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8/3/2011
1
Partnership for Patients-National Priorities Partnership©
Patient Safety Webinar Series
Webinar #4: Reducing Infections in the Intensive Care
Unit (ICU)
August 3, 2011
© National Priorities Partnership
Today’s Hosts and Speaker
Moderator
� Steve Findlay, MPH, Senior Health Policy Analyst, Consumers Union, NPP Partner, and former Co-Chair of the NPP Safety Workgroup
Featured Speaker
� Peter Pronovost, MD, PhD, Medical Director, Johns Hopkins University School of Medicine
8/3/2011
© National Priorities Partnership
Today’s Reactor Panel
� Helen Macfie, PharmD, FABC, Senior Vice President, Performance Improvement, Memorial Medical Care Centers
� Michael Klompas, MD, MPH, Associate Hospital Epidemiologist, Brigham and Women’s Hospital
� Victoria Nahum, Executive Director, Safe Care Campaign
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© National Priorities Partnership
Welcome to the Patient Safety Webinar Series
The objectives of the series are to:
� Share strategies for “getting started” to accelerate improvements in national patient safety efforts
� Highlight the role of public-private partnership in achieving Partnership for Patients goals
� Describe NPP’s role in catalyzing action and enabling change
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© National Priorities Partnership
Objectives for Today’s Webinar
© National Priorities Partnership
� Provide an opportunity for thought leaders in the field of hospital-acquired infections to share best practices, success stories, and strategies for getting started
� Generate action in organizations and communities nationwide
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Objectives for Today’s Webinar (cont.)� Provide examples of public-private partnerships
working collaboratively to achieve results
� Address the Partnership for Patients goals of reducing catheter-associated urinary tract infections (CAUTI), central line-associated blood stream infections (CLABSI), and ventilator-associated pneumonia (VAP)
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© National Priorities Partnership
About the Audience
21%
56%
6%
2%
2%
2%
1%
1%
9%
0% 10% 20% 30% 40% 50% 60%
Other
Hospital
Healthcare provider (non-hospital)
Clinican (non-hospital)
Consumer organization
Healthcare purchaser
University / Academia
Supplier Industry
Quality Improvement Organization
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© National Priorities Partnership
Audience Regional Location
Northeast, 16%
South, 34%
Midwest, 21%
West, 17%
No Response, 12%
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© National Priorities Partnership
Polling Question
Which demographic best describes your organization or community?
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Developing a National Quality Strategy
Health reform legislation, the Affordable Care Act (ACA), requires the Secretary of Health and Human Services to “establish a national strategy to improve the delivery of healthcare services, patient health outcomes, and population health.”
HR 3590 §3011, amending the Public Health Service Act (PHSA) by adding §399HH (a)(1)
© National Priorities Partnership
8/3/2011
HHS’ Domains and Principles for the National Quality Strategy
Principles reflect:
� Patient-centeredness and family engagement
� Quality care for patients of all ages, populations, service locations, and sources of coverage
� Elimination of disparities
� Alignment of public and private sectors
© National Priorities Partnership
BETTERCARE
AFFORDABLECARE
HEALTHY PEOPLE/
COMMUNITIES
8/3/2011
HHS 2011 National Quality Strategy:Six National Priorities
1. Making care safer by reducing harm caused in the delivery of care.
2. Ensuring that each person and family are engaged as partners in their care.
3. Promoting effective communication and coordination of care.
4. Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovasculardisease.
5. Working with communities to promote wide use of best practices to enable healthy living.
6. Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.
© National Priorities Partnership
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NPP has been specifically asked to provide input to HHS on identified priorities as well as at least:
� three goals per priority area
� two strategic opportunities per goal
� two measures per goal
© National Priorities Partnership
NPP’s Ongoing Role in Consultation to HHS on the National Quality Strategy
8/3/2011
Partnership for Patients Goals
� Keep patients from getting injured or sicker. By the end of 2013, preventable hospital-acquired conditions would decrease by 40%compared to 2010.
� Help patients heal without complication. By the end of 2013, preventable complications during a transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20%compared to 2010.
