1. Evolving a Culture of Patient Safety Lessons from the Elimination of CLABS Allegheny General Hospital Pittsburgh Regional Healthcare Initiative

2. The Key Message The data must not only be reportable, but actionable. You can come surprisingly close to eliminating hospital acquired infections with determination as opposed to resources. Hospital acquired infections are costing hospitals and society millions of dollars, illustrating the conspiracy of error and waste.

3. Who Are We? We are a 600 bed tertiary care teaching, hospital in Pittsburgh. 25,000 admissions with 6 ICU The MICU and CCU are contiguous units with 28 beds and about 1750 admissions each year. Cardiology and pulmonary fellows and categorical Internal Medicine Residents

4. What Did We Know (or think we knew) Before? Our results were average and average is ok. CLABs are evitable. It is the price you pay for sophisticated, complex care. CLABs are benign and readily treated with antibiotics. CLABs are a common accompaniment of complex care and covered in outlier payments.

5. Problems With Bench Marking The Difference Between Reporting and Actionable Data CCU/MICU NNIS PRHI

6. Where Would You Want to Have a Central line Placed? Unit 1 Teaching Unit 2 Community Unit 3 AMC Rates 5/1000 line- days 4/1000 line- days # of infections 25128 Line-days 500 lines X 10 days 50 lines X 4 days 360 lines X 19 days Deaths10 (40%)0 (0%)7 (25%) Risk1 in 201 in 501 in 13

7. What Does 5.1 infections/ 1000 line days Really Mean?? 37 patients 49 infections 193 lines were employed (5.2 lines / patient) 1753 admissions 1063 patients had central access for more than 12 hours 1 out of 28 patients with a central line became infected.

8. What Does 5.1 infections/ 1000 line days Really Mean?? Blood Isolates  Coagulase (-) Staph 17 (35%)  Staph aureus15 (30%)  MRSA10 (67%)  Candida species 9 (19%)  Gram negative rods 8 (16%)

9. What Did We Learn ? We were reporting only half of the actual CLABs. Central lines had a 3% chance of blood stream infection. Two-thirds of the infections involved virulent organisms. Twenty percent were MRSA. 19/37 patients died (51%).

10. What Not to Do? Don’t blame Don’t form another committee Make everybody responsible (not just the infection control officer !) Resist the temptation to meet / embrace the desire to act At the start, there are no right answers

11. What Did We Do? PPC Step 1: Make data actionable Step 2: Observe variations in work Step 3: Real time problem solving Step 4: Implement and test countermeasures

12. Toyota Production System Rules in Use Activity (specified as to content sequence, timing, location, expected outcome) Connections (direct and unambiguous) Pathways (predefined, simple and direct) Improvement (highly specified under the guidance of a mentor, at the level of the work, toward an ideal)

13. The Rules of TPS Applied to Healthcare Work (line placement and maintenance) should be highly specified such that variations/problems are immediately apparent. When problems (CLABs) are encountered, they should be solved to root cause in real time by the people doing the work. When a worker cannot solve a problem, they invoke the help chain to solve the problem.

15. Setting/Attending to Goals Goal de jour “Some is not a number..soon is not a time” Ambitious

17. Variation in the Course of Work (Line Placement) No standard pre-procedure checklist Informed consent in 25% of procedures Eight different ways to “gown and glove” Six different ways to “prep and drape” Four different approaches to central veins Five different insertion kits 55% of procedures were documented

18. Variation in the Course of Work (Line Maintenance) No specified role No standardized definitions of “site at risk” No standardized dressing kit No standardized procedure for dressing change No standard record of line location and duration.

19. Why is Disorder Condoned? Genetic variation The concept of individual care Physician autonomy

20. Genetic Variation: Highly Overrated Human genome: 27,000 genes Murine genome: 24,000 genes Drosophilia genome: 19,000 genes It’s Quality not Quantity that Counts

22. Real Time Problem Solving July 2003 R IJ infection (7/7) (MRSA) R fem infection (7/8) (E.Coli) Groshon catheter infection (7/9) Lines present on transfer (7/9) Re-wiring of line Catheter left in for > 96 hours Catheter choice Duration of line placement InfectionCause Root Cause Established Within 24 Hours

23. Understanding Problems Leads to Solutions Introducer linked and rewired Fem line in place > 96 hrs Patient transferred with line in place for 21 days Infected Groshon catheter Dysfunctional catheters should be replaced, not rewired Replace all femoral lines within 12 hours Replace line present on transfer Subclavian or PICC line preferred Real Time Problem SolvingCountermeasures

24. FY 2003 Traditional Approach FY 2004 PPC Approach ICU Admissions (n) 17531798 Patients with CLABs (n) 376 Age ( years ) 62 (24-80)62 (50-74) Gender (male/female) 22/153/3 Total CLABS 496 Line days 46835052 Overall rates (infections /1000 line days) 10.51.2 Rates reported to NNIS (infections /1000 line days) 5.11.2 Deaths in patients with CLABs 19 (51%)1 (16%) Comparative Results Risk of CLAB 1 in 281 in 185

26. Additional Countermeasures Line Skills Lines for a long time Difficult access Education / Credentialing BioPatch dressings SonoSite ultrasound Micropuncture kits Vascular access team Antibiotic locks Real Time Problem SolvingCountermeasures

27. Summary CLABs are a common, morbid and mortal complication of ICU care Femoral lines contribute significantly to the problem and should be considered in the NNIS definition CLABs can be eliminated (nearly).

