Universal Components of an IV Culture of Safety

3M IV Leadership SummitMay 15-17, 2013St Paul, MNRuss Nassof, JDEVPRiskNomics, LLC 1

Conflict of Interest• Russ Nassof is a paid consultant to Becton, Dickinson and

Company

2

Objectives• Define issues contributing to the disparity in device-associated

healthcare-associated infection practices from nation to nation;

• Identification of 6 key elements which can reduce disparity and form the foundation for establishment of a uniform culture of safety to prevent device-associated healthcare-associated infections; and,

• Identification of critical risk exposure points for device-associated infections and how to manage those risks to effectively create a universal IV culture of safety. 3

Prevention• Once it is established that an adverse healthcare event can be

“PREVENTED”…• Best evidence based practices will be revised as necessary;• The standard of care (what another reasonably prudent

professional would do in the same or similar circumstances) will change as necessary; and,

• Liability can be imposed based on the failure to adhere to best practices and meet the standard of care.

However… What Can Be Prevented in Minnesota May Not Be Reasonably Preventable in Mali

4

Diversity of Problems• Difficult to Find Commonality in the Prevention of Device-

associated Healthcare-associated Infections (DA-HAIs) Across the Globe

5

Diversity of Problems• Difficult to Find Commonality…

Disparity in Wealth- World Bank- 68% of World Economies Representing 75% of the World Population Identified as Low Resource Countries

6

Diversity of Problems• Difficult to Find Commonality…Disparity in Infection Control Practice

Reporting/Collecting DataRegulations/AccreditationDefinitionsVariability in PracticePatient PopulationsSurveillanceHealthcare StructureResourcesHCW/Patient Ratios

7

Diversity of Problems• Difficult to Find Commonality…

Disparity in HAI Device-associated Rates- While the rate of device use in low resource country ICUs is analogous or even lower than that in the USA, device-associated HAIs rates and antimicrobial resistance rates are HIGHER

8

Culture of Safety• What Doesn’t Work?

Do NOT impose solutions- “ASK, don’t Tell”Healthcare Microcosm/Gladwell

Pronovost/Rosenthal- CLABSI solutions that work in Lansing may not work in LhasaDon’t include CHG in your bundle if povidone iodine is the only

optionDon’t require single patient rooms if you don’t have single patient

bedsIncluding unattainable interventions in infection prevention

bundles creates more problems than not having any bundles at all 9

Culture of Safety• What Does Work –FINDING COMMONALITY

ASK- IDENTIFY

FOCUS ON IV PRODUCT ISSUES-selection, technologyFOCUS ON IV PRACTICE ISSUES-insertion, maintenance, hygieneEDUCATION/COMPETENCY SOLICIT MULTIDISCIPLINARY INPUTKEEP IT LOCALKEEP IT SIMPLEKEEP IT ECONOMICAL

10

Culture of Safety• What Does Work- FINDING COMMONALITY

MAKE IMPROVEMENTS

SIMPLEEASILY ATTAINABLEMUST BRING “VALUE”

11

Culture of Safety• What Does Work-FINDING COMMONALITY

EMBED IMPROVEMENTS-SUSTAINABILITY

COMPETENCYSTANDARDIZATION/UNIFORMITYMULTIDISCIPLINARY INVOLVEMENTBUNDLES/CHECKLISTSINCENTIVESDOCUMENTATIONCONSISTENCY (IMPROVEMENT)

12

Culture of Safety• What Does Work-FINDING COMMONALITY

INNOVATE

CONTINUOUS EVALUATION OF NEW PRODUCTS/PRACTICEIMPLEMENT WHEN REALISTICBE AWARE OF NEW RISKS CREATED

13

Culture of Safety• What Does Work- FINDING COMMONALITY

COMMUNICATE/TEAMWORK

Communication problems in healthcare are considered to be a leading cause of medical errors and are often the root cause of sentinel events

Most medical errors result from a breakdown in communication among staff, physicians, and patients

Poor communication and lack of teamwork in the healthcare arena have been identified as major causes of errors leading to patient morbidity and mortality

14

Culture of Safety• What Does Work-FINDING COMMONALITY

APOLOGIZE (when mistakes are made)

EMPATHY VS. ADMISSION OF FAULT/LIABILITYASSURANCE THAT MISTAKE WILL NOT RECURVOW TO DO BETTER IN THE FUTURESINCERITYTIMINGTRANSPARENCYIN PERSON/IN PRIVATE/ENGAGEDDOCUMENT 15

Culture of Safety• What Does Work-Finding Commonality

• Critical Risk Exposure Points for Device-associated Infections

Education/CompetencyInsertionMaintenanceResponding to Adverse EventsIncorporating Technology

16

Risk Exposure Points• Education/Competency

What standards/policies/practices are being followed and why?Are written policies in place reflecting those standards?

If yes- do those policies adhere to the standards? If yes, do practices comport with the written policies? If no, do practices comport with the standards adopted?

Is training/education provided to applicable HCPs on policies?Are appropriate products/devices/ medications available to meet

policy requirements?Are inappropriate products/devices/medications available?Are controls in place to ensure compliance?Are competency evaluations performed?Is Surveillance performed?

17

Risk Exposure Points• Insertion

Hand hygieneSite preparationSite selectionDevice selectionSite assessmentTechniqueStabilizationMedicationPatient factors 18

Risk Exposure Points• Maintenance

MonitorDressing changeDevice securementReplacementFlushing MedicationSite observation

19

Risk Exposure Points• Responding to Adverse Events

Periodic site assessmentCriteria for response and procedural next stepsCriteria for removal of deviceCriteria for dressing change

20

Risk Exposure Points• Technology

Product innovationPractice innovationDevice securementAntimicrobial dressing/devices

• Technological innovation may result in shifting preventability and may also create new areas of risk.

21