Reducing Avoidable Harm in the MICU
Reducing Avoidable Harm in the
MICU
November 4, 2010
Background
• The incidence of Healthcare-associated infections (HAIs) is
approximately 4.5 for every100 hospital admissions.
• Health care-associated infections (HAIs) result in 1.7 million
infections and 99,000 deaths each year.
• The added financial burden attributable to HAIs is estimated
to be between $35.7 billion to $45 billion for in-patient hospital
services1.
-CDC March 2009
Our Aim
• Our aim at UT Southwestern is to address patient safety
issues by reducing the number of safety related events
by 50% by end of calendar year 2010.
• The priority areas for this project are
• Catheter –associated urinary tract infections (CAUTI)
• Ventilator associated pneumonias (VAP)
• Central line associated blood stream infections
(CLABSI)
• Patient falls
Our 2009 MICU Baseline
• 72 patients were harmed in our
MICU in 2009
– 14 Patients with Ventilator Associated
Pneumonia “VAP”
– 23 Patients with Central Line Associated
Blood Stream Infections “CALBSI”
– 26 patients with Catheter Associated Urinary
Tract Infections “CAUTI”
– 9 Patient Falls
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Act
Plan
Study
Do
Pareto Chart
Avoidable Harm CVICU, MSICU, 7 West ICU CY 2009
30
100%
26
23
80%
17
17
60%
14
15
14
40%
9
20%
CV VAP
MS FALLS
CV FALLS
7
MS VAP
CV CALBSI
CV CAUTI
5
MS CLABSI
10
MS CAUTI
HAI TALLY
20
Cumulative %
25
0
0%
HEALTHCARE ASSOCIATED HARM
Vital Few
Useful Many
Cumulative%
Cut Off %
[42]
Our Unit Comparison 2009
MICU = 72
CVICU = 55
 CAUTI= 26
 CLABSI = 23
 VAP = 14
 Falls = 9
 CLABSI = 17
 CAUTI = 17
 Falls = 14
 VAP = 7
Interventions
All ICU VAP Bundle Compliance
100.0%
98.0%
96.0%
94.0%
92.0%
% Compliance
90.0%
All Bundle
Elements
88.0%
86.0%
84.0%
82.0%
80.0%
Feb-10
7 West ICU
MSICU
CVICU
Feb-10
91.5%
93.0%
86.7%
Mar-10
94.2%
95.1%
91.9%
Mar-10
Apr-10
93.1%
97.7%
95.3%
Apr-10
May-10
May-10
99.3%
97.1%
97.5%
Jun-10
Jun-10
97.1%
97.0%
96.8%
Jul-10
Jul-10
99.3%
97.6%
97.3%
Aug-10
Aug-10
99.4%
97.5%
98.3%
Sep-10
Sep-10
98.5%
98.2%
97.6%
Avoidable Harm Tally
MSICU & 7 West ICU
14
Harm Tally MICU
12
Started
CS & E
10
8
Engaged the staff:
re-educated and
applied bundles
6
4
Joined
CUSP
Automated bundle
compliance audits
2
Yellow Socks
for ICU patients
0
MICU 2009 Harm Totals
UCL
+2 Sigma
+1 Sigma
Average
-1 Sigma
-2 Sigma
LCL
Process Map
VTE Prophylaxis
Process Map
PUD Prophylaxis
Process Map
Indwelling Catheter Necessity
Process Map
Central Line Maintenance
Fishbone Diagram
Patient Falls
People
Processes
Poor Vision
Age
Unsteady gait, weakness
Slow response time
Diarrhea
Nurse doesn’t get there quick enough
Non compliant
Nurse doesn’t make it to room in time to assist to bathroom
Confused
Non skid slippers not in use
Syncope
Fall precaution not instituted
Bed alarms not in use
Left in bathroom alone
Fall Risk
