Getting to Zero and other Possible Dreams

1. Getting to Zero and other Possible Dreams Don Goldmann, M.D. Senior Vice President Institute for Healthcare Improvement Professor of Pediatrics Harvard Medical School No conflicts to declare

2. 100,000 Lives Campaign Objectives (December 2004 – June 2006) • Avoid 100,000 unnecessary deaths in participating hospitals • Enroll more than 2,000 facilities • Raise the profile of the problem - and hospitals’ proactive response • Build a reusable national infrastructure for change Some is not a number, soon is not a time - Berwick

3. 100,000 Lives Campaign “Planks” • Rapid response teams • Evidence-based care for acute myocardial infarction • Prevention of adverse drug events (medication reconciliation) • Prevention of central line infections (Central Line Bundle) • Prevention of surgical site infections (correct perioperative antibiotics at the proper time and other elements of the Surgical Infection Bundle) • Prevention of ventilator-associated pneumonia (Ventilator Bundle)

4. Campaign Field Operations Introduction, expert support/science, ongoing orientation, learning network development, national environment for change IHI and Campaign Leadership Ongoing communication Local recruitment and support of a smaller network through communication/collaboratives NODES (> 55) *Each Node Chairs 1 Network Implementation (with roles for each stakeholder in hospital and use of existing spread strategies FACILITIES (3000-plus) *30 to 60 Facilities per Network

5. Measurement Strategy • Change in aggregate hospital mortality, compared to 2004, in terms of “lives saved” • Case mix adjustment from three sources, but not yet Hospital Standardized Mortality Ration (HSMR) • Direct submission of monthly raw mortality data (deaths/discharges) to IHI • Optional data at the intervention-level (e.g., ventilator pneumonia rates, process measures)

6. 100,000 Lives Campaign Results • Estimated 120,000 lives saved by participating hospitals through overall improvement (IHI cannot attribute change in mortality to the Campaign per se – research studies pending) • Over 3,100 Hospitals Enrolled • Over 78% of all acute care beds • Participation in Campaign Interventions • Rapid Response Teams: 60% • AMI Care Reliability: 77% • Medication Reconciliation: 73% • Surgical Site Infection Bundles: 72% • Ventilator Bundles: 67% • Central Venous Line Bundles: 65% • All six: 42%

7. 100,000 Lives Campaign Results • Over 55 field offices (“nodes”) and over 130 mentor hospitals • Strong national partner support (CDC, AHRQ, Joint Commission, ACC/AHA, etc.) • Thousands on national calls • Large increase in web activity and downloads of Campaign tool kits • Great media coverage (Newsweek, US News and World Report, Wall Street Journal, NY Times) • Related campaigns forming nationally and globally (Canada, Australia, Denmark, England) • Changes in expectations for care (“getting to zero”) in some participating facilities (many reports of zero ventilator-associated pneumonia or catheter-related BSIs)

8. Success Factors • Inspiring goal and clear deadline • Easy sign-up • Minimal reporting requirements • Straightforward interventions • Optimism, personal motivation, volunteerism • Practical direction for hospital leaders • Demonstrated link between quality and cost • Useful tools • Vibrant, distributed national learning network • Young, dedicated field team, logistics

9. 5 Million Lives Campaign • A campaign against harm (injuries/adverse events) • Harm is defined as levels e-i using NCC MERP* Index criteria • Level e is temporary harm that required intervention • Level i is death • Harm is counted… • Whether or not it is considered preventable • Even if present on admission to the hospital if attributable to medical care * National Coordinating Council for Medication Error Reporting and Prevention

10. How did IHI Decide on 5 Million Harms? • 37 million admissions to acute care US hospitals annually • AHA National Hospital Survey, 2005 • 40-50 level e-i harms per 100 admissions • Chart reviews in 3 hospitals using IHI Global Trigger Tool (GTT)* • Therefore, about 15 million harms occur per year (37 million admissions X 40 harms per 100 admissions) • If best known results can be replicated, might avoid 3.5 million harms per year = 7 million in 2 years • 5 million seemed like a good stretch goal • We know that even perfect compliance with all of the planks will not be enough to avoid 5 million harms • Further validation of GTT psychometrics pending * http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Literature/ IHIGlobalTriggerToolforMeasuringAEs.htm

11. 5 Million Lives Campaign Planks • Reduce Surgical Complications – Adopt “SCIP” • Prevent Harm from High Alert Medications • Prevent MRSA Infections • Reduce Readmissions in patients with Congestive Heart Failure • Prevent Pressure Ulcers • Get Boards on Board

