Central Line Associated Blood Stream Infections (CLABSI)
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Transcript Central Line Associated Blood Stream Infections (CLABSI)
Comprehensive Unit-Based Safety
Program (CUSP)
Central Line Associated Blood Stream
Infections
Terri Conner, Ph.D.
Nybeck Analytics
Partnership for Patients Initiative at
Texas Center for Quality & Patient Safety
GOALS
Work to eliminate central-line associated
blood stream infections (CLABSI) in your unit
Improve safety culture
Learn from defects
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
4E’S TO ENSURING PATIENTS
RECEIVE EVIDENCE
Engage
– How does this make the world a better place?
Educate
– What do we need to know?
Execute
– What do we need to do?
– What keeps me from doing it?
– How can we do it with our resources and culture?
Evaluate
– How do we know we improved safety?
ENGAGE
CLABSIs associated with significant
morbidity, mortality, and costs
Patients in ICUs are at an increased risk
–
–
–
48% of ICU patients have indwelling central
venous catheters
15 million central line days per year in United
States ICUs
As many as 28,000 ICU patients die from
CLABSIs annually in the U.S. alone.
ENGAGE
Share about a patient who was infected
Post baseline rates of infections
Estimate number of deaths and dollars from
current infection rates
Remind staff that most CLABSI are
preventable
EDUCATE
Conduct in-service regarding CLABSI prevention
Create forum to jointly educate physicians and
nurses
Add CLABSI prevention to ICU orientation
Give staff fact sheets, articles, and slides of
evidence
EXECUTE
Standardize and reduce complexity: Create line cart
Create independent checks: Create BSI checklist
Ask providers daily whether catheters could be removed
Empower nurses to ensure physicians comply with checklist
–
Nurses can stop takeoff
Learn from mistakes: review every infection
EVALUATE
Monitor rates of infections using CDC
definitions
Post rates of infections per year in the unit
Post number of weeks or months without an
infection
CUSP
Comprehensive Unit-based Safety Program
An intervention to learn from mistakes and
improve safety culture
A good approach whenever there is a gap
between evidence-based practice and current
practice on your unit.
CUSP: EMPHASIS ON CULTURE
Shared attitudes, values, goals, practices,
behaviors
Culture influences behavior
–
Participation in quality improvement efforts
–
Communication
Breakdown in communication contributes to nearly all
adverse events.
CUSP: COMPREHENSIVE UNITBASED SAFETY PROGRAM
Safety practices part of daily work
Implemented at the unit level
Led by clinicians
Structured program, yet flexible
PRE-CUSP STEPS
Assemble Safety Team
–
Multidisciplinary
–
Different levels of experience
–
Encourage joining team at any phase of the
program
PRE-CUSP STEPS
Team Members
–
–
–
–
–
–
–
Project Leader (Unit Champion)
Nurse Manager
Physician Champion
Senior Hospital Executive
Patient Safety Coordinator
Epidemiology / Infection Control
Coach
PRE-CUSP STEPS
Measure Safety Culture
–
Before CUSP implementation, and then every 12-18 months
–
Use AHRQ’s The Hospital Survey on Patient Safety Culture
(HSOPS)
–
All clinical and non-clinical providers
–
Report results to the unit and senior hospital executive
CUSP STEPS
1.
Science of safety training
2.
Identify defects
3.
Assign executive to adopt unit
4.
Learn from defects
5.
Implement teamwork tools
STEP 1: SCIENCE OF SAFETY
TRAINING
Goals
–
Magnitude of patient safety problem
–
Foundation for investigating safety defects
–
Providers’ involvement significantly affects patient
safety
STEP 1: SCIENCE OF SAFETY
TRAINING
Learning Objectives
–
Safety is a property of the system
–
Use strategies to improve system performance
Standardize work
Create independent checks for key processes
Learn from mistakes
–
Apply strategies to both technical work and team work
–
Teams make wise decisions with diverse and independent
input
STEP 1: SCIENCE OF SAFETY
TRAINING
Training Session
–
3-part “Improving Safety” presentation by Dr. Peter
Pronovost
–
Part 1: http://www.youtube.com/watch?v=GOJJHHm7lnM
Part 2 http://www.youtube.com/watch?v=wpzb7nM6oFQ&feature=rela
ted
Part 3 http://www.youtube.com/watch?v=6BnXs4KtER8&feature=relat
ed
Instruct staff on reporting of safety concerns
STEP 2: IDENTIFY DEFECTS
Eyes and ears of patient safety
Ongoing process
Disseminate Staff Safety Assessment Form
Combine results and prioritize defects
WHAT IS A DEFECT?
Anything you do not want to have happen
again.
Blood stream infections are almost always
preventable. They should be viewed as
defects.
STEP 2: IDENTIFY DEFECTS
Staff Safety Assessment Form
–
Purpose: Tap into your knowledge and experiences at the
frontlines of patient care to find out what risks are present
on your unit that do or could jeopardize patient safety.
–
All health care providers in the unit complete this form.
–
2-item questionnaire
STEP 2: IDENTIFY DEFECTS
Staff Safety Assessment Form
1.
Please describe how you think the next patient in
your unit/clinical area will be harmed.
2.
Please describe what you think can be done to
prevent or minimize this harm.
STEP 2: IDENTIFY DEFECTS
Combine Results
–
–
Group into common types of defects
Communication
Medication process
Patient falls
Supplies
Frequency distributions
Example: communication, 57%
STEP 2: IDENTIFY DEFECTS
Prioritize safety concerns
–
Obtain input from CUSP team senior executive
–
Prioritize based on
Likelihood of causing patient harm
Severity of harm
How common is the problem
Likelihood it can be solved by implementing a daily work
process
STEP 4: LEARN FROM DEFECTS
Four Key Questions
1.
