Reducing Avoidable Harm in the MICU
Sustaining & Spreading Improvements
October 24, 2011
Background
• 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 $28 billion to $33 billion each
year1.
-CDC March 2009
Our Aim
• Our aim at UT Southwestern is to sustain improvements
gained in the MICUs by reducing the combined number
of device related HAIs and falls with injury by 50% of the
2010 count by end of calendar year 2011
• 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 with injury
Measures of Success
• The combined count of all our CAUTI, VAP,
CLABSI and falls in the MICUs in 2009
measured against the counts for 2010, and
2011 YTD.
• Reduction in HAI rates: normalized infection
counts using device days in order to measure
and study our progress.
• Estimated direct medical costs of HAI’s.
• Staff engagement from 2010 and 2011, using
the National Database of Nursing Quality
Improvement (NDNQI).
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
Source:
*Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The
Improvement Guide: A Practical Approach to Enhancing Organizational
Performance (2nd edition). San Francisco: Jossey-Bass Publishers; 2009
Our Baseline Improvements
2009 MICU = 66 2010 MICU = 32
 CAUTI= 26
 CLABSI = 23
 VAP = 14
 Falls = 3 with injury
 CAUTI=23
 CLABSI = 3
 VAP = 6
 Falls = 0 with injury
51.52% Improvement
Interventions
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]
Pareto Chart
Avoidable Costs CVICU, MSICU, 7 West ICU CY 2009
$800,000
100%
$700,000
80%
$500,000
60%
$400,000
40%
CVICU CAUTI
MICU CAUTI
CVICU VAP
MICU VAP
MICU CLABSI
$100,000
CVICU CLABSI
$300,000
$200,000
Cumulative %
$600,000
20%
$0
0%
Avoidable Costs of HAI
Vital Few
Useful Many
Cumulative%
Cut Off %
[42]
Process Map
Central Line Maintenance
Process Map
PUD Prophylaxis
Annotated Control Charts
MSICU & 7 West ICU Avoidable Harm Tally
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
Fishbone Diagram
Contributing Factors
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
Run Charts
Progress Over Time
All St. Paul ICU VAP -2010 & 2011
Bundle Compliance
7 West ICU
100.00%
80.00%
% Compliance
All Bundle
Elements
60.00%
40.00%
20.00%
0.00%
MSICU
CVICU
Pareto Chart:
Focus
Pareto Chart of CAUTIs
Jan-Aug 2011
25
100%
20
80%
60%
10
40%
8
7
20%
5th Floor
7 South
6 South
6 North
7 North
3North
5
UHZL 6
5
UHZL 5
5
4th Floor
3 South
UHZL 8
CVICU
5
SICU
5
MS/7W ICU
CAUTIs
15
15
Cumulative %
20
0
0%
Hospital Units
Vital Few
Useful Many
Cumulative%
Cut Off %
[42]
Pareto Chart:
Focus
Reasons for CLABSI in CVICU
14
100%
12
11
10
Votes
80%
12
11
9
8
60%
9
7
6
40%
6
5
4
5
4
4
Cumulative %
12
20%
2
4
3
3
2
2
2
2
2
1
0
1
0%
Causes
Vital Few
Useful Many 4 3 3 3 2 2 2…
[42]
The first 12 Causes cover 80.51% of the Total Votes
Cumulative Percentage Cutoff:
Votes
80%
#
Causes
1
2
-Disconnecting lines/ laying open lines on bed
-Dressing loose or disc saturated
12
12
Cumulative%
10.2%
20.3%
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
-Improper insertion: not washing hands; improper CHX prep; not using head to toe drape, not using full barrier precautions, poor sterile technique
-Insufficient swabbing of hubs
-Femoral line placement
