St. Joseph Mercy Health System Keystone ICU Collaborative:

Making your ICUs safer

The secret ingredients are culture and team

Pat Posa RN, BSN, MSASystem Performance Improvement Leader

St. Joseph Mercy Health SystemAnn Arbor, MI

patposa@comcast.net

Objectives

Review the purpose of the ICU Comprehensive Unit-Based Safety Program/CLABSI Initiative. Understand how your ICU and your hospital will benefit from participation.

Build the skills of physicians, nurses, and other care team to improve teamwork and build a safety culture.

Engage in discussion with national experts on best practices in reducing infections, preventing central line infections

Statewide initiative-75 Hospitals, 127 ICUsIn Collaboration with Johns Hopkins’Quality and Research InstituteReduce errors and improve patient outcomes in ICUsCombination of evidence based medicine and quality improvement5 interventions implemented over a 2 year Grant funded periodStill going strong after 6 years!!!!

Science of Safety(CUSP)

BSI VAP Daily Goals Sepsis Oral Care Delirium and

Progressive mobility

Partnership between Johns Hopkins University and MHAInitiated with AHRQ Matching Grant Sustained with participant fees in 2005 and 2006

St. Joseph Mercy StoryCUSP in the ICU and beyond

Preventing CLABSI in ICU and beyond

Building on CUSP and CLABSI for other workDaily goalsVAP preventionSepsis identification and management Intra-abdominal hypertension identification and

managementDelirium and Progressive mobility

Keystone ICU Team

Denise Harrison RN, MSN, Director of Critical Care

Christine Curran, MD, physician project leader

Mary-Anne Purtill MD, medical director SICU

Pat Posa RN, MSA, system performance improvement leader

Marco Hoesel MD, surgical resident

Amy Heeg RN, BSN CCU-Livingston

Brian Kurylo RN, CCU

Cathy Stewart RN, BSN, CCRN Resourse Pool

Diane Jones PA, cardiac surgery

David Holmes, cardiac surgery

Sondra RN CCU-Livingston

Andreea Sandu RN, MICU

Angie Malcolm RN, MICU

Michael Maher, RN, SICU

Emily McGee, RN, Case Nurse, SICU

Shikha Kapila, Pharm. D

Cheryl Morrin MPH, infection control

Chris Kiser, Pharmacy, Livingston

Beverly Bay-Jones, RRT, Resp Therapy

Tahnee Thibodeau., RD, MICU dietitican

Wendy Nieman RN, Project Impact

Start with:

Assess culture of safety---must get 60%+ return rate

Educate staff on science of safety

Identify defects

Assign executive to adopt unit

Learn from one defect per quarter

Implement team/communication tools

Reassess culture every 18 months- 2 years

Keep focus on this throughout the journey!!!

Understand system determines performance

Use strategies to improve system performanceStandardizeCreate Independent checks for key processLearn from Mistakes

Apply strategies to both technical work and team work.

Recognize that teams make wise decisions with diverse and independent input

How we do this:• Educate all personnel in all the ICU—RN, RT, residents, PA/NP• Educate the attending---difficult but important• Part of orientation

1. Tell us about the last patient who would have been harmed without your intervention.

2. How will the next patient be harmed?

3. What steps can you do to prevent this harm? by either preventing the mistake, making the mistake visible or

mitigating the harm should it occur

Safety Issues Survey

This is a very important tool. Use this to identify some of the‘whys’ mistakes are happening and what is impacting culture

Taking an identified patient safety issue from the frontline staff and create an action plan to resolve this is an early win for this program and staff buy-in

Learn from a Defect ToolDesigned to rigorously analyze the various components and conditions that contributed to an adverse event and is likely to be successful in the elimination of future occurrences.

Tool can serve to organize factors that may have contributed to the defect and provides a logical approach to breaking down faulty system issues.

Learn from a Defect Tool(LDT)Divided into three sections:

Section 1 asks the users to identify what happened or the defect they want to investigate

Section 2 is a framework provided for the investigators to identify any contributing factors. These factors include: patient, task, caregiver, and team related, training and education, local environment, information technology and institutional environment.

Section 3 asks participants to develop an action plan with assigned responsibility for task completion and follow up dates for each item.

