St. Joseph Mercy Health System
Keystone ICU Collaborative:
Making your ICUs safer
The secret ingredients are culture and team
Pat Posa RN, BSN, MSA
System Performance Improvement Leader
St. Joseph Mercy Health System
Ann Arbor, MI
patposa@comcast.net
Objectives
Review the purpose of the ICU Comprehensive UnitBased Safety Program/CLABSI Initiative. Understand
how your ICU and your hospital will benefit from
participation.
Build the skills of physicians, nurses, and other care
team to improve teamwork and build a safety culture.
Engage in discussion with national experts on best
practices in reducing infections, preventing central
line infections
Statewide initiative-75 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
Grant funded period
Still going strong after 6 years!!!!
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Science of
Safety(CUSP)
BSI
VAP
Daily Goals
Sepsis
Oral Care
Delirium and
Progressive
mobility
Partnership between Johns Hopkins University and MHA
Initiated with AHRQ Matching Grant Sustained with participant fees in
2005 and 2006
St. Joseph Mercy Story
CUSP in the ICU and beyond
Preventing CLABSI in ICU and beyond
Building on CUSP and CLABSI for other
work
Daily goals
 VAP prevention
 Sepsis identification and management
 Intra-abdominal hypertension identification
and management
 Delirium and Progressive mobility
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Start with:
Keystone ICU Team
Denise Harrison RN, MSN, Director
of Critical Care
Christine Curran, MD, physician
project leader
Mary-Anne Purtill MD, medical
director SICU
Pat Posa RN, MSA, system
performance improvement leader
Marco Hoesel MD, surgical resident
Amy Heeg RN, BSN CCULivingston
Brian Kurylo RN, CCU
Cathy Stewart RN, BSN, CCRN
Resourse Pool
Diane Jones PA, cardiac surgery
David Holmes, cardiac surgery
Sondra RN CCU-Livingston
Andreea Sandu RN, MICU
Angie Malcolm RN, MICU
Michael Maher, RN, SICU
Emily McGee, RN, Case Nurse,
SICU
Shikha Kapila, Pharm. D
Cheryl Morrin MPH, infection control
Chris Kiser, Pharmacy, Livingston
Beverly Bay-Jones, RRT, Resp
Therapy
Tahnee Thibodeau., RD, MICU
dietitican
Wendy Nieman RN, Project Impact
Assess culture of safety---must get 60%+ return rate
Educate staff on science of safety
Identify defects
Assign executive to adopt unit
Learn from one defect per quarter
Implement team/communication tools
Reassess culture every 18 months- 2 years
Keep focus on this throughout the journey!!!
Understand system determines performance
Use strategies to improve system performance
 Standardize
 Create Independent checks for key process
 Learn from Mistakes
Apply strategies to both technical work and team work.
Recognize that teams make wise decisions with diverse
and independent input
How we do this:
• Educate all personnel in all the ICU—RN, RT, residents, PA/NP
• Educate the attending---difficult but important
• Part of orientation
Safety Issues Survey
1.
2.
3.
Tell us about the last patient who would have been
harmed without your intervention.
How will the next patient be harmed?
What steps can you do to prevent this harm?
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by either preventing the mistake, making the mistake visible or
mitigating the harm should it occur
This is a very important tool. Use this to identify some of the
‘whys’ mistakes are happening and what is impacting culture
Taking an identified patient safety issue from the frontline staff and
create an action plan to resolve this is an early win for this program
and staff buy-in
Learn from a Defect Tool
Designed to rigorously analyze the various
components and conditions that contributed
to an adverse event and is likely to be
successful in the elimination of future
occurrences.
Tool can serve to organize factors that may
have contributed to the defect and provides a
logical approach to breaking down faulty
system issues.
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.
Finding Defects to Learn From
Staff feedback
Event reporting
Quality and safety measures
Gaps in application of the evidence
Have staff complete short 3 question
survey
Mistakes and near misses are
defects
Have each ICU present learning from a
defect each quarter
NG placed in the lungs
 Missed respiratory treatments
 Delay in radiology tests for ICU pts
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This is very hard to continue to do, we did it first for the first year.
We didn’t keep it up----but are trying to get back to focusing on
doing this. The biggest challenge is following up on each action plan
giving the feedback to the staff.