© National Priorities Partnership
8/3/2011
Partnership for Patients Nine Areas of Focus
� Catheter-Associated Urinary Tract Infections (CAUTI)
� Central Line Associated Blood Stream Infections (CLABSI)
� Injuries from Falls and Immobility
� Adverse Drug Events
� Obstetrical Adverse Events
� Pressure Ulcers
� Surgical Site Infections
� Venous Thromboembolism
� Ventilator-Associated Pneumonia (VAP)
© National Priorities Partnership
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Partnership for Patients: Goals forHospital-Acquired Infections
� Catheter-Associated Urinary Tract Infections Goal: Reduce the number of CAUTIs by 50% by 2013.
� Central-Line Associated Blood Infections Goal: Reduce preventable CLABSIs by 50% by 2013.
� Ventilator-Associated Pneumonia Goal: Reduce preventable cases of VAP by 50% by 2013.
© National Priorities Partnership
8/3/2011
How Will Change Actually Happen?
And how will it happen at scale?
© National Priorities Partnership
8/3/2011
How Will Change Actually Happen?� There is no “silver bullet,” but we know we
must:
� work together
� provide thoughtful incentives
� engage patients and families, authentically
� engage leadership
� assist in the painstaking work of improvement
© National Priorities Partnership
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The Centers for Disease Control and Prevention (CDC) supports states in preventing hospital acquired infections (HAI) through funding and technical support:
� CDC has multiple investments with the American Recovery and Reinvestment Act (ARRA) and the Affordable Care Act (ACA)
� $39.8 million in ARRA funds to 49 states, the District of Columbia, and Puerto Rico
� $11.75 million in ACA funds for FY 2011; $20 million proposed for FY 2012
� Funds support state and local HAI prevention and control strategies, and improve the quality and quantity of HAI reporting
CDC: A Federal Partner in HAI Prevention and Surveillance
© National Priorities Partnership
8/3/2011
CDC: A Federal Partner in HAI Prevention and Surveillance
CDC contributes to HAI surveillance through:
� Maintaining the nation’s reference laboratory
� Developing new methods for susceptibility testing and environmental testing
� Providing direct support to hospitals, healthcare facilities and health departments when outbreaks occur
© National Priorities Partnership
8/3/2011
CDC Links and Resources
� State Prevention Projects Map
� National Healthcare Safety Network
� Healthcare Infection Control Practices Advisory Committee (HICPAC) Guidelines for CLABSI and CAUTI
� CDC’s Prevention Epicenters
These links are available in the Resources tab, on the top left corner of your screen.
© National Priorities Partnership
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Peter Pronovost, MD, PhD, FCCM
Johns Hopkins University
Eliminating CLABSI:Eliminating CLABSI:
a model for reducing preventable harma model for reducing preventable harm
I Will …I Will …
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Median and Mean CRBSI Rate
0
1
2
3
4
5
6
7
8
9
Base
line
Interv
ention
0-3
4-6
7-9
10-1
2
13-1
5
16-1
8
19-2
1
22-2
4
25-2
7
28-3
0
31-3
3
34-3
6
Time (months)
Median CRBSI Rate Mean CRBSI Rate
Pronovost NEJM 2006: Pronovost BMJ 2010: Sawyer CCM2010
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Impact of Statewide Quality Improvement
Initiative on Hospital Mortality
0.7
0.8
0.9
1
1.1
Pre-implementation (12
months: Oct 02 - Sept 03)
Project Initiation (5 months:
Oct 03 - Feb 04)
Implementation (12 months:
Mar 04 - Feb 05)
Post-implementation (12
months: Mar 05 - Feb 06)
Post-implementation (12
months: Mar 06 - Dec 06)
Study Group Adjusted OR Comparison Group Adjust OR
Ad
just
ed
Od
ds
Ra
tio
Impact of Michigan Keystone Project on Hospital Mortality
Lipitz: BMJ 20118/3/2011
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10
Slide 28
Infect Control Hosp Epidemiol 2011;32(4):epub
Michigan Keystone ICU
(n=
Slide 29
Getting to 0 in a HospitalGetting to 0 in a Hospital
• CEO commits to 0
• ICU leaders accountable, know rates, commit to 0
• ICU makes it easy to comply with checklist
• ICU empowers nurses to ensure compliance
• ICU reviews every infection as a defect
• ICU standardizes, audits, and improves catheter maintenance
• ICU posts and discuss infection rates weeks without an infection
http://www.modernhealthcare.com/article/20110725/SUPPLEMENT/307259972/-1
Slide 30
How Can We SpreadHow Can We Spread
• A fractal is the same
geometric pattern repeated in different sizes and shapes.