What happened?
2.
Why did it happen?
3.
What will you do to reduce the chance it will
recur?
4.
How do you know that you reduced the risk that
it will happen again?
WHAT HAPPENED?
Reconstruct the timeline and explain what happened
Put yourself in the place of those involved, in the middle of the
event as it was unfolding
Try to understand what they were thinking and the reasoning
behind their actions/decisions
Try to view the world as they did when the event occurred
WHY DID IT HAPPEN?
SYSTEM FAILURES
Arise from managerial and organizational
decisions that shape working conditions
Often results from production pressures
Damaging consequences may not be evident
until a “triggering event” occurs
Develop lenses to see the system factors that
lead to the event
WHAT WILL YOU DO TO REDUCE
THE RISK OF IT HAPPENING AGAIN?
Prioritize most important contributing factors
Prioritize most beneficial interventions
Safe design principles
–
Standardize what we do
–
Create independent check
–
Make it visible
Safe design applies to technical and team work
WHAT WILL YOU DO TO REDUCE
THE RISK OF IT HAPPENING AGAIN?
Develop list of interventions
For each intervention:
–
Rate how well the intervention solves the problem or
mitigates the contributing factors for the accident
–
Rate the team belief that the intervention will be
implemented and executed as intended
Select top interventions (2 to 5) and develop intervention plan
–
Assign person, task follow-up date
HOW DO YOU KNOW RISKS WERE
REDUCED?
Did you create a policy or procedure?
Do staff know about policy or procedure?
Are staff using the procedure as intended?
–
Behavior observations, audits
Do staff believe risks were reduced?
STEP 4: LEARN FROM DEFECTS
Summarize and Share Findings
–
Learning from Defects Tool
–
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Detailed form for each incident or identified defect
Case Summary Form
Summarize the case
Identify system failures
Identify opportunities for improvement
List actions taken to prevent future harm
Share your findings
EXAMPLES
Defect: Nasoduodenal tube placed in lung
Intervention: Protocol developed for NDT placement
Defect: Bronchoscopy cart missing equipment
Intervention: Checklist developed for stocking cart
Defect: Inconsistent use of Daily Goals rounding tool.
Intervention: Gained consensus on required elements of Daily
Goals rounding tool.
STEP 4: LEARNING FROM
DEFECTS
Key Points
–
Focus on systems, not people
–
Prioritize
–
Go mile deep and inch wide, rather than mile wise and inch
deep
–
Pilot test
–
Learn from 1 defect a quarter
–
Answer the four questions
STEP 5: TEAM WORK TOOLS
Staff Safety Assessment
Safety Issues Worksheet
Status of Safety Issues
Learning from Defects Tool
Case Summary Form
Daily Goals Checklist
Morning Briefing Tool
Shadowing Another Professional
Observing Rounds
STAFF SAFETY ASSESSMENT
Used to identify defects in the unit
1.Please
describe how you think the next
patient in your unit/clinical area will be harmed.
2.Please
describe what you think can be done
to prevent or minimize this harm.
SAFETY ISSUES WORKSHEET
Identified Issue
1.
2.
3.
Potential/
Recommended
Solution
Resourc
es
Needed
Resources
Not
Needed
STATUS OF SAFETY ISSUES
New and Ongoing
Date
Date
Safety Issue
Safety Issue
Contact
New and Ongoing
Contact
Status
Status
Goal
Goal
Completed
Date
Safety Issue
Contact
Status
Goal
LEARNING FROM DEFECTS
Explain what happened.
Check off the factors that negatively or positively contributed to the
incident.
Describe how you will reduce the likelihood of this defect happening
again by completing the tables.
Develop interventions, and choose 2-5 to implement.
– What will be done?
– Who will lead the intervention?
– When is follow-up?
Describe how you know you have reduced the risk.
Summarize your findings using the Case Summary Form.
CASE SUMMARY FORM
Form Sections
Safety tips
Case
summary
System
failures
Opportunities
Actions
for improvement
taken to prevent harm
DAILY GOALS CHECKLIST
Care plan for patients
Lists needs for the day to safely move a
patient closer to discharge
Used to improve communication among care
team members and family members.
Use during morning and evening rounds, and
kept at patient’s bedside.
Adapt to your own unit’s environment.
MORNING BRIEFING TOOL
Structured approach to assist physicians and charge nurses in
identifying the problems that occurred during the night and
potential problems during the clinical day.
Tool used by:
– Physicians who conduct patient rounds
– Charge nurses and nurse managers who make patient
assignments
Complete this tool daily prior to starting patient care rounds by
meeting with the charge nurse.
SHADOWING ANOTHER
PROFESSIONAL
Designed to provide a structured approach to identify communication,
collaboration and teamwork defects among different practice domains.
Purpose: to improve teamwork, collaboration, and communication that
affect patient care delivery
Who should use this tool?
–
Anyone on the CUSP team
–
Staff unfamiliar with responsibilities and practice domains of
another profession
–
Executive team member may want to shadow practitioners
Recommended when <60% of unit members report good teamwork or
good safety climate.
OBSERVING ROUNDS
Purpose: Provide a structured approach for improving teamwork, and
communication behaviors across and between disciplines that
negatively affect staff morale and patient care delivery.
Who Should Use this Tool?
– Physicians who conduct patient rounds.
– Administrators, house officers, nurses, pharmacists, respiratory
therapists, medical and nursing students
better understand the dynamics of multidisciplinary rounds
identify defects in communication
foster collaboration among disciplines or practice domains
target areas where communication can be improved in the
rounding process and in setting patient daily goals
CUSP IS A CONTINUOUS
JOURNEY!
THANK YOU