-Hand washing before touching patient
-Drooling on line
-Patients who continuously ooze/weep/bleed at insertion site
-Not daily evaluating if the central line is still needed
-Use of central line for frequent blood draws
-Leaving IV/stopcock ports uncapped
-Nurses afraid to speak up if they see a problem
-Susceptible/ at-risk patient due to immunosuppression, etc
-Lines in too long just for blood draws
-Not changing Statlock holders with every PICC dressing change
-Choice of CL vs. PICC, multi ports vs. single lumen
-Non-compliance with line care protocol
-Not maintaing sterile technique with dressing changes
-Multiple line insertion attempts
-Existing skin infections
11
11
9
9
7
6
5
5
4
4
4
3
3
3
2
2
2
2
29.7%
39.0%
46.6%
54.2%
60.2%
65.3%
69.5%
73.7%
77.1%
80.5%
83.9%
86.4%
89.0%
91.5%
93.2%
94.9%
96.6%
98.3%
21
22
-Improper dressing: biopatch not flush against skin, dressing "tented" over skin folds
-Multiple use of IV tubing
1
1
99.2%
100.0%
Our Results
NDNQI Practice Environment Scale
(PES) on a 4 point scale
2010 NDNQI
2011 NDNQI
• PES 7 West = 3.2
• PES MSICU = 3.03
• PES 7 West 3.22
• PES MSICU = 3.18
NDNQI Academic Mean
2.92
NDNQI Academic Mean
2.88
X MICU West VAP / 1000 Vent Days
Jan 2009- Sept 2011
MICU 7/WestVAP / 1000 Vent Days
UCL
+2 Sigma
+1 Sigma
Average
-1 Sigma
-2 Sigma
LCL
12.0
UCL
11.0
MICU 7/West VAP / 1000 Vent Days
10.0
Post CS & E Course
8.0
6.9
6.0
CL
5.2
4.0
2.0
0.0
-2.0
1.6
LCL
-0.5
Pre CS & E Course
-3.6
-4.0
X MICU & 7 West ICU CLABSI /1000 Central Line Days
Jan 2009-Sept 2011
PBSI /1000 Central Line Days
10.00
UCL
UCL
+2 Sigma
+1 Sigma
Average
-1 Sigma
-2 Sigma
LCL
9.78
PBSI /1000 Central Line Days
8.00
6.00
Post CS & E Course
4.50
4.00
CL
3.99
2.00
0.78
0.00
-2.00
LCL
-1.81
-2.94
Pre CS & E Course
-4.00
Avoidable HAI & Falls Adult ICUs UH St. Paul
CVICU HAI
MSICU HAI
120
100
Count
80
MSICU HAI
66
60
MSICU HAI
32
40
20
MSICU HAI
26
CVICU HAI
43
CVICU HAI
24
CVICU HAI
16
0
2009
2010
Jan-Aug 2011
VAP Elimination Adult ICUs UH St. Paul
Jan 2009-Aug 2011
CVICU
MS/7W ICU
VAP Count
Infection Control Reports
20
MS/7W ICU,
14
15
MS/7W ICU
6
10
5
CVICU
7
CVICU
8
2009
2010
MS/7W ICU, 1
CVICU, 1
0
2011 Jan-Aug
CALBSI Elimination Adult ICUs UH St. Paul
Jan 2009-Aug 2011
CVICU
MS/7W ICU
40
35
CLABSI Count
Infection Control Reports
30
MS/7W ICU
23
25
20
15
10
CVICU
17
5
MS/7W ICU
3
CVICU
6
MS/7W ICU
4
2010
2011 Jan-Aug
CVICU
6
0
2009
MICU 7 West ICU
CLABSI
CAUTI
VAP
Falls
70
Falls , 3
Count of Device-related HAI and Falls with Injury
Infection Control & Fall Reports
60
VAP , 14
50
40
CAUTI , 26
30
VAP , 6
VAP , 1
20
10
CAUTI , 23
CAUTI , 21
CLABSI , 3
CLABSI , 4
2010 Avoidable Harm
2011 Avoidable Harm Q1-Q2 2011
CLABSI , 23
0
2009 Avoidable Harm
Spreading
Improvements
Control Chart
UH St. Paul Hand Hygiene Improvement
Data1
UCL
+2 Sigma
+1 Sigma
Average
-1 Sigma
-2 Sigma
LCL
% Compliance Reported by ICP Surveillance Team
98.00
96.56
96.00
94.00
Pre-Intervention
92.73
92.00
UCL
91.15
90.00
88.90
88.00
CL
88.10
Post-intervention
1. 6th & 7th Floor HH Pilot
Project Feb. 2011
2.CNO HH Focus (Select
86.00
LCL
84.00
85.04
Process Map
Ventilator Liberation Process CVICU
N
Patient arrives
in CVICU from
OR
"rest".
