Page 67 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

36 PART 1: An Overview of the Approach to and Organization of Critical Care

2. Walking the process: One of the barriers discovered when inves-
TABLE 5-2 Description of Learning From Defects Tool 40
tigating the use of the infection control practices was the fact that
Summary Description physicians traveled to eight different places to gather supplies
Section I Explain “what happened” needed to comply with the checklist items. To remove this barrier,
a “central line cart” was developed to store all of the equipment
Section II Review and check all factors that caused or increased risk of patient harm needed to comply with the checklist, reducing eight steps to one.
(negatively contributed) and all factors that reduced or eliminated harm 3. Measuring performance: Both process measures (how often
(positively contributed)
patients receive the recommended therapy) and outcome mea-
Section III List specific actions to reduce the likelihood of this defect from happening sures (evaluate the results of therapy) were measured. A pilot test
again, assign a project leader to be accountable for the activities and set a of the performance measures, data collection forms, and database
follow-up date, and consider how to evaluate if risk has been reduced interface was done, and a plan established for a data quality control
Data from Pronovost PJ, Holzmueller CG, Martinez E, et al. A practical tool to learn from defects in plan. Then baseline performance was measured, the intervention
patient care. Jt Comm J Qual Patient Saf. February 2006;32(2):102-108. implemented, and performance continued to be measured to
evaluate the impact of the project on CLABSI.
4. Ensuring that all patients reliably receive the intervention: We
are not physically in the unit. Patient demographics and institu- used the four Es approach to improve reliability of care.
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tional factors, as well as greater comorbidity or illness complexity 5. Engaged staff by sharing real-life stories of patients who suf-
at presentation, may play a significant role in misdiagnosis. Some fered preventable harm because of inappropriate evidence-based
46
misdiagnoses may be directly linked to limited sensitivity and speci- therapies.
ficity of individual tests in the critical care setting, but remediable 6. Educated all staff about the evidence supporting the proposed
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causes are most often associated with failures in information process- interventions and about the science of safety through the CUSP
ing. Cognitive errors are also a major contributor to misdiagnoses. intervention. Clearly defined the roles, tasks, and timing to avoid
A recent review identified a large number of tested and untested ambiguity.
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interventions (eg, simulation training, reflective practice) that may 7. Executed the intervention by pilot testing and walking the pro-
help reduce cognitive errors and hence, misdiagnoses. cess to ensure there were no barriers when implementing the
A major impediment to developing a better understanding of diag- intervention.
nostic errors is the declining autopsy rate. One alternative that might 8. Evaluated the impact by measuring the CLABSI rates (outcome)
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improve the rate of autopsy is the “virtual autopsy,” using sophisti- before starting the intervention and for a defined period of time
cated radiological techniques as opposed to dissection. Wichmann after implementing it.
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recently reported a comparison of “virtual autopsy” to traditional
autopsy in ICU patients, suggesting that it compares favorably and B. CUSP: A culture-based program was put into place before the
has a higher acceptance rate in terms of percent of deaths referred to CLABSI intervention to provide a foundation for safety awareness,
postmortem analysis. With further refinement, virtual autopsy may establish interdisciplinary teamwork, and encourage the execution
offer a mechanism to obtain the postmortem information required to of evidence-based practices. Nurses must feel comfortable question-
more clearly analyze the source of preventable harm. ing senior physicians about failure to comply with the checklist. As
described earlier in this chapter, the CUSP is designed to improve a
■ AN INTEGRATED APPROACH TO PATIENT SAFETY unit’s teamwork and safety culture. In the Keystone project and sub-
sequent nationwide program the following occurred:
Bloodstream infections are one of the four most common health care Step 1: Staff were educated about the science of safety using a slide
presentation and a series of interactive discussions with staff.
infections, along with urinary tract and surgical site infections, and Step 2: Staff were asked to identify how the next patient would be
ventilator-associated pneumonias. These four account for up to 800,000 harmed on their unit, and what they would do to prevent this harm
preventable infections, 60,000 preventable deaths, and $27 million dol- from occurring; a CUSP improvement team was formed to lead the
lars in excess costs annually in the United States. The Keystone ICU work.
project was a safety project developed at Johns Hopkins and imple- Step 3: A senior hospital administrator partnered with the unit,
mented in over 100 ICUs across Michigan and led to a 66% reduction in reviewed the safety hazards identified by the unit staff with the
central line–associated bloodstream infections (CLABSI) and a median improvement team, provided the resources and political support
CLABSI rate of zero, with improvements sustained for >4 years. This needed to implement risk reduction interventions, and held the staff
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project encompassed both the technical (eg, summarizing evidence, accountable for mitigating hazards
using robust measurement) and adaptive (eg, culture change) work Step 4: Teams were trained to use the learning from defects tool, and
needed to successfully implement any quality and safety improvement asked to investigate at least one defect each month.
initiative. 52,53 Step 5: Teams were offered a menu of tools to improve communi-
A program called On the CUSP: Stop BSI was formulated from the cation and teamwork and instructed to modify the tools to fit the
Keystone project, with the goal of implementation in every state across context to ensure ease of implementation.
the country. At the root of this program structure is a mechanism to
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move evidence to the bedside and foster a culture where the focus is the C. Data collection system: Improvement teams partnered with the
patient. The three main components include hospital infection preventionist for surveillance and data collec-
tion. Explicit definitions from the Centers for Disease Control and
A. A model to prevent CLABSI: translating research into practice Prevention were used, and infection data (number of infections
(TRIP) 54 and central line-days) obtained monthly from the infection preven-
1. Summarizing the science: The Centers for Disease Control and tionist were entered in a centralized database for management and
Prevention guidelines were reviewed and the following five-item ensuring of data quality.
checklist of infection prevention practices was created: (1) wash
full barrier precautions, (4) avoid the femoral site if possible, and ■ SAFETY SCORECARDS: A TOOL FOR ICU QUALITY IMPROVEMENT
your hands, (2) clean the patient’s skin with chlorhexidine, (3) use
(5) remove unnecessary catheters. This type of checklist helped External agencies such as the CMS, the Leapfrog Group, and The Joint
democratize knowledge and ensure that the entire team and Commission have developed measures to evaluate patient safety and qual-
patients were clear about expected behaviors. ity of care. Such measures should be meaningful to clinicians who will use

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