“critical care management of cardiovascular patients” · “critical care management of...

ldquoCritical Care Management of

Cardiovascular Patientsrdquo

Glenn J R Whitman MD

Director CVSICU and Heart Transplant

Johns Hopkins Hospital

September 12 2016 1

Michigan Society of Thoracic and Cardiovascular Surgery

August 132016

Disclosures

bull Abbott Nutrition

September 12 2016 2

QUALITY AND

REPORTING

September 12 2016 3

Consumer Reports August 2014

September 12 2016 6

STS Star Ratings for

Coronary Bypass Surgery

NQF Report Metrics

1 Operative Mortality (Risk-Adjusted)

2 Major Morbidity (5 Risk-Adjusted variables)

RF Reop Stroke Mediastinitis Intub gt 24 hrs

3 Use of Internal Mammary Artery

4 Medications

o Pre-op Beta Blockers

o Discharge Beta Blockers

o Discharge Anti-Lipids

o Discharge Anti-Platelets

STS Composite Score

September 12 2016 9

It is all about ldquomorbidity and mortalityrdquo

0

5

10

15

20

25

30

35

40

To

tal

Ris

k B

ene

fit

Tim

ing

of

Surg

ery

Card

ioge

nic

Sh

ock

Ju

dg

me

nt

Cata

str

op

he

Heart

Fa

ilure

Myo

ca

rdia

l V

iabili

ty

Hig

h R

isk

To

tal

Te

chn

ical

Ju

dg

me

nt

Myca

rdia

l P

rote

ction

Myo

ca

rdia

l p

rote

ctio

n

Recog

nitio

n

Str

oke

To

tal

Respir

ato

ry

Sep

sis

Recog

nitio

n

Cata

str

op

he

Hem

odyn

am

ic M

ana

gem

en

t

Arr

hyth

mia

Man

ag

em

ent

Card

iac A

rrest

Card

ioge

nic

Sh

ock

Ris

k B

ene

fit

To

tal

Recog

nitio

n

Cata

str

op

he

Dysrh

yth

mia

Pha

rmaco

logic

al M

an

ag

em

en

t

Sep

sis

Ju

dg

me

nt

Respir

ato

ry

To

tal

Cata

str

op

he

PreOp IntraOp PostOp ICU PostOP Floor Discharge

Deaths by POCA Category and

Problem

Shannon FL1 Fazzalari FL Theurer PF Bell GF Sutcliffe KM Prager RL

Michigan Society of Thoracic and Cardiovascular Surgeons

Full Time Intensivists How It All

Began

September 12 2016 13

JAMA

19842522023

bull St Barnabas Hospital Bronx NY

bull 1979-1981 10 bed ICU n =1070

ICU Care Daytime Nighttime

Yr 1 Office based MD Agency MD board eligible

Yr 2 Full time MD (IMCards) Subspecialty Fellow

Benefit of On-Site Physician

Mortality Decreased (OR 062 p=001)

September 12 2016 14Li et al JAMA 19842522023

bull 26 Observational Trials staffing

patterns and outcomes

bull Staffing

bull Low Intensity no intensivistelective

consultation

bull High Intensity closed ICUmandatory

consult


Pronovost et al JAMA 20022882151

Staffing Patterns Matter in the ICU


FULL TIME INTENSIVIST ICU

STAFFING

bull Improves Mortality

bull Decreases Length of Stay

bull Improves Cost Efficiency


Fuchs et al

Clinical Anesthesiology 200519125-135

Effect of Multi-D Rounds and ICU Mortality

Kim M et al Arch Int Med

2010170369-376

Pa Hospitals n = 112

Patients = 108000

2004-2006

Low intensity Intensivist

optionalnone

Hi intensity

Intensivist mandatory

Multi-Dbull Pharmacy

bull Resp Therapy

bull Social Work

Date of download 1222014Copyright copy 2014 American Medical

Association All rights reserved

From Pharmacist Participation on Physician Rounds and Adverse Drug Events in the Intensive Care Unit

JAMA 1999282(3)267-270 doi101001jama2823267

Figure Legend

MICU CCU

366 recommendations

with a 95 acceptance rate

20

Pronovost JCC 20031871-75

Daily Goals Impact on ICU Care


N Engl J Med 2009 360(5)491-499

Selected Process Measures before and after Checklist Implementation According to Site

Years 2007- 2008

8 hospitals

8 countries

2 time intervals pre

and post checklist

Appr 3750 pts

group


Haynes AB et al N Engl J Med 2009360491-499


Outcomes before and after Checklist Implementation According to Site




0

10

20

30

40

50

60

70

80

90

100

Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Apr16 May16 Jun16

POD0 Complete

Signed

Goal

POD 0 Checklist Compliance

ICU TEAMWORK MATTERS


Cardiac Surgery Quality Assurance

Performance Improvement Committee (2009 ndash 2012)

bull First and Third Friday of Every Month

bull Representatives From

bull Attendings

bull Fellows

bull APrsquos both CVSICU and CVPCU

bull RespiratoryTherapy

bull Physical Therapy

bull Pharmacy

bull Nursing both CVSICU and CVPCU

bull Administration

bull Quality Improvement

INFLUENCE OF THE COMPREHENSIVE

UNITndashBASED SAFETY PROGRAM IN ICUS

EVIDENCE FROM THE KEYSTONE ICU

PROJECT


Hsu Y Marsteller J

Am J Med Qual 201631349-

357

CUSP Comprehensive Unit Based

Safety Program

bull CUSP Members

bull Team Leader

bull Physician Champion

bull Executive Champion

bull Nurse Manager

bull Infection Prevention Representative

bull Resp Therapy Environmental Invited

Stakeholders


CUSP

bull Monthly Meetings

bull Monthly Safety Rounds

bull Identify system defects

bull Develop safety and monitoring tools

bull Educate the staff

bull Present outcomes


0

10

20

30

40

50

60

70

Teamwork Safety Job Satisfaction Stress Recognition Perceptions of Mgmt Working Conditions Teamwork Safety Job Satisfaction Stress Recognition Perceptions of Mgmt Working Conditions

Non-CUSP ICUs CUSP ICUs

significantly positive difference

Hsu Y Marsteller J

American Journal of Medical Quality 201631349ndash357

Influence of CUSP on ICU Culture

Improvement in

bull Teamwork

bull Safety

bull Satisfaction

bull Environment

Teamwork Climate

The Effect of a Comprehensive Unit

Based Safety Program on CLABSI


Miller K et al 2016 Am J Infection Control

The Impact of ICU Structure and

Processes on Outcomes

bull Full Time Intensivists

bull Multidisciplinary Teams

bull Organization of Rounds

bull Checklists

bull Teamwork

bull Performance Improvement and

Metrics


0

5

10

15

20

25

30

35

40

1-6 6-12 12-24 24-48 gt48

Infe

cti

on

Rate

Post Op Vent Time (hrs)

Non-PNA Infxn

PNA

Post-Op SSI and PNA Rate in Open Heart

Surgery Patients

Johns Hopkins Hospital 112011 ndash 32014

(n = 2253)

Primary Outcome

Postoperative Overall Infection (n=127)

withwithout Vent time adjusted

Odds of

Infection

(95CI)

Without Vent

Timep-value

With Vent

Timep-value

Intraop + Postop

Transfusion

RBC

(unit)11(10-12) 004 10(09-11) 076

FFP 13 (08-22) 026 11(06-18) 081

Platelet 08(05-13) 034 08(05-14) 048

Cryo 12 (06-25) 060 12(04-32) 078

Preop

WBC11(10-11) lt0001 105(10-11) 0001

Preop

COPD33(22-50) lt0001 26(16-43) lt0001

Preop Crgt

15mgdL17(10-27) 004 134(08-22) 026

Adjusted variables were blood products previous cardiac surgery preoperative WBC value heart failure within 2 weeks prior to

surgery preoperative COPD preoperative serum creatinine CPB time and surgery type vs isolated CABG and postoperative

ventilation time Only values lt 005 are shown except for transfusions

1

25 26

147

0

2

4

6

8

10

12

14

16

0-12 12-24 24-48 48+O

dd

s o

f o

ve

rall

In

fec

tio

n

Postoperative Ventilation Time (hours)

ref

p=003p=0004

plt0001

0

5

10

15

20

25

30

35

JHH2008

STS Like2008

STS National2008

Patients Extubated lt6hrs

(CABG Only)

Early Extubation Performance at the

Johns Hopkins Hospital - 2008

0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

Patients Extubated

lt6hrs (CABG Only)

n= 1174

n= 637

STS National Average 2009 37

STS Like Institutions 2009 32

plt001 compared to JHH Period 1

Pre vs Post Implementation of New MV

Weaning Protocol

A Bow Around Your Finger

0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

JHH Period 3(912011-6302012)

n=1174

n=637

Ŧ



Patients Extubated

lt6hrs(CABG Only)

n=236

plt001 compared to JHH Period 1 Ŧ plt001 compared to JHH Period 2 Fitch ZW Debesa O Ohkuma R et al

J Thorac Cardiovasc Surg 2014 Apr 147(4)1344-50

Results Following Additional Protocol

Changes

12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)

STS Like Institutions 2014

plt001 compared to JHH Period 1 Ŧ plt001 compared to JHH Period 2

n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)