Resume
weaning next
day or until he
says
N
Y
Stable
hemod
ynamic
s?
N
Y
Y
Tolerat
ed?
N
Y
N
Tolerat
ed?
Tolerat
ed?
Tolerat
ed?
"rest".
Resume
weaning next
day or until he
says
Pt is
Extubated
Pt is
Extubated
Y
Orders
Orders
extubation
Orders
extubation
Fast Track
Extubation
Initiate VAP Bundle ( VAP
prevention protocol ) 1113
CVTS Post op CV Surgery
Turn off
Sedation
Sedative
Holiday
Inform MD
Initiate
Sedative
Holiday
Inform MD
Inform MD
Inform MD
Document
response?
Initiate
weaning
Documentation?
?
Weaning Parameters
1. NIF -25
2. FVC >1L
3. Pt. can lift head
4.
(No orders)
Wean to CPAP/
FiO2 40%
Extubate
Patient
(No orders)
Wean to CPAP/
FiO2 40%
Extubate
Patient
Device Related HAI & Falls CVICU,MSICU, 7 West ICU
HAI & Falls CVICU/MSICU/7 West ICU
UCL
+2 Sigma
Pre CS & E Course
18.00
UCL
+1 Sigma
Average
-1 Sigma
-2 Sigma
LCL
Post CS & E Course
16.72
Device Related HAI & Falls /1000 pt days
16.00
14.00
12.80
12.00
10.00
CL
8.53
8.00
6.00
4.49
4.00
2.00
LCL
0.00
0.35
Avoidable Harm ICUs Combined
7 West ICU, CVICU, MSICU, SICU
Data1
UCL
+2 Sigma
+1 Sigma
Average
-1 Sigma
-2 Sigma
LCL
14.00
UCL
13.25
12.22
Device-Related HAI & Falls/1000 Pt Days
12.00
Pre CS & E Course
Post CS & E Course
10.00
8.00
CL
8.04
6.00
4.78
4.00
LCL
2.00
0.00
2.84
CLABSI Rates 6 North & 6 South Combined
CLABSI/1000 device days
UCL
+2 Sigma
+1 Sigma
Average
-1 Sigma
-2 Sigma
LCL
20.0
UCL
17.5
Pre CS & E Course
Post CS & E Course
15.0
CLABSI/1000 device days
10.0
5.0
5.2
CL
3.6
1.1
0.0
-3.1
-5.0
-10.0
-15.0
LCL
-10.3
Patient Falls with Injury
6 North & 6 South Combined
Pt falls w Injury/1000 pt days
UCL
+2 Sigma
+1 Sigma
Average
-1 Sigma
-2 Sigma
LCL
5.50
Pre CS & E Course
4.50
UCL
Post CS & E Course
3.78
Pt falls w Injury/1000 pt days
3.50
2.71
2.50
1.50
CL
1.49
0.50
0.50
-0.50
-1.50
-2.50
LCL
-0.79
-1.71
Big Picture
CAUTI Progress
2009-Sept 2011 (Non-ICU Not Tallied until
2011)
2011 Jan-Sept:
45 ICU & 42 Non-ICU CAUTI Cases
CVICU
9
11%
45
40
35
15
10
5
CVICU, 10
MS/7W ICU, 23
SICU, 13
20
CVICU, 9
MS/7W ICU, 21
SICU, 15
Non-ICU CAUTI, 42
25
CVICU, 17
MS/7W ICU, 26
SICU, 18
CAUTI Case Count
30
0
2009
2010
2011 YTD
NonICU
CAUTI
42
48%
MS/7
W ICU
21
24%
SICU
15
17%
Spreading & Sustaining Improvements
Nursing Quality Council
Membership:
Quality Council Chair & Co Chair, Physician Champions
NDNQI Committee Chair/Reporter
HAI Council Leader s
Patient Safety Council Leaders
Patient Experience Council Leaders
Director Advisor ZLUH, Director Advisor SPUH