• Each piece is part of the
whole.
• Provides mechanism for
vertical and horizontal integration
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Slide 31
Levers to Support ChangeLevers to Support Change
• Regulatory
• Hierarchy- management
• Economic pressure
• External Social pressures
• Networks/ Communities provided with technical support
Slide 32
Clinical CommunitiesClinical Communities
• Commit to work together to achieve goals
• Responsible for outcomes
• Interdependent and united by common purpose
• Supported by vertically integrated technical core
• Supports horizontal learning
• Supports participatory forms of decision making
• Adaptable and flexible
• Aveling, E. 2011
Slide 33
Why Did This WorkWhy Did This Work
• Started with goal and worked backwards
• Kept score with measure clinicians believed valid
• Guided by science, phase 1, 2, 3
• Committed to collaborate
• Modified locally to fit context
• Focused on adaptive work
• Framed CLABSI as a social program capable of
being solved
• Created a community
Laws and the enforcement of laws, important though they are, can
never substitute for the character of the citizens themselves
Teddy Roosevelt
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I Will …I Will …
Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley, JE, Milanovich S, Garrett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 2004;32:2014-2020.
Pronovost PJ, Goeschel CA, Colantuoni E, Watson S, Lubomski LH, Berenholtz SM, Thompson DA, Sinopoli D, Cosgrove S, Sexton JB, Marsteller JA, Hyzy RC, Welsh R, Posa P, Schumacher K, Needham D. Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: Observational study. British Med J 2010;340:c309.
DePalo VA, McNicoll L, Cornell M, Rocha JM, Adams L, Pronovost PJ. The Rhode Island ICU Collaborative: A model for reducing central line-associated bloodstream infection and ventilator-associated pneumonia statewide. Qual Saf Health Care 2010;19:555-561.
Berenholtz SM, Pham JC, Thompson DA, Needham DM, Lubomski LH, Hyzy RC, Welsh R, Cosgrove SE, Sexton JB, Colantuoni E, Watson S, Goeschel CA, Pronovost PJ. An intervention to reduce ventilator-associated pneumonia in the ICU: Collaborative cohort study. Infect Control Hosp Epidemiol 2011, in press.
Sexton JB, Berenholtz SM, Goeschel CA, Watson S, Holzmueller CG, Thompson DA, Hyzy RC, Marsteller JA, Schumacher K, Pronovost PJ. Assessing and improving safety climate in a large cohort of intensive care units. Crit Care Med Feb 2011.
Lipitz-Snyderman A, Steinwachs D, Needham DM, Colantuoni E, Morlock LL, Pronovost PJ. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: Retrospective comparative analysis. Brit Med J 2011;342:d219.
Pronovost, PJ, Marsteller JA, Goeschell CA. Preventing Bloodstream Infections: A Measurable National Success Story: Health Affairs 2011;20:628-634
Dixon-Woods M, Bosk CL, Aveling EL, Goeschel CA, Pronovost PJ.. Explaining Michigan: developing an ex post theory of a qualityimprovement program: Milbank Q. 2011 Jun;89(2):167-205
References
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© National Priorities Partnership
Response from the Audience
Tell us about your experience in
reducing infections in the ICU
What supports do you need to accelerate change and improve patient safety in your organization?
To provide questions or comments, please type into the chat box at the bottom left corner of your screen.
Your responses will be addressed during the audience discussion later on in the webinar.
8/3/2011
© National Priorities Partnership
Polling Question
What is your organization currently doing to minimize infections, such as CAUTI,
CLABSI, and VAP?
