The Science of Improving Patient Safety

1. On the CUSP: Stop CAUTI The Science of Improving Patient Safety Sean Berenholtz, MD MHS Johns Hopkins University Quality and Safety Research Group

2. 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.

3. RAND Study Confirms Continued Quality Gap McGlynn EA, Asch SM, Adams J, et al., N Engl J Med, 2003.

4. 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

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

7. System is a set of parts interacting to achieve a goal “Every system is perfectly designed to achieve the results it gets” Caregivers are not to blame

8. On the CUSP: Stop CAUTI 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

9. System Failure Leading to This Error Communication between resident and nurse Inadequate training and supervision Catheter pulled with Patient sitting Lack of protocol For catheter removal Patient suffers Venous air embolism Pronovost PJ, Wu Aw, Sexton, JB et al., Ann Int Med, 2004. Reason J, Hobbs A., 2000.

10. 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

11. Eliminate Steps

12. Create Independent Checks

13. 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

14. 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

15. Standardize

16. 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.

17. Daily Goals • 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? • J Crit Care 2003;18(2):71-75

18. Impact on Catheter-Related BSI VAD Policy Line Cart Checklist Daily goals Empower Nursing Crit Care Med 2004;32(10):2014. 18

19. Michigan Keystone ICU N Engl J Med 2006;355:2725-32 19

20. Michigan Keystone ICU Infect Control Hosp Epidemiol. 2010 (in press) 20

21. On the CUSP: Stop CAUTI Principles of Safe Design Apply to Technical and Team Work

22. Basic Components and Process of Communication Dayton E, Henriksen K, JtComm J Qual Patient Saf, 2007. 22

23. % of respondents reporting above adequate teamwork L&D RN/MD ICU RN/MD OR RN/Surg CRNA/Anesth

24. Teamwork Tools • Call list • Daily Goals • AM briefing • Shadowing • Culture check up • TeamSTEPPS

25. Systems • Every system is designed to achieve the results it gets • To improve performance we need to change systems • Start with pilot test one patient, one day, one physician, one room

26. 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.

27. Action Items • Have all members of 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)