VAP
Committee
Chair/Co-Chair,
Staff members
CLABSI
Committee
Chair/Co-Chair,
Staff Members
CAUTI
Committee
Staff Safety
Committee
Falls
Committee
Skin
Committee
Code Blue
RRT
Committee
Chair/Co-chair,
Staff members
Sharps,
Exposures,
other injuries
Medication
Safety
Committee
Chair/Co-Chair,
Staff Members
Chair/Co-Chair,
Staff Members
Chair/Co-Chair,
Staff Members
Chair/Co-Chair,
Staff Members
Estimated Avoidable
Costs
Estimated Avoidable Costs of Device-Related HAIs
7 West ICU, CVICU, MSICU Combined
$2,000,000.00
$1,808,209.00
$1,800,000.00
$1,600,000.00
$1,400,000.00
$1,200,000.00
61.6%
Improvement
$1,000,000.00
$800,000.00
$694,747.00
45.5%
Improvement
$600,000.00
$378,786.00
$400,000.00
$200,000.00
$2009
1.
2010
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
Q1-Q3 2011
Estimated Avoidable Costs
7 West ICU, MSICU, CVICU Combined
$2,000,000.00
CAUTI
$1,800,000.00
$1,600,000.00
VAP
$1,400,000.00
$1,200,000.00
$1,000,000.00
$800,000.00
CAUTI
$600,000.00
CLABSI
VAP
$400,000.00
CAUTI
VAP
$200,000.00
CLABSI
CLABSI
2010 Avoidable Costs
Q1 to Q3 CY2011 Avoidable Costs
$2009 Avoidable Costs
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
HAI Estimated Avoidable Costs of Device-Related HAI
MSICU /7 West ICU
$1,200,000.00
$1,095,882.00
$1,000,000.00
$800,000.00
74.3%
Improvement
$600,000.00
41%
Improvement
$400,000.00
$281,677.00
$166,279.00
$200,000.00
$-
CY 2009
1.
CY 2010
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
Q1-Q3 CY2011
HAI Estimated Avoidable Costs
MICU/7 West ICU
CLABSI
VAP
CAUTI
$1,200,000.00
CAUTI , $26,182.00
$1,000,000.00
VAP
$399,112.00
$800,000.00
$600,000.00
$400,000.00
CAUTI , $23,161.00
VAP
$171,048.00
CLABSI
$670,588.00
CAUTI , $21,147
VAP ; $28,508
CLABSI ; $87,468.00
CLABSI ; $116,624
2009
2010
Q1 to Q3 CY2011
$200,000.00
$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
HAI Avoidable Costs
CVICU
$800,000.00
$712,327.00
$700,000.00
42%
Improvement
$600,000.00
$500,000.00
$413,070.00
$400,000.00
49%
Improvement
$300,000.00
$212,507.00
$200,000.00
$100,000.00
$-
CY 2009
1.
CY 2010
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
Q1-Q3 2011
Estimated Avoidable Costs by Device-related HAI
CVICU
$800,000
$700,000
CAUTI , $17,119.00
$600,000
VAP
$199,556.00
$500,000
$400,000
CAUTI , $10,070.00
$300,000
VAP
$228,064.00
CLABSI ,
$495,652.00
$200,000
CLABSI ,
$174,936.00
$100,000
CAUTI , $5,035.00
VAP , $28,508.00
CLABSI , $58,312.00
$-
2009
1.
