Erik Garpestad, MD Therese Hudson-Jinks, RN, MSN Tufts Medical Center Erik Garpestad, MD Therese Hudson-Jinks, RN, MSN

Tufts Medical Center Boston, MA We strive to heal, to comfort, to teach, to learn, and to seek the knowledge to promote health and prevent disease. Our patients and their families are at the center of everything we do. We dedicate ourselves to furthering our rich tradition of health care innovation, leadership, charity and the highest standard of care and service to all in our community.

Objectives Participants will earn an innovative strategy to align team members in a quest for excellence. Participants will learn communication tools vital to the success of quality improvement. Participants will learn how to excite clinicians engaging them in the change process.

FY 2008 2009 caBSI Adult Patient Population

FY 2008 2009 caBSI Adult Patient Population New Policy Roll Out

Standardizing Insertion 2007- 2009 What was done? 2007 – 2009 Nearly 50 member committee organized into MD practice, RN practice, equipment. (Lots of hard work, lots of time) Much emphasis placed on development of best practice policy and guidelines for caBSI elimination with a focus on: Standardizing Insertion SIMs lab review, competency MD development standards Standardizing maintenance 100% RN policy and practice review, twice: ‘Task Focused’

Results: Little to no progress !! 2007- 2009 What was done? 2007 – 2009 Nearly 50 member committee organized into MD practice, RN practice, equipment. Much emphasis placed on development of best practice policy and guidelines for caBSI elimination with a focus on: Standardizing Insertion SIMs lab review, competency MD development standards Standardizing maintenance 100% RN policy and practice review, twice: ‘Task Focused’ Results: Little to no progress !!

New Plan: Fall 2009 CaBSI CaUTI VAP Fall 2009 Commitment by Senior Leadership to eliminate Hospital Acquired Infections Infection Prevention Priority Initiatives defined CaBSI CaUTI VAP

Stop Central Line Associated Blood Stream Infection (caBSI) Team Appointment The Team was appointed by Senior Leadership with the authority and responsibility to influence, ensure, and be accountable to best practice principles regarding central line placement and maintenance at Tufts Medical Center. Goal: Rapid Cycle Change Process resulting in sustainable results at or better than national rates.

MEMBERSHIP DEPARTMENT Stop Central Line Associated Blood Stream Infection (caBSI) Team Structure MEMBERSHIP DEPARTMENT Margaret Vosburgh, COO Executive Sponsor Dorothy Didomenico RN Clinical Educator, CCU CMC Shira Doron MD Infectious Disease Terry Hudson-Jinks RN Patient Care Services/Nursing Eric Garpestad MD Medical Director MICU, Critical Care Committee Chair Tricia Lemon, RN Infection Prevention/Quality and Patient Safety

Looking back, What worked? Diverse team membership, frequent meetings. Open mind, willingness to provide care differently Agreement to have a unified ‘Quest for ZERO’ infections Sense of Team Humility Crazy passion, ‘fire in the belly’ Strong support of CEO, CMO, CNO CEO support of Tufts participation with MHA CUSP October 2009:8 Member Tufts Team attended CUSP Kick Off

Looking back, What worked? Diverse team membership Open mind, willingness to provide care differently Agreement to have a unified ‘Quest for ZERO’ infections Sense of Team Humility Crazy passion, ‘fire in the belly’ Strong support of CEO, CMO, CNO CEO support of Tufts participation with MHA CUSP October 2009:8 Member Tufts Team attended CUSP Kick Off

Looking back, What worked? Diverse team membership Open mind, willingness to provide care differently Agreement to have a unified ‘Quest for ZERO’ infections Sense of Team Humility Crazy passion, ‘fire in the belly’ Strong support of CEO, CMO, CNO CEO support of Tufts participation with MHA CUSP October 2009:8 Member Tufts Team attended CUSP Kick Off