Extubation lt 6 Hours Current

Performance 2014


CVSICU Reasons For

Extubation gt6h

Hemodynamic Instability4 Hypoxia

3CVA or delirium

5

Bleeding20

Open chest ECMO17

Metabolic Acidosis28

Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110

Isolated CAB Morbidity

Failed to Prescribe All Eligible

Medications for Isolated CAB

54

If you donrsquot know your performance

you are not doing as well as you think you are

Intervention ndash PCR testing

bull Preoperative PCR testing for MRSA

ndash Nasal swab by PAs on preop visit

bull If positive

ndash Intranasal mupirocin bid

ndash Chlorhexidine baths

bull Both for 5 days (or as many days as possible preop

full course completed in ICU if necessary)

Overall SSI in CABG Patients

05 005

37

265

0

1

2

3

4

5

Pre-Intervention (n=1357) Intervention (n=1990)

Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients

Un-adjusted Adjusted

OR 95 CI p-value OR 95 CI p-value

Intervention Era 064 044 093 002 058 040 086 0007

MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

MRSA-Positive on ICU Admission

Univariate Multivariate


Intervention Era 05 037 074 lt0001 05 037 076 lt0001

MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14





MRSA ICU Transmission

Adjusted Poisson Regression MRSA transmissions

aIRR 95 CI P

Intervention era 029 013 065 0002

16

04

00

02

04

06

08

10

12

14

16

18

Pre-Intervention(14733 pt days)

Intervention(21467 pt days)

Incid

ence R

ate

per

1000 p

tdays

Staph Screening Miss CategoriesJuly 2016


1

2

2

3Transfer

True Miss

gt45 Days

Discontinued

Group but not Individual

Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)

CVSICU Hand Hygiene Compliance by Year

45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week

All Surgeons Combined

Weekly Transfusions with Corresponding Hgb for All

Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week

For a Single Surgeon


Procedures

Period 1 Period 2 Period 3

45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)


Percent of Transfusions at Increasing Hgb

Thresholds All Surgeons Combined

above Hgb of 8 gmdL

above Hgb of 9 gmdL

above Hgb of 10 gmdL

Denotes significantly different than period 1


Monthly Cardiac Surgery Dashboard

bull Vent Times

bull Reasons for ext gt 6 hrs

bull iNO vs Veletri hrs

bull HyperHypo glycemia

bull Checklist Compliance

bull Staph screening (with reasons

for misses)

bull Blood Utilization

bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights

bull Transfers gt 6 pm

bull Bouncebacks (Total lt 24 hrs)

with Reasons)


And Weekly Mortality and Morbidity

The Johns Hopkins Cardiac Surgery

Code of Conduct and Professional Behavior


Critical Care of the Cardiovascular PatientThe essentials for high quality

1 Full time intensivists

2 Structured Multi-D rounds (Pharmacy)

3 Nurse readbacks

4 Checklists

5 Culture of safetyteamwork (CUSP)

6 Performance improvement requires

bull Multidisciplinary input

bull Agreed upon targets

bull Review of outcomes

bull Continual reassessment

6 Individual accountability matters

Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18

ANY MORBIDITY(Total)

ProlongedVentilation

MultipleMorbidities

Reoperation Renal Failure CerebrovascularAccident

Deep SternalWound

Mediastinitis

2014 Jan 1 ndash Jun 30

bull Universal public reporting is inevitable

bull ICU care plays a major role in patient

outcomes


Surgeon-Reported Conflicts with Intensivists About

Postoperative Goals of Care

JAMA Surg 201314829-35

bull Vascular Neurologic and

Cardiothoracic Surgeons

bull Mail Questionnaire

bull 56 response rate n = 2100


Rates of Surgeon Reported ConflictsJAMA Surg 201314829-35


0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution

Count of Cardiac Surg

Count of Gen Surg CC

Count of Card Surg CC

Count of Anesth

Count of Anesth CC

Count of Cardiac Anesth

Count of Card Anesth CC

Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained

Heterogeneity of Specialties in Cardiac

Intensive Care Units

446537

556

75

889

1943

0 - 6 hrs 6 - 9 hrs 9 - 12 hrs 12 - 18 hrs 18 - 24 hrs gt 24 hrs

ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005

Unadjusted ICU Length of Stay

67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001

Unadjusted Hospital Length of Stay

Multidisciplinary Teams

Physician Nurse and ge 1 more Health Care

Professional

of Patients with Infection by

RBC Units Transfused2

7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+

Overall Infection Pneumonia Sepsis SSI

Total Number of RBC units Transfused

o

f p

ati

en

ts w

ith

In

fecti

on

significantly different (plt005) compared to no RBC exposure

Relationship between Infection

and Ventilation Time1

7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+

Ventilation Time vs Infection ()


Length of Mechanical Ventilation (hrs)

P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e

Note 48 of all infections occurred in patients with 48+ hours ventilation

significantly different (plt005) compared to vent time lt12 hrs group

Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP

bull Step 1 Safety Attitude Questionnaire (SAQ)

bull Step 2 Educate re Science of Improving

bull Step 3 Identify Defects ( events that should

not recur)

bull Step 4 Executive Partnership to ldquoBridge the

Gaprdquo

bull Step 5 Choose a Defect each Month that

poses a hazard

bull Step 6 ReassessSeptember 12 2016 80

Patients with BD lt -4 and

K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement

- Insight regarding what metric to target

- A sense of comfort to embark upon

new initiatives

- Involves ability to create consensus


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week


Weekly Transfusions with Corresponding Hgb for

CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion

bull Though recognizing that this is as yet untested the

perspective that comes with cardiothoracic surgical

training and practice best addresses the above

issues which face every cardiothoracic surgical team

and ICU

As a result thoracic surgeons

bull Should be the directors of the CTICU and

bull Should play an integral part in the delivery of day to day ICU

care


9122016 87

Procedure groups for which models exist bull Isolated CABG (CAB)

bull Isolated Aortic Valve Replacement (AVRepl)

bull Aortic Valve Replacement and CABG (AVRepl+CAB)

bull Isolated Mitral Valve Replacement (MVRepl)

bull Mitral Valve Replacement and CABG (MVRepl+CAB)

bull Isolated Mitral Valve Repair (MVRepr)

bull Mitral Valve Repair and CABG (MVRepr+CAB)

Model endpoints bull Operative Mortality

bull Stroke

bull Renal Failure

bull Prolonged Ventilation

bull Deep Sternal Wound Infection

bull Reoperation

bull MortalityMorbidity combined endpoint (any of the 6 previous endpoints)

bull Prolonged length of stay (length of stay gt14 days)

bull Short length of stay (length of stay lt 6 days

(Based on roughly 27 million patients)

Procedures for which the STS

database has a predictive model

Disclosures

bull Abbott Nutrition

September 12 2016 2

QUALITY AND

REPORTING

September 12 2016 3


September 12 2016 6



NQF Report Metrics





4 Medications





STS Composite Score

September 12 2016 9


0

5

10

15

20

25

30

35

40

To

tal

Ris

k B

ene

fit

Tim

ing

of

Surg

ery

Card

ioge

nic

Sh

ock

Ju

dg

me

nt

Cata

str

op

he

Heart

Fa

ilure

Myo

ca

rdia

l V

iabili

ty

Hig

h R

isk

To

tal

Te

chn

ical

Ju

dg

me

nt

Myca

rdia

l P

rote

ction

Myo

ca

rdia

l p

rote

ctio

n

Recog

nitio

n

Str

oke

To

tal

Respir

ato

ry

Sep

sis

Recog

nitio

n

Cata

str

op

he

Hem

odyn

am

ic M

ana

gem

en

t

Arr

hyth

mia

Man

ag

em

ent

Card

iac A

rrest

Card

ioge

nic

Sh

ock

Ris

k B

ene

fit

To

tal

Recog

nitio

n

Cata

str

op

he

Dysrh

yth

mia

Pha

rmaco

logic

al M

an

ag

em

en

t

Sep

sis

Ju

dg

me

nt

Respir

ato

ry

To

tal

Cata

str

op

he



Problem




Began


JAMA

19842522023


bull 1979-1981 10 bed ICU n =1070









bull Staffing


consultation


consult






STAFFING





Fuchs et al




2010170369-376


Patients = 108000

2004-2006


optionalnone

Hi intensity



bull Resp Therapy

bull Social Work




JAMA 1999282(3)267-270 doi101001jama2823267

Figure Legend

MICU CCU

366 recommendations


20




N Engl J Med 2009 360(5)491-499


Years 2007- 2008

8 hospitals

8 countries


and post checklist

Appr 3750 pts

group








0

10

20

30

40

50

60

70

80

90

100


POD0 Complete

Signed

Goal








bull Attendings

bull Fellows




bull Pharmacy


bull Administration





PROJECT


Hsu Y Marsteller J


357


Safety Program

bull CUSP Members

bull Team Leader



bull Nurse Manager



Stakeholders


CUSP








0

10

20

30

40

50

60

70




Hsu Y Marsteller J



Improvement in

bull Teamwork

bull Safety

bull Satisfaction

bull Environment

Teamwork Climate










bull Checklists

bull Teamwork


Metrics


0

5

10

15

20

25

30

35

40

1-6 6-12 12-24 24-48 gt48

Infe

cti

on

Rate


Non-PNA Infxn

PNA


Surgery Patients


(n = 2253)

Primary Outcome



Odds of

Infection

(95CI)

Without Vent

Timep-value

With Vent

Timep-value

Intraop + Postop

Transfusion

RBC

(unit)11(10-12) 004 10(09-11) 076

FFP 13 (08-22) 026 11(06-18) 081

Platelet 08(05-13) 034 08(05-14) 048

Cryo 12 (06-25) 060 12(04-32) 078

Preop

WBC11(10-11) lt0001 105(10-11) 0001

Preop

COPD33(22-50) lt0001 26(16-43) lt0001

Preop Crgt

15mgdL17(10-27) 004 134(08-22) 026




1

25 26

147

0

2

4

6

8

10

12

14

16

0-12 12-24 24-48 48+O

dd

s o

f o

ve

rall

In

fec

tio

n


ref

p=003p=0004

plt0001

0

5

10

15

20

25

30

35

JHH2008

STS Like2008

STS National2008


(CABG Only)



