Integrating Quality and Safety Competencies to Improve Outcomes: Application to Infusion Therapy Practice Barb Nickel APRN-CNS, NP-C, CCRN, CRNI Dr. Gwen Sherwood PhD, RN, FAAN, ANEF 2017 Chicago

Objectives On completion of this scenario based session, participants will be able to: Define the role of Evidence Based Standards of Practice in an incident investigation Identify at least one intervention to improve patient safety through application of QSEN competencies and Infusion Therapy Standards of Practice

Infusion Therapy Infusion Nurses Society Barb Nickel, CNS, CRNI Premier authority on Infusion Therapy Infusion Therapy Standards of Practice provide a framework to guide clinical practice. The Standards define and develop organizational infusion-based policies and procedures for all practice settings. Critical Care CNS for community hospital in Nebraska Member, then chair/lead nurse planner for the Infusion Nursing Society’s National Council on Education from 2010-2016 Reviewer for 2011 and 2016 Infusion Therapy Standards of Practice

What attitudes guide actions? QSEN: Professional Identity Formation to have a Mindset for Quality and Safety Knowledge Skills Attitudes Competency What do you need to know? What do you need to do? What attitudes guide actions?

How are these competencies integrated into nursing education and practice? Teamwork and Collaboration: how we work together Patient Centered Care: how we include, treat patients/families Evidence Based Practice: best practices Informatics: managing information Safety: reducing risk individual & system Quality Improvement: closing gaps in care

Patient Safety Culture Safety Culture: Collective beliefs, attitudes, and behaviors of every worker in the organization regarding safety Critical aspects in a culture of safety: Reporting structure Individual and organizational accountability Transparency Effective process of investigation when deviations occur Commitment to process changes to improve patient safety http://patientsafetyed.duhs.duke.edu/module_e/swiss_cheese.html

Incident Investigation Preventable deaths linked to human factors Risks inherent to infusion therapy A culture of safety sees errors/mistakes as opportunities for growth A full investigation process should include: Careful timeline of events Staff interviews to understand the context Relevant Standards of Practice Objective evaluation to identify deviations Commitment to identify and implement evidence based process improvements Careful monitoring of related metrics Feedback to clinicians on findings/plan Reflective practice is critical---staff are asked to reflect back on their care against EBP to identify any issues. These are reviewed by the investigative team for common trends/deviations

Cost of Central Line Associated Blood Stream Infections (CLABSI) In ICU and non-ICU patients, estimated cost of CLABSI: $32,0007 CLABSI costs vary from $21,400 to $110,8001 CLABSI was associated with a 2.27-fold increased risk of mortality7 In comparison to other healthcare-associated infections, CLABSIs were associated with the highest number of preventable deaths CLABSI initiatives have saved at least $1.8 billion in excess healthcare costs An estimated 5,520 to 20,239 lives could be saved annually with best practice implementation1 CLABSI represents a serious, continuing patient safety threat and a major economic burden for healthcare1 CLABSI is the term used by the US Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN)6 (see NHSN CLABSI information at http://www.cdc.gov/nhsn/psc_da.html). A CLABSI is a primary bloodstream infection (that is, there is no apparent infection at another site) that develops in a patient with a central line in place within the 48-hour period before onset of the bloodstream infection that is not related to infection at another site. Culturing the catheter tip or peripheral blood is not a criterion for CLABSI. (Joint Commission 2012) Research indicates that the majority of CLABSIs are preventable. Umscheid and colleagues also suggest that 65-70 percent of CLABSIs are preventable by implementing evidence-based strategies currently available to healthcare professionals. Apic

Case Study 57 year old female patient with complex history of bowel resection, complicated by dehiscence and chronic infections, obesity, diabetes Admitted for wound debridement/treatment, application of negative pressure wound therapy and replacement of her central venous access device (CVAD) Long term central venous access required for total parenteral nutrition (TPN) A tunneled CVAD was removed due to catheter fracture at the external hub A non-tunneled peripherally inserted central catheter (PICC) line was inserted for continued long term antibiotics and continued TPN

Case Study continues The patient was dismissed 4 days later The Home Care nurse completed her initial assessment on the day of dismissal from acute care and found: 8cm of exposed catheter under the dressing Redness/tenderness at the PICC line insertion site A PICC line dressing that was loose, and had been reinforced Patient was febrile, tachycardic No indication of abdominal wound infection