Align yourself with a National Agenda CUSP

On The CUSP Stop BSI PRIMARILY Adaptive (CUSP) 4 Massachusetts ICU Safe Care Initiative Comprehensive Unit-Based Safety Program On The CUSP Stop BSI PRIMARILY Technical (CLABSI) CVC Insertion CVC Line Cart 1. Contents inventory Evidence based BSI prevention (hands, site, skin prep, barrier, removal) 1. Presentation of evidence 2. CLABSI factsheet 3. Insertion checklist 4. Vascular access quiz 5. Vascular access manual/ policy 6.Annotated bibliography CVC Management 1. Daily goals 2. Dressing change 3. Vascular access manual/ policy protocol PRIMARILY Adaptive (CUSP) Science of Safety Training 1. Science of safety presentation 3. Attendance sheet Staff Identify Defects 1. Staff safety assessment form 2. Indentifying hazards presentation Senior Executive Partnership Briefings Learning from Defects LFD toolkit Implement Tools for Teamwork and Communication 2. Shadowing 3. AM briefing 4. Call list 6. Team check up tool Assemble a CUSP team, Partner with a senior executive; Baseline CLABSI Data Exposure Survey and Technology Survey 4 15

Maximal Barrier Precautions Upon Insertion Stop Central Line Associated Blood Stream Infection (caBSI) Central Line Bundle Hand Hygiene Maximal Barrier Precautions Upon Insertion Central Line Insertion Check List Use of a Line Insertion Cart Chlorhexidine (CHG) skin antisepsis Optimal Catheter Site Selection (Avoid Femoral site over IJ) Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines

Looking back, What worked? Benefits of CUSP (Comprehensive Unit Based Safety Program): Provided the framework to align Senior Executives with clinicians in the goal for patient safety Validated key aspects of Tufts Medical Center Policy Provided leverage Frameworks, tool kits, informational sources, rich in details necessary to make key decisions, and the power to let go of old practices. Blood Cultures Goal Sheet Clave use Dressing and line protocols CHG bathing/Elimination of wash basins Network of experts within and beyond New England with key first hand learning experiences. Assisted in disbanding belief that patients are too ill, elimination not possible. Provided a competitive spirit, energizing

Symbols of Change Take strong, decisive steps forward Take Risks Consider making several changes at one time Disrupt routine

Stop Central Line Associated Blood Stream Infection (caBSI) 2009 High Risk Areas for CaBSI MICU CTU SICU North 8 CMC In combination were responsible for 67% (56/83) of all line infections Accounted for 50% (11853/23345) of all line days.

Intervention: CHG/Sulfadiazine Impregnated Lines in High Risk Areas Antimicrobial Impregnated catheters in high risk populations Piloted in select areas first MICU CCU Based on results plan to roll out house wide Shorter length catheter keeps sterile dressing intact Standard line length was 20 cm New standard 16 cm Allergy alert stickers on each kit Insert picture of new kit

Stop Central Line Associated Blood Stream Infection (caBSI) Intervention: New Practice Guidelines Change culture and practice for drawing blood cultures Policy revision – drafted Blood culture algorithm to guide when and how Weekly data shows blood cultures off central lines decreasing

Intervention: New Bathing Technique (Pilot) 1.)Elimination of Wash Bins 2.)CHG Bathing of all patients in high risk locations MICU CCU CTU SICU CMC North 8

Stop Central Line Associated Blood Stream Infection (caBSI) Results Adult Critical Care (CaBSI rates per 1000 central line days) Begun House wide Daily rounding on all central lines Policy Reeducation 100% all RNs MD Education Placement Training Signoff

Stop Central Line Associated Blood Stream Infection (caBSI) Results Adult Critical Care (CaBSI rates per 1000 central line days) Begun House wide Daily rounding on all central lines Policy Reeducation 100% all RNs Impregnated Catheters CCU and MICU CHG Bathing CCU MICU Staff Meetings Impregnated Catheters SICU and CTU Shadow Check list Program

Intervention: Staff Engagement/Communication Strategy nolineinfections@tuftsmedicalcenter.org Email Account Connecting to the Clinicians at the bedside: Creation and communication of email site: nolineinfections@tuftsmedicalcenter.org Create platform for two way dialogue with clinicians. Take down barriers to care. Enhance transparency. Engage all staff including unit coordinators, techs, physical therapists, on the journey. Communicate changes in practices and policy. Facilitate problem solving, share knowledge, best practices, and success stores. Keep the quest of caBSI elimination front and center.

