Tufts Medical Center

Erik Garpestad, MD Therese Hudson-Jinks, RN, MSN

Tufts Medical Center Boston, MA

We strive to heal, to comfort, to teach, to learn, and to seek the knowledge to promote health and prevent disease. Our

patients and their families are at the center of everything we do. We dedicate ourselves to furthering our rich tradition of health care innovation, leadership, charity and the highest

standard of care and service to all in our community.

Objectives

•Participants will earn an innovative strategy to align team members in a quest for excellence.

•Participants will learn communication tools vital to the success of quality improvement.

•Participants will learn how to excite clinicians engaging them in the change process.

FY 2008 2009caBSI Adult Patient Population

FY 2008 2009caBSI Adult Patient Population

New Policy Roll Out

2007- 2009 What was done?

• 2007 – 2009 – Nearly 50 member committee organized into MD practice, RN

practice, equipment. (Lots of hard work, lots of time)– Much emphasis placed on development of best practice policy and

guidelines for caBSI elimination with a focus on:

•Standardizing Insertion– SIMs lab review, competency MD development standards

•Standardizing maintenance– 100% RN policy and practice review, twice: ‘Task Focused’

2007- 2009 What was done?

• 2007 – 2009

– Nearly 50 member committee organized into MD practice, RN practice, equipment.

– Much emphasis placed on development of best practice policy and guidelines for caBSI elimination with a focus on:

• Standardizing Insertion– SIMs lab review, competency MD development standards

• Standardizing maintenance– 100% RN policy and practice review, twice: ‘Task Focused’

Results: Little to no progress !!

New Plan: Fall 2009

• Fall 2009

– Commitment by Senior Leadership to eliminate Hospital Acquired Infections

– Infection Prevention Priority Initiatives defined

•CaBSI•CaUTI•VAP

Stop Central Line Associated Blood Stream Infection (caBSI) Team Appointment

The Team was appointed by Senior Leadership with the authority and responsibility to influence, ensure, and be accountable to best practice principles regarding central line placement and maintenance at Tufts Medical Center. Goal: Rapid Cycle Change Process resulting in sustainable results at or better than national rates.

Stop Central Line Associated Blood Stream Infection (caBSI) Team Structure

MEMBERSHIP DEPARTMENT

Margaret Vosburgh, COO Executive Sponsor

•Dorothy Didomenico RN •Clinical Educator, CCU CMC

•Shira Doron MD •Infectious Disease

•Terry Hudson-Jinks RN •Patient Care Services/Nursing

•Eric Garpestad MD •Medical Director MICU, Critical Care Committee Chair

•Tricia Lemon, RN •Infection Prevention/Quality and Patient Safety

Looking back, What worked?

• Diverse team membership, frequent meetings.• Open mind, willingness to provide care differently• Agreement to have a unified ‘Quest for ZERO’ infections • Sense of Team• Humility• Crazy passion, ‘fire in the belly’• Strong support of CEO, CMO, CNO• CEO support of Tufts participation with MHA CUSP

• October 2009:8 Member Tufts Team attended CUSP Kick Off

Looking back, What worked?

• Diverse team membership• Open mind, willingness to provide care differently• Agreement to have a unified ‘Quest for ZERO’ infections • Sense of Team• Humility

• Crazy passion, ‘fire in the belly’• Strong support of CEO, CMO, CNO• CEO support of Tufts participation with MHA CUSP

• October 2009:8 Member Tufts Team attended CUSP Kick Off

Looking back, What worked?• Diverse team membership• Open mind, willingness to provide care differently• Agreement to have a unified ‘Quest for ZERO’ infections • Sense of Team• Humility

• Crazy passion, ‘fire in the belly’• Strong support of CEO, CMO, CNO• CEO support of Tufts participation with MHA CUSP

