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Evolving a Culture of Patient Safety

Evolving a Culture of Patient Safety. Lessons from the Elimination of CLABS Allegheny General Hospital Pittsburgh Regional Healthcare Initiative. The Key Message. The data must not only be reportable, but actionable.

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Evolving a Culture of Patient Safety

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  1. Evolving a Culture of Patient Safety Lessons from the Elimination of CLABS Allegheny General Hospital Pittsburgh Regional Healthcare Initiative

  2. The Key Message • The data must not only be reportable, but actionable. • You can come surprisingly close to eliminating hospital acquired infections with determination as opposed to resources. • Hospital acquired infections are costing hospitals and society millions of dollars, illustrating the conspiracy of error and waste .

  3. Who Are We? • We are a 600 bed tertiary care teaching, hospital in Pittsburgh. • 25,000 admissions with 6 ICU • The MICU and CCU are contiguous units with 28 beds and about 1750 admissions each year. • Cardiology and pulmonary fellows and categorical Internal Medicine Residents

  4. What Did We Know (or think we knew) Before? • Our results were average and average is ok. • CLABs are evitable. It is the price you pay for sophisticated, complex care. • CLABs are benign and readily treated with antibiotics. • CLABs are a common accompaniment of complex care and covered in outlier payments.

  5. Problems With Bench MarkingThe Difference Between Reporting and Actionable Data NNIS CCU/MICU PRHI

  6. Where Would You Want to Have a Central line Placed?

  7. What Does 5.1 infections/ 1000 line days Really Mean?? • 37 patients • 49 infections • 193 lines were employed (5.2 lines / patient) • 1753 admissions • 1063 patients had central access for more than 12 hours • 1 out of 28 patients with a central line became infected.

  8. What Does 5.1 infections/ 1000 line days Really Mean?? • Blood Isolates • Coagulase (-) Staph 17 (35%) • Staph aureus 15 (30%) • MRSA 10 (67%) • Candida species 9 (19%) • Gram negative rods 8 (16%)

  9. What Did We Learn ? • We were reporting only half of the actual CLABs. • Central lines had a 3% chance of blood stream infection. • Two-thirds of the infections involved virulent organisms . Twenty percent were MRSA. • 19/37 patients died (51%).

  10. What Not to Do? • Don’t blame • Don’t form another committee • Make everybody responsible (not just the infection control officer !) • Resist the temptation to meet / embrace the desire to act • At the start, there are no right answers

  11. What Did We Do?PPC • Step 1: Make data actionable • Step 2: Observe variations in work • Step 3: Real time problem solving • Step 4: Implement and test countermeasures

  12. Toyota Production SystemRules in Use • Activity (specified as to content sequence, timing, location, expected outcome) • Connections (direct and unambiguous) • Pathways (predefined, simple and direct) • Improvement (highly specified under the guidance of a mentor, at the level of the work, toward an ideal)

  13. The Rules of TPS Applied to Healthcare • Work (line placement and maintenance) should be highly specified such that variations/problems are immediately apparent. • When problems (CLABs) are encountered, they should be solved to root cause in real time by the people doing the work. • When a worker cannot solve a problem, they invoke the help chain to solve the problem.

  14. Setting/Attending to Goals • Goal de jour • “Some is not a number..soon is not a time” • Ambitious

  15. Variation in the Course of Work (Line Placement) • No standard pre-procedure checklist • Informed consent in 25% of procedures • Eight different ways to “gown and glove” • Six different ways to “prep and drape” • Four different approaches to central veins • Five different insertion kits • 55% of procedures were documented

  16. Variation in the Course of Work (Line Maintenance) • No specified role • No standardized definitions of “site at risk” • No standardized dressing kit • No standardized procedure for dressing change • No standard record of line location and duration.

  17. Why is Disorder Condoned? • Genetic variation • The concept of individual care • Physician autonomy

  18. Genetic Variation: Highly Overrated • Human genome: 27,000 genes • Murine genome: 24,000 genes • Drosophilia genome: 19,000 genes It’s Quality not Quantity that Counts

  19. R IJ infection (7/7) (MRSA) R fem infection (7/8) (E.Coli) Groshon catheter infection (7/9) Lines present on transfer (7/9) Re-wiring of line Catheter left in for > 96 hours Catheter choice Duration of line placement Real Time Problem SolvingJuly 2003 Infection Cause Root Cause Established Within 24 Hours

  20. Introducer linked and rewired Fem line in place > 96 hrs Patient transferred with line in place for 21 days Infected Groshon catheter Dysfunctional catheters should be replaced, not rewired Replace all femoral lines within 12 hours Replace line present on transfer Subclavian or PICC line preferred Understanding Problems Leads to Solutions Real Time Problem Solving Countermeasures