Sample Email From: No Line Infections Sent: Monday, January 03, 2011 1:28 PM To: Tufts MC All Employees Subject: No Line Infections 2011   Thank you  to all clinicians and employees  for  embracing the  challenge of central line infection elimination.  Our quest for  zero  continues into 2011    Trends in caBSI  Infections FY 2009 – FY 2011 YTD Tufts  Medical Center  & Floating Hospital for Children 

Subject: RE: No Line Infections 2011 Sample Email Response To: No Line Infections Subject: RE: No Line Infections 2011 Excellent goal and superb improvement/performance. Do we publish these data externally?

Staff engagement: Priority # 1! GOAL: Eliminate Central Line Infections, keep the momentum Consistent messaging at every level, Board, Division, Unit etc. Search constantly for validation of policy in practice at the bedside Staff Participation/Engagement: Each ICU is sponsoring a champion for each Quality Initiative to ensure we continue to shrink the distance between policy and practice. March 2010 Weekly unit based Quality Staff In-services. Each ICU Quality Initiative will be discussed and framed for that units trend. Successes to be celebrated, staff participation essential. Transition 100% check list Shadow to Spot assessments based on compliance. Continue to validate practice with national benchmarks in practice and results.

Present Data Differently

Months with Zero Rate High Risk Population

CLABSIs, by line type, all medical center units

CLABSIs – All ICUs – FY 09 - 11 MICU 14 2632 5.32 3 2113 1.42 4 2328 UNIT FY 09 FY 10 FY 2011   Cases Days Rate MICU 14 2632 5.32 3 2113 1.42 4 2328 1.72 CCU 7 2048 3.42 2040 1.96 2 2124 0.94 CTU 2221 1.80 1 2653 0.38 2447 0.41 SICU 6 1889 3.18 1965 1.02 2030 1.48 NCCU 222 4.50 NICU 3362 4.16 8 2685 2.98 2888 1.04 PICU 848 0.00 845 3.55 674 TOTAL 45 13000 3.46 21 12301 1.71 15 12713 1.18

Surgical ICU

CMC caBSI 2009 - 2011

CMC caBSI 2009 - 2011

Leadership commitment + Evidence Based Practice + Staff Engagement Key to success Leadership commitment + Evidence Based Practice + Staff Engagement = Success

CaBSI Control Chart FY 2009 - 2011

“Bladder Bundle” Aseptic insertion and proper maintenance Bladder ultrasound (may avoid indwelling catheterization) Condom or intermittent catheter in appropriate patients Do not use indwelling catheters unless you must! (See appropriate indications) Early removal of the catheter

Consequences of UTIs Pain and discomfort Pyelonephritis Urosepsis Increased mortality Prolonged hospitalization Additional exposure to antibiotics (increased risk for C. difficile) Increased hospital expenditures

Bladder Scanner: Patient Equipment

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caUTI Adult ICUs Impact of RN Driven Protocol

Nurse Driven Protocol for Removing Indwelling Urinary Catheter Month 00, 2008 Change footer on slide master

Respect the Foley

BEST PERFORMER: Floating Hospital For Children: PICU

Plans 2012 Focus on insertion Demonstrate RN competency of 100% RNs throughout the Medical Center Two person insertion Continue weekly practice audits 1 Ultrasound per ICU Encourage shiftly assessment and removal Share each UTI with the staff Post unit based results Identify a champion passionate about safety Observe practice, educate. Reinforce excellence in practice, tell a story: RN within one unit challenged an MD order to reinsert foley and used condom catheter.