Case Study continues The Home Care nurse facilitated a clinic visit to evaluate the patient’s current condition The provider suspected a new onset of CVAD-related sepsis The patient was readmitted; blood cultures were drawn Over the next two days, the patient rapidly progressed to organ system dysfunction, septic shock After 6 days in the ICU, the patient expired. Cause of death was ruled as septic shock due to a central line blood stream infection

Small Groups Your group will be a part of the incident investigation Each group will be given a part of the findings from the Root Cause Analysis with 3 questions to discuss Quickly chose a spokesperson, then review the information and answer the questions With our remaining time, we will do brief report outs related to each QSEN competency as it relates to pertinent Infusion Therapy Standards of Practice and potential process improvements

QSEN Competency: Safety What safety concerns did your team note as you reviewed your portion of the investigation? Name one relevant Infusion Therapy Standard of Practice that was critical to this case. Name at least one intervention that should be considered to mitigate further patient risk.

QSEN Competency : Quality Improvement What Quality concerns did your team note as you reviewed your portion of the investigation? Name one relevant Infusion Therapy Standard of Practice that was critical to this case. Name at least one intervention that should be considered to mitigate further patient risk.

QSEN Competency: Evidence Based Practice What opportunities for EBP utilization did your team note as you reviewed your portion of the investigation? Name one relevant Infusion Therapy Standard of Practice that was critical to this case. Name at least one intervention that should be considered to mitigate further patient risk.

QSEN Competency: Teamwork/Collaboration What teamwork/collaboration concerns did your team note as you reviewed your portion of the investigation? Name one relevant Infusion Therapy Standard of Practice that was critical to this case. Name at least one intervention that should be considered to mitigate further patient risk.

QSEN Competency: Patient Centered Care As you reviewed your portion of the investigation, were there opportunities to improve Patient Centered Care? Name one relevant Infusion Therapy Standard of Practice that was critical to this case. Name at least one intervention that should be considered to mitigate further patient risk.

QSEN Competency: Informatics What opportunities for improved utilization of informatics did your team note as you reviewed your portion of the investigation? Name one relevant Infusion Therapy Standard of Practice that was critical to this case. Name at least one intervention that should be considered to mitigate further patient risk.

Summary QSEN competencies establish a solid framework for integration Standards of Practice in specialty areas such as Infusion Therapy A culture of Patient Safety is a critical foundation for quality care Incident investigation provides an opportunity for: Reflective practice Objective comparison of current state to Evidence Based Standards of Practice Identification and prioritization of Process Improvement goals Improvement of Patient Centered Care Improved Patient Outcomes

References Association for Professionals in Infection Control and Epidemiology (APIC), 2015, Guide to Preventing Central Line- Associated Bloodstream Infections, ISBN: 1-933013-56-7, 2015,, Inc. (APIC). Retrieved at http://apic.org/Resource_/TinyMceFileManager/2015/APIC_CLABSI_WEB.pdf Gregory, B. & Kaprielan, V. Patient Safety-Quality Improvement, Anatomy of an Error, Duke Center for Instructional Technology retrieved on 5/9/17 from http://patientsafetyed.duhs.duke.edu/module_e/swiss_cheese.html. Gorski L., Hadaway L, Hagle ME, McGoldrick M, Orr M, Doellman, D. Infusion therapy standards of practice. Journal of Infusion Nursing. 2016; 39 (suppl 1):S1-S159. O’Grady, et al. 2011. Centers for Disease Control. Guidelines for the Prevention of Intravascular Catheter-Related Infections, Retrieved from https://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf Roberts K , Yu K , van Stralen D . Patient safety is an organizational systems issue: Lessons from a variety of industries . In B. Youngberg , ed. Patient safety handbook (2nd ed.). Burlington, MA : Jones & Bartlett . 2013 : 143 – 156 . Sherwood G . Driving forces in patient safety . In Sherwood G. , Barnsteiner J. , eds. Quality and safety in nursing: A competency approach to improving outcomes . Hoboken, NJ : Wiley - Blackwell ; 2012. Stevens V, Geiger K, Concannon C, et al. 2014. Inpatient costs, mortality and 30-day re-admission in patients with central-line-associated bloodstream infections. Clin Microbiol Infect. 2014 May;20(5):O318-24. doi: 10.1111/1469- 0691.12407. Epub 2013 Nov 6. The Joint Commission. 2012. Preventing Central Line–Associated Bloodstream Infections: A Global Challenge, A Global Perspective. Retrieved from https://www.jointcommission.org/assets/1/18/CLABSI_Monograph.pdf