0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

Patients Extubated

lt6hrs (CABG Only)

n= 1174

n= 637





Weaning Protocol


0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

JHH Period 3(912011-6302012)

n=1174

n=637

Ŧ



Patients Extubated

lt6hrs(CABG Only)

n=236




Changes

12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)



n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)


Performance 2014


CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







QUALITY AND

REPORTING

September 12 2016 3


September 12 2016 6



NQF Report Metrics





4 Medications





STS Composite Score

September 12 2016 9


0

5

10

15

20

25

30

35

40

To

tal

Ris

k B

ene

fit

Tim

ing

of

Surg

ery

Card

ioge

nic

Sh

ock

Ju

dg

me

nt

Cata

str

op

he

Heart

Fa

ilure

Myo

ca

rdia

l V

iabili

ty

Hig

h R

isk

To

tal

Te

chn

ical

Ju

dg

me

nt

Myca

rdia

l P

rote

ction

Myo

ca

rdia

l p

rote

ctio

n

Recog

nitio

n

Str

oke

To

tal

Respir

ato

ry

Sep

sis

Recog

nitio

n

Cata

str

op

he

Hem

odyn

am

ic M

ana

gem

en

t

Arr

hyth

mia

Man

ag

em

ent

Card

iac A

rrest

Card

ioge

nic

Sh

ock

Ris

k B

ene

fit

To

tal

Recog

nitio

n

Cata

str

op

he

Dysrh

yth

mia

Pha

rmaco

logic

al M

an

ag

em

en

t

Sep

sis

Ju

dg

me

nt

Respir

ato

ry

To

tal

Cata

str

op

he



Problem




Began


JAMA

19842522023


bull 1979-1981 10 bed ICU n =1070









bull Staffing


consultation


consult






STAFFING





Fuchs et al




2010170369-376


Patients = 108000

2004-2006


optionalnone

Hi intensity



bull Resp Therapy

bull Social Work




JAMA 1999282(3)267-270 doi101001jama2823267

Figure Legend

MICU CCU

366 recommendations


20




N Engl J Med 2009 360(5)491-499


Years 2007- 2008

8 hospitals

8 countries


and post checklist

Appr 3750 pts

group








0

10

20

30

40

50

60

70

80

90

100


POD0 Complete

Signed

Goal








bull Attendings

bull Fellows




bull Pharmacy


bull Administration





PROJECT


Hsu Y Marsteller J


357


Safety Program

bull CUSP Members

bull Team Leader



bull Nurse Manager



Stakeholders


CUSP








0

10

20

30

40

50

60

70




Hsu Y Marsteller J



Improvement in

bull Teamwork

bull Safety

bull Satisfaction

bull Environment

Teamwork Climate










bull Checklists

bull Teamwork


Metrics


0

5

10

15

20

25

30

35

40

1-6 6-12 12-24 24-48 gt48

Infe

cti

on

Rate


Non-PNA Infxn

PNA


Surgery Patients


(n = 2253)

Primary Outcome



Odds of

Infection

(95CI)

Without Vent

Timep-value

With Vent

Timep-value

Intraop + Postop

Transfusion

RBC

(unit)11(10-12) 004 10(09-11) 076

FFP 13 (08-22) 026 11(06-18) 081

Platelet 08(05-13) 034 08(05-14) 048

Cryo 12 (06-25) 060 12(04-32) 078

Preop

WBC11(10-11) lt0001 105(10-11) 0001

Preop

COPD33(22-50) lt0001 26(16-43) lt0001

Preop Crgt

15mgdL17(10-27) 004 134(08-22) 026




1

25 26

147

0

2

4

6

8

10

12

14

16

0-12 12-24 24-48 48+O

dd

s o

f o

ve

rall

In

fec

tio

n


ref

p=003p=0004

plt0001

0

5

10

15

20

25

30

35

JHH2008

STS Like2008

STS National2008


(CABG Only)



0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

Patients Extubated

lt6hrs (CABG Only)

n= 1174

n= 637





Weaning Protocol


0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

JHH Period 3(912011-6302012)

n=1174

n=637

Ŧ



Patients Extubated

lt6hrs(CABG Only)

n=236




Changes

12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)



n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)


Performance 2014


CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation








September 12 2016 6



NQF Report Metrics





4 Medications





STS Composite Score

September 12 2016 9


0

5

10

15

20

25

30

35

40

To

tal

Ris

k B

ene

fit

Tim

ing

of

Surg

ery

Card

ioge

nic

Sh

ock

Ju

dg

me

nt

Cata

str

op

he

Heart

Fa

ilure

Myo

ca

rdia

l V

iabili

ty

Hig

h R

isk

To

tal

Te

chn

ical

Ju

dg

me

nt

Myca

rdia

l P

rote

ction

Myo

ca

rdia

l p

rote

ctio

n

Recog

nitio

n

Str

oke

To

tal

Respir

ato

ry

Sep

sis

Recog

nitio

n

Cata

str

op

he

Hem

odyn

am

ic M

ana

gem

en

t

Arr

hyth

mia

Man

ag

em

ent

Card

iac A

rrest

Card

ioge

nic

Sh

ock

Ris

k B

ene

fit

To

tal

Recog

nitio

n

Cata

str

op

he

Dysrh

yth

mia

Pha

rmaco

logic

al M

an

ag

em

en

t

Sep

sis

Ju

dg

me

nt

Respir

ato

ry

To

tal

Cata

str

op

he



Problem




Began


JAMA

19842522023


bull 1979-1981 10 bed ICU n =1070









bull Staffing


consultation


consult






STAFFING





Fuchs et al




2010170369-376


Patients = 108000

2004-2006


optionalnone

Hi intensity



bull Resp Therapy

bull Social Work




JAMA 1999282(3)267-270 doi101001jama2823267

Figure Legend

MICU CCU

366 recommendations


20




N Engl J Med 2009 360(5)491-499


Years 2007- 2008

8 hospitals

8 countries


and post checklist

Appr 3750 pts

group








0

10

20

30

40

50

60

70

80

90

100


POD0 Complete

Signed

Goal








bull Attendings

bull Fellows




bull Pharmacy


bull Administration





PROJECT


Hsu Y Marsteller J


357


Safety Program

bull CUSP Members

bull Team Leader



bull Nurse Manager



Stakeholders


CUSP








0

10

20

30

40

50

60

70




Hsu Y Marsteller J



Improvement in

bull Teamwork

bull Safety

bull Satisfaction

bull Environment

Teamwork Climate










bull Checklists

bull Teamwork


Metrics


0

5

10

15

20

25

30

35

40

1-6 6-12 12-24 24-48 gt48

Infe

cti

on

Rate


Non-PNA Infxn

PNA


Surgery Patients


(n = 2253)

Primary Outcome



Odds of

Infection

(95CI)

Without Vent

Timep-value

With Vent

Timep-value

Intraop + Postop

Transfusion

RBC

(unit)11(10-12) 004 10(09-11) 076

FFP 13 (08-22) 026 11(06-18) 081

Platelet 08(05-13) 034 08(05-14) 048

Cryo 12 (06-25) 060 12(04-32) 078

Preop

WBC11(10-11) lt0001 105(10-11) 0001

Preop

COPD33(22-50) lt0001 26(16-43) lt0001

Preop Crgt

15mgdL17(10-27) 004 134(08-22) 026




1

25 26

147

0

2

4

6

8

10

12

14

16

0-12 12-24 24-48 48+O

dd

s o

f o

ve

rall

In

fec

tio

n


ref

p=003p=0004

plt0001

0

5

10

15

20

25

30

35

JHH2008

STS Like2008

STS National2008


(CABG Only)



0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

Patients Extubated

lt6hrs (CABG Only)

n= 1174

n= 637





Weaning Protocol


0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

JHH Period 3(912011-6302012)

n=1174

n=637

Ŧ



Patients Extubated

lt6hrs(CABG Only)

n=236




Changes

12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)



n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)


Performance 2014


CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation









NQF Report Metrics





4 Medications





STS Composite Score

September 12 2016 9


0

5

10

15

20

25

30

35

40

To

tal

Ris

k B

ene

fit

Tim

ing

of

Surg

ery

Card

ioge

nic

Sh

ock

Ju

dg

me

nt

Cata

str

op

he

Heart

Fa

ilure

Myo

ca

rdia

l V

iabili

ty

Hig

h R

isk

To

tal

Te

chn

ical

Ju

dg

me

nt

Myca

rdia

l P

rote

ction

Myo

ca

rdia

l p

rote

ctio

n

Recog

nitio

n

Str

oke

To

tal

Respir

ato

ry

Sep

sis

Recog

nitio

n

Cata

str

op

he

Hem

odyn

am

ic M

ana

gem

en

t

Arr

hyth

mia

Man

ag

em

ent

Card

iac A

rrest

Card

ioge

nic

Sh

ock

Ris

k B

ene

fit

To

tal

Recog

nitio

n

Cata

str

op

he

Dysrh

yth

mia

Pha

rmaco

logic

al M

an

ag

em

en

t

Sep

sis

Ju

dg

me

nt

Respir

ato

ry

To

tal

Cata

str

op

he



Problem




Began


JAMA

19842522023


bull 1979-1981 10 bed ICU n =1070









bull Staffing


consultation


consult






STAFFING





Fuchs et al




2010170369-376


Patients = 108000

2004-2006


optionalnone

Hi intensity



bull Resp Therapy

bull Social Work




JAMA 1999282(3)267-270 doi101001jama2823267

Figure Legend

MICU CCU

366 recommendations


20




N Engl J Med 2009 360(5)491-499


Years 2007- 2008

8 hospitals

8 countries


and post checklist

Appr 3750 pts

group








0

10

20

30

40

50

60

70

80

90

100


POD0 Complete

Signed

Goal








bull Attendings

bull Fellows




bull Pharmacy


bull Administration





PROJECT


Hsu Y Marsteller J


357


Safety Program

bull CUSP Members

bull Team Leader



bull Nurse Manager



Stakeholders


CUSP








0

10

20

30

40

50

60

70




Hsu Y Marsteller J



Improvement in

bull Teamwork

bull Safety

bull Satisfaction

bull Environment

Teamwork Climate










bull Checklists

bull Teamwork


Metrics


0

5

10

15

20

25

30

35

40

1-6 6-12 12-24 24-48 gt48

Infe

cti

on

Rate


Non-PNA Infxn

PNA


Surgery Patients


(n = 2253)

