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

The Marvel of Modern Medicine 2

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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 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, Andrews L, Stocking C, Krizek T, et al., Lancet, Kohn L, Corrigan J, Donaldson M., To Err Is Human, Klevens M, Edwards J, Richards C, et al., PHR, 2007 Ending Health Care-Associated Infections, AHRQ,

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 5

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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 blame 7

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 8

System Factors Impact Safety Hospital Departmental Factors Work Environment Team Factors Individual Provider Task Factors Patient Characteristics Institutional Adapted from Vincent 9

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 10

System Failure Leading to Error Bronch cart not stocked Did not verify equipment availability Communication between resident and nurse Fatigue Patient suffers Hypoxic arrest 11

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 12

Eliminate Steps 13

Create Independent Checks 14

Design Examples StandardizationRedundancy 15

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 16

Standardize 17

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):

NEJM 2006, BMJ 2010 Michigan Keystone ICU 19

Rhode Island ICU CLABSI Rates Qual Saf Health Care 2010;19(6):

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 21

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? 22

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? 23

Infect Control Hosp Epidemiol Michigan Keystone ICU 24

Preventing Catheter-Associated Urinary Tract Infection Most common healthcare-associated infection (~ 40%) Many urinary catheters used inappropriately 1 Prevention guidelines: – HICPAC – 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 Fakih MG, et al. Infec Control Hosp Epi Meddings J et al. Clin Infect Dis

Principles of Safe Design Apply to Technical and Team Work On the CUSP: Stop CAUTI 26

27 Basic Components and Process of Communication Dayton E, Henriksen K, Jt Comm J Qual Patient Saf,

Teamwork Tools Daily Goals AM briefing Shadowing Culture check up TeamSTEPPS 28

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,

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 30

Action Items Have all members of the CUSP CAUTI Team view the Science of Improving Patient Safety video Science of Improving Patient Safety 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) 31

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