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September 5, 2007 2
Purpose
• By the end of this call, participants will have:– Updated information on the SHN Campaign,
Getting Started Kits and reporting worksheets – Heard successes and learnings from
Improvement Teams– Answers to your team’s questions about
intervention-specific changes and measurement– An understanding of benefits and expectations of
enrolling in the Canadian ICU Collaborative
September 5, 2007 3
Campaign Structure
Partner Network
Peer SupportNetwork
CAPHC
Measurement Working Group & CMT Education & Resource
Working Group
Clinical Support
Canadian ICU Collaborative
ISMPCanada
Operations
Teams
Other Canadian Faculty
Communication Working Group
Atlantic
NodeOntario
Node
Western Node
Campaign SupportSHN National Steering Committee
Secretariat - CPSI
Patients
CCHSA CIHI
QuebecCampaign
IHI
September 5, 2007 4
Teams Continue to EnrollSafer Healthcare Now! Overview Total # Enrolled Teams
September 2005 to August 2007
118
296
403443
491
546 557579
602
669695
718 734
628
0
100
200
300
400
500
600
700
800
Total # of Enrolled Teams
Sep-05 Nov-05 Mar-06 Jun-06 Aug-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 May-07 Jun-07 Jul-07 Aug-07
Updated August 21, 2007
September 5, 2007 5
Safer Healthcare Now! Enrollment by Intervention
Intervention Number of Teams
Deploy Rapid Response Teams 52
Improve Care for Acute Myocardial Infarction 111
Prevent Adverse Drug Events through Medication Reconciliation
282
Prevent Central Line-Associated Bloodstream Infection 66
Prevent Surgical Site Infection 129
Prevent Ventilator-Associated Pneumonia 94
Total 734
As at August 21, 2007
September 5, 2007 6
Safer Healthcare Now! Enrollment by Province & Territory
Province/Territory Number of Teams
New Brunswick 24
Newfoundland & Labrador 16
Nova Scotia 56
Prince Edward Island 11
Quebec 22
Ontario 278
Alberta 63
British Columbia 118
Manitoba 55
Northwest Territories 1
Saskatchewan 22
Yukon 1
Total 669As at May, 2007
September 5, 2007 7
West Ontario Atlantic Quebec
Total
Healthcare Delivery Organizations [includes hospitals, agencies, services and regions (with one or more hospitals participating)]
53 115 25 17 210*
*Total at August 21, 2007
Enrollment Update
September 5, 2007 8
INTERVENTION - CLI MEASURE: 1.0 Central Line-Associated Primary Bloodstream Infection (BSI) Rate per 1000 Central Line-Days
0
1
2
3
4
5
6
7
8
9
10
Nov-0
5
Dec-0
5
Jan-
06
Feb-0
6
Mar
-06
Apr-0
6
May
-06
Jun-
06
Jul-0
6
Aug-0
6
Sep-0
6
Oct-06
Nov-0
6
Dec-0
6
Jan-
07
Feb-0
7
Mar
-07
Apr-0
7
May
-07
Jun-
07
Jul-0
7
Aug-0
7
Sep-0
7
Oct-07
Nov-0
7
Dec-0
7
Jan-
08
Feb-0
8
Mar
-08
Apr-0
8
May
-08
Jun-
08
Month
Blo
od
stre
am In
fect
ion
Rat
e p
er 1
000
day
s
Local Team National Goal
CLI Rate
September 5, 2007 9
Insertion Bundle Compliance
INTERVENTION - CLI MEASURE: 2.0 Central Line Insertion Bundle Compliance
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Nov-0
5
Dec-0
5
Jan-
06
Feb-0
6
Mar
-06
Apr-0
6
May
-06
Jun-
06
Jul-0
6
Aug-0
6
Sep-0
6
Oct-06
Nov-0
6
Dec-0
6
Jan-
07
Feb-0
7
Mar
-07
Apr-0
7
May
-07
Jun-
07
Jul-0
7
Aug-0
7
Sep-0
7
Oct-07
Nov-0
7
Dec-0
7
Jan-
08
Feb-0
8
Mar
-08
Apr-0
8
May
-08
Jun-
08
Month
Per
cen
t C
om
pli
ance
Local Team National Goal
September 5, 2007 10
Maintenance Bundle Compliance