Primary Outcome



Odds of

Infection

(95CI)

Without Vent

Timep-value

With Vent

Timep-value

Intraop + Postop

Transfusion

RBC

(unit)11(10-12) 004 10(09-11) 076

FFP 13 (08-22) 026 11(06-18) 081

Platelet 08(05-13) 034 08(05-14) 048

Cryo 12 (06-25) 060 12(04-32) 078

Preop

WBC11(10-11) lt0001 105(10-11) 0001

Preop

COPD33(22-50) lt0001 26(16-43) lt0001

Preop Crgt

15mgdL17(10-27) 004 134(08-22) 026




1

25 26

147

0

2

4

6

8

10

12

14

16

0-12 12-24 24-48 48+O

dd

s o

f o

ve

rall

In

fec

tio

n


ref

p=003p=0004

plt0001

0

5

10

15

20

25

30

35

JHH2008

STS Like2008

STS National2008


(CABG Only)



0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

Patients Extubated

lt6hrs (CABG Only)

n= 1174

n= 637





Weaning Protocol


0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

JHH Period 3(912011-6302012)

n=1174

n=637

Ŧ



Patients Extubated

lt6hrs(CABG Only)

n=236




Changes

12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)



n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)


Performance 2014


CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







STS Composite Score

September 12 2016 9


0

5

10

15

20

25

30

35

40

To

tal

Ris

k B

ene

fit

Tim

ing

of

Surg

ery

Card

ioge

nic

Sh

ock

Ju

dg

me

nt

Cata

str

op

he

Heart

Fa

ilure

Myo

ca

rdia

l V

iabili

ty

Hig

h R

isk

To

tal

Te

chn

ical

Ju

dg

me

nt

Myca

rdia

l P

rote

ction

Myo

ca

rdia

l p

rote

ctio

n

Recog

nitio

n

Str

oke

To

tal

Respir

ato

ry

Sep

sis

Recog

nitio

n

Cata

str

op

he

Hem

odyn

am

ic M

ana

gem

en

t

Arr

hyth

mia

Man

ag

em

ent

Card

iac A

rrest

Card

ioge

nic

Sh

ock

Ris

k B

ene

fit

To

tal

Recog

nitio

n

Cata

str

op

he

Dysrh

yth

mia

Pha

rmaco

logic

al M

an

ag

em

en

t

Sep

sis

Ju

dg

me

nt

Respir

ato

ry

To

tal

Cata

str

op

he



Problem




Began


JAMA

19842522023


bull 1979-1981 10 bed ICU n =1070









bull Staffing


consultation


consult






STAFFING





Fuchs et al




2010170369-376


Patients = 108000

2004-2006


optionalnone

Hi intensity



bull Resp Therapy

bull Social Work




JAMA 1999282(3)267-270 doi101001jama2823267

Figure Legend

MICU CCU

366 recommendations


20




N Engl J Med 2009 360(5)491-499


Years 2007- 2008

8 hospitals

8 countries


and post checklist

Appr 3750 pts

group








0

10

20

30

40

50

60

70

80

90

100


POD0 Complete

Signed

Goal








bull Attendings

bull Fellows




bull Pharmacy


bull Administration





PROJECT


Hsu Y Marsteller J


357


Safety Program

bull CUSP Members

bull Team Leader



bull Nurse Manager



Stakeholders


CUSP








0

10

20

30

40

50

60

70




Hsu Y Marsteller J



Improvement in

bull Teamwork

bull Safety

bull Satisfaction

bull Environment

Teamwork Climate










bull Checklists

bull Teamwork


Metrics


0

5

10

15

20

25

30

35

40

1-6 6-12 12-24 24-48 gt48

Infe

cti

on

Rate


Non-PNA Infxn

PNA


Surgery Patients


(n = 2253)

Primary Outcome



Odds of

Infection

(95CI)

Without Vent

Timep-value

With Vent

Timep-value

Intraop + Postop

Transfusion

RBC

(unit)11(10-12) 004 10(09-11) 076

FFP 13 (08-22) 026 11(06-18) 081

Platelet 08(05-13) 034 08(05-14) 048

Cryo 12 (06-25) 060 12(04-32) 078

Preop

WBC11(10-11) lt0001 105(10-11) 0001

Preop

COPD33(22-50) lt0001 26(16-43) lt0001

Preop Crgt

15mgdL17(10-27) 004 134(08-22) 026




1

25 26

147

0

2

4

6

8

10

12

14

16

0-12 12-24 24-48 48+O

dd

s o

f o

ve

rall

In

fec

tio

n


ref

p=003p=0004

plt0001

0

5

10

15

20

25

30

35

JHH2008

STS Like2008

STS National2008


(CABG Only)



0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

Patients Extubated

lt6hrs (CABG Only)

n= 1174

n= 637





Weaning Protocol


0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

JHH Period 3(912011-6302012)

n=1174

n=637

Ŧ



Patients Extubated

lt6hrs(CABG Only)

n=236




Changes

12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)



n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)


Performance 2014


CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







0

5

10

15

20

25

30

35

40

To

tal

Ris

k B

ene

fit

Tim

ing

of

Surg

ery

Card

ioge

nic

Sh

ock

Ju

dg

me

nt

Cata

str

op

he

Heart

Fa

ilure

Myo

ca

rdia

l V

iabili

ty

Hig

h R

isk

To

tal

Te

chn

ical

Ju

dg

me

nt

Myca

rdia

l P

rote

ction

Myo

ca

rdia

l p

rote

ctio

n

Recog

nitio

n

Str

oke

To

tal

Respir

ato

ry

Sep

sis

Recog

nitio

n

Cata

str

op

he

Hem

odyn

am

ic M

ana

gem

en

t

Arr

hyth

mia

Man

ag

em

ent

Card

iac A

rrest

Card

ioge

nic

Sh

ock

Ris

k B

ene

fit

To

tal

Recog

nitio

n

Cata

str

op

he

Dysrh

yth

mia

Pha

rmaco

logic

al M

an

ag

em

en

t

Sep

sis

Ju

dg

me

nt

Respir

ato

ry

To

tal

Cata

str

op

he



Problem




Began


JAMA

19842522023


bull 1979-1981 10 bed ICU n =1070









bull Staffing


consultation


consult






STAFFING





Fuchs et al




2010170369-376


Patients = 108000

2004-2006


optionalnone

Hi intensity



bull Resp Therapy

bull Social Work




JAMA 1999282(3)267-270 doi101001jama2823267

Figure Legend

MICU CCU

366 recommendations


20




N Engl J Med 2009 360(5)491-499


Years 2007- 2008

8 hospitals

8 countries


and post checklist

Appr 3750 pts

group








0

10

20

30

40

50

60

70

80

90

100


POD0 Complete

Signed

Goal








bull Attendings

bull Fellows




bull Pharmacy


bull Administration





PROJECT


Hsu Y Marsteller J


357


Safety Program

bull CUSP Members

bull Team Leader



bull Nurse Manager



Stakeholders


CUSP








0

10

20

30

40

50

60

70




Hsu Y Marsteller J



Improvement in

bull Teamwork

bull Safety

bull Satisfaction

bull Environment

Teamwork Climate










bull Checklists

bull Teamwork


Metrics


0

5

10

15

20

25

30

35

40

1-6 6-12 12-24 24-48 gt48

Infe

cti

on

Rate


Non-PNA Infxn

PNA


Surgery Patients


(n = 2253)

Primary Outcome



Odds of

Infection

(95CI)

Without Vent

Timep-value

With Vent

Timep-value

Intraop + Postop

Transfusion

RBC

(unit)11(10-12) 004 10(09-11) 076

FFP 13 (08-22) 026 11(06-18) 081

Platelet 08(05-13) 034 08(05-14) 048

Cryo 12 (06-25) 060 12(04-32) 078

Preop

WBC11(10-11) lt0001 105(10-11) 0001

Preop

COPD33(22-50) lt0001 26(16-43) lt0001

Preop Crgt

15mgdL17(10-27) 004 134(08-22) 026




1

25 26

147

0

2

4

6

8

10

12

14

16

0-12 12-24 24-48 48+O

dd

s o

f o

ve

rall

In

fec

tio

n


ref

p=003p=0004

plt0001

0

5

10

15

20

25

30

35

JHH2008

STS Like2008

STS National2008


(CABG Only)