• October 2009:8 Member Tufts Team attended CUSP Kick Off

Align yourself with a National Agenda

CUSP

Massachusetts ICU Safe Care Initiative Comprehensive Unit-Based Safety Program

4

Stop Central Line Associated Blood Stream Infection (caBSI) Central Line Bundle

• Hand HygieneHand Hygiene• Maximal Barrier Precautions Upon InsertionMaximal Barrier Precautions Upon Insertion• Central Line Insertion Check ListCentral Line Insertion Check List• Use of a Line Insertion CartUse of a Line Insertion Cart• Chlorhexidine (CHG) skin antisepsisChlorhexidine (CHG) skin antisepsis• Optimal Catheter Site Selection (Avoid Femoral site over IJ)Optimal Catheter Site Selection (Avoid Femoral site over IJ)• Daily Daily Review of Line Necessity with Prompt Removal of Review of Line Necessity with Prompt Removal of

Unnecessary LinesUnnecessary Lines

Looking back, What worked?

• Benefits of CUSP (Comprehensive Unit Based Safety Program):– Provided the framework to align Senior Executives with clinicians in the goal for patient safety

– Validated key aspects of Tufts Medical Center Policy

– Provided leverage

– Frameworks, tool kits, informational sources, rich in details necessary to make key decisions, and the power to let go of old practices.

• Blood Cultures• Goal Sheet• Clave use• Dressing and line protocols• CHG bathing/Elimination of wash basins

– Network of experts within and beyond New England with key first hand learning experiences.

– Assisted in disbanding belief that patients are too ill, elimination not possible.

– Provided a competitive spirit, energizing

Symbols of Change

•Take strong, decisive steps forward•Take Risks•Consider making several changes at one time•Disrupt routine

Stop Central Line Associated Blood Stream Infection (caBSI)

• 2009 High Risk Areas for CaBSI

– MICU– CTU– SICU– CTU– North 8– CMC

• In combination were responsible for 67% (56/83) of all line infections• Accounted for 50% (11853/23345) of all line days.

Intervention:CHG/Sulfadiazine Impregnated Lines in High Risk Areas

Insert picture of new kit

•Antimicrobial Impregnated catheters in high risk populations– Piloted in select areas first

• MICU• CCU

– Based on results plan to roll out house wide•Shorter length catheter keeps sterile dressing intact

– Standard line length was 20 cm– New standard 16 cm

•Allergy alert stickers on each kit

Stop Central Line Associated Blood Stream Infection (caBSI) Intervention:New Practice Guidelines

Change culture and practice for drawing blood cultures•Policy revision – drafted•Blood culture algorithm to guide when and how•Weekly data shows blood cultures off central lines decreasing

Intervention:New Bathing Technique (Pilot) The Benefits of CHG Bathing

One of the programs at Tufts Medical Center that has started to help prevent infections is the use of special

antibacterial bathing cloths. • These cloths contain Chlorhexidine Gluconate (CHG), which kills germs and fights infection. • Studies have shown that using these cloths will greatly reduce the amount of germs on your skin. • These cloths are the primary way you will be bathed while in the hospital and will be in place of showering. These cloths will come to you warmed in 3 packages of two per pack. •Once applied your skin will feel sticky/ tacky until the prep dries. We suggest you allow a little extra time for drying in the folds of your skin. • The cloths work better than soap and water because it helps fight infection, without drying your skin. The CHG works on your skin between bathing helping you guard against infections.

If you have any questions please ask your Registered Nurse.