2010
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
Q1 to Q2 CY2011
Next Steps
Next Steps
• Safety Debriefing
– Tools that help us study where our systems
and processes failed
– Involved the direct care-giver team in the unit,
and close to the time of occurrence
– Help quantify common causes for failure in
order to systematically improve our processes
Next Steps
• Learning from Defects
– Nursing Quality Council: Multidisciplinary &
Collaborative
– Debrief every defect closer to the actual time of the
event
– Spread learnings from CUSP (Comprehensive Unitbased Safety Program)
– Educate the staff on the science of safety
– Continue to debrief each harm event with the team
involved
– Learn from one defect (patient harm event) from each
focus area per month
Contributing Factors (Example)
Patient Factors:
Patient was acutely ill or agitated (Elderly patient in renal failure, secondary to congestive heart
failure.)
There was a language barrier (Patient did not speak English)
There were personal or social issues (Patient declined therapy)
Task Factors:
Was there a protocol available to guide therapy? (Protocol for mixing medication concentrations is
posted above the medication bin.)
Were test results available to help make care decision? (Stat blood glucose results were sent in
20 minutes.)
Were tests results accurate? (Four diagnostic tests done; only MRI results needed quickly—
results faxed.)
Caregiver Factors
Was the caregiver fatigued? (Tired at the end of a double shift, nurse forgot to take a blood
pressure reading.)
Did the caregiver’s outlook/perception of own professional role impact on this event? (Doctor
followed up to make sure cardiac consult was done expeditiously.)
Was the physical or mental health of the provider a factor? (Provider having personal issues and
missed hearing a verbal order.)
Team Factors
Was verbal or written communication during hand offs clear, accurate, clinically relevant and goal
directed? (Oncoming care team was debriefed by out-going staff regarding patient’s condition.)
Was verbal or written communication during care clear, accurate, clinically relevant and goal
directed? (Staff was comfortable expressing his/her concern regarding high medication dose.)
Was verbal or written communication during crisis clear, accurate, clinically relevant and goal
directed? (Team leader quickly explained and direct his/her team regarding the plan of action.)
Was there a cohesive team structure with an identified and communicative leader? (Attending
physician gave clear instructions to the team.)
Negatively
Contributed
Positively
Contributed
Next Steps
Complete the Learning From Defects tool on one defect from each focus area
per month.
Provide a clear, through, and concise statement of what happened.
List factors that negatively or positively impact the defect.
Describe how you will reduce the likelihood of this defect happening again.
Describe how you know that you have reduced the risk of the defect .
Summarize your findings with a Case Summary. Share the findings !
Next Steps: Get to ZERO
ICU Device-Related HAI & Falls with Injury
Q1-Q3 CY2011
VAP
7
11%
Falls with Injury
0
CLABSI
12
19%
CAUTI
45
70%
Next Steps: Get to ZERO
Patient-Related Factors
Care-giver Related Factors
Inappropriate use
Improper securement
Female
Diabetes
Improper hand-hygiene
Age > 50 yrs
Fecal incontinence
Colonization of resistance organisms
Previous admission to LTAC or nursing home
Cluttered unclean environment
Inconsistent cleaning between patients
Clustering of patients with catheters
Breaks in closed system
Bag above level of bladder
Lack of fecal incontinence
control
Prolonged use of catheter (beyond
necessity)
Multi-patient use of measuring graduate
Bacterial adherence to catheter surface
No standardization of
equipment
No anti-reflux system
Environment Factors
Equipment Factors
Problem
Statement
Our current rate of
Catheter-associated
urinary tract
infections remains
static, and above
the NSHN mean.
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
Acknowledgements
• 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
• Nursing Quality and Safety Council
• Internal Medicine Faculty and Fellows
• Special Thanks to Dr. Gary Reed