  21. FY 2003 Traditional Approach FY 2004 PPC Approach ICU Admissions (n) 1753 1798 Patientswith CLABs (n) 37 6 Age (years) 62 (24-80) 62 (50-74) Gender (male/female) 22/15 3/3 TotalCLABS 49 6 Linedays 4683 5052 Overallrates (infections /1000 line days) 10.5 1.2 RatesreportedtoNNIS (infections /1000 line days) 5.1 1.2 Deaths in patients with CLABs 19 (51%) 1 (16%) ComparativeResults Risk of CLAB 1 in 28 1 in 185

  22. Line Skills Lines for a long time Difficult access Education / Credentialing BioPatch dressings SonoSite ultrasound Micropuncture kits Vascular access team Antibiotic locks Additional Countermeasures Real Time Problem Solving Countermeasures

  23. Summary • CLABs are a common, morbid and mortal complication of ICU care • Femoral lines contribute significantly to the problem and should be considered in the NNIS definition • CLABs can be eliminated (nearly).

  24. Drivers of Change • Moral: it’s the right thing to do • Scientific: It works • Practical: It can be done in your hospital, not just a research setting • Economics: What’s the impact on the hospital’s and system’s bottom line?

  25. The Conspiracy of Error and Waste • What is the cost of a CLAB in human and financial terms? • What does society pay for healthcare associated infections (HAI)? • Do hospitals and physicians make money on HAIs ?

  26. Case 1: • 37 year old video game programmer, father of 4, admitted with acute pancreatitis secondary to hypertriglyceridemia. • Day 3: developed hypotension, and respiratory failure • Day 6 : fever and blood cultures positive for MRSA secondary to a femoral vein catheter in place for 4 days. • Multiple infectious complications requiring exploratory laparotomy and eventually tracheostomy • Day 86: Discharged to nursing home • Highmark Select Blue

  27. CLAB Transfer 5/04/02 M. S. 2/07/02 2/12/02 Day 1 6 86

  28. Case 3 Charges and Costs Attributable to CLAB

  29. The Impact of CLABs on Gross Margin

  30. Case 3 • 49 year old obese female was admitted for elective surgical gastroplasty. • She developed respiratory distress post operatively and was intubated for respiratory failure. • On day 22, blood cultures were positive for Staph epidermidis, enterococcus fecaelis, and Candida. • The right femoral line tip grew all three organisms. The line was in place for 16 days. • On hospital day 48, she was transferred to a SNF. • Medicare/ Three Rivers

  31. CLAB 2/10/03 Transfer 3/08/03 1/20/03 Day 1 22 48

  32. Case 1 Charges and Costs Attributable to CLAB

  33. The Impact of CLABs on Gross Margin

  34. CLABS Scorecard

  35. The Human and Economic Costs of Nosocomial Infections * Defined by Infection Control ** no routine surveillance

  36. AGH Losses Associated with Nosocomial Infections Gross Margins (FY 04) Actual Projected Based Upon Underreporting Saving (90% Reduction) CLAB (n=72) (-$1,049,184) (-$1,748,640) [$944,265] VAP (n=33) (-$567,171) (-$2,268,684) [$510,453] MRSA (n=188) (-$8,127,428) (-$12,130,489) [$7,314,685] Loss associated with nosocomial infections (-$9,743,783) [$8,769,403] (-16,147,813)

  37. What Could You Do With $10 million? • Hire 166 nurses or ICPs • Hire 200 respiratory techs • Hire 220 more interns • Give all 3,500 employees a $2,857 raise • Buy 2.5 million BioPatch dressings • Insure one thousand uninsured Americans • Treat 8,000 Haitians with HIV

  38. Progress: It Can Be Infectious • Initiatives now across all units • VAPs reduced by 70% • CLABs reduced by 40% • MRSA surveillance (96%) 8% of admissions 2% transmission rate • Real Time Mortality review

  39. Conclusions • The human and financial costs of CLABs are daunting. • These costs do not include physician costs or costs of skilled nursing care. Thus, the magnitude remains understated. • The costs of CLABs are not recovered in outlier payments. • The elimination of nosocomial infections, in general, and CLABs, in particular is multi-million dollar proposition for the healthcare industry.

  40. Sources of Variation • Observations and standardization of dressing changes. SC: 5 minutes IJ: 5 minutes Fem: 15 minutes • Standardize dressing change kits • Document current condition of site daily • Assist in understanding PICC line use PRHI

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