1.)Elimination of Wash Bins

2.)CHG Bathing of all patients in high risk locations

•MICU •CCU •CTU •SICU•CMC•North 8

Stop Central Line Associated Blood Stream Infection (caBSI) Results Adult Critical Care (CaBSI rates per 1000 central line days)

00.5

11.5

22.5

33.5

44.5

5

FY2009

9-Oct

Adult ICUs

Begun House wide Daily rounding on all central lines

Policy Reeducation 100% all RNs

MD EducationPlacement TrainingSignoff

Stop Central Line Associated Blood Stream Infection (caBSI) Results Adult Critical Care (CaBSI rates per 1000 central line days)

00.5

11.5

22.5

33.5

44.5

5

FY2009

9-Oct 9-Nov 9-Dec Jan-10

Adult ICUs

Begun House wide Daily rounding on all central lines

CHG BathingCCU MICU

Policy Reeducation 100% all RNs

Staff Meetings

Impregnated Catheters CCU and MICU

Shadow Check list Program

Impregnated Catheters SICU and CTU

Intervention: Staff Engagement/Communication Strategy nolineinfections@tuftsmedicalcenter.org Email Account

Connecting to the Clinicians at the bedside:

Creation and communication of email site:

nolineinfections@tuftsmedicalcenter.org – Create platform for two way dialogue with clinicians.– Take down barriers to care.– Enhance transparency.– Engage all staff including unit coordinators, techs, physical therapists, on the journey.– Communicate changes in practices and policy.– Facilitate problem solving, share knowledge, best practices, and success stores.– Keep the quest of caBSI elimination front and center.

Sample Email

From: No Line Infections Sent: Monday, January 03, 2011 1:28 PMTo: Tufts MC All EmployeesSubject: No Line Infections 2011

 Thank you  to all clinicians and employees

 for  embracing the  challenge of central line infection elimination. 

Our quest for  zero  continues into 2011    Trends in caBSI  Infections

FY 2009 – FY 2011 YTD Tufts  Medical Center  & Floating Hospital for Children 

Sample Email Response

To: No Line Infections

Subject: RE: No Line Infections 2011

Excellent goal and superb improvement/performance.Do we publish these data externally?

Staff engagement: Priority # 1!

GOAL: Eliminate Central Line Infections, keep the momentum

• Consistent messaging at every level, Board, Division, Unit etc.• Search constantly for validation of policy in practice at the bedside• Staff Participation/Engagement: Each ICU is sponsoring a champion for each Quality Initiative to ensure we

continue to shrink the distance between policy and practice.• March 2010 Weekly unit based Quality Staff In-services.

– Each ICU Quality Initiative will be discussed and framed for that units trend. Successes to be celebrated, staff participation essential.

• Transition 100% check list Shadow to Spot assessments based on compliance. • Continue to validate practice with national benchmarks in practice and results.

Present Data Differently

Months with Zero RateHigh Risk Population

Central Line Associated Bacteremia - High Risk Populations (Mar 09 - Feb 10 = 12 months)

0

2

4

6

8

10

12

14

PBMT CTU PICU CCU SICU CMU NICU MICU N8

Mon

ths w

ith Z

ero

Rate

CLABSIs, by line type, all medical center units

31

CLABSIs – All ICUs – FY 09 - 11

32

UNIT FY 09 FY 10 FY 2011  Cases Days Rate Cases Days Rate Cases Days Rate

MICU 14 2632 5.32 3 2113 1.42 4 2328 1.72CCU 7 2048 3.42 4 2040 1.96 2 2124 0.94CTU 4 2221 1.80 1 2653 0.38 1 2447 0.41SICU 6 1889 3.18 2 1965 1.02 3 2030 1.48NCCU             1 222 4.50NICU 14 3362 4.16 8 2685 2.98 3 2888 1.04PICU 0 848 0.00 3 845 3.55 1 674 1.48TOTAL 45 13000 3.46 21 12301 1.71 15 12713 1.18