12. Tough Questions • IHI claims that organizations need to have leadership commitment, improvement expertise and capacity, and the ability to apply QI methods (rapid cycle PDSAs) – just for starters • But contact with many participating hospitals suggests that such capability is not widespread • So….are we • Encouraging brute force (“hire-a-nurse”) projects to implement a few “planks?” Relying on charismatic champions? ….or…. • Creating fertile soil for true institutional transformation? • How good is the evidence? When is it good “good enough” to spread? • MRSA and RRTs: more later

13. Prevent MRSA Infection

14. S. aureus bacteraemia: methicillin sensitivity (English NHS acute Trusts, voluntary surveillance 1990-2006) Mandatory enhanced surveillance October 2005 Baseline year for targets 2003/04 Mandatory surveillance introduced April 2001 Provisional data

15. Temporal trends in MRSA bacteraemia rates, by region Introduction of national target Estimated overall ratedecrease3% per quarter Homogeneous regional patterns Estimated overall rateincrease% per quarter Heterogeneous regional patterns 0.5 Provisional data

16. MRSA in Europe

17. Is this remarkable variation due to: • Transmissibility and virulence of distinct genotypes? • Size, design, or type of hospital? • Case mix? • Practice variation? • Compliance with known, measurable evidence based practices? • Less tangible features, such as culture and organization of an intensive care unit? • Are nosocomial infections an “expected” consequences of caring for very sick, complex patients, or intolerable, potentially preventable adverse events • Vermont Oxford NICQ visits to “best of breed” NICUs

18. A Modest Proposal… • Improve reliability of basic infection control procedures • Hand hygiene • Isolation procedures • Screening cultures

19. Reliability Science Health care is riddled with defects 40-50% compliance with hand hygiene!!?? What happens at Intel… What happens in Bowling Green… From the patient’s point of view, it’s “all or nothing” Reliability science offers robust approaches to reducing defects and harm in health care

20. Component vs. Composite AdherenceContact Precautions • COMPONENT:80% hand hygiene, gloves on entering room • COMPONENT:78% gowns on entering room • COMPONENT:65% hand hygiene after removing gloves • COMPOSITE:50% get all three

21. Reliability is failure free operation over time from the viewpoint of the patient

22. Defects in outpatient asthma care Defects in hospital care Acute asthma attack Admission through discharge Defects in outpatient care Years/Months Days Years/Months Defect free care overtime from the patient’s viewpoint

23. Levels of Reliability • Chaotic process: Failure in greater than 20% of opportunities • 10-1: 80 or 90 percent success: 1 or 2 failures out of 10 opportunities (no consistent articulated process) • 10-2: 5 failures or fewer out of 100 opportunities (process is articulated by front line) • 10-3: 5 failures or fewer out of 1000 opportunities • 10-4: 5 failures or fewer out of 10,000 opportunities Blood banking and anesthesiology alone achieve the higher levels of reliability in medicine

24. Reliability in Healthcare • Remember, it’s “all or nothing” – not compliance with each individual component of “best practice” • Most institutions do fairly well with individual components of evidence-based practice, but performance drops dramatically when the standard is “all or nothing” • We are trying to decrease the “defect rate” and to achieve a reliability of performance to the 10-2 level (at least 95% compliance with the entire package of evidence-based practice)

25. Guidelines v. Bundles (Intervention Packages) • Guidelines tend to be long, all-inclusive, and confusing • Many potential interventions are supported by some evidence • Guidelines are difficult to translate into action and often are ignored by clinicians • What if just a few key, actionable interventions, supported by strong evidence, were culled from the guidelines?

26. What Is a Bundle? • A grouping of best practices with respect to a disease process that individually improve care, but when applied together result in substantially greater improvement • The science behind the bundle is so well established that it should be considered standard of care • Bundle elements are dichotomous and compliance can be measured: yes/no answers • Bundles eschew the piecemeal application of proven therapies in favor of an “all or none” approach

27. Central Venous Catheter Bundle • Hand hygiene before inserting a catheter or manipulating the system and catheter site • Maximal barrier precautions for line insertion • Hand hygiene • Non-sterile cap and mask • Sterile gown and gloves • Large sterile drape • Antiseptic prep used for catheter insertion as per hospital protocol • 2% chlorhexidine supported by evidence (but FDA warning for neonates) • Site selection • Timely removal

28. Central line-associated bloodstream infection rate in 66 ICUs, Southwestern Pennsylvania, April 2001-March 2005 CDC Pronovost et al.,N Engl J Med; 2006;355:2725 Decrease from 7.7 to 1.4 per 1000 catheter days in 103 ICUs

30. Imagine what would happen to the MRSA infection rate in there were nearly zero central venous catheter infections…

31. A Hand Hygiene “Bundle” • Staff knowledge • Staff competency • Alcohol and gloves available at the point of care • Operational, full dispensers providing correct volume of rub • At least 2 sizes of gloves • Correct performance of hand hygiene + gloves worn for standard precautions • Concurrent monitoring and feedback • Focus on leaving the bedside • Staff accountability

