1. Erik Garpestad, MD Therese Hudson-Jinks, RN, MSN
Tufts Medical Center
Erik Garpestad, MD
Therese Hudson-Jinks, RN, MSN

2. Tufts Medical Center Boston, MA
We strive to heal, to comfort, to teach, to learn, and to seek the knowledge to promote health and prevent disease. Our patients and their families are at the center of everything we do. We dedicate ourselves to furthering our rich tradition of health care innovation, leadership, charity and the highest standard of care and service to all in our community.

3. Objectives
Participants will earn an innovative strategy to align team members in a quest for excellence.
Participants will learn communication tools vital to the success of quality improvement.
Participants will learn how to excite clinicians engaging them in the change process.

4. FY 2008 2009 caBSI Adult Patient Population

5. FY 2008 2009 caBSI Adult Patient Population
New Policy Roll Out

6. Standardizing Insertion
What was done?
2007 – 2009
Nearly 50 member committee organized into MD practice, RN practice, equipment. (Lots of hard work, lots of time)
Much emphasis placed on development of best practice policy and guidelines for caBSI elimination with a focus on:
Standardizing Insertion
SIMs lab review, competency MD development standards
Standardizing maintenance
100% RN policy and practice review, twice: ‘Task Focused’

7. Results: Little to no progress !!
What was done?
2007 – 2009
Nearly 50 member committee organized into MD practice, RN practice, equipment.
Much emphasis placed on development of best practice policy and guidelines for caBSI elimination with a focus on:
Standardizing Insertion
SIMs lab review, competency MD development standards
Standardizing maintenance
100% RN policy and practice review, twice: ‘Task Focused’
Results: Little to no progress !!

8. New Plan: Fall 2009 CaBSI CaUTI VAP Fall 2009
Commitment by Senior Leadership to eliminate Hospital Acquired Infections
Infection Prevention Priority Initiatives defined
CaBSI
CaUTI
VAP

9. Stop Central Line Associated Blood Stream Infection (caBSI) Team Appointment
The Team was appointed by Senior Leadership with the authority and responsibility to influence, ensure, and be accountable to best practice principles regarding central line placement and maintenance at Tufts Medical Center.
Goal: Rapid Cycle Change Process resulting in sustainable results at or better than national rates.

10. MEMBERSHIP DEPARTMENT
Stop Central Line Associated Blood Stream Infection (caBSI) Team Structure
MEMBERSHIP
DEPARTMENT
Margaret Vosburgh, COO
Executive Sponsor
Dorothy Didomenico RN
Clinical Educator, CCU CMC
Shira Doron MD
Infectious Disease
Terry Hudson-Jinks RN
Patient Care Services/Nursing
Eric Garpestad MD
Medical Director MICU, Critical Care Committee Chair
Tricia Lemon, RN
Infection Prevention/Quality and Patient Safety

11. Looking back, What worked?
Diverse team membership, frequent meetings.
Open mind, willingness to provide care differently
Agreement to have a unified ‘Quest for ZERO’ infections
Sense of Team
Humility
Crazy passion, ‘fire in the belly’
Strong support of CEO, CMO, CNO
CEO support of Tufts participation with MHA CUSP
October 2009:8 Member Tufts Team attended CUSP Kick Off

12. Looking back, What worked?
Diverse team membership
Open mind, willingness to provide care differently
Agreement to have a unified ‘Quest for ZERO’ infections
Sense of Team
Humility
Crazy passion, ‘fire in the belly’
Strong support of CEO, CMO, CNO
CEO support of Tufts participation with MHA CUSP
October 2009:8 Member Tufts Team attended CUSP Kick Off

13. Looking back, What worked?
Diverse team membership
Open mind, willingness to provide care differently
Agreement to have a unified ‘Quest for ZERO’ infections
Sense of Team
Humility
Crazy passion, ‘fire in the belly’
Strong support of CEO, CMO, CNO
CEO support of Tufts participation with MHA CUSP
October 2009:8 Member Tufts Team attended CUSP Kick Off