Staff feedback

Event reporting

Quality and safety measures

Gaps in application of the evidence

Have staff complete short 3 question survey

Finding Defects to Learn From

Mistakes and near misses are defects

Have each ICU present learning from a defect each quarterNG placed in the lungsMissed respiratory treatments Delay in radiology tests for ICU pts

This is very hard to continue to do, we did it first for the first year. We didn’t keep it up----but are trying to get back to focusing on doing this. The biggest challenge is following up on each action plan giving the feedback to the staff.

Daily rounds/goals

Pre-procedure briefing

Morning briefing

Huddles

Learn from a defect

Executive Safety Rounds

Morbidity and Mortality Conference

Purpose: Improve communication among care team and family members regarding the patient’s plan of care

Goals should be specific and measurable

Documented where all care team members have access

Checklist used during rounds prompts caregivers to focus on what needs to be accomplished that day to safely move the patient closer to transfer out of the ICU

Measure effectiveness of rounds—team dynamics, communication

Interdisciplinary rounds with daily goals

Hardest initiative to implement, especially if you have an open unit and/or no intensivists

We had each unit create their own daily goal checklists---each unit culture and process is different. Changed this form multiple times---and in two units we gave up.

Focused first on create a daily goal and recording those either on the white board in the room or on a sheet of paper

One year ago: closed our MICU and started intensivist program in the SICU

Relooking at this again, and focusing on team dynamics and created a defined role for the nurse: survey and observation

Interdisciplinary rounds with daily goals---Challenges and Opportunities

Pre-procedure briefing• Make introductions• Discuss patient information and procedure• Agree upon a time for line insertion• Review best practice for line insertion (if necessary)• Nurse defines their role to physician: provide equipment, monitor

patient, provide patient comfort, observe for compliance with best practices and STOP procedure if sterile process compromised• Establish communication expectation for sterile procedure breaks• Examples include: your sleeve has touched the IV pole, the guide-

wire touched the headboard• Identify any special supply or procedural needs• Discuss any special patient issues (IE: patient confused, patient awake)• Answer any additional questionsTIME OUT: RIGHT PATIENT---RIGHT PROCEDURE

Used this when rolled out CLABSI bundle to non-ICU

Purpose: Increase communication between physicians and nursing staff while efficiently prioritizing patient care delivery and ICU admissions and discharges

What is it? A morning briefing is a dialogue between 2 or more

persons using concise and relevant information to promote effective communication prior to rounds

Morning Briefing

Have used this for a long time between charge nurses from shift to shift. Since we have closed the units, now this also

occurs with charge nurse and intensivist.

Tool: answer following questionsWhat happened overnight that I need to know

about?Where should I begin rounds? (patient that requires

immediate attention based on acuity)Which patients do you believe will be transferring

out of the unit today?Who has discharge orders written?How many admissions are planned today?What time is the first admission?

Morning Briefing

Enable teams to have frequent but short briefings so that they can stay informed, review work, make plans, and move ahead rapidly.

Allow fuller participation of front-line staff and bedside caregivers, who often find it impossible to get away for the conventional hour-long improvement team meetings.

They keep momentum going, as teams are able to meet more frequently.

Huddles

Beginning to use this strategy to begin to recovery immediately from defects---IE: falls, sepsis

CUSP-Challenges and StrategiesIssues Strategies

Engaging frontline staff (including off-shifts) owning this work

Part of team(especially night shift staff), bulletin boards, newsletters,

Timely follow through with identified defects or safety issues and strategies to resolve

Manager shares updates/status at staff meetings,

Continued engagement of the executive

MHA Keystone letters to executive, locally at each hospital—through one on one conversations

Implementing strategies and tools to help improve culture and teamwork

Learn from a defect, MDR with focus on communication, survey team members on perception of communication, morning briefings, debriefings

Continual learning from defects Have each unit learn from a defect quarterly and share at meetings

Lessons LearnedSpend sufficient time on CUSP before moving on to implementing practice changes

CUSP is the foundation and needs to be a continued focus-----forever!!!!

Must work on culture and team improvement strategies throughout the journey

CUSP must be unit based. Culture is different on each unit, therefore opportunities for improvement and strategies might be different

Define at beginning a communication plan that includes all levels of the organization

This work must be the responsibility of everyone, but important to have someone who’s job is to focus and drive this daily

Strategies to Improve CultureMultidisciplinary Rounds with Daily Goals

Closed MICU to only Intensivists

Surgical Intensivists Program-SICU

Learn from a defect

Define/implement Critical Care Standards of Nursing and Medical Practice

Standardize RN-RN Shift Handoff

Simulation Program—focus on teamwork and communication

ACLS certification

Critical Care Nurse Certification

Can we change practice through Can we change practice through process improvement alone?process improvement alone?