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© National Priorities Partnership
Polling Question
In your organization, what is the principle barrier to reducing infections in the
intensive care unit?
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© National Priorities Partnership
Reactor Panel Discussion
Moderated by Steve Findlay
NPP Partner
8/3/2011
Frontline Provider Perspective
Michael Klompas, MD, MPH
Associate Hospital Epidemiologist
Brigham and Women’s Hospital
The VAP Prevention ParadoxVAP
Rates
Vent
LOS
ICU
LOS
Hospital
LOSDeath
Head-of-bed elevation
Regular oral care with chlorhexidine
Continous aspiration of subglottic secretions
Silver-coated endotrachealtubes
Klo
mpas,
Critica
l Care
2009;1
3:3
15
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The VAP Prevention ParadoxVAP
Rates
Vent
LOS
ICU
LOS
Hospital
LOSDeath
Head-of-bed elevation
Regular oral care with chlorhexidine
Continous aspiration of subglottic secretions
Silver-coated endotrachealtubes
Klo
mpas,
Critica
l Care
2009;1
3:3
15
Daily sedative interruptions
Readiness to extubate
Sedative interruptions ANDReadiness to extubate8/3/2011
A Cautionary Tale…
100% 93% 92% 97% 95%100% 93% 100% 97% 97%100% 93% 100% 97% 97%97% 100% 100% 94% 92%94% 93% 90% 97% 89%100% 100% 100% 100% 100%
Element
HOB
Daily Sedation Holiday
DVT
GI Prophylaxis
Oral Care Prophylaxis
Readiness to Extubate
Unit by UnitVentilator Bundle Compliance Report
UNIT A B C D E
© National Priorities Partnership
8/3/2011
A Cautionary Tale…
100% 93% 92% 97% 95%100% 93% 100% 97% 97%100% 93% 100% 97% 97%97% 100% 100% 94% 92%94% 93% 90% 97% 89%100% 100% 100% 100% 100%
Element
HOB
Daily Sedation Holiday
DVT
GI Prophylaxis
Oral Care Prophylaxis
Readiness to Extubate
Unit by UnitVentilator Bundle Compliance Report
UNIT A B C D E
On investigation-Daily sedation holiday and readiness to extubate marked as “contraindicated” in ~50% of patients
© National Priorities Partnership
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Consumer Advocacy Perspective
Victoria Nahum
Executive Director
Safe Care Campaign
Just as Dr. Pronovost’s successful Checklist Approach requires that certain components be in place in order to realize best expected outcomes, certain components must be in place within a Patient-Centric / Patient-Involved Safety Culture in order to realize best expected outcomes.
“Checklists have a role in improving patient safety. But they only get us part way down the
field. To reach our ultimate goal - making patients safer - we must engage teams to
embrace the concepts behind checklists and become full partners in developing and
improving this life-saving tool. And, we must measure our results to make sure that every
patient always gets the care they deserve.”
– Peter Pronovost
© National Priorities Partnership
8/3/2011
Patient and Family EngagementPatient and Family EducationPatient and Family Empowerment
The 3 E’s.Actual harm to the patient can and probably will be caused by lack of any of these 3 components.
Lacking these necessary components, healthcare will never completely attain the highest levels of best outcomes we aspire to.
We cannot begin to call what we currently have “A True Culture of Safety” until we incorporate these components into every care plan for every patient.
