The Safe Critical Care Initiative

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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_at_vanderbilt.edu

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Safe Critical Care Team

• Vanderbilt
• 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

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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.

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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.

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Methods

• Hospital Corporation of America (HCA)
• 172 Medical and Surgical Centers
• 60 suburban and 32 urban
• Recruited 61 Hospitals

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Methods RCT Design

• 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

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Methods Tool Kit HCA Intranet-Atlas
SiteKeyword 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

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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

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Results Characteristics of HCA ICUs

• 80 have lt 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

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Results Baseline
Baseline Characteristics Collaborative N 31 Tool Kit N 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
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BSI ResultsRelative Risk 1.14 (95 CI 0.93,
1.40), p .20
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VAP ResultsRelative Risk 1.28 95 CI (1.03,
1.57), p .023
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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

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

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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

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Collaborative Qualitative ResultsChallenges -
Data

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

• Solutions
• Meditech/PCM documentation of protocols
• Design tools
• Monitoring

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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

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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

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SAQ ResultsVariation in Safety Climate
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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.

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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.

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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.