The Safe Critical Care Initiative

An HCA-Vanderbilt Quality Improvement Project

On Healthcare Associated Infection

Partnerships in Implementing Patient Safety (PIPS)

Funded by AHRQ

ted.speroff@vanderbilt.edu

Safe Critical Care TeamVanderbilt• Ted Speroff• Robert Dittus• Jay Deshpande• E. Wesley Ely• Dan France• Robert Greevy • Shirley Liu• Samuel K Nwosu• Thomas R. Talbot • Richard Wall• Matthew B. Weinger

Hospital Corp of America• Laurie Brewer• Hayley Burgess• Jane Englebright• Steve Horner• Frank Houser• Jeanne James• Susan Littleton• Patsy McFadden• Steve Mok• Joan Reischel• Sheri Tejedor• Mark Williams

Aims of Safe Critical Care

• To prevent catheter-related blood stream infections (BSI) and ventilator-associated pneumonia (VAP) in the ICU.

• To implement a campaign for Improving Critical Care (Blood-Stream Infections and Ventilator-Associated Pneumonia) as part of the IHI 100,000 Lives Campaign.

Aims of Safe Critical Care

• To compare a Collaborative approach to a Local Hospital Quality Improvement approach for implementing an improvement initiative.

• To examine the organizational and provider factors that contribute toward and enable successful performance improvement.

Methods• Hospital Corporation of America (HCA)

– 172 Medical and Surgical Centers– 60% suburban and 32% urban– Recruited 61 Hospitals

HCA-Vanderbilt Toolkits HCA core development of

Meditech tools Feedback reports from

surveys and data collection Safe Critical Care Project

Atlas Site

HCA-Vanderbilt Toolkits HCA core development of

Meditech tools Feedback reports from

surveys and data collection Safe Critical Care Project

Atlas Site Collaborative

communications Social networking Content experts Collaborative teleconference

meetings

Toolkit Group: Local Hospital

Initiative

Collaborative Group

Randomized

Methods: RCT Design

Methods: Tool Kit HCA Intranet-Atlas Site

Keyword: Safe Critical Care

• Continuing Education Programs• BSI Tool Kit• VAP Tool Kit• Project Metrics• FAQ/Fact sheet: Quick links• QI/PDSA Tools• Statistical Control Chart Tools

Methods: Measures• Clinical Outcomes: BSI and VAP rates

• Administrative Data

• Safety Attitude Questionnaire: ICU safety climate

• Organizational Culture

• Survey of ICU Practices and Quality Improvement Activities

• Post-Project Evaluation Survey

Results: Characteristics of HCA ICUs

• 80% have < 20 ICU beds• 35% are medical-surgical-coronary ICU, 20%

medical-surgical• 65% have physician medical director, 95%

have a nurse manager• 27% intensivist required, 36% intensivist

optional, 37% no intensivist• 67% have pharmacist rounding• 65% have daily, integrated interdisciplinary

team

Results: BaselineBaseline

CharacteristicsCollaborative N= 31

Tool KitN= 30

P-value

in IHI Campaign 96% 100% 1.0

Hospital Vol median (IQR) 2720 (1499,3827) 2616 (1242,3360) .90

ICU Volume median (IQR) 595 (337,909) 578 (244,1077) .80

ICU LOS median (IQR) 4026 (1978,5824) 4228 (1645,6725) .82

ICU Mortality % (sd) 5.9% (2.9%) 7.1% (3.6%) .19

Medicare/Medicaid % (sd) 68.4% (9.6%) 68.4% (10%) 1.0

Emer.Dept Admit % (sd) 72% (14%) 67% (20%) .2

Female % (sd) 49.7% (5.6%) 50.3% (7.7%) .83

Charge weight mean (sd) 1258 (1004) 1295 (1110) .94

SAQ: mean (sd) 3.60 (.29) 3.67 (.28) .21

BSI & VAP Projects % 68% 60% .54

BSI Rate per 1000 days 2.3 (2.5) 4.4 (5.8) .26

VAP Rate per 1000 days 3.4 (3.5) 4.7 (5.9) .73

BSI ResultsRelative Risk = 1.14

(95% CI 0.93, 1.40), p = .20

VAP ResultsRelative Risk = 1.28

95% CI (1.03, 1.57), p = .023

Safe Critical Care: QI Interventions• Adoption of bundles for patient

care• Interdisciplinary team rounding• Rounding form/checklist • Empower nurses to encourage

physician compliance• Unit champions• Nurses empowered to stop

procedure if break in sterile field

• Checklist implementation• Kit changes & cart• Checklist in kits• Standards of Practice revised• Order set protocols