0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

Patients Extubated

lt6hrs (CABG Only)

n= 1174

n= 637





Weaning Protocol


0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

JHH Period 3(912011-6302012)

n=1174

n=637

Ŧ



Patients Extubated

lt6hrs(CABG Only)

n=236




Changes

12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)



n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)


Performance 2014


CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation








Began


JAMA

19842522023


bull 1979-1981 10 bed ICU n =1070









bull Staffing


consultation


consult






STAFFING





Fuchs et al




2010170369-376


Patients = 108000

2004-2006


optionalnone

Hi intensity



bull Resp Therapy

bull Social Work




JAMA 1999282(3)267-270 doi101001jama2823267

Figure Legend

MICU CCU

366 recommendations


20




N Engl J Med 2009 360(5)491-499


Years 2007- 2008

8 hospitals

8 countries


and post checklist

Appr 3750 pts

group








0

10

20

30

40

50

60

70

80

90

100


POD0 Complete

Signed

Goal








bull Attendings

bull Fellows




bull Pharmacy


bull Administration





PROJECT


Hsu Y Marsteller J


357


Safety Program

bull CUSP Members

bull Team Leader



bull Nurse Manager



Stakeholders


CUSP








0

10

20

30

40

50

60

70




Hsu Y Marsteller J



Improvement in

bull Teamwork

bull Safety

bull Satisfaction

bull Environment

Teamwork Climate










bull Checklists

bull Teamwork


Metrics


0

5

10

15

20

25

30

35

40

1-6 6-12 12-24 24-48 gt48

Infe

cti

on

Rate


Non-PNA Infxn

PNA


Surgery Patients


(n = 2253)

Primary Outcome



Odds of

Infection

(95CI)

Without Vent

Timep-value

With Vent

Timep-value

Intraop + Postop

Transfusion

RBC

(unit)11(10-12) 004 10(09-11) 076

FFP 13 (08-22) 026 11(06-18) 081

Platelet 08(05-13) 034 08(05-14) 048

Cryo 12 (06-25) 060 12(04-32) 078

Preop

WBC11(10-11) lt0001 105(10-11) 0001

Preop

COPD33(22-50) lt0001 26(16-43) lt0001

Preop Crgt

15mgdL17(10-27) 004 134(08-22) 026




1

25 26

147

0

2

4

6

8

10

12

14

16

0-12 12-24 24-48 48+O

dd

s o

f o

ve

rall

In

fec

tio

n


ref

p=003p=0004

plt0001

0

5

10

15

20

25

30

35

JHH2008

STS Like2008

STS National2008


(CABG Only)



0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

Patients Extubated

lt6hrs (CABG Only)

n= 1174

n= 637





Weaning Protocol


0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

JHH Period 3(912011-6302012)

n=1174

n=637

Ŧ



Patients Extubated

lt6hrs(CABG Only)

n=236




Changes

12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)



n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)


Performance 2014


CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation












bull Staffing


consultation


consult






STAFFING





Fuchs et al




2010170369-376


Patients = 108000

2004-2006


optionalnone

Hi intensity



bull Resp Therapy

bull Social Work




JAMA 1999282(3)267-270 doi101001jama2823267

Figure Legend

MICU CCU

366 recommendations


20




N Engl J Med 2009 360(5)491-499


Years 2007- 2008

8 hospitals

8 countries


and post checklist

Appr 3750 pts

group








0

10

20

30

40

50

60

70

80

90

100


POD0 Complete

Signed

Goal








bull Attendings

bull Fellows




bull Pharmacy


bull Administration





PROJECT


Hsu Y Marsteller J


357


Safety Program

bull CUSP Members

bull Team Leader



bull Nurse Manager



Stakeholders


CUSP








0

10

20

30

40

50

60

70




Hsu Y Marsteller J



Improvement in

bull Teamwork

bull Safety

bull Satisfaction

bull Environment

Teamwork Climate










bull Checklists

bull Teamwork


Metrics


0

5

10

15

20

25

30

35

40

1-6 6-12 12-24 24-48 gt48

Infe

cti

on

Rate


Non-PNA Infxn

PNA


Surgery Patients


(n = 2253)

Primary Outcome



Odds of

Infection

(95CI)

Without Vent

Timep-value

With Vent

Timep-value

Intraop + Postop

Transfusion

RBC

(unit)11(10-12) 004 10(09-11) 076

FFP 13 (08-22) 026 11(06-18) 081

Platelet 08(05-13) 034 08(05-14) 048

Cryo 12 (06-25) 060 12(04-32) 078

Preop

WBC11(10-11) lt0001 105(10-11) 0001

Preop

COPD33(22-50) lt0001 26(16-43) lt0001

Preop Crgt

15mgdL17(10-27) 004 134(08-22) 026




1

25 26

147

0

2

4

6

8

10

12

14

16

0-12 12-24 24-48 48+O

dd

s o

f o

ve

rall

In

fec

tio

n


ref

p=003p=0004

plt0001

0

5

10

15

20

25

30

35

JHH2008

STS Like2008

STS National2008


(CABG Only)



0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

Patients Extubated

lt6hrs (CABG Only)

n= 1174

n= 637





Weaning Protocol


0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

JHH Period 3(912011-6302012)

n=1174

n=637

Ŧ



Patients Extubated

lt6hrs(CABG Only)

n=236




Changes

12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)



n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)


Performance 2014


CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation










STAFFING





Fuchs et al




2010170369-376


Patients = 108000

2004-2006


optionalnone

Hi intensity



bull Resp Therapy

bull Social Work




JAMA 1999282(3)267-270 doi101001jama2823267

Figure Legend

MICU CCU

366 recommendations


20




N Engl J Med 2009 360(5)491-499


Years 2007- 2008

8 hospitals

8 countries


and post checklist

Appr 3750 pts

group








0

10

20

30

40

50

60

70

80

90

100


POD0 Complete

Signed

Goal








bull Attendings

bull Fellows




bull Pharmacy


bull Administration





PROJECT


Hsu Y Marsteller J


357


Safety Program

bull CUSP Members

bull Team Leader



bull Nurse Manager



Stakeholders


CUSP








0

10

20

30

40

50

60

70




Hsu Y Marsteller J



Improvement in

bull Teamwork

bull Safety

bull Satisfaction

bull Environment

Teamwork Climate










bull Checklists

bull Teamwork


Metrics


0

5

10

15

20

25

30

35

40

1-6 6-12 12-24 24-48 gt48

Infe

cti

on

Rate


Non-PNA Infxn

PNA


Surgery Patients


(n = 2253)

Primary Outcome



Odds of

Infection

(95CI)

Without Vent

Timep-value

With Vent

Timep-value

Intraop + Postop

Transfusion

RBC

(unit)11(10-12) 004 10(09-11) 076

FFP 13 (08-22) 026 11(06-18) 081

Platelet 08(05-13) 034 08(05-14) 048

Cryo 12 (06-25) 060 12(04-32) 078

Preop

WBC11(10-11) lt0001 105(10-11) 0001

Preop

COPD33(22-50) lt0001 26(16-43) lt0001

Preop Crgt

15mgdL17(10-27) 004 134(08-22) 026




1

25 26

147

0

2

4

6

8

10

12

14

16

0-12 12-24 24-48 48+O

dd

s o

f o

ve

rall

In

fec

tio

n


ref

p=003p=0004

plt0001

0

5

10

15

20

25

30

35

JHH2008

STS Like2008

STS National2008


(CABG Only)



0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

Patients Extubated

lt6hrs (CABG Only)

n= 1174

n= 637





Weaning Protocol


0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

JHH Period 3(912011-6302012)

n=1174

n=637

Ŧ



Patients Extubated

lt6hrs(CABG Only)

n=236




Changes

12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)



n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)


Performance 2014


CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation









2010170369-376


Patients = 108000

2004-2006


optionalnone

Hi intensity



bull Resp Therapy

bull Social Work




JAMA 1999282(3)267-270 doi101001jama2823267

Figure Legend

MICU CCU

366 recommendations


20




N Engl J Med 2009 360(5)491-499


Years 2007- 2008

8 hospitals

8 countries


and post checklist

Appr 3750 pts

group








0

10

20

30

40

50

60

70

80

90

100


POD0 Complete

Signed

Goal








bull Attendings

bull Fellows




bull Pharmacy


bull Administration





PROJECT


Hsu Y Marsteller J


357


Safety Program

bull CUSP Members

bull Team Leader



bull Nurse Manager



Stakeholders


CUSP








0

10

20

30

40

50

60

70




Hsu Y Marsteller J



Improvement in

bull Teamwork

bull Safety

bull Satisfaction

bull Environment

Teamwork Climate










bull Checklists

bull Teamwork


Metrics


0

5

10

15

20

25

30

35

40

1-6 6-12 12-24 24-48 gt48

Infe

cti

on

Rate


Non-PNA Infxn

PNA


Surgery Patients


(n = 2253)

Primary Outcome



Odds of

Infection

(95CI)

Without Vent

Timep-value

With Vent

Timep-value

Intraop + Postop

Transfusion

RBC

(unit)11(10-12) 004 10(09-11) 076

FFP 13 (08-22) 026 11(06-18) 081

Platelet 08(05-13) 034 08(05-14) 048

Cryo 12 (06-25) 060 12(04-32) 078

Preop

WBC11(10-11) lt0001 105(10-11) 0001

Preop

COPD33(22-50) lt0001 26(16-43) lt0001

Preop Crgt

15mgdL17(10-27) 004 134(08-22) 026




1

25 26

147

0

2

4

6

8

10

12

14

16

0-12 12-24 24-48 48+O

dd

s o

f o

ve

rall

In

fec

tio

n


ref

p=003p=0004

plt0001

0

5

10

15

20

25

30

35

JHH2008

STS Like2008

STS National2008


(CABG Only)



