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On the CUSP: Stop CAUTI. The Science of Improving Patient Safety. Sean Berenholtz, MD MHS Johns Hopkins University Quality and Safety Research Group. The Problem is Large. In U.S. Healthcare system 7% of patients suffer a medication error 2

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the science of improving patient safety

On the CUSP: Stop CAUTI

The Science of Improving Patient Safety

Sean Berenholtz, MD MHS

Johns Hopkins University

Quality and Safety Research Group

the problem is large
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.

rand study confirms continued quality gap
RAND Study Confirms Continued Quality Gap

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

healthcare associated infections a preventable epidemic
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

case is this death preventable
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
slide7

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

slide8

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

system failure leading to this error
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.

principles of safe design
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
healthcare associated infections a preventable epidemic13
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

evidence based behaviors to prevent clabsi
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

cr bsi checklist
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.

daily goals
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
impact on catheter related bsi
Impact on Catheter-Related BSI

VAD Policy

Line Cart

Checklist

Daily goals

Empower Nursing

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

18

slide19

Michigan Keystone ICU

N Engl J Med 2006;355:2725-32

19

slide20

Michigan Keystone ICU

Infect Control Hosp Epidemiol. 2010 (in press)

20

basic components and process of communication
Basic Components and Process of Communication

Dayton E, Henriksen K, JtComm J Qual Patient Saf, 2007.

22

slide23

% of respondents reporting above adequate teamwork

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

teamwork tools
Teamwork Tools
  • Call list
  • Daily Goals
  • AM briefing
  • Shadowing
  • Culture check up
  • TeamSTEPPS
systems
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
teams make wise decisions when there is diverse and independent input
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.

action items
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)