1. The Safe Critical Care Initiative An HCA-Vanderbilt Quality Improvement Project On Healthcare Associated Infection Partnerships in Implementing Patient Safety (PIPS) Funded by AHRQ ted.speroff@vanderbilt.edu

2. Safe Critical Care Team Vanderbilt Ted Speroff Robert Dittus Jay Deshpande E. Wesley Ely Dan France Robert Greevy Shirley Liu Samuel K Nwosu Thomas R. Talbot Richard Wall Matthew B. Weinger Hospital Corp of America Laurie Brewer Hayley Burgess Jane Englebright Steve Horner Frank Houser Jeanne James Susan Littleton Patsy McFadden Steve Mok Joan Reischel Sheri Tejedor Mark Williams

3. Aims of Safe Critical Care To prevent catheter-related blood stream infections (BSI) and ventilator-associated pneumonia (VAP) in the ICU. To implement a campaign for Improving Critical Care (Blood-Stream Infections and Ventilator-Associated Pneumonia) as part of the IHI 100,000 Lives Campaign.

4. Aims of Safe Critical Care To compare a Collaborative approach to a Local Hospital Quality Improvement approach for implementing an improvement initiative. To examine the organizational and provider factors that contribute toward and enable successful performance improvement.

5. Methods Hospital Corporation of America (HCA) –172 Medical and Surgical Centers – 60% suburban and 32% urban – Recruited 61 Hospitals

6. HCA-Vanderbilt Toolkits HCA core development of Meditech tools Feedback reports from surveys and data collection Safe Critical Care Project Atlas Site HCA-Vanderbilt Toolkits HCA core development of Meditech tools Feedback reports from surveys and data collection Safe Critical Care Project Atlas Site Collaborative communications Social networking Content experts Collaborative teleconference meetings Toolkit Group: Local Hospital Initiative Collaborative Group Randomized Methods: RCT Design

7. Methods: Tool Kit HCA Intranet-Atlas Site Keyword: Safe Critical Care Continuing Education Programs BSI Tool Kit VAP Tool Kit Project Metrics FAQ/Fact sheet: Quick links QI/PDSA Tools Statistical Control Chart Tools

9. Methods: Measures Clinical Outcomes: BSI and VAP rates Administrative Data Safety Attitude Questionnaire: ICU safety climate Organizational Culture Survey of ICU Practices and Quality Improvement Activities Post-Project Evaluation Survey

10. Results: Characteristics of HCA ICUs 80% have < 20 ICU beds 35% are medical-surgical-coronary ICU, 20% medical-surgical 65% have physician medical director, 95% have a nurse manager 27% intensivist required, 36% intensivist optional, 37% no intensivist 67% have pharmacist rounding 65% have daily, integrated interdisciplinary team

11. Results: Baseline Baseline Characteristics Collaborative N= 31 Tool Kit N= 30 P-value in IHI Campaign 96%100%1.0 Hospital Vol median (IQR) 2720 (1499,3827)2616 (1242,3360).90 ICU Volume median (IQR) 595 (337,909)578 (244,1077).80 ICU LOS median (IQR) 4026 (1978,5824)4228 (1645,6725).82 ICU Mortality % (sd) 5.9% (2.9%)7.1% (3.6%).19 Medicare/Medicaid % (sd) 68.4% (9.6%)68.4% (10%)1.0 Emer.Dept Admit % (sd) 72% (14%)67% (20%).2 Female % (sd)49.7% (5.6%)50.3% (7.7%).83 Charge weight mean (sd) 1258 (1004)1295 (1110).94 SAQ: mean (sd)3.60 (.29)3.67 (.28).21 BSI & VAP Projects %68%60%.54 BSI Rate per 1000 days2.3 (2.5)4.4 (5.8).26 VAP Rate per 1000 days3.4 (3.5)4.7 (5.9).73

