St. Mary’s and St. Joseph’s Stop BSI Project

The Science of Improving Patient Safety

A Johns Hopkins collaborative

Document 7Coaching Call 2, 10/19/2010

Learning ObjectivesLearning Objectives

To understand that every system is designed to achieve the results it gets

To know the basic principles of safe design of both technical and teamwork

To understand how teams make wise decisions

The Problem is LargeThe Problem is Large

In U.S. Healthcare system

7% of patients suffer a medication error

On average every patient admitted to an ICU suffer s

adverse event

44,000- 98,000 deaths

Nearly 100,000 deaths from HAIs

Approximately 30,000 deaths from CLABSIs

$50 billion in total costs

Similar results in UK and Australia Kohn To err is human

How Can We Improve?How Can We Improve?Understand the Science of SafetyUnderstand the Science of Safety

Every system is perfectly designed to achieve the results it gets

Understand principles of safe design standardize, create checklists, learn when things go wrong

Recognize these principles apply to technical and team work

Teams make wise decision when there is diverse and independent input

Caregivers are not to blameCaregivers are not to blame

Case Scenario

Pt’s dialysis catheter is to be removed. Resident and nurse enter room and resident pulls line while patient is sitting upright. In the end, the pt suffers from a venous emboli and dies. Where are the holes in our current process that we can focus on to achieve better outcomes?

SystemSystem FailureFailure LeadingLeading toto ThisThis ErrorError

Catheter pulled withPatient sitting

Communication betweenresident and nurse

Lack of protocol For catheter removal

Inadequate trainingand supervision

Pronovost Annals IM 2004; Reason

Patient suffers

Venous air embolism

Systems 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

Principles of Safe DesignPrinciples 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

How will we standardize?

Standardize by using a cart or aStandardize by using a cart or amaximum sterile barrier kit maximum sterile barrier kit which which ICU has on supply cart to insert ICU has on supply cart to insert a a central linecentral line

StandardizeStandardize

Teamwork ToolsTeamwork Tools

Daily rounds to assess line

Report reason to continue line

Line management-proper technique

 

% o

f res

pond

ents

repo

rting

abo

ve a

dequ

ate

team

work

ICUSRS Data

ICU Physicians and ICU RN CollaborationICU Physicians and ICU RN Collaboration

Are we truly working as a team?

Teams Make Wise Decisions When There is Diverse & Teams Make Wise Decisions When There is Diverse & Independent InputIndependent Input

Wisdom of Crowds

Alternate between convergent and divergent thinking

2 Year Results from 103 ICUs2 Year Results from 103 ICUs

Time period Median CRBSI rate Incidence rate ratio

Baseline 2.7 1

Peri intervention 1.6 0.76

0-3 months 0 0.62

4-6 months 0 0.56

7-9 months 0 0.47

10-12 months 0 0.42

13-15 months 0 0.37

16-18 months 0 0.34

Pronovost NEJM 2006

St. Mary’s Goal

We are teaming up with Johns Hopkins to decrease our blood stream infection rate to zero!

SM BSI rate for this year:

1/901 central line days x1000= .47 for ICU

Total House= 8/26,254= .30 #BSI/total pt days x1000

We will begin tomorrow October 1st, 2009

Who is rounding?

DeAnna Francisco (PICC nurse), Jami Fronckewicz (Infection Control nurse), and Dr. Borsa will be rounding daily to monitor the appearance of lines in the unit as well as assessing the continued need for a line.

Observing Line Placement

A nurse has to observe any line being placed in the ICU.

If a nurse is unavailable to do so, please call Jami x55242

Once the line has been placed, please send completed checklists to DeAnna through interdepartmental mail—the checklist is NOT part of the chart.

Central Line checklist items

Permit signed Education FAQ on BSI given to patient Time out completed Hand hygiene must be performed Sterile gown Sterile gloves Mask Hair Covering Sterile drape from head to toe Chlorahexidine scrub used for skin prep

Central Venous Catheter (CVC) Insertion Checklist Direction for use: Nurse assisting physician must complete this checklist.

Today’s date: ____________ Consent signed Yes No Location of patient _____ 1. Type of CVC: ______ TLC _____Swan Ganz ______PICC _______Temp Dialysis

2. Is the procedure ________elective ___________emergent Time out Yes No

3. Physician performing insertion ________________ Education sheet provided Yes No

4. Before the procedure did the inserter perform Hand Hygiene? (using either soap & water or alcohol based product) Yes No Don’t know

Was the

Equipment listed below available

for use? 5, Maximal Sterile Barrier Precautions Used by Mask Yes No Yes No Inserter? Sterile Gown Yes No Yes No

Large Sterile Drape Yes No Yes No Sterile Gloves Yes No Yes No Cap Yes No Yes No 6. Skin Preparation: Chloraprep Yes No Yes No Povidone Iodine Yes No Yes No Alcohol Yes No Yes No 7. Did personnel involved in setting up the sterile site or assisting in the procedure wear a mask? Yes No Yes No 8. After procedure was a Biopatch placed? Yes No Yes No 9. After procedure was a dressing dated and initialed? Yes No Form completed by _________________________

Patient sticker Send completed forms to IV/PICC Team

Any Questions?

Contact: DeAnna Francisco

Pager # 816-821-1149 Jami Fronckewicz

x55242 or pager # 816-821-2067