Daily rounds/goals
Pre-procedure briefing
Morning briefing
Huddles
Learn from a defect
Executive Safety Rounds
Morbidity and Mortality Conference
Interdisciplinary rounds with daily
goals
Purpose: Improve communication among care team
and family members regarding the patient’s plan of
care
Goals should be specific and measurable
Documented where all care team members have
access
Checklist used during rounds prompts caregivers to
focus on what needs to be accomplished that day to
safely move the patient closer to transfer out of the
ICU
Measure effectiveness of rounds—team dynamics,
communication
Interdisciplinary rounds with daily goals--Challenges and Opportunities
Hardest initiative to implement, especially if you have an open
unit and/or no intensivists
We had each unit create their own daily goal checklists---each
unit culture and process is different. Changed this form multiple
times---and in two units we gave up.
Focused first on create a daily goal and recording those either
on the white board in the room or on a sheet of paper
One year ago: closed our MICU and started intensivist program
in the SICU
Relooking at this again, and focusing on team dynamics
and created a defined role for the nurse: survey and
observation
Pre-procedure briefing
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Make introductions
Discuss patient information and procedure
Agree upon a time for line insertion
Review best practice for line insertion (if necessary)
Nurse defines their role to physician: provide equipment, monitor
patient, provide patient comfort, observe for compliance with best
practices and STOP procedure if sterile process compromised
• Establish communication expectation for sterile procedure breaks
• Examples include: your sleeve has touched the IV pole, the guidewire touched the headboard
• Identify any special supply or procedural needs
• Discuss any special patient issues (IE: patient confused, patient awake)
• Answer any additional questions
TIME OUT: RIGHT PATIENT---RIGHT PROCEDURE
Used this when rolled out CLABSI bundle to non-ICU
Morning Briefing
Purpose: Increase communication between physicians
and nursing staff while efficiently prioritizing patient care
delivery and ICU admissions and discharges
What is it?
 A morning briefing is a dialogue between 2 or more
persons using concise and relevant information to
promote effective communication prior to rounds
Have used this for a long time between charge nurses from
shift to shift. Since we have closed the units, now this also
occurs with charge nurse and intensivist.
Morning Briefing
Tool: answer following questions
What happened overnight that I need to
know about?
 Where should I begin rounds? (patient that
requires immediate attention based on
acuity)
 Which patients do you believe will be
transferring out of the unit today?
 Who has discharge orders written?
 How many admissions are planned today?
 What time is the first admission?
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Huddles
Enable teams to have frequent but short briefings so that
they can stay informed, review work, make plans, and
move ahead rapidly.
Allow fuller participation of front-line staff and bedside
caregivers, who often find it impossible to get away for
the conventional hour-long improvement team meetings.
They keep momentum going, as teams are able to meet
more frequently.
Beginning to use this strategy to begin
to recovery immediately from defects--IE: falls, sepsis
CUSP-Challenges and Strategies
Issues
Strategies
Engaging frontline staff (including
off-shifts) owning this work
Part of team(especially night shift
staff), bulletin boards, newsletters,
Timely follow through with identified
defects or safety issues and
strategies to resolve
Manager shares updates/status at
staff meetings,
Continued engagement of the
executive
MHA Keystone letters to executive,
locally at each hospital—through
one on one conversations
Implementing strategies and tools to Learn from a defect, MDR with
help improve culture and teamwork focus on communication, survey
team members on perception of
communication, morning briefings,
debriefings
Continual learning from defects
Have each unit learn from a defect
quarterly and share at meetings
Lessons Learned
Spend sufficient time on CUSP before moving on to
implementing practice changes
CUSP is the foundation and needs to be a continued
focus-----forever!!!!
Must work on culture and team improvement
strategies throughout the journey
CUSP must be unit based. Culture is different on
each unit, therefore opportunities for improvement
and strategies might be different
Define at beginning a communication plan that
includes all levels of the organization
This work must be the responsibility of everyone,
but important to have someone who’s job is to
focus and drive this daily
Strategies to Improve Culture
Multidisciplinary Rounds with Daily Goals
Closed MICU to only Intensivists
Surgical Intensivists Program-SICU
Learn from a defect
Define/implement Critical Care Standards of Nursing
and Medical Practice
Standardize RN-RN Shift Handoff
Simulation Program—focus on teamwork and
communication
ACLS certification
Critical Care Nurse Certification
Can we change practice through
process improvement alone?
or
Will successful change require
an altering of the value structure
within the unit?
