On the CUSP: Stop CAUTI
The Science of Improving
Patient Safety
Sean Berenholtz, MD MHS
Johns Hopkins University
Quality and Safety Research Group
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CAUTI Content Call Schedule
CUSP/CAUTI Content Call #1 – CUSP
Moderator – Sam Watson; Speaker – Sean Berenholtz
03/07/11
2 ET/1 CT/12 MT/11 PT
Attendee: (866) 256-9295
CUSP/CAUTI Content Call #2 - The Science of Safety
Moderator – Sam Watson; Speaker – Sean Berenholtz
03/22/11
2 ET/1 CT/12 MT/11 PT
Attendee: (866) 256-9295
CUSP/CAUTI Content Call #3 - Care and Removal Intervention
Moderator – Sam Watson; Speaker – Mohamad Fakih
04/05/11
2 ET/1 CT/12 MT/11 PT
Attendee: (866) 256-9295
CUSP/CAUTI Content Call #4 - Data Collection
Moderator – Sam Watson; Speaker – Christine George
04/19/11
2 ET/1 CT/12 MT/11 PT
Attendee: (866) 256-9295
CUSP/CAUTI Content Call #5 - The View from the Bedside
Moderator – Sam Watson; Speaker – Russ Olmsted
05/03/11
2 ET/1 CT/12 MT/11 PT
Attendee: (866) 256-9295
CUSP/CAUTI Content Call #6 - Implementation in a Community Hospital
Moderator – Sam Watson; Speaker – Mary Jo Skiba
05/17/11
2 ET/1 CT/12 MT/11 PT
Attendee: (866) 256-9295
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60 Min.
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The Marvel of Modern Medicine
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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.
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.
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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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How Can These Errors Happen?
• People are fallible
• Medicine is still treated as an art, not science
• Need to view the delivery of healthcare as a
science
• Need systems that catch mistakes before they
reach the patient
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 Factors Impact Safety
Institutional
Hospital
Departmental Factors
Work Environment
Team Factors
Individual Provider
Task Factors
Patient Characteristics
Adapted from Vincent
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Case Example
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65 yo M s/p lung resection for cancer
Admit to ICU; discharged to floor POD 1
POD 3 develops hypoxia
Admitted to ICU, intubated
CXR shows extensive left lung collapse
Decision to perform broncoscopy
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System Failure Leading to Error
Did not verify
equipment availability
Fatigue
Bronch cart
not stocked
Patient suffers
Communication between
resident and nurse
Hypoxic arrest
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Principles of Safe Design
• Standardize
– Eliminate steps if possible
• Create independent checks
• Learn when things go wrong
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–
–
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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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Design Examples
Standardization
Redundancy
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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
MMWR. 2002;51:RR-10
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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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Michigan Keystone ICU
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1
0
B
In as
te el
rv in
e e
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ti
o
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1 9
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-1
1 2
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1 5
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-1
1 8
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2 1
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-2
2 4
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2 7
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3 0
1
-3
3 3
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-3
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CRBSI Rate
Me dia n a nd Me a n CRBSI Ra te
Time (mont hs)
M e d ia n C R B S I R a te
M e a n C R B S I R ate
NEJM 2006, BMJ 2010
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Rhode Island ICU CLABSI Rates
Qual Saf Health Care 2010;19(6):555-561
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Improving Care for
Ventilated Patients
• Semirecumbant positioning
• Peptic ulcer disease and DVT prophylaxis
• Appropriate sedation
• Daily assessment of readiness to extubate
• Oral care with antiseptics
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Improving Care for Ventilated Patients
• Educate staff
• Decrease complexity / create redundancy:
– Standardized order sets and protocols
– Daily goals checklist
• Other independent redundancies
– Nursing and families
– Are patients receiving the prevention they should?
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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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Michigan Keystone ICU
Infect Control Hosp Epidemiol. 2011
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Preventing Catheter-Associated
Urinary Tract Infection
• Most common healthcare-associated infection (~ 40%)
• Many urinary catheters used inappropriately 1
• Prevention guidelines:
– HICPAC www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf
– SHEA/IDSA: Infect Control Hosp Epid 2008;29:S41-S50
• Nurse-Led multidisciplinary rounds to reduce unnecessary
urinary catheters 2
• Urinary catheter reminders and stop-orders decrease
infection rates 3
1 Saint S, et al. Am J Med 2000
2 Fakih
MG, et al. Infec Control Hosp Epi 2008
3 Meddings J et al. Clin Infect Dis 2010
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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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Teamwork Tools
• Daily Goals
• AM briefing
• Shadowing
• Culture check up
• TeamSTEPPS
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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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Summary
• Develop lenses to see systems
• Understand principles of safe design
– standardize,
– create redundancies,
– learn when things go wrong
• Recognize these principles apply to technical and team work
• Teams make wise decisions when there is diverse and
independent input
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Action Items
• Have all members of the 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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