Improving Patient Safety In Critical Care

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Improving Patient Safety In Critical Care
From Bench to Bedside

• Michael E. Westley MD
• Medical Director Critical Care and Respiratory
  Therapy
• Virginia Mason Medical Center
• October 3, 2005

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New York Times, Science Tuesday February 17, 2004
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Therapies that make a difference
Mortality Reduction

• Limit tidal volume in ALI/ARDS
• Elevate HOB, Daily SBT, Daily sedation/analgesia
  holiday, DVT prophylaxis, SU prophylaxis,
  (Ventilator Bundle ) to prevent VAP
• Maximum barrier protection to reduce device
  related blood stream infections
• Intensive Insulin Therapy in Critically Ill
  Patients

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Therapies that make a difference
Mortality Reduction

• Early Goal Directed Therapy for sepsis
• Stress steroid replacement relative adrenal
  insufficiency in sepsis
• APC (drotrecogin) in sepsis
• Proper Hand Hygiene

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How long on average does it take from discovery
of effective therapies to their routine use?

• 17 Years?

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Adapted from Bero LA, et al. Getting research
findings into practice, Cochrane Database of
Systematic Reviews. BMJ 1998 317465-468
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Safety is a system property.
Every system is designed to get exactly the
results it gets. Paul Batalden
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Complex Systems

• Probability of performing perfectly

Probability of success, each element
0.95
0.99
0.999
0.9999
of steps
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Nominal Human Error Rates
Salvendy G. Handbook of human factors
ergonomics 1997.
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Nominal Human Error Rates
Salvendy G. Handbook of human factors
ergonomics 1997.
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Nominal Human Error Rates
Salvendy G. Handbook of human factors
ergonomics 1997.
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Nominal Human Error Rates
Salvendy G. Handbook of human factors
ergonomics 1997.
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Nominal Human Error Rates
Salvendy G. Handbook of human factors
ergonomics 1997.
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.inherent limitation of human memory, effects
of stress and fatigue, the risks associated with
distraction and interruptions and limited ability
to multitask ENSURE that even skilled,
experienced providers WILL make mistakes.
Leonard M, et al Qual Saf Health Care 200413
(supp 1)i85-i90
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www.baddesigns.com
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Human Factors X System Design Reliability
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Health Care Process Reliabilities
For further reading, see McGlynn EA, Asch SM,
Adams J, et al. The quality of health care
delivered to adults in the United States. New
England Journal of Medicine. 2003348.
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Evidence brings responsibilitymanagement of
acute MI and unstable angina

• Aspirin 67 - 83
• Thrombolytic therapy 43 - 64
• Heparin 24 - 63
• ACE inhibitors 59 - 65
• Beta blocker 21 - 60

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Intent, Vigilance and Hard Work 10-1
Performanceto 10-2 transition Level 1

• Standardization (mostly structure)
• Personal check lists
• Working harder next time
• Feedback of information
• Awareness and training

Roger Resar MD
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Ideas from Human Factors and Reliability
Science Improve error rates from 1/100 to
1/1000Level 2

• Decision aids and reminders built into the system
  
• Desired action the default (based on evidence)
• Redundancy
• Takes advantage of habits and patterns
• Standardization of process

Checklists and check sheets (Vent/Central Line)
Insulin infusion if two readings gt 130
Both RN and RT check HOB
Time out before surgery to assure right site,
report
Daily SBT trial
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High Reliability Organization 10-4
PerformanceLevel 3

• Sophisticated design of human interactions and
  working relationships

Roger Resar MD
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Mistakes are inevitable..but defects and harm
to patients are NOT!
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The Ventilator Bundle

• .is a package of evidence-based interventions
  that, when implemented together for all patients
  on mechanical ventilation, has resulted in
  dramatic reductions in the incidence of
  ventilator-associated pneumonia.

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Ventilator Bundle (IHI)

• Head of bed elevation
• Sedation vacation
• DVT prophylaxis
• PUD prophylaxis

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VMMC Ventilator Bundle

• Head of Bed elevation
• Daily sedation vacation
• Daily trial of spontaneous breathing when
  appropriate
• DVT prophylaxis
• PUD prophylaxis
• ALI Screen New January 2005

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Compliance with VMMC Ventilator Bundle
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Central Line Bundle Elements

• Hand hygiene
• Maximal barrier precautions
• Chlorhexidine skin antisepsis
• Optimal catheter site selection, with subclavian
  vein as the preferred site for non-tunneled
  catheters in adults
• Daily review of line necessity with prompt
  removal of unnecessary lines

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Eliminating device related BSI at VMMC (Central
Line Bundle)

• No unnecessary lines
• Maximum barrier precautions used by ALL providers
  (line cart has all needed supplies)
• Proper skin prep
• Ultrasound Neck and groin vessels
• Transduce or manometer all lines during insertion

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Eliminating device related BSI at VMMC (Central
Line Bundle)

• Procedural Pause
• Check sheet to assure all steps followed. No
  is not acceptable
• Standardized line dressing care
• Continuous infection surveillance-no batching

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Jobes DR, Schwartz AJ, Stephenson LW, et al.
Safer jugular vein cannulation Recognition of
arterial puncture and preferential use of the
external jugular route. Anesthesiology
59353-355, 1983.
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Policing or Participating?
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Monthly BSI in the ICU
Annotations1 Intensivist Program2 line cart,
maximal sterile barriers3 Anesthesia adopts
protocol max barriers4 CCU RN responsible for
drsg changes5 Antimicrobial impregnated triple
lumen caths6 denominator missing - no events7
procedural pause, and transducer set-up
standard8 hospital-wide checklist
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Why are tasks done reliably?

• I have to document
• Immediate/predictable consequences if I dont do
  it
• I think it is important for my patient (safety)
• Habit

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Underlying Principles

• Constancy of Purpose
• Zero Defects (in our processes)
• Standard work
• Simplification
• Reminders
• Visual controls
• Redundancy
• Measurement
• Consequences (accountability) New Feb 2005

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Mistakes are Fixed at the Source
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VMMC CCU Bundle
A Bundle of Bundles Or Our commitment to you!
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If you are admitted to our ICU we will

• Use proper hand hygiene
• Identify and treat your ALI/ARDS with low volume
  ventilation
• Use our Vent Bundle to prevent needless VAP and
  mechanical complications
• Prevent a needles device related BSI by using our
  Line Bundle

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If you are admitted to our ICU we will

• Tightly control your glucose
• Promptly identify and treat your sepsis with the
  Sepsis Bundle with Early Goal Directed Therapy
  
• Assess your need for supplemental steroids if you
  have septic shock
• Prevent all avoidable skin breakdown