The Science of Improving Patient Safety

On the CUSP: Stop CAUTI

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Sean Berenholtz, MD MHSJohns Hopkins UniversityQuality and Safety Research Group

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CUSP/CAUTI Content Call #2 - The Science of SafetyModerator – Sam Watson; Speaker – Sean Berenholtz03/22/11 2 ET/1 CT/12 MT/11 PT Attendee: (866) 256-9295 60 Min.CUSP/CAUTI Content Call #3 - Care and Removal InterventionModerator – Sam Watson; Speaker – Mohamad Fakih04/05/11 2 ET/1 CT/12 MT/11 PT Attendee: (866) 256-9295 60 Min.CUSP/CAUTI Content Call #4 - Data CollectionModerator – Sam Watson; Speaker – Christine George04/19/11 2 ET/1 CT/12 MT/11 PT Attendee: (866) 256-9295 60 Min.CUSP/CAUTI Content Call #5 - The View from the BedsideModerator – Sam Watson; Speaker – Russ Olmsted05/03/11 2 ET/1 CT/12 MT/11 PT Attendee: (866) 256-9295 60 Min.CUSP/CAUTI Content Call #6 - Implementation in a Community HospitalModerator – Sam Watson; Speaker – Mary Jo Skiba05/17/11 2 ET/1 CT/12 MT/11 PT Attendee: (866) 256-9295 60 Min.

CUSP/CAUTI Content Call #1 – CUSP Moderator – Sam Watson; Speaker – Sean Berenholtz03/07/11 2 ET/1 CT/12 MT/11 PT Attendee: (866) 256-9295 60 Min.

CAUTI Content Call Schedule

The Marvel of Modern Medicine

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The Problem is Large• In U.S. Healthcare system

– 7% of patients suffer a medication error 2

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

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

– Nearly 100,000 deaths from HAIs 6

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

– Cost of HAIs is $28-33 billion 7

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

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

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Healthcare-Associated Infections: A Preventable Epidemic

• Focus on 4 HAIs: VAP, SSI, CRBSI, UTI• $5 billion per year excess costs• 1.7 million patients per year– 1 out of 20 patients

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

together– 6th leading cause of preventable deaths

http://oversight.house.gov/story.asp?id=1865

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How Can These Errors Happen?

• People are fallible• Medicine is still treated as an art, not science• Need to view the delivery of healthcare as a

science• Need systems that catch mistakes before they

reach the patient

Caregivers are not to blameCaregivers are not to blame

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

James Reason, Human Error, 1990

On the CUSP: Stop CAUTI

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System Factors Impact Safety

Hospital

Departmental Factors

Work Environment

Team Factors

Individual Provider

Task Factors

Patient Characteristics

Institutional

Adapted from VincentAdapted from Vincent

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Case Example

• 65 yo M s/p lung resection for cancer• Admit to ICU; discharged to floor POD 1• POD 3 develops hypoxia• Admitted to ICU, intubated• CXR shows extensive left lung collapse• Decision to perform broncoscopy

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System Failure Leading to Error

Bronch cart not stocked

Did not verify equipment availability

Communication betweenresident and nurse

Fatigue

Patient suffers

Hypoxic arrest

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Principles of Safe Design

• Standardize – Eliminate steps if possible

• Create independent checks• Learn when things go wrong

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

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Eliminate Steps

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Create Independent Checks

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Design Examples

Standardization Redundancy

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EVIDENCE-BASED BEHAVIORS TO PREVENT CLABSI

• Remove Unnecessary Lines• Wash Hands Prior to Procedure• Use Maximal Barrier Precautions• Clean Skin with Chlorhexidine • Avoid Femoral Lines

MMWR. 2002;51:RR-10

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Standardize

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CR-BSI Checklist

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

– Drape entire patient in a sterile fashion

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

• Did all personnel assisting with procedure follow the above precautions

• Empowered nursing to stop the procedure if violation occurred

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

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NEJM 2006, BMJ 2010

Michigan Keystone ICUMedian and Mean CRBSI Rate

0123456789

Time (months)

CR

BS

I R

ate

Median CRBSI Rate Mean CRBSI Rate

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Rhode Island ICU CLABSI Rates

Qual Saf Health Care 2010;19(6):555-561

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Improving Care for Ventilated Patients

• Semirecumbant positioning

• Peptic ulcer disease and DVT prophylaxis

• Appropriate sedation

• Daily assessment of readiness to extubate

• Oral care with antiseptics

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Improving Care for Ventilated Patients

• Educate staff

• Decrease complexity / create redundancy: – Standardized order sets and protocols– Daily goals checklist

• Other independent redundancies– Nursing and families– Are patients receiving the prevention they should?

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Daily Goals

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

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

• What is the patients greatest safety risk?

• What can we do to reduce the risk?

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

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Infect Control Hosp Epidemiol. 2011

Michigan Keystone ICUMichigan Keystone ICU

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Preventing Catheter-Associated Urinary Tract Infection

• Most common healthcare-associated infection (~ 40%) • Many urinary catheters used inappropriately 1

• Prevention guidelines:– HICPAC www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf– SHEA/IDSA: Infect Control Hosp Epid 2008;29:S41-S50

• Nurse-Led multidisciplinary rounds to reduce unnecessary urinary catheters 2

• Urinary catheter reminders and stop-orders decrease infection rates 3

1 Saint S, et al. Am J Med 20002 Fakih MG, et al. Infec Control Hosp Epi 20083 Meddings J et al. Clin Infect Dis 2010

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Principles of Safe Design Apply to Technical and Team Work

On the CUSP: Stop CAUTI

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Basic Components and Process of Communication

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

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Teamwork Tools

• Daily Goals• AM briefing• Shadowing

• Culture check up• TeamSTEPPS

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Teams Make Wise Decisions When There is Diverse and Independent Input

• Wisdom of Crowds

• Alternate between convergent and divergent thinking

• Get from the dance floor to the balcony level

Heifetz R, Leadership Without Easy Answers,1994.

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Summary• Develop lenses to see systems

• Understand principles of safe design – standardize, – create redundancies, – learn when things go wrong

• Recognize these principles apply to technical and team work

• Teams make wise decisions when there is diverse and independent input

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Action Items

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

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

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

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

individual admin hours)

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