Can we change practice through Can we change practice through process improvement alone?process improvement alone?

or

Will successful change require Will successful change require an altering of the value structure an altering of the value structure

within the unit?within the unit?

Will successful change require Will successful change require an altering of the value structure an altering of the value structure

within the unit?within the unit?

Translating Evidence into Standard Practice

Translating Evidence into Practice Multidisciplinaryteam (Keystone ICU team) Including bedside RN and Physician champions

Reviewed evidence to define ‘best practice’ CLABSI prevention bundle

Gathered baseline dataImplemented the CLABSI Bundle Central line Checklist Line carts Empower nursing staff to identify and correct errors

(support of chief of surgery and medicine)Communication of new practice through medical and nursing committee structuresMeasure rates and Compliance with process

Central Line Associated Blood Stream Infection Rate:Infections per 1000 Line Days

Baseline 2004 2005 2006 2007 2008 2009ICUs Ann Arbor

7.6 6.12 2.2 1.2 1.25 0.95 0.66

MHA Keystone

7.7 2.51 1.51 1.25 1.17 0.98 0.89

Translating Evidence into Practice

Expanding beyond the ICU• Can’t have multiple standards for line insertion• All floors, ED, OR and anywhere they put in a line• Got a group together of non ICU providers to define a

process for line insertion• Pre-procedure briefing• Central line bag vs line cart

• Talk with medical and surgical residents and asked them what their barriers were to placing the lines following the best practice strategies

• Challenges with getting denominator: line days in the non-ICU area.

• Our focus now is the non-ICU CLABSI and understanding why they are happening

Getting to Zero and Sustaining the Gains

Monitor process and outcomes and provide information to team and staff

Try to understand ‘why’ if an infection occurs

Continue to evaluate the evidence

Apply additional evidence-based strategies as necessary based on the causes of the defect: CHG baths CHG dressing Antiseptic/antimicrobial catheters

After CLABSI—what was next?

Chose VAP prevention, since it was the other major HAI in the ICU

Ensure you have respiratory therapy on your team

Used same model for implementation Engage: what are our rates? and how many people are

dying---tell stories Educate: review the evidence and agree on the bundle

components, Execute: bedside tools, automatic orders for pts on the

vent Evaluate: prospective vent bundle rounding

Ventilator Pneumonia Prevention Bundle

HOB at 30 degreesWAKE UP AND BREATH Daily Spontaneous Breathing Trials Appropriate Sedation

PUD ProphylaxisDVT ProphylaxisGlucose ControlOral Care q 2 hours plus CHG rinse every 12 hrsDon’t routinely instill NS with suctioningHandling of suctioning and oral care equipmentUse of pulmonary specialty bedsSubglottal suctioningProgressive Mobility

Ventilator Associated Pneumonia:

Infections per 1000 Ventilator Days

Baseline 2004 2005 2006 2007 2008 2009

ICUs Ann Arbor

7.75 3.89 1.9 1.53 3.96 2.05 1.44

MHA Keystone

7.6 4.68 3.87 2.89 2.46 1.93 1.6

Challenges/Strategies with Vent Bundle

Issues Strategies

Sedation Holiday•Nurses fear that pt will be wild•No one’s responsibility

Daily vent bundle rounding, set specific time to do the holiday, link with SBT, understand why the nurses aren’t doing it,

SBT•RT staffing•Poor communication between RN-RT

Working with RT to define time to perform these that will result in patient being successful, discuss on rounds everyday

Glucose Control*lacking evidence for best target* Time consuming

Selected middle of road target, measure rate of hypoglycemia, revise targets based on new evidence

* Based on data for septicemia † Reflects hospital-wide cases of severe sepsis as defined by infection in the presence of organ dysfunction 1. Sands KE, Bates DW, Lanken PN, et al. Epidemiology of sepsis syndrome in 8 academic medical centers. JAMA 1997;278:234-40.2. National Vital Statistics Reports. 2005.3. Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: analysis of incidence,

outcome and associated costs of care. Crit Care Med 2001;29:1303-10.

