Improving Care Throughout New Jersey Peter Pronovost, MD, PhD

1. Improving Care Throughout New JerseyPeter Pronovost, MD, PhD

2. Objectives Who are we? Where are we going? How are we going to get there?

3. Who are We?

4. Most ICUs can prevent a death a week Most ICUs can prevent a death a week

5. Where are we going? BSI below 25th percentile ICU and hospital LOS reduced by 1 day ICU and hospital mortality reduced 30% VAP reduced 50% Culture improved 50% Improve turnover and direct costs 30%

6. How will we get there? �Every system is perfectly designed to achieve the results it gets�

7. A Medication Error Story

8. System Factors Impact Safety

9. What is needed for transformation Will: create will with personal stories of current reality Executive will Team will Staff will Team Compelling direction; clear, consequential, and challenging Accountable and responsible for outcome Correct people, skills and resources Measurement system (information technology resources) Reward system for team Expert coaching Execute Standardize Independent checks Evaluate defects

10. Approach Pick an area Identify what we should do Measure if we are doing it Ensure we do what we should Document outcomes improved

11. How to ensure patients receive the care they should Create culture of safety Ensure team knows goals, evidence Standardize what is done, when it is done Reduce complexity Create independent checks for key processes Measure and evaluate defects

12. Improving Reliability

13. How are we going to get there? CUSP Daily goals and multidisciplinary rounds BSI bundle Ventilator bundle Medication reconciliation Other

14. Comprehensive Safety Program Evaluate culture of safety Educate staff on science of safety Identify staff�s safety concerns Executive adopt an ICU Prioritize improvement efforts Implement improvements Share stories and disseminate results Evaluate culture

16. Impact of CUSP on LOS and Turnover

17. How to Implement Daily Goals and Interdisciplinary Rounds

19. Percent Understanding Patient Care Goals

20. Key attributes of ICU physician staffing Present Posses skill/knowledge Works as a team Helps to leads and manage the ICU

21. Journey to achieve key attributes Ensure nurses know who to call Start daily rounds Midlevel providers Hospitalists partner with teaching hospitals Regionalization Intensivist

22. Impact on ICU Length of Stay

23. How to Reduce CR-BSI

24. Strategies for Prevention: 5 Key �Best Practices� Remove Unnecessary Lines Hand Hygiene Use of Maximal Barrier Precautions Chlorhexidine for Skin Antisepsis Avoid femoral lines I want to highlight 5 startgeies specifically because they are well supported by the evdience. Central lines should be discontinued when they are no longer needed. Strict compliance with hand washing is essential. we should use MBP during cl insertion, We should use chlor for skin preparation if the patient is not allergic, and if we have a choice, subclavian sites are preferred over IJ or femoral sites. The benefit of removing central lines when they are no longer needed is self-explanatory . One point that I would ask you to consider though is whther you have a mechanism in place to assess the need for central access for your patients on a daily basis. If not, you need to develop one and I would be happy to share with you our approach. What about hand washing? I want to highlight 5 startgeies specifically because they are well supported by the evdience. Central lines should be discontinued when they are no longer needed. Strict compliance with hand washing is essential. we should use MBP during cl insertion, We should use chlor for skin preparation if the patient is not allergic, and if we have a choice, subclavian sites are preferred over IJ or femoral sites. The benefit of removing central lines when they are no longer needed is self-explanatory . One point that I would ask you to consider though is whther you have a mechanism in place to assess the need for central access for your patients on a daily basis. If not, you need to develop one and I would be happy to share with you our approach. What about hand washing?

25. Improve reliability of evidence-based process Culture Education with HEIC Policy nurses assist with beginning of line Standardize Complexity Line cart � store all equipment in one place Work with purchasing to get chlorhexadine prep Redundancy Check list

26. ICU catheter-related blood stream infections

27. How to Implement the Ventilator Bundle?

28. Bundle Revolution Bundle: a group of interventions linked in time and space Simple rules How we think

29. Ventilator Bundle Improve care of ventilated patients Elevate HOB Provide DVT prophylaxis Provide PUD prophylaxis Hold sedation Test for ability to extubate Control glucose* Oral chlorhexadine/Gastric decontamination*

31. VHA TICU Program

34. Tips for success Culture Educate all staff Empower non physician staff Complexity Standard orders Glucose and SGD protocols Independent checks RT and Nursing flow sheet

35. Our To Do List Establish team- include executive Use some project management tools Do one thing per week Complete CUSP Select BSI, daily goals and rounds, or ventilator bundle (ICUSRS and Med rec) Implement new intervention every 3 month Submit data

36. �Empowerment is useless without purpose��Empowerment is useless without purpose�

37. Tips for success Common vision and goals Publicly commit that harm is untenable Culture, complexity and redundancy Measurement and feedback Recognition and visibility (work with PR) CELEBRATE SUCCESS !

38. Is Safety your Hedgehog Concept ?

39. Who is willing to shave their Head ? Who is willing to commit to improving patient safety in New Jersey?

41. References Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Do intensivists improve the outcome of critically ill patients? JAMA. 2002; 288:2151-2162 Pronovost; 2004 Pronovost PJ, Berenholtz SM, Ngo K, McDowell M, Holzmueller CG, Haraden C, Resar R, Rainey T, Nolan T, Dorman T. Developing and Pilot Testing Quality Indicators in the Intensive Care Unit. Journal of Critical Care. 2003; 18(3):145-155. Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care. 2003; 18(2):71-75.Joint Commission J of Quality improvement; executive adopt ICU Pronovost P, Hobson DB, Earsing K, Lins ES, Rinke ML, Emery K, Berenholtz SM, Lipsett PA, Dorman T. A Practical Tool to Reduce Medications Errors During patient Transfer from an Intensive Care Unit. JCOM. 2004; 11(1):26-33. Pronovost PJ, Weast B, Bishop K, Paine L, Griffith R, Rosenstein BJ, Kidwell RP, Haller KB, Davis R. Patient Safety, Senior Executive Adopt-a-Work Unit: A Model for Safety Improvement. Joint Commission Journal on Quality and Safety. 2004; 30(2):59-68. Pronovost PJ, Weast B, Schwarz M, Wyskiel RM, Prow D, Milanovich SN, Berenholtz S, Dorman T, Lipsett P. Medication Reconciliation: A practical tool to reduce the risk of medication errors. J Crit Care. 2003; 18(4):201-5. Pronovost PJ, Bereholtz S: Improving sepsis care in the intensive care unit; An evidence-based approach. VHA research series 2004: www.vha.com Pronovost PJ, Nolan T, Zeger S, Miller, M, Rubin H. How can clinicians measure quality and safety in acute care. Lancet. 2004; 363:1061-67.