14. Align yourself with a National Agenda
CUSP

15. On The CUSP Stop BSI PRIMARILY Adaptive (CUSP) 4
Massachusetts ICU Safe Care Initiative Comprehensive Unit-Based Safety Program
On The CUSP
Stop BSI
PRIMARILY Technical (CLABSI)
CVC Insertion
CVC Line Cart
1. Contents inventory
Evidence based BSI prevention (hands, site, skin prep, barrier, removal)
1. Presentation of evidence
2. CLABSI factsheet
3. Insertion checklist
4. Vascular access quiz
5. Vascular access manual/ policy 6.Annotated bibliography
CVC Management
1. Daily goals
2. Dressing change
3. Vascular access manual/ policy protocol
PRIMARILY Adaptive (CUSP)
Science of Safety Training
1. Science of safety presentation
3. Attendance sheet
Staff Identify Defects
1. Staff safety assessment form
2. Indentifying hazards presentation
Senior Executive Partnership
Briefings
Learning from Defects
LFD toolkit
Implement Tools for Teamwork and Communication
2. Shadowing
3. AM briefing
4. Call list
6. Team check up tool
Assemble a CUSP team,
Partner with a senior executive;
Baseline CLABSI Data
Exposure Survey and Technology Survey 4 15

16. Maximal Barrier Precautions Upon Insertion
Stop Central Line Associated Blood Stream Infection (caBSI) Central Line Bundle
Hand Hygiene
Maximal Barrier Precautions Upon Insertion
Central Line Insertion Check List
Use of a Line Insertion Cart
Chlorhexidine (CHG) skin antisepsis
Optimal Catheter Site Selection (Avoid Femoral site over IJ)
Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines

17. Looking back, What worked?
Benefits of CUSP (Comprehensive Unit Based Safety Program):
Provided the framework to align Senior Executives with clinicians in the goal for patient safety
Validated key aspects of Tufts Medical Center Policy
Provided leverage
Frameworks, tool kits, informational sources, rich in details necessary to make key decisions, and the power to let go of old practices.
Blood Cultures
Goal Sheet
Clave use
Dressing and line protocols
CHG bathing/Elimination of wash basins
Network of experts within and beyond New England with key first hand learning experiences.
Assisted in disbanding belief that patients are too ill, elimination not possible.
Provided a competitive spirit, energizing

18. Symbols of Change
Take strong, decisive steps forward
Take Risks
Consider making several changes at one time
Disrupt routine

19. Stop Central Line Associated Blood Stream Infection (caBSI)
2009 High Risk Areas for CaBSI
MICU
CTU
SICU
North 8
CMC
In combination were responsible for 67% (56/83) of all line infections
Accounted for 50% (11853/23345) of all line days.

20. Intervention: CHG/Sulfadiazine Impregnated Lines in High Risk Areas
Antimicrobial Impregnated catheters in high risk populations
Piloted in select areas first
MICU
CCU
Based on results plan to roll out house wide
Shorter length catheter keeps sterile dressing intact
Standard line length was 20 cm
New standard 16 cm
Allergy alert stickers on each kit
Insert picture of new kit

21. Stop Central Line Associated Blood Stream Infection (caBSI) Intervention: New Practice Guidelines
Change culture and practice for drawing blood cultures
Policy revision – drafted
Blood culture algorithm to guide when and how
Weekly data shows blood cultures off central lines decreasing

22. Intervention: New Bathing Technique (Pilot)
1.)Elimination of Wash Bins
2.)CHG Bathing of all patients in high risk locations
MICU
CCU
CTU
SICU
CMC
North 8

23. Stop Central Line Associated Blood Stream Infection (caBSI) Results Adult Critical Care (CaBSI rates per 1000 central line days)
Begun House wide Daily rounding
on all central lines
Policy
Reeducation
100%
all RNs
MD Education
Placement Training
Signoff

24. Stop Central Line Associated Blood Stream Infection (caBSI) Results Adult Critical Care (CaBSI rates per 1000 central line days)
Begun House wide Daily rounding
on all central lines
Policy
Reeducation
100%
all RNs
Impregnated Catheters CCU and MICU
CHG Bathing
CCU MICU
Staff Meetings
Impregnated Catheters SICU and CTU
Shadow Check list Program

25. Intervention: Staff Engagement/Communication Strategy Account
Connecting to the Clinicians at the bedside:
Creation and communication of site:
Create platform for two way dialogue with clinicians.
Take down barriers to care.
Enhance transparency.
Engage all staff including unit coordinators, techs, physical therapists, on the journey.
Communicate changes in practices and policy.
Facilitate problem solving, share knowledge, best practices, and success stores.
Keep the quest of caBSI elimination front and center.