Patient not informed of fall risk
MI, PE
Noted as fall risk but not treated as fall risk
Urinary frequency
Bed alarms not in use for fall risk
Not wearing non slip socks
Not clear who fall patients are. Lack of
Patient doesn’t call
communication
Patient doesn’t want to burden staff by calling for help
Falls
SCDs
IV Pumps
Foley
Oxygen tubing
No BSC available
Wound vac
Room lighting. Rooms are
dark at night
Equipment
Slip on wet floors
Rooms far away from
nurses station
Cords
Environment
Process
Diuretics, Lasix
Laxative
Pain Medications
Shift Change
P.T. evaluation not
ordered
Transfer at shift change or nurse
not informed when
patient arrives on unit
Combined MICU
Rate per 1000 pt days
22.00
20.00
MICU HAC Rate per 1000 pt days
18.00
16.00
Started
CS & E
14.00
Automated bundle
compliance audits
12.00
10.00
8.00
Engaged the staff:
re-educated and
applied bundles
6.00
Yellow Socks
for ICU patients
4.00
Visual Cues for
bundle compliance
2.00
0.00
Joined
CUSP
MICU HAC/ 1000 pt days
UCL
+2 Sigma
+1 Sigma
Average
-1 Sigma
-2 Sigma
LCL
Our Results
2009 Total & Q1-Q3 CY 2010 Comparison
MICU Falls, CLABSI, CAUTI, VAP
80
75
72
70
Tally of Avoidable Harm
65
60
55
50
50
45
40
35
30
22
25
20
15
10
5
0
MICU & Avoidable Harm
2009
MICU Avoidable Harm Q1Q3 CY 2009
MICU Avoidable Harm Q1Q3 CY 2010
MICU Falls
2009 Total & Q1-Q3 Comparisons
10
9
Number of CLABSI Cases
9
8
7
6
6
5
4
3
2
2
1
0
Falls 2009
Falls Q1-Q3 CY 2009Falls Q1-Q3 CY 2010
MICU VAP
2009 Totals & Q1-Q3 Comparisons
16
Number of VAP Cases
14
14
12
10
8
8
6
4
3
2
0
MICU Total VAP
2009
VAP Q1-Q3 2009
VAP Q1-Q3 2010
MICU Central Line Associated BSI
2009 Total & Q1-Q3 Comparisons
Number of CLABSI Cases
25
20
15
10
23
17
5
2
0
CLABSI MICU 2009
CLABSI Q1-Q3 CY
2009
CLABSI Q1-Q3 CY
2010
2009 Totals & Q1-Q3 CY2010 Comparison
CVICU Falls, VAP, CAUTI, CLABSI
60
55
Tally of Avoidable Harm
55
50
45
40
38
35
30
25
23
20
15
10
5
0
CVICU Avoidable Harm CVICU Avoidable Harm CVICU Avoidable Harm
2009
Q1-Q3 CY 2009
Q1-Q3 CY 2010
CVICU Catheter Associated UTI
2009 Totals and Q1-Q3 Comparisons
18
17
16
Number of CAUTI Cases
14
11
12
10
7
8
6
4
2
-
CVICU Total CAUTI 2009
CAUTI Q1-Q3 CY 2009
CAUTI Q1-Q3 CY 2010
MSICU, 7 West ICU, CVICU
Combined Avoidable Harm
18.00
Avoidable Harm Tally
16.00
14.00
12.00
10.00
8.00
6.00
4.00
2.00
0.00
Harm / 1000 Pt Days
UCL
+2 Sigma
+1 Sigma
Average
-1 Sigma
-2 Sigma
LCL
2009 Total & Q1-Q3 CY 2010 Comparisons
Tally of Avoidable Harm
Combined MICU & CVICU Falls, CLABSI, CAUTI, VAP
135
130
125
120
115
110
105
100
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
127
88
45
MICU & CVICU
Avoidable Harm 2009
MICU & CVICU
MICU & CVICU
Avoidable Harm Q1-Q3 Avoidable Harm Q1-Q3
CY 2009
CY 2010
Estimated Avoidable
Costs
2009 & Q1-Q3 Estimated Avoidable Costs*
MICU VAP, CLABSI, CAUTI
$1,200,000.00
$1,095,882.00
$1,000,000.00
$770,350.00