INTERVENTION - CLI MEASURE: 3.0 Central Line Maintenance Bundle Compliance
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Nov-0
5
Dec-0
5
Jan-
06
Feb-0
6
Mar
-06
Apr-0
6
May
-06
Jun-
06
Jul-0
6
Aug-0
6
Sep-0
6
Oct-06
Nov-0
6
Dec-0
6
Jan-
07
Feb-0
7
Mar
-07
Apr-0
7
May
-07
Jun-
07
Jul-0
7
Aug-0
7
Sep-0
7
Oct-07
Nov-0
7
Dec-0
7
Jan-
08
Feb-0
8
Mar
-08
Apr-0
8
May
-08
Jun-
08
Month
Per
cen
t C
om
plia
nc
e
Local Team National Goal
September 5, 2007 11
Updates to GSK
• Essentially unchanged since previous edition
• Suggestions for implementation:– Begin with insertion bundle– Standardize policies, equipment and cleaning
agents
• Suggestions for measurement:– Deviation from bundle components will assist
with strategizing for improvement
September 5, 2007 12
Updates to Measurement Worksheets
• Three worksheets for each measure: chart, data entry and submitted by
• Compliance to individual bundle components
• Instructions for new section
September 5, 2007 13
Resources
• CLI Getting Started Kit & Worksheets
http://www.saferhealthcarenow.ca/Default.aspx?folderId=82&contentId=180
• Communities of Practice
http://www.saferhealthcarenow.ca/Default.aspx?folderId=124
• Canadian ICU Collaborative Improvement Guide
Available when enrolled in the Collaborative
T. Northway, RN, MSN, & A. Robin, RN, BScN, BC Children’s Hospital;E. Folz, RN, BScN, Alberta Children’s Hospital;
M. Golberg, RN, BScN, NP, Stollery Children’s Hospital;J. Plouffe, RN, BScN, NP, Winnipeg Children’s Hospital
Reduction of Catheter Related Blood Stream Infections
A Canadian National
PICU Collaborative Experience
October 2004 to October 2005
September 5, 2007 17
Incidence of CRBSI
• Comparatively high rate of CRBSI in PICU (NNIS 6.6/1000 CVC line days)
• CDC reports 5.3/1000 CVC line days adult ICU• Attributable cost approximately $34,500-$56,000 US• Increased LOS (3 weeks)• Estimated mortality rate 13% - 19% (child) & 12% -
25% (adult)
oElward, A et al. (2005). Pediatrics 115(4), 868-872.o(2007) http://www.edwards.com/Products/CentralVenous/VantexInservice.htm?wbc_purpose=Basic&WBCMODE=PresentationUnpublishedoSlonim, A et. Al (2001). Pediatric Critical Care Medicine 2, 170-174.oYogaraj, J. et al. (2002). Pediatrics 110(3), 481-485.
September 5, 2007 18
Aim and Goals/Objectives
Aim:• To reduce the incidence of catheter related
blood stream infections (CRBSI) within Canadian PICUs
Goals/Objectives:• To reduce the incidence of CRBSIs by 20%
to 50% within 12 months (October 2005)
September 5, 2007 20
CRBSI Improvement Bundles
Insertion Bundle• Hand Hygiene• Maximum Barrier
Precautions (Inserter & Patient)
• Chlorhexidine for Skin Prep
• Site selection
Maintenance Bundle• Hand Hygiene• Standardized Hub
Antisepsis • Standardized
Accessing of Line– Line set-up– Accessing hubs– Dressing & tubing
changes
• Daily Reviewing of Line Necessity
September 5, 2007 21
Changes Tested
AP
SD
AP
SD
AP
SD
D S
P A
AP
SD
AP
SD
AP
SD
D S
P A
Speci
fic T
est C
ycle
s
BaselineStream
EducationStream
Establish current reality
Adoption of insertion& maintenance bundles
Adoption of CDC definition
Handwashing campaign
Moving to a culture of safety
Celebrating successes!
Developing staff clinical champions
Increased understanding ofICU Collaborative & process
Awareness of current reality
Awareness of importanceOf CVC infections
Creating controversy through transparency!