© National Priorities Partnership
8/3/2011
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Health System PerspectiveApproach from MemorialCare
Helen Macfie, Pharm.D., FABCSenior VP, Performance Improvement and Strategy
MemorialCare Health System, Southern California
© National Priorities Partnership
The Four Keys� Make it Strategic
� Set “Bold Goals”
� Reduce Hospital Acquired Infections (HAIs) to the Zero Zone by June 2012
� Hand Hygiene� Standardize
definition
� Marketing campaign
� Training for ALL
� Champions, surveillance
� Amnesty’s over
Evolving Our Bold GoalsSystem-Wide Strategic Plan
• FY’12� Reduce mortality by 20%
� Achieve “perfect care” to 95%
� Reduce code emergencies outside of the ICU by 50%
� Reduce hospital acquired infections to the “Zero Zone” (zero or rare)
� Increase our patient experience to top 20th percentile for HCAHPS Overall Rating (% 9s and 10s)
� Reduce hospital acquired pressure ulcer Stage 2-4 rates to the “Zero Zone”
� Achieve hand hygiene compliance of 100%
� Reduce patient falls by 75%
� Reduce sepsis mortality by 30%
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© National Priorities Partnership
The Four Keys� Hard-Wired Best
Practices� System-wide HAI Best
Practice Team
� Gap analysis to evidence
� Tests of change
� Hard-wiring into EMR
� Results Visibility� Board, e-dashboards,
committees, department visibility boards
� Talk about rates and #s
� 187 Lives louched, reduced infections
� ~$2.1M/year saved
Hand Hygiene Serious infections - VAP, CLAS-BSI
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
1Q'06
2Q'06
3Q'064Q'06
1Q'07
2Q'07
3Q'0 7
4Q' 07
1Q'0 8
2Q' 08
3Q' 08
4Q' 08
1Q' 09
2Q'09
3Q'09
4Q'09
1Q'10
2Q'10
3Q'10
4Q'10
1Q'112Q
'11
Rat
e pe
r 10
00
0
2
4
6
8
10
12
14
# of
Infe
ctio
ns in
Peo
ple
CLABSI VAP CLABSI Rate per 1000 VAP Rate per 1000
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© National Priorities Partnership
Questions for the Panelists
1. In your work, how have you actively engaged patients and families to prevent infections?
2. What is your advice for webinar participants who want to accelerate change and achieve success?
3. What policy or environmental supports are needed to accomplish your goals?
8/3/2011
© National Priorities Partnership
Audience Discussion
Tell us about your experience in
reducing infections in the ICU
To provide questions or comments, please type into the chat box at the bottom left corner of your screen. To dial
into the discussion, call 1-888-203-7337, confirmation code 9168748, and press *1 to ask a question.
8/3/2011
© National Priorities Partnership
Polling Question
Does your organization have a system in place for educating patients and their families about
their role in reducing infections?
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© National Priorities Partnership
Scenario Polling Question
A patient is in the ICU with a complex condition. His brother and nurse are waiting for the physician to check on him. When the doctor enters the room, she forgets to wash her hands. What is most likely to happen next, in your hospital?
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© National Priorities Partnership
Audience Discussion
Talking About Your Experience
To provide questions or comments, please type into the chat box at the bottom left corner of your screen. To dial
into the discussion, call 1-888-203-7337, confirmation code 9168748, and press *1 to ask a question.
8/3/2011
© National Priorities Partnership
Conclusion
Next Steps, Further Resources, and Concluding Remarks
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© National Priorities Partnership
Polling Question
When do you plan to act on the information provided in this webinar?
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© National Priorities Partnership
Polling Question
Did you find tangible actions and practices you can put to use in your organization or
community in this webinar?
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© National Priorities Partnership
Further Resources
Resources, links and PDF documents are available now in
the top left corner of your screen, including:
� Partnership for Patients website
� National Priorities Partnership website
� National Quality Forum patient safety webpage
� Link to the John M. Eisenberg Patient Safety and Quality
Award – Application period open from Aug. 1 – Oct. 3
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© National Priorities Partnership
Patient Safety Webinar Series
Upcoming webinar topics:
� Surgical Site Infections – August 16
� Pressure Ulcers and Injuries from Falls –September 9
� Obstetrical Adverse Events – September 28
� Venous Thromboembolism - October 5
To register: eo2.commpartners.com/users/pfp/
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© National Priorities Partnership
Concluding Remarks
Steve Findlay, NPP Partner
8/3/2011
© National Priorities Partnership
Thank You
A recording of this webinar will be available on the National Quality Forum website within 48 hours. When
you exit, you will automatically be directed to an evaluation about this webinar.
For further questions, please contact [email protected]
8/3/2011