&D RN/O B O R RN/Surgeon ICU RN/MD CRNA/Anesthesiologist

Physicians and RN Collaboration

RN rates Physician Physician rates RN

% o

f res

pond

ents

repo

rtin

g ab

ove

adeq

uate

team

wor

k

L&D RN/MDL&D RN/MD ICU RN/MD OR RN/Surg CRNA/Anesth ICU RN/MD OR RN/Surg CRNA/Anesth

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Teamwork Tools

• Call list• Daily Goals• AM briefing• Shadowing

• Culture check up• TeamSTEPPS

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Systems

• Every system is designed to achieve the results it gets

• To improve performance we need to change systems

• Start with pilot test one patient, one day, one physician, one room

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Teams Make Wise Decisions When There is Diverse and Independent Input

• Wisdom of Crowds

• Alternate between convergent and divergent thinking

• Get from the dance floor to the balcony level

Heifetz R, Leadership Without Easy Answers,1994.

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Action Items

• Have all members of the CUSP CAUTI Team view the Science of Improving Patient Safety video

• Put together a roster of who on your unit needs to view the Science of Safety video

• Develop a plan to have all staff on your unit view the Science of Improving Patient Safety video– Assess what technologies you have available for staff to

view– Identify times for viewing it (e.g., staff meetings,

individual admin hours)

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