12. BSI Results Relative Risk = 1.14 (95% CI 0.93, 1.40), p =.20

13. VAP Results Relative Risk = 1.28 95% CI (1.03, 1.57), p =.023

14. Safe Critical Care: QI Interventions Adoption of bundles for patient care Interdisciplinary team rounding Rounding form/checklist Empower nurses to encourage physician compliance Unit champions Nurses empowered to stop procedure if break in sterile field Checklist implementation Kit changes & cart Checklist in kits Standards of Practice revised Order set protocols Alcohol gel dispensers Hand wash campaign Evaluate performance and practices Audits & surveillance Difference between standard audits and peer group observation Case reviews of BSI and VAP Reporting bundle compliance Feedback reports Monthly ICU newsletter Encourage staff feedback

15. Webcast Seminars Collaborative Group participated in more data topic seminars (52% vs 22%) and rated them as useful (78% vs 54%)

16. Usefulness of Tools A greater proportion of the Collaborative Group accessed the BSI and VAP Tools, accessed the SPC methods tools, and found the tools useful.

17. BSI Bundle Process 82% of the Collaborative Group implemented all components of The CVC Bundle compare to 56% of the Tool Kit Group (p=.027)

18. VAP Bundle Process 76% of the Collaborative Group implemented all components of The CVC Bundle compare to 64% of the Tool Kit Group (p=.30)

19. Collaborative Qualitative Results: Challenges - Physicians Challenges Resistance Use of barriers Use of checklists Site of insertion Multiple private MDs, Involvement Resistance to change vendors Solutions MD buy in, approval from MEC Hire Physician champion Intensivists Nurse empowerment Physician involvement in case review New order sets

20. Collaborative Qualitative Results Challenges - Staff Challenges Commitment Empowerment Resistance to tools Resistance to change in behavior Solutions Champions Enlist Hire Storyboard with examples so staff could conceptualize their roles Holding each other accountable is painful at times

21. Collaborative Qualitative Results Challenges - Data Challenges How to Data collection tools Access to data Solutions Meditech/PCM documentation of protocols Design tools Monitoring

22. Findings from Surveys ICU Staffing is variable –Most HCA ICUs are multipurpose diagnostic diversity requires task and workload diversity diverse demands on education and training requirements Intensivists available in 63% of HCA ICUs but with variable models of care delivery Documentation is nearly split between paper and computer Significant variability in the extent of ICU participation in quality improvement

23. Findings from Surveys Use of the NNIS definitions –98% for BSI –96% for VAP Difficulty obtaining IC denominator data –48% for BSI rates 23% hospitals reported having months where BSI rates could not be reported due to incomplete denominator reporting. –30% for VAP rates 13% hospitals reported having months where VAP rates could not be reported due to incomplete denominator reporting. 31% use Infection Control software for surveillance

24. SAQ Results Variation in Safety Climate

25. SAQ Survey: findings Overall Safety Climate is positively correlated with QI Measurement r =.39 SAQ and Hospital Size –Safety Climate and QI support varies with hospital size. –Smaller hospitals show more positive safety climate. –Smaller hospitals show need for administrative support in resources and measurement. –Larger hospitals give more empowerment to the team. –ICU teams provided with resources and training by the administration have more positive perceptions of safety climate.

26. Conclusions Monitoring outcomes such as hospital acquired infections is complicated and time consuming. While there was a trend for improvement and better outcomes for the Collaborative group, there was appreciable variability and the pattern of results varied over time These differences were associated with the Tool Kit group participating in fewer educational opportunities and making less use of Tool Kit elements than the Collaborative group. The Collaborative group paid greater attention to the methodological seminars and measurement tools. Once sites engaged in these resources they found the information and tools useful and sustained their use. The Collaborative group used more improvement strategies and more complete implementation of BSI and VAP evidence-based interventions.

27. Conclusions “Real world” studies bring to the surface the variation across hospitals and ICU settings. Whereas clinical, methodological, and informatics tools (Tool Kits) offer standardized core support, the solutions and approaches for tool, quality improvement, and patient safety implementation remain context dependent. A Collaborative seems to provide a social network that reinforces personal effort despite resistance and workload pressures, shares and facilitates problem solving, and fosters accountability for behavioral change; in such a way that the participant can tailor it all to their home organization. Our preliminary results support the ability of a participatory collaborative and support tools to decrease the incidence of catheter-related blood stream infections and ventilator-associated pneumonia in a diverse population of ICUs.