Translating Evidence into Standard
Practice
Translating Evidence into Practice
Multidisciplinaryteam (Keystone ICU team)
 Including bedside RN and Physician champions
Reviewed evidence to define ‘best practice’
 CLABSI prevention bundle
Gathered baseline data
Implemented the CLABSI Bundle
 Central line Checklist
 Line carts
 Empower nursing staff to identify and correct errors
(support of chief of surgery and medicine)
Communication of new practice through medical and
nursing committee structures
Measure rates and Compliance with process
Central Line Associated Blood
Stream Infection Rate:
Infections per 1000 Line Days
ICUs Ann
Arbor
MHA
Keystone
Baseline 2004 2005
7.6
6.12 2.2
7.7
2.51
1.51
2006
1.2
2007
1.25
2008
0.95
2009
0.66
1.25
1.17
0.98
0.89
Translating Evidence into Practice
Expanding beyond the ICU
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Can’t have multiple standards for line insertion
All floors, ED, OR and anywhere they put in a line
Got a group together of non ICU providers to define a process
for line insertion
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Pre-procedure briefing
Central line bag vs line cart
Talk with medical and surgical residents and asked them what
their barriers were to placing the lines following the best
practice strategies
Challenges with getting denominator: line days in the
non-ICU area.
Our focus now is the non-ICU CLABSI and
understanding why they are happening
Getting to Zero and Sustaining
the Gains
Monitor process and outcomes and provide
information to team and staff
Try to understand ‘why’ if an infection occurs
Continue to evaluate the evidence
Apply additional evidence-based strategies as
necessary based on the causes of the defect:
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CHG baths
CHG dressing
Antiseptic/antimicrobial catheters
After CLABSI—what was next?
Chose VAP prevention, since it was the other major
HAI in the ICU
Ensure you have respiratory therapy on your team
Used same model for implementation
 Engage: what are our rates? and how many
people are dying---tell stories
 Educate: review the evidence and agree on the
bundle components,
 Execute: bedside tools, automatic orders for pts
on the vent
 Evaluate: prospective vent bundle rounding
Ventilator Pneumonia Prevention Bundle
HOB at 30 degrees
WAKE UP AND BREATH
 Daily Spontaneous Breathing Trials
 Appropriate Sedation
PUD Prophylaxis
DVT Prophylaxis
Glucose Control
Oral Care q 2 hours plus CHG rinse every 12 hrs
Don’t routinely instill NS with suctioning
Handling of suctioning and oral care equipment
Use of pulmonary specialty beds
Subglottal suctioning
Progressive Mobility
Ventilator Associated
Pneumonia:
Infections per 1000 Ventilator Days
Baseline 2004 2005 2006 2007 2008 2009
ICUs
Ann
Arbor
MHA
Keystone
7.75
3.89 1.9
1.53 3.96 2.05 1.44
7.6
4.68 3.87 2.89 2.46 1.93 1.6
Challenges/Strategies with
Vent Bundle
Issues
Strategies
Sedation Holiday
•Nurses fear that pt will be wild
•No one’s responsibility
Daily vent bundle rounding, set
specific time to do the holiday, link
with SBT, understand why the
nurses aren’t doing it,
SBT
•RT staffing
•Poor communication between RNRT
Working with RT to define time to
perform these that will result in
patient being successful, discuss on
rounds everyday
Glucose Control
*lacking evidence for best target
* Time consuming
Selected middle of road target,
measure rate of hypoglycemia,
revise targets based on new
evidence
Severe Sepsis:
A Significant Healthcare Challenge
Major cause of morbidity and mortality worldwide
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Leading cause of death in noncoronary ICU (US)1
10th leading cause of death overall (US)2*
More than 750,000 cases of severe sepsis
in the US annually3
In the US, more than 500 patients die
of severe sepsis daily3†
* Based on data for septicemia
† Reflects hospital-wide cases of severe sepsis as defined by infection in the presence of organ dysfunction
1. Sands KE, Bates DW, Lanken PN, et al. Epidemiology of sepsis syndrome in 8 academic medical centers. JAMA 1997;278:234-40.
2. National Vital Statistics Reports. 2005.
3. Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: analysis of incidence,
outcome and associated costs of care. Crit Care Med 2001;29:1303-10.