0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

Patients Extubated

lt6hrs (CABG Only)

n= 1174

n= 637





Weaning Protocol


0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

JHH Period 3(912011-6302012)

n=1174

n=637

Ŧ



Patients Extubated

lt6hrs(CABG Only)

n=236




Changes

12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)



n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)


Performance 2014


CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation










JAMA 1999282(3)267-270 doi101001jama2823267

Figure Legend

MICU CCU

366 recommendations


20




N Engl J Med 2009 360(5)491-499


Years 2007- 2008

8 hospitals

8 countries


and post checklist

Appr 3750 pts

group








0

10

20

30

40

50

60

70

80

90

100


POD0 Complete

Signed

Goal








bull Attendings

bull Fellows




bull Pharmacy


bull Administration





PROJECT


Hsu Y Marsteller J


357


Safety Program

bull CUSP Members

bull Team Leader



bull Nurse Manager



Stakeholders


CUSP








0

10

20

30

40

50

60

70




Hsu Y Marsteller J



Improvement in

bull Teamwork

bull Safety

bull Satisfaction

bull Environment

Teamwork Climate










bull Checklists

bull Teamwork


Metrics


0

5

10

15

20

25

30

35

40

1-6 6-12 12-24 24-48 gt48

Infe

cti

on

Rate


Non-PNA Infxn

PNA


Surgery Patients


(n = 2253)

Primary Outcome



Odds of

Infection

(95CI)

Without Vent

Timep-value

With Vent

Timep-value

Intraop + Postop

Transfusion

RBC

(unit)11(10-12) 004 10(09-11) 076

FFP 13 (08-22) 026 11(06-18) 081

Platelet 08(05-13) 034 08(05-14) 048

Cryo 12 (06-25) 060 12(04-32) 078

Preop

WBC11(10-11) lt0001 105(10-11) 0001

Preop

COPD33(22-50) lt0001 26(16-43) lt0001

Preop Crgt

15mgdL17(10-27) 004 134(08-22) 026




1

25 26

147

0

2

4

6

8

10

12

14

16

0-12 12-24 24-48 48+O

dd

s o

f o

ve

rall

In

fec

tio

n


ref

p=003p=0004

plt0001

0

5

10

15

20

25

30

35

JHH2008

STS Like2008

STS National2008


(CABG Only)



0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

Patients Extubated

lt6hrs (CABG Only)

n= 1174

n= 637





Weaning Protocol


0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

JHH Period 3(912011-6302012)

n=1174

n=637

Ŧ



Patients Extubated

lt6hrs(CABG Only)

n=236




Changes

12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)



n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)


Performance 2014


CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







20




N Engl J Med 2009 360(5)491-499


Years 2007- 2008

8 hospitals

8 countries


and post checklist

Appr 3750 pts

group








0

10

20

30

40

50

60

70

80

90

100


POD0 Complete

Signed

Goal








bull Attendings

bull Fellows




bull Pharmacy


bull Administration





PROJECT


Hsu Y Marsteller J


357


Safety Program

bull CUSP Members

bull Team Leader



bull Nurse Manager



Stakeholders


CUSP








0

10

20

30

40

50

60

70




Hsu Y Marsteller J



Improvement in

bull Teamwork

bull Safety

bull Satisfaction

bull Environment

Teamwork Climate










bull Checklists

bull Teamwork


Metrics


0

5

10

15

20

25

30

35

40

1-6 6-12 12-24 24-48 gt48

Infe

cti

on

Rate


Non-PNA Infxn

PNA


Surgery Patients


(n = 2253)

Primary Outcome



Odds of

Infection

(95CI)

Without Vent

Timep-value

With Vent

Timep-value

Intraop + Postop

Transfusion

RBC

(unit)11(10-12) 004 10(09-11) 076

FFP 13 (08-22) 026 11(06-18) 081

Platelet 08(05-13) 034 08(05-14) 048

Cryo 12 (06-25) 060 12(04-32) 078

Preop

WBC11(10-11) lt0001 105(10-11) 0001

Preop

COPD33(22-50) lt0001 26(16-43) lt0001

Preop Crgt

15mgdL17(10-27) 004 134(08-22) 026




1

25 26

147

0

2

4

6

8

10

12

14

16

0-12 12-24 24-48 48+O

dd

s o

f o

ve

rall

In

fec

tio

n


ref

p=003p=0004

plt0001

0

5

10

15

20

25

30

35

JHH2008

STS Like2008

STS National2008


(CABG Only)



0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

Patients Extubated

lt6hrs (CABG Only)

n= 1174

n= 637





Weaning Protocol


0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

JHH Period 3(912011-6302012)

n=1174

n=637

Ŧ



Patients Extubated

lt6hrs(CABG Only)

n=236




Changes

12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)



n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)


Performance 2014


CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation










N Engl J Med 2009 360(5)491-499


Years 2007- 2008

8 hospitals

8 countries


and post checklist

Appr 3750 pts

group








0

10

20

30

40

50

60

70

80

90

100


POD0 Complete

Signed

Goal








bull Attendings

bull Fellows




bull Pharmacy


bull Administration





PROJECT


Hsu Y Marsteller J


357


Safety Program

bull CUSP Members

bull Team Leader



bull Nurse Manager



Stakeholders


CUSP








0

10

20

30

40

50

60

70




Hsu Y Marsteller J



Improvement in

bull Teamwork

bull Safety

bull Satisfaction

bull Environment

Teamwork Climate










bull Checklists

bull Teamwork


Metrics


0

5

10

15

20

25

30

35

40

1-6 6-12 12-24 24-48 gt48

Infe

cti

on

Rate


Non-PNA Infxn

PNA


Surgery Patients


(n = 2253)

Primary Outcome



Odds of

Infection

(95CI)

Without Vent

Timep-value

With Vent

Timep-value

Intraop + Postop

Transfusion

RBC

(unit)11(10-12) 004 10(09-11) 076

FFP 13 (08-22) 026 11(06-18) 081

Platelet 08(05-13) 034 08(05-14) 048

Cryo 12 (06-25) 060 12(04-32) 078

Preop

WBC11(10-11) lt0001 105(10-11) 0001

Preop

COPD33(22-50) lt0001 26(16-43) lt0001

Preop Crgt

15mgdL17(10-27) 004 134(08-22) 026




1

25 26

147

0

2

4

6

8

10

12

14

16

0-12 12-24 24-48 48+O

dd

s o

f o

ve

rall

In

fec

tio

n


ref

p=003p=0004

plt0001

0

5

10

15

20

25

30

35

JHH2008

STS Like2008

STS National2008


(CABG Only)



0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

Patients Extubated

lt6hrs (CABG Only)

n= 1174

n= 637





Weaning Protocol


0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

JHH Period 3(912011-6302012)

n=1174

n=637

Ŧ



Patients Extubated

lt6hrs(CABG Only)

n=236




Changes

12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)



n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)


Performance 2014


CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation














0

10

20

30

40

50

60

70

80

90

100


POD0 Complete

Signed

Goal








bull Attendings

bull Fellows




bull Pharmacy


bull Administration





PROJECT


Hsu Y Marsteller J


357


Safety Program

bull CUSP Members

bull Team Leader



bull Nurse Manager



Stakeholders


CUSP








0

10

20

30

40

50

60

70




Hsu Y Marsteller J



Improvement in

bull Teamwork

bull Safety

bull Satisfaction

bull Environment

Teamwork Climate










bull Checklists

bull Teamwork


Metrics


0

5

10

15

20

25

30

35

40

1-6 6-12 12-24 24-48 gt48

Infe

cti

on

Rate


Non-PNA Infxn

PNA


Surgery Patients


(n = 2253)

Primary Outcome



Odds of

Infection

(95CI)

Without Vent

Timep-value

With Vent

Timep-value

Intraop + Postop

Transfusion

RBC

(unit)11(10-12) 004 10(09-11) 076

FFP 13 (08-22) 026 11(06-18) 081

Platelet 08(05-13) 034 08(05-14) 048

Cryo 12 (06-25) 060 12(04-32) 078

Preop

WBC11(10-11) lt0001 105(10-11) 0001

Preop

COPD33(22-50) lt0001 26(16-43) lt0001

Preop Crgt

15mgdL17(10-27) 004 134(08-22) 026




1

25 26

147

0

2

4

6

8

10

12

14

16

0-12 12-24 24-48 48+O

dd

s o

f o

ve

rall

In

fec

tio

n


ref

p=003p=0004

plt0001

0

5

10

15

20

25

30

35

JHH2008

STS Like2008

STS National2008


(CABG Only)



0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

Patients Extubated

lt6hrs (CABG Only)

n= 1174

n= 637





Weaning Protocol


0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

JHH Period 3(912011-6302012)

n=1174

n=637

Ŧ



Patients Extubated

lt6hrs(CABG Only)

n=236




Changes

12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)



n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)


Performance 2014


CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation













bull Attendings

bull Fellows




bull Pharmacy


bull Administration





PROJECT


Hsu Y Marsteller J


357


Safety Program

bull CUSP Members

bull Team Leader



bull Nurse Manager



Stakeholders


CUSP








0

10

20

30

40

50

60

70




Hsu Y Marsteller J



Improvement in

bull Teamwork

bull Safety

bull Satisfaction

bull Environment

Teamwork Climate










bull Checklists

bull Teamwork


Metrics


0

5

10

15

20

25

30

35

40

1-6 6-12 12-24 24-48 gt48

Infe

cti

on

Rate


Non-PNA Infxn

PNA


Surgery Patients


(n = 2253)

