On the CUSP: STOP BSI Overview of STOP-BSI Program

Immersion Call Overview

Week 1: Project overview

Week 2: Science of Improving Patient Safety Week 3: Eliminating CLABSI Week 4: The Comprehensive Unit-Based Safety Program (CUSP) Week 5: Building a Team Week 6: Physician Engagement

Learning Objectives

• To delineate the goals of STOP-BSI • To describe the project organization • To define the interventions • To outline the planned learning sessions • To identify who to call for help

On the CUSP: STOP BSI Goals

• To work to eliminate central line associated blood stream infections (CLABSI): reaching state means less than 1/1000 catheter days, state median 0 • To improve safety culture by 50% • To learn from one defect per quarter

Measure

Have We Created a Safe Culture?

How Do We know We Learn from Mistakes?

CUSP Comprehensive Unit based Safety program How Often Do we Harm?

Are Patient Outcomes Improving?

(TRiP) Translating Evidence Into Practice

1.

2.

3.

4.

5.

Educate staff on science of safety Identify defects Assign executive to adopt unit Learn from one defect per quarter Implement teamwork tools 1. Summarize the evidence in a checklist 2. Identify local barriers to implementation 3. Measure performance 4. Ensure all patients get the evidence

IMPROVE

www.onthecuspstophai.org

The CUSP/ CLABSI Intervention

CUSP CLABSI

1. Educate staff on science of safety 2. Identify defects 3. Assign executive to adopt unit 4. Learn from one defect per quarter 5. Implement teamwork tools 1. Remove Unnecessary Lines 2. Wash Hands Prior to Procedure 3. Use Maximal Barrier Precautions 4. Clean Skin with Chlorhexidine 5. Avoid Femoral Lines www.onthecuspstophai.org

Safety Score Card Keystone ICU Safety Dashboard

How often did we harm (BSI) (median) How often do we do what we should

How often did we learn from mistakes* Have we created a safe culture % Needs improvement in Safety climate* Teamwork climate*

2004 2.8/1000 66% 100s 84% 82%

CUSP is an intervention to improve these*

2006 0 95% 100s 43% 42%

Project Organization

• State-wide effort coordinated by Hospital Association or designated collaborative agency • Learning collaborative model (e.g., multisite participation, 2 face-to-face meetings, monthly calls) • Standardized data collection tools and evidence • Local unit modification of how to implement interventions

On The CUSP Stop BSI Technical CLABSI

CVC Insertion Assemble a CUSP team, Partner with a senior executive; Baseline Data Exposure Survey and Technology Survey Culture Survey 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 Science of Safety Training

Staff Identify Defects Adaptive (CUSP)

Senior Executive Partnership Learning from Defects LFD toolkit Briefings 1. Science of safety presentation 3. Attendance sheet 1. Staff safety assessment form 2. Indentifying hazards presentation Implement Tools for Teamwork and Communication 1. Daily goals 2. Shadowing 3. AM briefing 4. Call list 6. Team check up tool 20

Intervention to Eliminate CLABSI

Pronovost, Berenholtz, Needham BMJ 2008

Evidence-based Behaviors to Prevent CLABSI

• Remove unnecessary lines • Wash hands prior to procedure • Use maximal barrier precautions • Clean skin with chlorhexidine • Avoid femoral lines MMWR. 2002;51:RR-10

Identify Barriers

• Ask staff about knowledge • Ask staff what is difficult about doing these behaviors • Walk the process of staff placing a central line • Observe staff placing central line

Ensure Patients Reliably Receive Evidence

Engage Educate Execute Evaluate

Senior leaders Team leaders Staff

How does this make the world a better place?

What do we need to do?

What keeps me from doing it?

How can we do it with my resources and culture?

How do we know we improved safety?

Pronovost: Health Services Research 2006

Ideas for Ensuring Patients Receive the Interventions: the 4Es

• Engage: stories, show baseline data • Educate staff on evidence • Execute – Standardize: Create line cart – – – Create independent checks: Create BSI checklist Empower nurses to stop takeoff Learn from mistakes • Evaluate – Feed back performance – View infections as defects

Comprehensive Unit-based Safety Program (CUSP)

Pre CUSP Work

• Create a unit-level team – Nurse, physician administrator, others – Assign a team leader • Measure culture in the unit • Seek out a senior executive to participate on unit level team

CUSP Elements

1. Educate staff on science of safety 2. Identify defects 3. Assign executive to adopt unit 4. Learn from one defect per quarter 5. Implement teamwork tools Pronovost J,

Patient Safety

, 2005

We are on a Continuous Journey

• We have toolkits, manuals, websites, and monthly calls to learn from and with each other.

• Your job is to join the calls, share with us your successes and more importantly the barriers you face.

• Commit to the premise that harm is untenable.

To Get Help

• Email /call state project leader • Talk to your team leader

Action Items

• Review content of website at www.safercare.net

• Toolkits • • Slidesets Manuals • Project Management Checklists – – – Pre-Implementation Checklist CEO/ Senior Leader Checklist Infection Preventionist Checklist

References

Measuring Safety

• Pronovost PJ, Goeschel CA, Wachter RM. The wisdom and justice of not paying for "preventable complications". JAMA. 2008; 299(18):2197-2199.

• Pronovost PJ, Miller MR, Wachter RM. Tracking progress in patient safety: An elusive target. JAMA. 2006; 296(6):696-699.

• Pronovost PJ, Sexton JB, Pham JC, Goeschel CA, Winters BD, Miller MR. Measurement of quality and assurance of safety in the critically ill. Clin Chest Med. 2008; in press.

References

Measuring Safety

• Pronovost PJ, Goeschel CA, Wachter RM. The wisdom and justice of not paying for "preventable complications". JAMA. 2008; 299(18):2197-2199.

• Pronovost PJ, Miller MR, Wachter RM. Tracking progress in patient safety: An elusive target. JAMA. 2006; 296(6):696-699.

• Pronovost PJ, Sexton JB, Pham JC, Goeschel CA, Winters BD, Miller MR. Measurement of quality and assurance of safety in the critically ill. Clin Chest Med. 2008; in press.

References

• Pronovost P, Weast B, Rosenstein B, et al. Implementing and validating a comprehensive unit-based safety program. J Pat Safety. 2005; 1(1):33-40. • Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care. 2003; 18(2):71-75.

• Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ. 2008 Oct 6;337.

• Pronovost PJ, Weast B, Bishop K, et al. Senior executive adopt-a-work unit: A model for safety improvement. Jt Comm J Qual Saf. 2004; 30(2):59-68.

• Thompson DA, Holzmueller CG, Cafeo CL, Sexton JB, Pronovost PJ. A morning briefing: Setting the stage for a clinically and operationally good day. Jt Comm J Qual and Saf. 2005; 31(8):476-479.