September 5, 2007 22
AP
SD
AP
SD
AP
SD
D S
P A
AP
SD
AP
SD
AP
SD
D S
P A
Speci
fic T
est C
ycle
s
InsertionStream
MaintenanceStream
Creation of insertion bundle•Hand hygiene•Full barrier precautions•Site selection•Cleansing solution change
Standardize equipment:Creation of vascular access tray
Standardize equipment:Creation of line insertion cart
Create line insertion checklist
Culture shift: RNs halting insertion if insertion bundle violated
Let’s make it easy to do the right thing & difficult to do the wrong thing!Let’s make it easy to do the right thing & difficult to do the wrong thing!
Daily Goal Sheet to review line necessity
Standardized data collection
CVC Maintenance Bundle:•Hand hygiene•Line set-up (closed system)•Dressing & tubing changes• Standardized cleansing solution
CVC maintenance OSCE station at annual RN
competency validation days
Changes Tested
September 5, 2007 23
0
1000
2000
3000
4000
5000
Hosp A Hosp B Hosp C Hosp D Hosp E Hosp F
PICU Line Counts (June to Dec 2005)
Total line days9030
0
5
10
15
Hosp A Hosp B Hosp C Hosp D Hosp E Hosp F
PICU Monthly CRBSI Incidence(June to Dec 2005)
Total CRBSI29
0.0
1.0
2.0
3.0
4.0
5.0
Hosp A Hosp B Hosp C Hosp D Hosp E Hosp F
Cumulative CRBSI per 1000 line days (June to Dec 2005)
Group 3.2 CRBSI/1000 line
days
Collaborative Results
September 5, 2007 24
NNIS Benchmark6.6 per 1000 Line Days
June to Dec 2005:Period with existing 6 teams contributing data
Collaborative Results
Initial Learning Session (LS)
for CRBSI Collaborative
September 5, 2007 26
CSSSNL
• Large regional, community hospital• 275 acute care beds• 12 beds 8 ICU and 4 CCU beds• Closed Unit• Working on Collaborative projects since
2003
September 5, 2007 27
Aims and objectives
• Eliminating C.L. infections• Implementing the insertion bundle• Initiate the maintenance bundle
September 5, 2007 28
Results
• 9 months of surveillance (insertion bundle)– Hand washing– Strict sterile technique– Chlorhéxidine– Insertion site
September 5, 2007 41
Results
• During the last year :• NO line infections for lines inserted on the
unit• BUT, 4 line infections during the 24 months
of provincial surveillance for lines cared for on the unit.
September 5, 2007 43
Results
Dx LOS GermSite
(days)Outcome
12005
VC Paralysis 67 Staph C- Fem. (2) Survived
22005
MVR 12 Candida Fem. (8) Died
32006
AAA 22 Staph C- IJ (6) Survived
42006
Urosepsis 16 Staph C- Fem. (3) Survived
September 5, 2007 48
Lessons Learned
• Small changes can bring big results• The maintenance bundle has to be
implemented as soon as possible…
September 5, 2007 49
Remerciements
• Thanks to the fantastic and hard working CSSSNL ICU quality team.
September 5, 2007 52
Benefits of Participating (continued)
• Face-to-face Learning Sessions• Evidence-based changes, ready to test and implement• Coaching from experienced Faculty on application of changes• Education and training on tools for improvement and
measurement• Advice on targeted strategies to overcome resistance and
address barriers• Monthly feedback on progress from the Collaborative Faculty• Monthly conference calls specific to challenges your team is
facing• A List-Serve that provides real-time sharing of information,
direct to your email Inbox• A website for storing and sharing your documents with others• A comprehensive Improvement Guide with examples,
checklists, tools• No cost to join!
September 5, 2007 53
Expectations for Participating Teams
• Commitment of a team sponsor• Full participation of a multidisciplinary team• Development of measures• Regular reporting of progress to the Faculty• Willingness and commitment to implement
rapid and widespread changes• Desire to innovate• Regular access to email and Internet
September 5, 2007 54
Collaborative Resources
• To Enroll
http://www.saferhealthcarenow.ca/Default.aspx?folderId=104&contentId=420
• About the ICU Collaborative
http://www.improvementassociates.com/dnn/Default.aspx?tabid=190
• About Breakthrough Series Collaboratives (general) http://www.ihi.org/IHI/Results/WhitePapers/TheBreakthroughSeriesIHIsCollaborativeModelforAchieving%20BreakthroughImprovement.htm