1. St. Mary’s and St. Joseph’s Stop BSI Project The Science of Improving Patient Safety A Johns Hopkins collaborative Document 7 Coaching Call 2, 10/19/2010

2. Learning 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

3. The 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

4. How Can We Improve? Understand 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 blame

5. 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?

6. System Failure Leading to This Error Catheter pulled with Patient sitting Communication between resident and nurse Lack of protocol For catheter removal Inadequate training and supervision Pronovost Annals IM 2004; Reason Patient suffers Venous air embolism

7. 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

8. Principles 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

9. How will we standardize?  Standardize by using a cart or a maximum sterile barrier kit which ICU has on supply cart to insert a central line

10. Standardize

11. Teamwork Tools  Daily rounds to assess line  Report reason to continue line  Line management-proper technique

12. % of respondents reporting above adequate teamwork ICUSRS Data ICU Physicians and ICU RN Collaboration Are we truly working as a team?

13. Teams Make Wise Decisions When There is Diverse & Independent Input  Wisdom of Crowds  Alternate between convergent and divergent thinking

14. 2 Year Results from 103 ICUs Time periodMedian CRBSI rateIncidence rate ratio Baseline2.71 Peri intervention1.60.76 0-3 months00.62 4-6 months00.56 7-9 months00.47 10-12 months00.42 13-15 months00.37 16-18 months00.34 Pronovost NEJM 2006

15. 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 1 st, 2009

16. 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.

17. 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.

18. 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

19.  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

20. Any Questions? Contact:  DeAnna Francisco Pager # 816-821-1149  Jami Fronckewicz x55242 or pager # 816-821-2067