• Alcohol gel dispensers• Hand wash campaign• Evaluate performance and

practices • Audits & surveillance • Difference between standard

audits and peer group observation

• Case reviews of BSI and VAP• Reporting bundle compliance• Feedback reports• Monthly ICU newsletter • Encourage staff feedback

Webcast Seminars

Collaborative Group participated in more data topic seminars (52% vs 22%)and rated them as useful (78% vs 54%)

Usefulness of Tools

A greater proportion of the Collaborative Group accessed the BSI and VAP Tools, accessed the SPC methods tools, and found the tools useful.

BSI Bundle Process

82% of the Collaborative Group implemented all components of The CVC Bundle compare to 56% of the Tool Kit Group (p=.027)

VAP Bundle Process

76% of the Collaborative Group implemented all components of The CVC Bundle compare to 64% of the Tool Kit Group (p=.30)

Collaborative Qualitative Results: Challenges - Physicians

Challenges• Resistance • Use of barriers• Use of checklists• Site of insertion• Multiple private MDs,

Involvement• Resistance to change

vendors

Solutions• MD buy in, approval

from MEC• Hire Physician

champion• Intensivists• Nurse empowerment• Physician involvement

in case review• New order sets

Collaborative Qualitative ResultsChallenges - Staff

Challenges• Commitment• Empowerment• Resistance to tools• Resistance to change

in behavior

Solutions• Champions• Enlist• Hire• Storyboard with

examples so staff could conceptualize their roles

• Holding each other accountable is painful at times

Collaborative Qualitative ResultsChallenges - Data

Challenges• How to• Data collection tools• Access to data

Solutions• Meditech/PCM

documentation of protocols

• Design tools• Monitoring

Findings from Surveys• ICU Staffing is variable

– Most HCA ICUs are multipurpose • diagnostic diversity requires task and workload diversity • diverse demands on education and training

requirements

• Intensivists available in 63% of HCA ICUs but with variable models of care delivery

• Documentation is nearly split between paper and computer

• Significant variability in the extent of ICU participation in quality improvement

Findings from Surveys• Use of the NNIS definitions

– 98% for BSI – 96% for VAP

• Difficulty obtaining IC denominator data – 48% for BSI rates

• 23% hospitals reported having months where BSI rates could not be reported due to incomplete denominator reporting.

– 30% for VAP rates • 13% hospitals reported having months where

VAP rates could not be reported due to incomplete denominator reporting.

• 31% use Infection Control software for surveillance

SAQ ResultsVariation in Safety Climate

SAQ Survey: findings• Overall Safety Climate is positively correlated with

QI Measurement r = .39• SAQ and Hospital Size

– Safety Climate and QI support varies with hospital size.– Smaller hospitals show more positive safety climate.– Smaller hospitals show need for administrative support in

resources and measurement.– Larger hospitals give more empowerment to the team.– ICU teams provided with resources and training by the

administration have more positive perceptions of safety climate.

Conclusions• Monitoring outcomes such as hospital acquired

infections is complicated and time consuming.• While there was a trend for improvement and better

outcomes for the Collaborative group, there was appreciable variability and the pattern of results varied over time

• These differences were associated with the Tool Kit group participating in fewer educational opportunities and making less use of Tool Kit elements than the Collaborative group.

• The Collaborative group paid greater attention to the methodological seminars and measurement tools.

• Once sites engaged in these resources they found the information and tools useful and sustained their use.

• The Collaborative group used more improvement strategies and more complete implementation of BSI and VAP evidence-based interventions.

Conclusions• “Real world” studies bring to the surface the variation

across hospitals and ICU settings. Whereas clinical, methodological, and informatics tools (Tool Kits) offer standardized core support, the solutions and approaches for tool, quality improvement, and patient safety implementation remain context dependent. A Collaborative seems to provide a social network that reinforces personal effort despite resistance and workload pressures, shares and facilitates problem solving, and fosters accountability for behavioral change; in such a way that the participant can tailor it all to their home organization.

• Our preliminary results support the ability of a participatory collaborative and support tools to decrease the incidence of catheter-related blood stream infections and ventilator-associated pneumonia in a diverse population of ICUs.