26. Sample
From: No Line Infections
Sent: Monday, January 03, :28 PM
To: Tufts MC All Employees
Subject: No Line Infections 2011
Thank you  to all clinicians and employees  for  embracing the  challenge of central line infection elimination. 
Our quest for  zero  continues into 2011
   Trends in caBSI  Infections
FY 2009 – FY 2011 YTD Tufts  Medical Center  & Floating Hospital for Children 

27. Subject: RE: No Line Infections 2011
Sample Response
To: No Line Infections
Subject: RE: No Line Infections 2011
Excellent goal and superb improvement/performance.
Do we publish these data externally?

28. Staff engagement: Priority # 1!
GOAL: Eliminate Central Line Infections, keep the momentum
Consistent messaging at every level, Board, Division, Unit etc.
Search constantly for validation of policy in practice at the bedside
Staff Participation/Engagement: Each ICU is sponsoring a champion for each Quality Initiative to ensure we continue to shrink the distance between policy and practice.
March 2010 Weekly unit based Quality Staff In-services.
Each ICU Quality Initiative will be discussed and framed for that units trend. Successes to be celebrated, staff participation essential.
Transition 100% check list Shadow to Spot assessments based on compliance.
Continue to validate practice with national benchmarks in practice and results.

29. Present Data Differently

30. Months with Zero Rate High Risk Population

31. CLABSIs, by line type, all medical center units

32. CLABSIs – All ICUs – FY 09 - 11 MICU 14 2632 5.32 3 2113 1.42 4 2328
UNIT
FY 09
FY 10
FY 2011
Cases
Days
Rate
MICU 14
2632
5.32 3
2113
1.42 4
2328
1.72
CCU 7
2048
3.42
2040
1.96 2
2124
0.94
CTU
2221
1.80 1
2653
0.38
2447
0.41
SICU 6
1889
3.18
1965
1.02
2030
1.48
NCCU
222
4.50
NICU
3362
4.16 8
2685
2.98
2888
1.04
PICU
848
0.00
845
3.55
674
TOTAL 45
13000
3.46 21
12301
1.71 15
12713
1.18

33. Surgical ICU

34. CMC caBSI

35. CMC caBSI

37. Leadership commitment + Evidence Based Practice + Staff Engagement
Key to success
Leadership commitment
+ Evidence Based Practice
+ Staff Engagement
= Success

38. CaBSI Control Chart FY 2009 - 2011

39. “Bladder Bundle” Aseptic insertion and proper maintenance
Bladder ultrasound (may avoid indwelling catheterization)
Condom or intermittent catheter in appropriate patients
Do not use indwelling catheters unless you must! (See appropriate indications)
Early removal of the catheter

40. Consequences of UTIs Pain and discomfort Pyelonephritis Urosepsis
Increased mortality
Prolonged hospitalization
Additional exposure to antibiotics (increased risk for C. difficile)
Increased hospital expenditures

41. Bladder Scanner: Patient Equipment

42. 42

43. 43

44. 44

45. 45

46. 46

47. caUTI Adult ICUs Impact of RN Driven Protocol

48. Nurse Driven Protocol for Removing Indwelling Urinary Catheter
Month 00, 2008
Change footer on slide master

49. Respect the Foley

50. BEST PERFORMER: Floating Hospital For Children: PICU

51. Plans 2012 Focus on insertion
Demonstrate RN competency of 100% RNs throughout the Medical Center
Two person insertion
Continue weekly practice audits
1 Ultrasound per ICU
Encourage shiftly assessment and removal
Share each UTI with the staff
Post unit based results
Identify a champion passionate about safety
Observe practice, educate.
Reinforce excellence in practice, tell a story:
RN within one unit challenged an MD order to reinsert foley and used condom catheter.