The Severe Sepsis Bundles: Surviving Sepsis Campaign/IHI
Resuscitation Bundle
Management Bundle
(To be accomplished as soon as possible
over first 6 hours):
(To be accomplished as soon as possible over first
24 hours):
 Serum lactate measured.
 Blood cultures obtained prior to antibiotics administered.
(1C)
 Perform imaging studies promptly to fine source (1C)
 From the time of presentation, broad- spectrum antibiotics
within 3 hours for ED admissions and
1 hour for non-ED ICU admissions. (1D/1B)
 For hypotension and/or lactate > 4 mmol/L:
Deliver an initial minimum of 20 mL/kg of crystalloid
(or colloid equivalent) (1C)
Apply vasopressors for hypotension not responding to
initial fluid resuscitation to maintain MAP > 65 mmHg.
 For persistent hypotension despite initial fluid resuscitation
(septic shock) and/or lactate
> 4 mmol/L: 1C
Achieve CVP > 8 mmHg & MAP > 65 mmHg & UO
>0.5mL/kg/hr
Achieve ScvO2 of > 70% or SvO2 > 65%.
 if ScvO2 not > 70% blood or dobutamine (2C)
 Low-dose steroids administered for septic
shock in accordance with a standardized
ICU policy. (Given to patients who respond
poorly to fluids or vasopressors) (2C)
 Drotrecogin alfa (activated) administered in
accordance with a standardized ICU policy.
(Given to patients with sepsis induced organ
dysfunction at high risk of death (2B)
 Glucose control maintained
to < 150 mg/dL (8.3 mmol/L). (2C)
 Tidal volume 6 ml/kg (1B) Inspiratory
plateau pressures
< 30 cmH2O for mechanically ventilated
patients. (1C)
Adapted from the revised guidelines: CCM 2008;36:296327.
4-Tier Process for
Severe Sepsis Program Implementation©
Sepsis Solutions Int.
Measuring
Success
Implementation of
the Sepsis Bundle
Early Screening with
Tools and Triggers
Organizational Consensus that Severe Sepsis
Must be Managed Early and Aggressively
Severe Sepsis
Screening Tool
Septic Shock Clinical Pathway
Challenges/Strategies with
Sepsis Program
Issues
Strategies
Staff buy-in
Part of team, Education frequently,
daily rounds by sepsis program
coordinator, data, data, data,
executive physician support,
executive management support
Identification of severe sepsis
patient
Screening process, lactate rounds,
RRT
Achieving interventions in timely
manner
Bedside tools, pocket cards,
education, daily rounding by sepsis
program coordinator
Continual learning---work in progress. This program
takes a long time to have it become the standard of
practice
Sepsis Mortality
Sepsis Program Outcomes
Severe Sepsis/Septic Shock
65% of patients achieve resuscitation goals
within 6 hours of septic shock diagnosis
 Hospital mortality: decrease from 45% to
26%
 Hospital average LOS: decrease from 26
days to 14 days
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Lessons Learned- Sepsis
Must have program coordinator (like stroke and
trauma) to oversee and lead this work. This person
has to have leadership skill set and thick skin.
ICU medical leadership plays key role in physician
buy-in
Frequent team meeting (twice a month)—lots of work
by coordinator between meetings to ensure
continued forward movement and buy-in
Employ all change management strategies
Data is hard to capture, but VITAL to move program
forward
Keep executive management engaged---give them
frequent data, have them help with removing barriers
ACCOUNTABILITY for all team members
What’s Next
Program lead (nurse and physician)
continue to review literature and identify
gaps in practice
Delirium
Progressive mobility
A Healthcare Imperative
“In medicine, as in any profession,
we must grapple with systems,
resources, circumstances,
people-and our own
shortcomings, as well. We face
obstacles of seemingly endless
variety. Yet somehow we must
advance, we must refine, we must
improve.”
Atul Gawande, Better: A Surgeon’s Notes on Performance
QUESTIONS ?????
Objectives
Review the purpose of the ICU Comprehensive UnitBased Safety Program/CLABSI Initiative. Understand
how your ICU and your hospital will benefit from
participation.
Build the skills of physicians, nurses, and other care
team to improve teamwork and build a safety culture.
Engage in discussion with national experts on best
practices in reducing infections, preventing central
line infections