Primary Outcome



Odds of

Infection

(95CI)

Without Vent

Timep-value

With Vent

Timep-value

Intraop + Postop

Transfusion

RBC

(unit)11(10-12) 004 10(09-11) 076

FFP 13 (08-22) 026 11(06-18) 081

Platelet 08(05-13) 034 08(05-14) 048

Cryo 12 (06-25) 060 12(04-32) 078

Preop

WBC11(10-11) lt0001 105(10-11) 0001

Preop

COPD33(22-50) lt0001 26(16-43) lt0001

Preop Crgt

15mgdL17(10-27) 004 134(08-22) 026




1

25 26

147

0

2

4

6

8

10

12

14

16

0-12 12-24 24-48 48+O

dd

s o

f o

ve

rall

In

fec

tio

n


ref

p=003p=0004

plt0001

0

5

10

15

20

25

30

35

JHH2008

STS Like2008

STS National2008


(CABG Only)



0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

Patients Extubated

lt6hrs (CABG Only)

n= 1174

n= 637





Weaning Protocol


0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

JHH Period 3(912011-6302012)

n=1174

n=637

Ŧ



Patients Extubated

lt6hrs(CABG Only)

n=236




Changes

12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)



n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)


Performance 2014


CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation










PROJECT


Hsu Y Marsteller J


357


Safety Program

bull CUSP Members

bull Team Leader



bull Nurse Manager



Stakeholders


CUSP








0

10

20

30

40

50

60

70




Hsu Y Marsteller J



Improvement in

bull Teamwork

bull Safety

bull Satisfaction

bull Environment

Teamwork Climate










bull Checklists

bull Teamwork


Metrics


0

5

10

15

20

25

30

35

40

1-6 6-12 12-24 24-48 gt48

Infe

cti

on

Rate


Non-PNA Infxn

PNA


Surgery Patients


(n = 2253)

Primary Outcome



Odds of

Infection

(95CI)

Without Vent

Timep-value

With Vent

Timep-value

Intraop + Postop

Transfusion

RBC

(unit)11(10-12) 004 10(09-11) 076

FFP 13 (08-22) 026 11(06-18) 081

Platelet 08(05-13) 034 08(05-14) 048

Cryo 12 (06-25) 060 12(04-32) 078

Preop

WBC11(10-11) lt0001 105(10-11) 0001

Preop

COPD33(22-50) lt0001 26(16-43) lt0001

Preop Crgt

15mgdL17(10-27) 004 134(08-22) 026




1

25 26

147

0

2

4

6

8

10

12

14

16

0-12 12-24 24-48 48+O

dd

s o

f o

ve

rall

In

fec

tio

n


ref

p=003p=0004

plt0001

0

5

10

15

20

25

30

35

JHH2008

STS Like2008

STS National2008


(CABG Only)



0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

Patients Extubated

lt6hrs (CABG Only)

n= 1174

n= 637





Weaning Protocol


0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

JHH Period 3(912011-6302012)

n=1174

n=637

Ŧ



Patients Extubated

lt6hrs(CABG Only)

n=236




Changes

12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)



n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)


Performance 2014


CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation








Safety Program

bull CUSP Members

bull Team Leader



bull Nurse Manager



Stakeholders


CUSP








0

10

20

30

40

50

60

70




Hsu Y Marsteller J



Improvement in

bull Teamwork

bull Safety

bull Satisfaction

bull Environment

Teamwork Climate










bull Checklists

bull Teamwork


Metrics


0

5

10

15

20

25

30

35

40

1-6 6-12 12-24 24-48 gt48

Infe

cti

on

Rate


Non-PNA Infxn

PNA


Surgery Patients


(n = 2253)

Primary Outcome



Odds of

Infection

(95CI)

Without Vent

Timep-value

With Vent

Timep-value

Intraop + Postop

Transfusion

RBC

(unit)11(10-12) 004 10(09-11) 076

FFP 13 (08-22) 026 11(06-18) 081

Platelet 08(05-13) 034 08(05-14) 048

Cryo 12 (06-25) 060 12(04-32) 078

Preop

WBC11(10-11) lt0001 105(10-11) 0001

Preop

COPD33(22-50) lt0001 26(16-43) lt0001

Preop Crgt

15mgdL17(10-27) 004 134(08-22) 026




1

25 26

147

0

2

4

6

8

10

12

14

16

0-12 12-24 24-48 48+O

dd

s o

f o

ve

rall

In

fec

tio

n


ref

p=003p=0004

plt0001

0

5

10

15

20

25

30

35

JHH2008

STS Like2008

STS National2008


(CABG Only)



0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

Patients Extubated

lt6hrs (CABG Only)

n= 1174

n= 637





Weaning Protocol


0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

JHH Period 3(912011-6302012)

n=1174

n=637

Ŧ



Patients Extubated

lt6hrs(CABG Only)

n=236




Changes

12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)



n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)


Performance 2014


CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







CUSP








0

10

20

30

40

50

60

70




Hsu Y Marsteller J



Improvement in

bull Teamwork

bull Safety

bull Satisfaction

bull Environment

Teamwork Climate










bull Checklists

bull Teamwork


Metrics


0

5

10

15

20

25

30

35

40

1-6 6-12 12-24 24-48 gt48

Infe

cti

on

Rate


Non-PNA Infxn

PNA


Surgery Patients


(n = 2253)

Primary Outcome



Odds of

Infection

(95CI)

Without Vent

Timep-value

With Vent

Timep-value

Intraop + Postop

Transfusion

RBC

(unit)11(10-12) 004 10(09-11) 076

FFP 13 (08-22) 026 11(06-18) 081

Platelet 08(05-13) 034 08(05-14) 048

Cryo 12 (06-25) 060 12(04-32) 078

Preop

WBC11(10-11) lt0001 105(10-11) 0001

Preop

COPD33(22-50) lt0001 26(16-43) lt0001

Preop Crgt

15mgdL17(10-27) 004 134(08-22) 026




1

25 26

147

0

2

4

6

8

10

12

14

16

0-12 12-24 24-48 48+O

dd

s o

f o

ve

rall

In

fec

tio

n


ref

p=003p=0004

plt0001

0

5

10

15

20

25

30

35

JHH2008

STS Like2008

STS National2008


(CABG Only)



0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

Patients Extubated

lt6hrs (CABG Only)

n= 1174

n= 637





Weaning Protocol


0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

JHH Period 3(912011-6302012)

n=1174

n=637

Ŧ



Patients Extubated

lt6hrs(CABG Only)

n=236




Changes

12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)



n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)


Performance 2014


CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







0

10

20

30

40

50

60

70




Hsu Y Marsteller J



Improvement in

bull Teamwork

bull Safety

bull Satisfaction

bull Environment

Teamwork Climate










bull Checklists

bull Teamwork


Metrics


0

5

10

15

20

25

30

35

40

1-6 6-12 12-24 24-48 gt48

Infe

cti

on

Rate


Non-PNA Infxn

PNA


Surgery Patients


(n = 2253)

Primary Outcome



Odds of

Infection

(95CI)

Without Vent

Timep-value

With Vent

Timep-value

Intraop + Postop

Transfusion

RBC

(unit)11(10-12) 004 10(09-11) 076

FFP 13 (08-22) 026 11(06-18) 081

Platelet 08(05-13) 034 08(05-14) 048

Cryo 12 (06-25) 060 12(04-32) 078

Preop

WBC11(10-11) lt0001 105(10-11) 0001

Preop

COPD33(22-50) lt0001 26(16-43) lt0001

Preop Crgt

15mgdL17(10-27) 004 134(08-22) 026




1

25 26

147

0

2

4

6

8

10

12

14

16

0-12 12-24 24-48 48+O

dd

s o

f o

ve

rall

In

fec

tio

n


ref

p=003p=0004

plt0001

0

5

10

15

20

25

30

35

JHH2008

STS Like2008

STS National2008


(CABG Only)



0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

Patients Extubated

lt6hrs (CABG Only)

n= 1174

n= 637





Weaning Protocol


0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

JHH Period 3(912011-6302012)

n=1174

n=637

Ŧ



Patients Extubated

lt6hrs(CABG Only)

n=236




Changes

12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)



n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)


Performance 2014


CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







Teamwork Climate










bull Checklists

bull Teamwork


Metrics


0

5

10

15

20

25

30

35

40

1-6 6-12 12-24 24-48 gt48

Infe

cti

on

Rate


Non-PNA Infxn

PNA


Surgery Patients


(n = 2253)

Primary Outcome



Odds of

Infection

(95CI)

Without Vent

Timep-value

With Vent

Timep-value

Intraop + Postop

Transfusion

RBC

(unit)11(10-12) 004 10(09-11) 076

FFP 13 (08-22) 026 11(06-18) 081

Platelet 08(05-13) 034 08(05-14) 048

Cryo 12 (06-25) 060 12(04-32) 078

Preop

WBC11(10-11) lt0001 105(10-11) 0001

Preop

COPD33(22-50) lt0001 26(16-43) lt0001

Preop Crgt

15mgdL17(10-27) 004 134(08-22) 026




1

25 26

147

0

2

4

6

8

10

12

14

16

0-12 12-24 24-48 48+O

dd

s o

f o

ve

rall

In

fec

tio

n


ref

p=003p=0004

plt0001

0

5

10

15

20

25

30

35

JHH2008

STS Like2008

STS National2008


(CABG Only)



