Presentation on theme: "Michigan’s Keystone ICU Project:"— Presentation transcript:
1 Michigan’s Keystone ICU Project: An exemplarChris Goeschel RN MPS MPSJohns Hopkins Quality and Safety Research Group
2 Consider in the end at the beginning: Are the citizens of Michigan less likely to harmed? How will we know ?
3 State wide effort to improve ICU care in Michigan Funded by AHRQ
4 Michigan: Facts Total Population: 10,120,860 (8). 2000 percent population 18 and over: 73.9;65 and over: 12.3; median age: 35.5.Major Industries - car manufacturing, farming (corn, soybeans, wheat), timber, fishing10,083 inland lakes and 3,288 mi of Great Lakes shoreline (most registered boaters in the US)138 acute care hospitals (not all with ICU’s)3 beds to 1500 beds
5 Keystone ICUThe aim was to use evidence-based tools to improve quality and patient safety in Michigan intensive care units.
6 Goals of Keystone ICU Reduce harm: BSI and VAP Ensure 90% of patients receive EB interventions for preventing VAP,Learn from one defect per monthImprove culture of safety 20% (SAQ)Improve quality improvement
7 Collaborative Process Written Commitment to Participate & Provide Resources to do the workSenior Leader as part of ICU TeamBi-weekly or Monthly Calls: Collaborative Leaders, Teams, HopkinsContent, Coaching and Team SharingMonthly Standardized Web based Data CollectionTransparency at local level“Harm is Untenable”
8 Comprehensive Unit-based Safety Program (CUSP) Evaluate culture of safetyEducate staff on science of safetyIdentify defectsAssign executive to partner with the unitLearn from one defect per month and implement teamwork tools; daily goals, a.m. briefing, culture checkupEvaluate culturePronovost J, Patient Safety, 2005
9 Interventions to prevent Central Line Blood Stream Infections: 5 Key Behaviors Remove Unnecessary LinesWash Hands Prior to ProcedureUse Maximal Barrier PrecautionsClean Skin with ChlorhexidineAvoid Femoral LinesI want to highlight 5 startgeies specifically because they are well supported by the evdience. Central lines should be discontinued when they are no longer needed. Strict compliance with hand washing is essential. we should use MBP during cl insertion, We should use chlor for skin preparation if the patient is not allergic, and if we have a choice, subclavian sites are preferred over IJ or femoral sites.The benefit of removing central lines when they are no longer needed is self-explanatory . One point that I would ask you to consider though is whther you have a mechanism in place to assess the need for central access for your patients on a daily basis. If not, you need to develop one and I would be happy to share with you our approach. What about hand washing?MMWR. 2002;51:RR-10
10 ACTIONS TAKEN TO PREVENT HARM IN THIS CASE Safety Tips: Label devices that work together to complete a procedure Rule: stock together devices need to complete a taskCASE IN POINT: An African American male ≥ 65 years of age was admitted to a cardiac surgical ICU in the early morning hours. The patient was status-post cardiac surgery and on dialysis at the time of the incident. Within 2 hours of admission to the ICU it was clear that the patient needed a transvenous pacing wire. The wire was Threaded using an IJ Cordis sheath, which is a stocked item in the ICU and standard for PA caths, but not the right size for a transvenous pacing wire. The sheath that Matched the pacing wire was not stocked in this ICU since transvenous pacing wiresare used infrequently. The wire was threaded and placed in the ventricle and staff Soon realized that the sheath did not properly seal over the wire, thus introducing risk of an air embolus. Since the wire was pacing the patient at 100%, there was no Possibility for removal at that time. To reduce the patient’s risk of embolus, the bedside nurse and resident sealed the sheath using gauze and tape.SYSTEM FAILURES:OPPORTUNITIES for IMPROVEMENT:Knowledge, skills & competence. Care providers lacked the knowledge needed to match a transvenous pacing wire with appropriate sized sheath.Regular training and education, even if infrequently used, of all devices and equipment.Unit Environment: availability of device. The appropriate size sheath for a transvenous pacing wire was not a stocked device. Pacing wires and matching sheathes packages separately… increases complexity.Infrequently used equipment/devices should still be stocked in the ICU. Devices that must work together to complete a procedure should be packaged together.Medical Equipment/Device. There was apparently no label or mechanism for warning the staff that the IJ Cordis sheath was too big for the transvenous pacing wire.Label wires and sheaths noting the appropriate partner for this device.ACTIONS TAKEN TO PREVENT HARM IN THIS CASEThe bedside nurse taped together the correct size catheter and wire that were stored in the supply cabinet. In addition, she contacted central supply and requested that pacing wires and matching sheaths be packaged together.
15 JHU Toolkits to Assist Teams Engage (local work)Opportunity calculator, stories of harmEducate (central work)Original papers, fact sheet, slidesExecute (local work)Standardize, create independent checks, learnEvaluate (central work)Web based data reports
16 Safety Scorecard State Hospital ICU How often did we harm? ( rate based measure: infections)How often do we do what we should? rate based (JCAHO, CMS, vent bundle)How do we know we learned from mistakes? (sentinel events, NQF Safe practices)Are We Improving Culture?
17 80% Reduction in BSI in One Year from 103 ICU Time periodMedian CRBSI rateIncidence rate ratioBaseline2.71Peri intervention1.60.760-3 months0.6210-12 months0.4216-18 months0.34Data from 100 ICUs Analysis: multilevel GLLAMM
18 Safety Climate Across Michigan ICUs % of respondents within an ICU reporting good safety climate
19 Teamwork Climate Across Michigan ICUs The strongest predictor of clinical excellence:caregivers feel comfortable speaking up if they perceive a problem with patient care% of respondents within an ICU reporting good teamwork climateNo BSI 21%No BSI 44%No BSI 31%No BSI = 6 months or more w/ zero
21 RN Turnover and Teamwork Climate: 26 Keystone ICUs reporting 1# RNs who left the ICUr=-.650, <.001# leaving indicates both terminations and transfers within the organzation# indicates warm bodies, not FTEs
22 In Hindsight, the Successful KICU Project Looks Easy Impression:In Hindsight, the Successful KICU Project Looks Easy
23 FACT:Participants Say These Results Never Would Have Been Achieved Without the Johns Hopkins Keystone ICU Collaborative Why is That??
25 Our Experience: Factors for Success Use evidence-based toolsPilot – Input from frontline staff is keyMake sure tools are practicalTreat the project like a clinical trialInvolve frontline staff in the initiative– ownership AND provide feedback
26 Our Experience: Factors for Success Project goals must drive measurementCare most about patient level goals; others are predictor variablesDesign data collection and management plan at outsetReduce bias in data collectionGive up on quantity not quality of dataCentral Development/ local implementationStrive for scientifically sound, feasible, useable
27 Our Experience: Factors for Success Adaptive lessonsCommit that harm is untenable; make harm visibleWhat are CLABSI rates? Do all clinical caregivers know them?OhanaHow have you shared what you are learning with others? Administrators, clinicians, teams, facilities?Local modification of executionHave you adapted the implementation in light of your organizational culture?
28 Our Experience: Factors for Success Leadership EngagementRegional Collaborative LeadersHospital Executive/AdministrationCliniciansOwnershipThe teams and staff must own the projectCollaborative “Virtual Learning Community”OHANA