Surgical ICU

2.573.18

1.02 0.88

0.00

2.00

4.00

Infection Rate

FY2008 FY2009 FY2010 YTD FY2011

CMC caBSI 2009 - 2011

0

5

10

15

20

Infection Rate

"---" 2011 Tufts Target = 1.50

CMC caBSI 2009 - 2011

2.82 3.38

0.00012345

Infection Rate

FY2009 FY2010 YTD FY2011

Fiscal Year 2009, 2010 & YTD 2011 - Total Adult Intensive Care Units Performance

3.53

1.14 0.98

0.00

2.00

4.00

6.00

Infection Rate

FY2009 FY2010 YTD FY2011

CCU, CTU, MICU, SICUTotal Adult ICU Performance - claBSI Rate

Central Line Associated Bacteremias Dashboard

claBSI - April 2011

Key to success

Leadership commitment

+ Evidence Based Practice

+ Staff Engagement

= Success

CaBSI Control Chart FY 2009 - 2011

0.00

1.70

0.66

1.34

1.40

0.720.70

0.000.00

1.39

0.72

0.75

0.71

4.46

1.35

0.00

0.71

2.33

0.68

1.42

2.79

1.95

3.323.16

3.02

+2 St.Dev.

+1 St.Dev.

Mean Rate(center l ine)

-1 St.Dev.

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

5.00

Sep-

09

Oct

-09

Nov-

09

Dec-

09

Jan-

10

Feb-

10

Mar

-10

Apr-

10

May

-10

Jun-

10

Jul-1

0

Aug-

10

Sep-

10

Oct

-10

Nov-

10

Dec-

10

Jan-

11

Feb-

11

Mar

-11

Apr-

11

May

-11

Jun-

11

Jul-1

1

Aug-

11

Sep-

11

Rate (per 1000 l ine days ) Rate trend

“Bladder Bundle”• Aseptic insertion and proper maintenance

• Bladder ultrasound (may avoid indwelling catheterization)

• Condom or intermittent catheter in appropriate patients

• Do not use indwelling catheters unless you must! (See appropriate indications)

• Early removal of the catheter

Consequences of UTIs

• Pain and discomfort

• Pyelonephritis

• Urosepsis

• Increased mortality

• Prolonged hospitalization

• Additional exposure to antibiotics (increased risk for C. difficile)• Increased hospital expenditures

Bladder Scanner: Patient Equipment

42

43

44

45

46

caUTI Adult ICUsImpact of RN Driven Protocol

0

2

4

6

Oct Nov Dec Jan Feb March April May June July August Sept

Adult ICUsFY 2011 Goal Stretch

Month 00, 2008 Change footer on slide master48

Nurse Driven Protocol for Removing Indwelling Urinary Catheter

Respect the Foley

-2 St.Dev.

2.161.81

2.022.17

3.21

2.33

1.12

5.19

4.06

3.40

3.50

2.482.31

4.73

5.38

2.40

3.36

1.20

0.94

3.51

1.07

3.02

5.39

2.00

+2 St.Dev.

+1 St.Dev.

Mean Rate(center l ine)

-1 St.Dev.

0.00

1.00

2.00

3.00

4.00

5.00

6.00

Oct

-09

Nov-

09

Dec-

09

Jan-

10

Feb-

10

Mar

-10

Apr-

10

May

-10

Jun-

10

Jul-1

0

Aug-

10

Sep-

10

Oct

-10

Nov-

10

Dec-

10

Jan-

11

Feb-

11

Mar

-11

Apr-

11

May

-11

Jun-

11

Jul-1

1

Aug-

11

Sep-

11

Rate (per 1000 indwelling urinary catheter days) Rate trend

BEST PERFORMER: Floating Hospital For Children: PICU

0.00

10.00

20.00

30.00

40.00

Infection Rate

"---" 2011 Tufts Target = 2.1 "-- -- --" NHSN Benchmark 3.4

Plans 2012

• Focus on insertion• Demonstrate RN competency of 100% RNs throughout the Medical Center• Two person insertion• Continue weekly practice audits• 1 Ultrasound per ICU• Encourage shiftly assessment and removal• Share each UTI with the staff• Post unit based results• Identify a champion passionate about safety• Observe practice, educate.• Reinforce excellence in practice, tell a story:

– RN within one unit challenged an MD order to reinsert foley and used condom catheter.