$800,000.00
$600,000.00
86.78 %
Reduction
$400,000.00
$200,000.00
$144,858.00
$0.00
Estimated Costs of HAI
2009
*Centers for Disease Control and Prevention. ( March 2009)
Estimated Costs of HAI Q1- Estimated costs of HAI Q1Q3 2009
Q3 CY2010
2009 & Q1-Q3 Estimated Avoidable Costs*
CVICU VAP, CLABSI, CAUTI
$800,000.00
$712,327.00
$700,000.00
46.44%
Reduction
$600,000.00
$531,997.00
$500,000.00
$381,541.00
$400,000.00
$300,000.00
$200,000.00
$100,000.00
$0.00
Estimated Costs of HAI 2009 Estimated Costs of HAI Q1- Estimated costs of HAI Q1-Q3
Q3 2010
CY2010
*Centers for Disease Control and Prevention. ( March 2009)
2009 & Q1-Q3 Estimated Avoidable Costs*
MICU & CVICU VAP, CLABSI, CAUTI
$2,000,000.00
$1,808,209.00
$1,800,000.00
$1,600,000.00
$1,400,000.00
$1,302,347.00
69.11 %
Reduction
$1,200,000.00
$1,000,000.00
$800,000.00
$540,482.00
$600,000.00
$400,000.00
$200,000.00
$0.00
Estimated Costs of HAI
2009
*Centers for Disease Control and Prevention. ( March 2009)
Estimated costs of HAI Q1- Estimated costs of HAI Q1Q3 2009
Q3 CY2010
Next Steps
MICU Avoidable Harm Tally
14
12
MICU HAC Tally
10
?
8
6
4
2
0
MICU 2009 Harm Totals
UCL
+2 Sigma
+1 Sigma
Average
-1 Sigma
-2 Sigma
LCL
CVICU Avoidable Harm Tally
CVICU Avoidable Harm Tally
10
8
?
6
4
2
0
Totals
UCL
+2 Sigma
+1 Sigma
Average
-1 Sigma
-2 Sigma
LCL
7 West, MICU, & CVICU
Combined Avoidable Harm
22
20
MICU HAC Rate per 1000 pt days
18
?
16
14
12
10
8
6
4
2
0
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
MICU HAC/ 1000 pt days
UCL
+2 Sigma
+1 Sigma
Average
-1 Sigma
-2 Sigma
LCL
A
M
J
J
A
S
Q1-Q3 CY2010 Avoidable Harm
CVICU, 7 WEST ICU, MSICU
16
100%
15
14
80%
60%
7
6
6
40%
3
CV FALLS
MS VAP
CV VAP
2
CV CAUTI
4
CV CALBSI
3
0
2
2
MS FALLS
7
MS CLABSI
8
Cumulative %
10
MS CAUTI
HAI TALLY
12
20%
0%
HEALTHCARE ASSOCIATED HARM
Vital Few
Useful Many
Cumulative%
Cut Off %
[42]
Beyond the Bundles
• Safety Debriefing
– Allows us to study where our systems and
processes failures
– Involves the direct care-giver team in the unit,
– We conduct the safety debriefing close to the
time of occurrence
– Helps quantify common causes for failures in
order to systematically improve our processes
Acknowledgement
• Core Team:
– Mike Mayo RN Manager MICU,
– Chris Davis RN Clinical Coordinator 7 West
ICU,
– Pearl Kim RN Clinical Coordinator MSICU,
– Pamela Woltjen AA
• Nursing and Respiratory Therapy Staff MSICU, 7 West
ICU, CVICU
• Tammie OConnor RN CC CVICU
• Internal Medicine Faculty and Fellows
• Special Thanks to Dr. Gary Reed
Reference
1. Centers for Disease Control and
Prevention. ( March 2009) The Direct
Medical costs of Healthcare-Associated
Infections in U.S Hospitals and the
Benefits of Prevention. Division of
Healthcare Quality Promotion. National
Center for Preparedness, Detection, and
Control of Infectious Disease.
Coordinating Center for Infectious
Diseases