0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

Patients Extubated

lt6hrs (CABG Only)

n= 1174

n= 637





Weaning Protocol


0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

JHH Period 3(912011-6302012)

n=1174

n=637

Ŧ



Patients Extubated

lt6hrs(CABG Only)

n=236




Changes

12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)



n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)


Performance 2014


CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation
















bull Checklists

bull Teamwork


Metrics


0

5

10

15

20

25

30

35

40

1-6 6-12 12-24 24-48 gt48

Infe

cti

on

Rate


Non-PNA Infxn

PNA


Surgery Patients


(n = 2253)

Primary Outcome



Odds of

Infection

(95CI)

Without Vent

Timep-value

With Vent

Timep-value

Intraop + Postop

Transfusion

RBC

(unit)11(10-12) 004 10(09-11) 076

FFP 13 (08-22) 026 11(06-18) 081

Platelet 08(05-13) 034 08(05-14) 048

Cryo 12 (06-25) 060 12(04-32) 078

Preop

WBC11(10-11) lt0001 105(10-11) 0001

Preop

COPD33(22-50) lt0001 26(16-43) lt0001

Preop Crgt

15mgdL17(10-27) 004 134(08-22) 026




1

25 26

147

0

2

4

6

8

10

12

14

16

0-12 12-24 24-48 48+O

dd

s o

f o

ve

rall

In

fec

tio

n


ref

p=003p=0004

plt0001

0

5

10

15

20

25

30

35

JHH2008

STS Like2008

STS National2008


(CABG Only)



0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

Patients Extubated

lt6hrs (CABG Only)

n= 1174

n= 637





Weaning Protocol


0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

JHH Period 3(912011-6302012)

n=1174

n=637

Ŧ



Patients Extubated

lt6hrs(CABG Only)

n=236




Changes

12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)



n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)


Performance 2014


CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







0

5

10

15

20

25

30

35

40

1-6 6-12 12-24 24-48 gt48

Infe

cti

on

Rate


Non-PNA Infxn

PNA


Surgery Patients


(n = 2253)

Primary Outcome



Odds of

Infection

(95CI)

Without Vent

Timep-value

With Vent

Timep-value

Intraop + Postop

Transfusion

RBC

(unit)11(10-12) 004 10(09-11) 076

FFP 13 (08-22) 026 11(06-18) 081

Platelet 08(05-13) 034 08(05-14) 048

Cryo 12 (06-25) 060 12(04-32) 078

Preop

WBC11(10-11) lt0001 105(10-11) 0001

Preop

COPD33(22-50) lt0001 26(16-43) lt0001

Preop Crgt

15mgdL17(10-27) 004 134(08-22) 026




1

25 26

147

0

2

4

6

8

10

12

14

16

0-12 12-24 24-48 48+O

dd

s o

f o

ve

rall

In

fec

tio

n


ref

p=003p=0004

plt0001

0

5

10

15

20

25

30

35

JHH2008

STS Like2008

STS National2008


(CABG Only)



0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

Patients Extubated

lt6hrs (CABG Only)

n= 1174

n= 637





Weaning Protocol


0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

JHH Period 3(912011-6302012)

n=1174

n=637

Ŧ



Patients Extubated

lt6hrs(CABG Only)

n=236




Changes

12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)



n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)


Performance 2014


CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







Primary Outcome



Odds of

Infection

(95CI)

Without Vent

Timep-value

With Vent

Timep-value

Intraop + Postop

Transfusion

RBC

(unit)11(10-12) 004 10(09-11) 076

FFP 13 (08-22) 026 11(06-18) 081

Platelet 08(05-13) 034 08(05-14) 048

Cryo 12 (06-25) 060 12(04-32) 078

Preop

WBC11(10-11) lt0001 105(10-11) 0001

Preop

COPD33(22-50) lt0001 26(16-43) lt0001

Preop Crgt

15mgdL17(10-27) 004 134(08-22) 026




1

25 26

147

0

2

4

6

8

10

12

14

16

0-12 12-24 24-48 48+O

dd

s o

f o

ve

rall

In

fec

tio

n


ref

p=003p=0004

plt0001

0

5

10

15

20

25

30

35

JHH2008

STS Like2008

STS National2008


(CABG Only)



0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

Patients Extubated

lt6hrs (CABG Only)

n= 1174

n= 637





Weaning Protocol


0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

JHH Period 3(912011-6302012)

n=1174

n=637

Ŧ



Patients Extubated

lt6hrs(CABG Only)

n=236




Changes

12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)



n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)


Performance 2014


CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







0

5

10

15

20

25

30

35

JHH2008

STS Like2008

STS National2008


(CABG Only)



0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

Patients Extubated

lt6hrs (CABG Only)

n= 1174

n= 637





Weaning Protocol


0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

JHH Period 3(912011-6302012)

n=1174

n=637

Ŧ



Patients Extubated

lt6hrs(CABG Only)

n=236




Changes

12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)



n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)


Performance 2014


CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

Patients Extubated

lt6hrs (CABG Only)

n= 1174

n= 637





Weaning Protocol


0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

JHH Period 3(912011-6302012)

n=1174

n=637

Ŧ



Patients Extubated

lt6hrs(CABG Only)

n=236




Changes

12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)



n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)


Performance 2014


CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation








0

5

10

15

20

25

30

35

40

45

50

JHH Period 1(132005-9292009)

JHH Period 2(1012009-8312011)

JHH Period 3(912011-6302012)

n=1174

n=637

Ŧ



Patients Extubated

lt6hrs(CABG Only)

n=236




Changes

12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)



n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)


Performance 2014


CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







12

24

38

51

0

10

20

30

40

50

60

JHH Period 1 (132005-9292009)

JHH Period 2 (1012009-8312011)

JHH Period 3 (912011-6302012)

JHH Period 4 (112014-8152014)



n=236

n=637

n=1174

n=236

Ŧ

Patients Extubated

lt6hrs(CABG Only)


Performance 2014


CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation








CVSICU Reasons For

Extubation gt6h


3CVA or delirium

5

Bleeding20

Open chest ECMO17


Other23

CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







CVSICU Arrival Temp

1215

5

137

14 13 11 11 10 118

0

20

40

60

80

100


Temp gt35

Temp lt 350

0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







0

2

4

6

8

10

12

14

16

18

2013 n=390

2014 n=348

2015 n=469

Q1-2016 n=110




54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation









54






bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation










bull If positive






05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation








05 005

37

265

0

1

2

3

4

5


Non-MRSA

MRSA42

27

Perc

enta

ge o

f C

AB

G p

atients




MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







MRSA ICU Admissions

26

14

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns





MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







MRSA ICU Admissions

10

26

04

0

1

2

3


Perc

enta

ge o

f IC

U A

dm

issio

ns

No PCR

PCR Screened

14







aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation









aIRR 95 CI P


16

04

00

02

04

06

08

10

12

14

16

18



Incid

ence R

ate

per

1000 p

tdays



1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation









1

2

2

3Transfer

True Miss

gt45 Days

Discontinued


Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation








Accountability


65

74

81

71

87 8892

0

10

20

30

40

50

60

70

80

90

100

2009 2010 2011 2012 2013 2014 2015 (Jan-March)


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures

Period 1 Period 2

45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







45

67

89

10

11

12

13

14

15

Hg

b(g

msd

L)

1 2 3 4 5 6 7 8 9 10 11 12131415 16171819 20212223 24 25

Week



Procedures


45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25

Week



Procedures


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL





bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation








bull Vent Times






for misses)


bull CVSICU arrival

bull K+

bull Temp

bull Base Deficit

bull Daily Weights



with Reasons)









3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation













3 Nurse readbacks

4 Checklists








Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis




outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation









outcomes




JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation









JAMA Surg 201314829-35








0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation









0

1

2

3

4

1 2 3 4 5 6 7 8 9 10

Institution




Count of Anesth

Count of Anesth CC



Count of Pulm CC

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic

radic = CT trained



446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







446537

556

75

889

1943


ICU

Sta

y(h

rs)

me

an

plusmnS

D

Intubation Duration

p lt 001

p = 070

p = 005


67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







67 7

8

85

13


Hospital S

tay

(days)

media

n

(IQ

R)

Intubation Duration

p lt 001

p lt 001

p lt 001




Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation









Professional



7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation









7

26 3

2

44

90

12

5

21 2

6

26

39

70

12

5

03

00 02 03

17

11

06

00 04 05 1

0

00

0 1 2 3-5 6-9 10+



o

f p

ati

en

ts w

ith

In

fecti

on




7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation









7

43 46

24

1

13

36 39

20

9

01

02 07

35

04

05

00

23

0-12 12-24 24-48 48+




P

ati

en

ts w

ith

Infe

cti

on

by T

yp

e



Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







Isolated CABG

Post Op Morbidities

0

2

4

6

8

10

12

14

16

18



MultipleMorbidities


Deep SternalWound

Mediastinitis

2013

2014

n= 390

n= 181


2013 and 2014

The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







The Tenets of CUSP




not recur)


Gaprdquo


poses a hazard



K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation








K lt 33 by Month

21

01

2

0 0

6

01

2

00

5

10

15

20

25

30

35

40


Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







Quality Improvement



new initiatives



45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







45

67

89

10

11

12

13

14

15

Hg

b(g

md

L)

1 2 3 4 5 6 7 8 9 10 11 12131415161718192021222324 25

Week



CABG Patients


02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







02

04

06

0

Tra

nsfu

sed

(

)




above Hgb of 8 gmdL

above Hgb of 9 gmdL




Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







Conclusion





and ICU




care


9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







9122016 87









bull Stroke

bull Renal Failure



bull Reoperation







“critical care management of cardiovascular patients” · “critical care management of...

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