28. Drivers of Change Moral: it’s the right thing to do Scientific: It works Practical: It can be done in your hospital, not just a research setting Economics: What’s the impact on the hospital’s and system’s bottom line?

29. The Conspiracy of Error and Waste What is the cost of a CLAB in human and financial terms? What does society pay for healthcare associated infections (HAI)? Do hospitals and physicians make money on HAIs ?

30. Case 1: 37 year old video game programmer, father of 4, admitted with acute pancreatitis secondary to hypertriglyceridemia. Day 3: developed hypotension, and respiratory failure Day 6 : fever and blood cultures positive for MRSA secondary to a femoral vein catheter in place for 4 days. Multiple infectious complications requiring exploratory laparotomy and eventually tracheostomy Day 86: Discharged to nursing home Highmark Select Blue

31. 686 CLAB Day 1 2/07/02 Transfer 5/04/02 2/12/02 M. S.

32. Case 3 Charges and Costs Attributable to CLAB

33. The Impact of CLABs on Gross Margin DRG 204/2721 (n=3) DRG 191 (n=3) DRG 483 (n=2) Case 1 Acute pancreatitis Pancreatitis w cc Pancreatitis w trach Revenue ($)5,90799,214125,576200,031 Expense5,78858,90598,094241,844 Gross Margin 11940,30927,482-41,813 Costs attributable to CLAB 170,565 LOS4384186

34. Case 3 49 year old obese female was admitted for elective surgical gastroplasty. She developed respiratory distress post operatively and was intubated for respiratory failure. On day 22, blood cultures were positive for Staph epidermidis, enterococcus fecaelis, and Candida. The right femoral line tip grew all three organisms. The line was in place for 16 days. On hospital day 48, she was transferred to a SNF. Medicare/ Three Rivers

35. Day 1 1/20/03 22 CLAB 2/10/03 48 Transfer 3/08/03

36. Case 1 Charges and Costs Attributable to CLAB

37. The Impact of CLABs on Gross Margin DRG 288 (n=10) DRG 483 (n=3) Case 3 Procedures for obesity Trach w obesity surgery Revenue22,023153,566101,521 Expense12,100148,969117,626 Gross Margin9,9236,597-16,105 Costs attributable to CLAB 41,009 LOS65147

38. CLABS Scorecard Optimal Care Less than optimal care Less than optimal + CLAB Patient +- --- Payor +----- Provider Hospital +++--- Provider Physician ++++++

39. CLABs* (n=72) VAP* (n=33) MRSA** (n=188) ( per patient) Revenue ($)68,18395,27226,112 Expenses82,183112,45969,343 Gross Margin-14,572-17,187-43,231 LOS355119 Mortality25%30%16% The Human and Economic Costs of Nosocomial Infections * Defined by Infection Control** no routine surveillance

40. AGH Losses Associated with Nosocomial Infections [$8,769,403] (-16,147,813) (-$9,743,783) Loss associated with nosocomial infections [$7,314,685](-$12,130,489)(-$8,127,428)MRSA (n=188) [$510,453](-$2,268,684)(-$567,171)VAP (n=33) [$944,265](-$1,748,640)(-$1,049,184)CLAB (n=72) Saving (90% Reduction) Projected Based Upon Underreporting ActualGross Margins (FY 04)

41. What Could You Do With $10 million? Hire 166 nurses or ICPs Hire 200 respiratory techs Hire 220 more interns Give all 3,500 employees a $2,857 raise Buy 2.5 million BioPatch dressings Insure one thousand uninsured Americans Treat 8,000 Haitians with HIV

42. Progress: It Can Be Infectious Initiatives now across all units VAPs reduced by 70% CLABs reduced by 40% MRSA surveillance (96%) 8% of admissions 2% transmission rate Real Time Mortality review

43. Conclusions The human and financial costs of CLABs are daunting. These costs do not include physician costs or costs of skilled nursing care. Thus, the magnitude remains understated. The costs of CLABs are not recovered in outlier payments. The elimination of nosocomial infections, in general, and CLABs, in particular is multi-million dollar proposition for the healthcare industry.

46. Sources of Variation Observations and standardization of dressing changes. SC: 5 minutes IJ: 5 minutes Fem: 15 minutes Standardize dressing change kits Document current condition of site daily Assist in understanding PICC line use PRHI