32. Prevent MRSA Infection and Colonization • Colonized patients comprise the reservoir for transmission (“colonization pressure”) • High rates of MRSA colonization complicate empiric antibiotic therapy (e.g., vancomycin) • Colonized patients have a high rate of MRSA infection • Nearly 1/3 develop infection, often after discharge • Colonization is long-lasting, and patients can transmit MRSA to patients in other health care settings (e.g., nursing homes), as well as to family members

33. Five Key Interventions • Compliance with Central Venous Catheter and Ventilator Bundles • Hand hygiene* • Active surveillance cultures (ASCs) • Decontamination of the environment and equipment • Contact precautions for infected and colonized patients * Especially before contact with the patient and after contact with the patient and environment

34. Drives Effect Cause What Changes Can We Make? Understanding the System

35. “Every system is perfectly designed to achieve the results that it gets” What Changes Can We Make?Understanding the System for Weight Loss Outcome = Structure + Process -Donabedian

36. How Will We Know We Are Improving?Understanding the System for Weight Loss with Measures Measures let us • Monitor progress in improving the system • Identify effective changes

37. What Changes Can We Make? Understanding the System for Reducing Hospital Acquired Infections See the ‘Change Package’

38. How Will We Know We Are Improving? Understanding the System for Reducing Hospital Acquired Infections with Measures

39. Active Surveillance • Perform active surveillance cultures (ASCs) to detect colonized patients on admission • Necessity of ASCs per se in controlling MRSA is controversial – why are we recommending it? • “Knowledge is power” – clinical cultures miss many colonized patients and vastly underestimate the magnitude of the problem • Added value varies by institution (Huang SS: JID 2007;195:330-8) • ASCs on admission, followed by testing weekly and/or at discharge, is necessary to document the extent of transmission and the success of control measures • Nose +/- perineum/axilla +/- rectum and skin lesions/broken skin • Successful programs combine ASCs with reliable implementation of other interventions • Controversy regarding ASCs for high-risk areas (ICUs) vs. entire hospital

40. Evidence for ASCs • European experience • Control of nosocomial MRSA outbreaks • Mathematical models • Observational studies from individual hospitals • Interrupted time series study • Cluster randomized trial

41. Antimicrobial Resistance in Staphylococcus aureus Blood Isolates, Denmark 1960-1995 100% 90% 80% 70% 60% 50% Methicillin resistance 40% 30% 20% 10% 0% 1960 1965 1970 1975 1980 1985 1990 1995 DANMAP Report, 1997. Rosdahl VT et al. Infect Control Hosp Epidemiol 1991;12:83-88.

42. Impact of Active Surveillance in ICUs Huang SS et al., Clin Infect Dis 2006;43:971-8

43. Active Surveillance • Perform active surveillance cultures (ASCs) to detect colonized patients on admission • Necessity of ASCs per se in controlling MRSA is controversial – why are we recommending it? • “Knowledge is power” – clinical cultures miss many colonized patients and vastly underestimate the magnitude of the problem • Added value varies by institution (Huang SS: JID 2007;195:330-8) • ASCs on admission, followed by testing weekly and/or at discharge, is necessary to document the extent of transmission and the success of control measures • Nose +/- perineum/axilla +/- rectum and skin lesions/broken skin • Successful programs combine ASCs with reliable implementation of other interventions • Controversy regarding ASCs for high-risk areas (ICUs) vs. entire hospital

44. Beware…. • Pseudomonas • Acinetobacter • Stenotrophomonas • Burkholderia • ESBL and carbapenemase-producing Gram-negative bacilli • And many others….

45. Weighing the Evidence • How much evidence is required before deciding to spread change? • What kind of evidence is appropriate? • Randomized controlled trials • Cluster randomized trials • Quasi-experimental studies • Statistical process control • Time-series analysis • Qualitative studies • Behavioral science, Sociology, Anthropology • Mixed methods

46. Transition from Descriptive Theory to Normative Theory – ⇧Degree of Belief Carlile and Christensen Practice and Malpractice In Management Research p.6

47. Pawson and Tilley: Realistic Evaluation 47

48. Pawson and Tilley The Classic Experimental Design: “OXO” 48 Pawson R, Tilley N. Realistic Evaluation. London: Sage Publications, Ltd.; 1997.

49. Pawson and Tilley Context + New Mechanism = Outcome C + M = O 49 Pawson R, Tilley N. Realistic Evaluation. London: Sage Publications, Ltd.; 1997.

50. Pawson and Tilley “Programs work (have successful ‘outcomes’) only in so far as they introduce the appropriate ideas and opportunities (‘mechanisms’) to groups in the appropriate social and cultural conditions (‘contexts’).” 50 Pawson R, Tilley N. Realistic Evaluation. London: Sage Publications, Ltd.; 1997.