Keystone ICU Project: Measurement

1
Diffusion of Innovation(Everett Rogers, PhD)

• British Navy should adopt citrus juice for scurvy
  prevention given these findings, correct?
• 1747 - James Lind (British Navy physician)
  confirmed Lancasters findings from 150 years
  earlier
• 1795 British Navy adopted this innovation and
  scurvy eradicated (48 years after Linds study)
• 1865 (70 years later) this innovation adopted
  in the British merchant marine

2
Preventing CLABSI System-level success

• Prospective cohort study, SICU concurrent
  control ICU
• Bundled CLABSI Prevention Interventions in SICU
• CLABSI rate decreased from 11.3 to 0.0/1,000 CVC
  days in SICU control ICU 5.7 to 1.6
• Estimated 42 CVC-BSIs avoided savings of gt 1.9
  million

Berenholtz SM. Crit Care Med 2004322014-20.
3
Preventing Surgical Site Infection System-level
success Usry GH, et al. AJIC 200230434-6.
Intervention Intranasal mupirocin 48 hrs prior
to through 5 days post op Results 94 of
patients Rx Rate of SSI dropped by 53
overall 55 for deep sternal
Rate Per 100 CABGs
4
Kicking It up a Notch Success on a Network
Level The Power of the NNIS Collaborative

• Decreases in CLABSI Rates Seen in All
  ICUs,1990-1999.

Gaynes R. EID 2001 7295-8.
5
Efficacy of Network level Performance
Improvement Collaborative, cont.

• Pittsburgh. Regional Health Initiative (PRHI)
• 66 ICUs 32 hospitals
• Education
• Equipment
• Process improve
• 68 drop in CVC-BSI 4.31 to 1.36/1000 CVC days
• MMWR 2005 (Oct.14)541013-16.

6
Diffusion of Infection Prevention Practices
Krein S, et al Mayo Clin Proc 200782672-8
High safety Culture ICP with CIC
collabor-ative Signif. more likely to use
BSI prevention practices
Max Barrier Prec.\ Chlorhexidine tincture \
Antimicr. CL \ CHG dressing
7
Is BSI Prevention Evidence Making it to the
Bedside?

• Survey of ICUs in 10 academic medical centers
  across the U.S.
• In 80 of the ICUs 5 separate groups of
  physicians inserted 24-50 of CLs
• Written policy for CL insertion (80)
• Policy Requires maximal sterile barriers at
  insertion (28)
• Formal education program for personnel (52)
• Policy stated hand hygiene prior to insertion
  (80)
• Policy stated hand hygiene prior to accessing CL
  (36)
• Warren DK, et al. Infect Control Hosp Epidemiol
  2006273-7

8
KEYSTONE-ICU PROJECT

• Statewide initiative-70 Hospitals, 127 ICUs
• In Collaboration with Johns Hopkins Quality and
  Research Institute
• Reduce errors and improve patient outcomes in
  ICUs
• Combination of evidence based medicine and
  quality improvement
• 5 interventions implemented over a 2 year period
  beginning Feb. 2004
• Patient Safety Program and incident reporting
• Eliminate Blood Stream Infections (BSIs)
• Improve care of the ventilated patient
• Implement Daily Goals Sheet
• Implement and evaluate an intervention to reduce
  ICU mortality

9
Keystone ICU Project The Results

• 66 reduction in Central Line Bloodstream
  Infections (CLBSI)
• Interventions
• Hand hygiene
• Max. barrier prec. during insertion
• CHG antiseptic on insertion site
• Avoid femoral CLs
• Remove CL when not needed
• Pronovost P, et al. NEJM 20063552725-32.

Rate Per 1,000 CL Days
10
K-ICU CLABSI Prevention Experience, SJMHS, Ann
Arbor Pat Posa, KICU Coordinator

• Strategy/Process
• Implement Best Practices
• Strategies to ensure practice changes and
  prevention of mistakes
• Process and Outcome Measures
• Assess Financial Impact
• When expectations arent met-Learn from a Defect
  Analysis
• Outcomes
• Spread of Best Practice throughout hospital
• Keys to Success

11
All Units BSI rate per 1000 catheter days SJMHS
Compared to state of MI and NNIS
CLABSI Prevention Bundle Implemented July 2004
YTD BSI rate 2.12
12
Process Indicators CLABSIALL UNITS, SJMHS
13
BSI rate per 1000 catheter days SJMH Compared to
state of MI and NHSN
Efficacy Need for Drill-Down Analysis SICU
CLABSI Rate Trends
14
Our Expectations werent met

• SICU continued to have 1-2 BSI per
  monthinconsistent with other units
• Why is this happening in SICU??
• Learn from a Defect Tool (LDT) was applied
• Further analysis/investigation was needed

15
Learn from a Defect Tool(LDT)

• Divided into three sections
• Section 1 asks the users to identify what
  happened or the defect they want to investigate
• Section 2 is a framework provided for the
  investigators to identify any contributing
  factors. These factors include patient, task,
  caregiver, and team related, training and
  education, local environment, information
  technology and institutional environment.
• Section 3 asks participants to develop an action
  plan with assigned responsibility for task
  completion and follow up dates for each item.

