On the CUSP: Stop CAUTI
The Science of Improving
Patient Safety
Sean Berenholtz, MD MHS
Johns Hopkins University
Quality and Safety Research Group
1
The Problem is Large
• In U.S. Healthcare system
– 7% of patients suffer a medication error 2
– On average, every patient admitted to an ICU suffers an adverse event 3,4
– 44,000- 98,000 people die each year as the result of medical errors 5
– Nearly 100,000 deaths from HAIs 6
– Estimated 30,000 to 62,000 deaths from CLABSIs 7
– Cost of HAIs is $28-33 billion 7
• 8 countries report similar findings to the U.S.
2
Bates DW, Cullen DJ, Laird N, et al., JAMA, 1995
Donchin Y, Gopher D, Olin M, et al., Crit Care Med, 1995.
Andrews L, Stocking C, Krizek T, et al., Lancet, 1997.
Kohn L, Corrigan J, Donaldson M., To Err Is Human, 1999.
Klevens M, Edwards J, Richards C, et al., PHR, 2007
Ending Health Care-Associated Infections, AHRQ, 2009.
RAND Study Confirms Continued Quality Gap
Condition
% of Recommended Care Received
Low back pain
68.5
Coronary artery disease
68.0
Hypertension
64.7
Depression
57.7
Orthopedic conditions
57.2
Colorectal cancer
53.9
Asthma
53.5
Benign prostatic hyperplasia
53.0
Hyperlipidemia
48.6
Diabetes mellitus
45.4
Headaches
45.2
Urinary tract infection
40.7
Hip fracture
22.8
Alcohol dependence
10.5
McGlynn EA, Asch SM, Adams J, et al., N Engl J Med, 2003.
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Healthcare-Associated Infections: A
Preventable Epidemic
• Focus on 4 HAIs: VAP, SSI, CRBSI, UTI
• $5 billion per year excess costs
• 1.7 million patients per year
– 1 out of 20 patients
• 98,000 deaths per year
– As many deaths as breast cancer and HIV/AIDS put
together
– 6th leading cause of preventable deaths
http://oversight.house.gov/story.asp?id=1865
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Case; Is this death preventable?
•
•
•
•
•
•
65 year-old male admitted to ICU with HAP
Requires intubation for ARDS
Zosyn 19 hours after admission
Culture sent, day 2 grew MRSA
Dx CA-BSI and DVT/PE
Died ICU day 21
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System is a set of parts interacting to
achieve a goal
“Every system is perfectly designed to
achieve the results it gets”
Caregivers are not to blame
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On the CUSP: Stop CAUTI
Rather than being the main instigators of
an accident, operators tend to be the
inheritors of system defects….. Their part
is that of adding the final garnish to a
lethal brew that has been long in the
cooking.”
James Reason, Human Error, 1990
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System Failure Leading to This Error
Communication between
resident and nurse
Inadequate training
and supervision
Catheter pulled with
Patient sitting
Lack of protocol
For catheter removal
Patient suffers
Venous air embolism
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Pronovost PJ, Wu Aw, Sexton, JB et al., Ann Int Med, 2004.
Reason J, Hobbs A., 2000.
Principles of Safe Design
• Standardize
– Eliminate steps if possible
• Create independent checks
• Learn when things go wrong
–
–
–
–
What happened
Why
What did you do to reduce risk
How do you know it worked
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Eliminate Steps
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Create Independent Checks
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Healthcare-Associated Infections:
A Preventable Epidemic
• Focus on 4 HAIs: VAP, SSI, CRBSI, UTI
• $5 billion per year excess costs
• 1.7 million patients per year
– 1 out of 20 patients
• 98,000 deaths per year
– As many deaths as breast cancer and HIV/AIDS put
together
– 6th leading cause of preventable deaths
http://oversight.house.gov/story.asp?id=1865
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EVIDENCE-BASED BEHAVIORS TO
PREVENT CLABSI
• Remove Unnecessary Lines
• Wash Hands Prior to Procedure
• Use Maximal Barrier Precautions
• Clean Skin with Chlorhexidine
• Avoid Femoral Lines
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MMWR. 2002;51:RR-10
Standardize
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CR-BSI Checklist
• Before the procedure, did they:
– Wash hands
– Sterilize procedure site
– Drape entire patient in a sterile fashion
• During the procedure, did they:
– Use sterile gloves, mask and sterile gown
– Maintain a sterile field
• Did all personnel assisting with procedure follow the
above precautions
• Empowered nursing to stop the procedure if violation
occurred
Crit Care Med 2004;32(10):2014.
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Daily Goals
• What needs to be done
for the patient to be
discharged?
• What is the patients
greatest safety risk?
• What can we do to
reduce the risk?
• Can any tubes, lines, or
drains be removed?
J Crit Care 2003;18(2):71-75
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Impact on Catheter-Related BSI
VAD Policy
Line Cart
Checklist
Daily goals
Empower Nursing
Crit Care Med 2004;32(10):2014.
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Michigan Keystone ICU
Median
CRBSI rate
2.7
1.6
Incidence
rate ratio
1
0.76
0-3 months
4-6 months
0
0
0.62
0.56
7-9 months
0
0.47
10-12 months
13-15 months
16-18 months
0
0
0
0.42
0.37
0.34
Time period
Baseline
Peri intervention
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N Engl J Med 2006;355:2725-32
Michigan Keystone ICU
Time period
Baseline
Intervention
0 – 3 months
4 – 6 months
7 – 9 months
10 – 12 months
13 – 15 months
16 – 18 months
19 – 21 months
22 – 24 months
25 – 27 months
28 – 30 months
Median VAP Rate
5.5
0
0
0
0
0
0
0
0
0
0
0
20
Incidence Rate Ratio
1.0 (reference)
0.59
0.67
0.47
0.47
0.39
0.48
0.51
0.44
0.32
0.34
0.28
Infect Control Hosp Epidemiol. 2010 (in press)
On the CUSP: Stop CAUTI
Principles of Safe Design Apply to
Technical and Team Work
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Basic Components and Process
of Communication
Dayton E, Henriksen K, Jt Comm J Qual Patient Saf, 2007.
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% of respondents reporting above adequate teamwork
Physicians and RN Collaboration
100
90
80
88%
83%
70
93%
90%
60
50
40
48%
54%
48%
59%
30
20
L&D RN/MD
ICU
RN/MD
OR RN/Surg
CRNA/Anesth
10
0
RN rates Physician
L&D RN/O B
OR RN/Surgeon
23
Physician rates RN
ICU RN/MD
CRNA/Anesthesiologist
Teamwork Tools
• Call list
• Daily Goals
• AM briefing
• Shadowing
• Culture check up
• TeamSTEPPS
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Systems
• Every system is designed to achieve the
results it gets
• To improve performance we need to
change systems
• Start with pilot test
 one patient, one day, one physician, one room
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Teams Make Wise Decisions When There is
Diverse and Independent Input
• Wisdom of Crowds
• Alternate between convergent and
divergent thinking
• Get from the dance floor to the
balcony level
Heifetz R, Leadership Without Easy Answers,1994.
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Action Items
• Have all members of CUSP/CAUTI Team view the
Science of Improving Patient Safety video
• Put together a roster of who on your unit needs to view
the Science of Safety video
• Develop a plan to have all staff on your unit view the
Science of Improving Patient Safety video
– Assess what technologies you have available for staff to
view
– Identify times for viewing it (e.g., staff meetings,
individual admin hours)
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