Severe Sepsis: A Significant Healthcare Challenge

Major cause of morbidity and mortality worldwide Leading cause of death in noncoronary ICU (US)1

10th leading cause of death overall (US)2*

More than 750,000 cases of severe sepsis in the US annually3

In the US, more than 500 patients dieof severe sepsis daily3†

The Severe Sepsis Bundles: Surviving Sepsis Campaign/IHI

Management Bundle(To be accomplished as soon as possible over first

24 hours):

Low-dose steroids administered for septic shock in accordance with a standardized ICU policy. (Given to patients who respond poorly to fluids or vasopressors) (2C)

Drotrecogin alfa (activated) administered in accordance with a standardized ICU policy. (Given to patients with sepsis induced organ dysfunction at high risk of death (2B)

Glucose control maintained to < 150 mg/dL (8.3 mmol/L). (2C)

Tidal volume 6 ml/kg (1B) Inspiratory plateau pressures < 30 cmH2O for mechanically ventilated patients. (1C)

Resuscitation Bundle(To be accomplished as soon as possible over first 6 hours):

Serum lactate measured. Blood cultures obtained prior to antibiotics administered.

(1C) Perform imaging studies promptly to fine source (1C) From the time of presentation, broad- spectrum antibiotics

within 3 hours for ED admissions and 1 hour for non-ED ICU admissions. (1D/1B)

For hypotension and/or lactate > 4 mmol/L: Deliver an initial minimum of 20 mL/kg of crystalloid

(or colloid equivalent) (1C)Apply vasopressors for hypotension not responding to

initial fluid resuscitation to maintain MAP > 65 mmHg. For persistent hypotension despite initial fluid

resuscitation (septic shock) and/or lactate > 4 mmol/L: 1CAchieve CVP > 8 mmHg & MAP > 65 mmHg & UO

>0.5mL/kg/hrAchieve ScvO2 of > 70% or SvO2 > 65%.

if ScvO2 not > 70% blood or dobutamine (2C)Adapted from the revised guidelines: CCM 2008;36:296-327.

Organizational Consensus that Severe SepsisMust be Managed Early and Aggressively

Early Screening with Tools and Triggers

Implementation of the Sepsis Bundle

Measuring Success

4-Tier Process for Severe Sepsis Program Implementation©

Sepsis Solutions Int.

Severe SepsisScreening Tool

Septic Shock Clinical Pathway

Challenges/Strategies with Sepsis Program

Issues Strategies

Staff buy-in Part of team, Education frequently, daily rounds by sepsis program coordinator, data, data, data, executive physician support, executive management support

Identification of severe sepsis patient

Screening process, lactate rounds, RRT

Achieving interventions in timely manner

Bedside tools, pocket cards, education, daily rounding by sepsis program coordinator

Continual learning---work in progress. This program takes a long time to have it become the standard of

practice

Sepsis Mortality

Sepsis Program Outcomes

Severe Sepsis/Septic Shock65% of patients achieve resuscitation goals

within 6 hours of septic shock diagnosisHospital mortality: decrease from 45% to

26%Hospital average LOS: decrease from 26

days to 14 days

Lessons Learned- SepsisMust have program coordinator (like stroke and trauma) to oversee and lead this work. This person has to have leadership skill set and thick skin.

ICU medical leadership plays key role in physician buy-in

Frequent team meeting (twice a month)—lots of work by coordinator between meetings to ensure continued forward movement and buy-in

Employ all change management strategies

Data is hard to capture, but VITAL to move program forward

Keep executive management engaged---give them frequent data, have them help with removing barriers

ACCOUNTABILITY for all team members

What’s Next

Program lead (nurse and physician) continue to review literature and identify gaps in practice

Delirium

Progressive mobility

A Healthcare Imperative

“In medicine, as in any profession, we must grapple with systems, resources, circumstances, people-and our own shortcomings, as well. We face obstacles of seemingly endless variety. Yet somehow we must advance, we must refine, we must improve.”

Atul Gawande, Better: A Surgeon’s Notes on Performance

QUESTIONS ?????

Objectives

Review the purpose of the ICU Comprehensive Unit-Based Safety Program/CLABSI Initiative. Understand how your ICU and your hospital will benefit from participation.

Build the skills of physicians, nurses, and other care team to improve teamwork and build a safety culture.

Engage in discussion with national experts on best practices in reducing infections, preventing central line infections