16
Resident / Physician Assistant Survey

• The line cart was very helpful, but often not
  stocked.
• Felt that the nurses presence in the room was
  valuable, but not consistently happening.
• Additional support and training was requested.

17
Chart Review of Cases of CLABSI

• No excess blood products given on these patients
• Median blood glucose was lt140 mg/dl
• All of the patients that had CLABSI had a
  single-lumen infusion catheter (SLIC) that had
  been placed by the nursing staff into an existing
  cordis (percutaneous sheath) introducer.
• Further discussion identified that maximal
  barrier precautions were not being used during
  placement of SLIC

18
Actions Taken In Response

• Reformat BSI checklist to ensure proper sequence
  of line insertion procedure
• Provide re-education to staff on basic surgical
  asepsis
• Educate nursing staff to use maximal barrier
  precautions during SLIC insertions
• Incoming residents able to take Fundamentals in
  Critical Care Course which includes line
  placement instruction and practice
• Educate staff on pre-procedure briefing process
• Line cart restocking process now 2 times per day
• Ordered ultrasonic vein finder

19
All Units BSI rate per 1000 catheter days SJMH
Compared to state of MI and NHSN
August 2006
CLABSI Best Practices Bundle Implemented July 2004
2005 BSI rate is 2.12
2006 YTD rate is 0.67
20
Unit Specific Resultsas of August 2006

• MICU 22 months without a BSI
• SICU 7 out of the last 12 months without a BSI
  (CLA-BSI rate YTD 2006 is 1.19)
• CCU 15 months without a BSI
• SJM-Livingston CCU 23 months without a BSI

21
Other K-ICU Bundles VAP Prevention

• Improve care of ventilated patients
• Elevate HOB
• Provide DVT prophylaxis
• Provide PUD prophylaxis
• Hold sedation
• Test for ability to extubate
• Glycemic control

22
VAP rate per 1000 ventilator days SJMHS Compared
to state of MI and NNIS
July 2006, ALL UNITS VAP RATES
2005 VAP Rate is 2.09
2006 VAP Rate is 1.45
23
The Expanding Use of Central Lines Outside the
ICU Setting answer to why were spreading BSI
Prevention

• Climo M, et al. 2003
• 1 Day Point Prevalence Survey Six Medical
  Centers
• 2,459 patients 29 with central lines (CL)
• ICU 43-80 had CL
• Non-ICU 7-39 with CL
• Of all CLs in use 66 were in non-ICU
• Vonberg RP, et al. 2006
• 42 hospitals, 77 non-ICUs, July 02- June 04
• CL utilization 8,317 CL days in 181,401 patient
  days
• Mean CLABSI rate 4.3/1,000 CL days

24
Hitting the Road with CL Kits
25
The Next Big Thing _at_ Keystone Center

• Hospital-Associated Infection (K-HAI) Prevention
  Project kickoff January 2007
• http//www.mha.org/mha_app/keystone/index.jsp
• 108 Hospitals in Michigan are participating
• Components
• Hand hygiene bundle
• The Bladder Bundle
• Expanding central line associated BSI prevention
  beyond the ICU
• Comprehensive Unit-based Safety Program (CUSP)

26
K-HAI, Progress To Date Pilot Units,
SJMHS SJMH-Ann Arbor - 3100 A/C Neonatal
ICU SJM Saline Hospital Med/Surg
Unit SJM-Livingston Family Birthing
Center i)Structural Assessment hand hygiene
products ii) Baseline direct observation ii)
Perceptions Beliefs Survey
27

• K-HAI, Next Steps
• Hand hygiene education
• Engaging all healthcare personnel in hand hygiene
• Direct Observation of adherence by healthcare
  personnel with hand hygiene

28
Summary Points Or Your mission should you decide
to accept it.

• Educational programs and multi-disciplinary
  teams may be effective strategies to reduce rates
  of HAI. Aboelela SW, et al. JHI 200766101-8
• MRSA and other problematic pathogens are not
  likely to obey laws - - - intervening at critical
  control points reliance on the ICPs critical
  problem solving skills remain the key.
• There is increasing evidence of the efficacy of
  infection prevention collaboratives.
• In SC, HIDA may have caused initial concern but
  it has established a statewide collaborative in
  rapid fashion
• Eddie I encourage further use of this as a
  mechanism for infection prevention