# Presentation: 649146

## The Safe Critical Care Initiative

**An HCA-Vanderbilt **
**Quality Improvement Project**
**On Healthcare Associated Infection**
**Partnerships in Implementing Patient Safety (PIPS)**
**Funded by AHRQ**
**ted.speroff@vanderbilt.edu**

## Safe Critical Care Team

**Vanderbilt**
**Ted Speroff**
**Robert Dittus**
**Jay Deshpande**
**E. Wesley Ely**
**Dan France**
**Robert Greevy **
**Shirley Liu**
**Samuel K Nwosu**
**Thomas R. Talbot **
**Richard Wall**
**Matthew B. Weinger**

**Hospital Corp of America**
**Laurie Brewer**
**Hayley Burgess**
**Jane Englebright**
**Steve Horner**
**Frank Houser**
**Jeanne James**
**Susan Littleton**
**Patsy McFadden**
**Steve Mok**
**Joan Reischel**
**Sheri Tejedor**
**Mark Williams**

## Aims of Safe Critical Care

- To prevent catheter-related blood stream infections (BSI) and ventilator-associated pneumonia (VAP) in the ICU.
- To implement a campaign for Improving Critical Care (Blood-Stream Infections and Ventilator-Associated Pneumonia) as part of the IHI 100,000 Lives Campaign.

## Aims of Safe Critical Care

- To compare a Collaborative approach to a Local Hospital Quality Improvement approach for implementing  an improvement initiative.
- To examine the organizational and provider factors that contribute toward and enable successful performance improvement.

## Methods

- Hospital Corporation of America (HCA)
- 172 Medical and Surgical Centers
-  60% suburban and 32% urban
-  Recruited 61 Hospitals

**Notes:**
Eligible hospitals were those with adult or pediatric ICUs.  The HCA hospitals are located primarily in the south and western regions of the USA.

## HCA-Vanderbilt Toolkits
HCA core development of Meditech tools
Feedback reports from surveys and data collection
Safe Critical Care Project Atlas Site

**HCA core development of Meditech tools**
**Feedback reports from surveys and data collection**
**Safe Critical Care Project Atlas Site**

**HCA-Vanderbilt Toolkits**
**HCA core development of Meditech tools**
**Feedback reports from surveys and data collection**
**Safe Critical Care Project Atlas Site**
**Collaborative communications**
**Social networking**
**Content experts**
**Collaborative teleconference meetings**

**Methods: RCT Design**

**Notes:**
61 hospitals were randomized.  31 into the Collaborative Group and 30 into the Tool Kit Group, one hospital was sold, leaving 29 in the Tool Kit Group.  Both groups had core support with intranet Web access to tools.  The Collaborative Group formed a virtual network connected by telecommunications and listserve. 

## Methods: Tool Kit HCA Intranet-Atlas SiteKeyword: Safe Critical Care  

- Continuing Education Programs
- BSI Tool Kit
- VAP Tool Kit
- Project Metrics
- FAQ/Fact sheet: Quick links
- QI/PDSA Tools
- Statistical Control Chart Tools

## Slide 8

**Notes:**
This screen shot is the project home page on the HCA Atlas web site showing access to web seminars, tool kit, reference material, and Collaborative notes and presentations. 

## Methods: Measures

- Clinical Outcomes: BSI and VAP rates
- Administrative Data
- Safety Attitude Questionnaire: ICU safety climate
- Organizational Culture
- Survey of ICU Practices and Quality Improvement Activities
- Post-Project Evaluation Survey

**Notes:**
BSI and VAP were based on the CDC National Nosocomial Infections Surveillance definitions.  Administrative data were abstracted quarterly from the HCA data warehouse.  The SAQ is a 30-item survey used to measure ICU safety climate.  We used instruments from the RAND ICICE study on IHI Breakthrough Collaboratives to measure organizational culture and teamwork.  The Survey of Effective Microsystem Characteristics was modified for organizational assessment of quality improvement.  A follow-up post-initiative survey was conducted on quality improvement implementation and use of tool kit.   

## Results:  Characteristics of HCA ICUs

*80% have < 20 ICU beds*
*35% are medical-surgical-coronary ICU, 20% medical-surgical*
*65% have physician medical director, 95% have a nurse manager*
*27% intensivist required, 36% intensivist optional, 37% no intensivist*
*67% have pharmacist rounding*
*65% have daily, integrated interdisciplinary team*

## Results: Baseline

| Baseline Characteristics | Collaborative 
N= 31 | Tool Kit
N= 30 | P-value |
| --- | --- | --- | --- |
| in IHI Campaign | 96% | 100% | 1.0 |
| Hospital Vol median (IQR) | 2720 (1499,3827) | 2616 (1242,3360) | .90 |
| ICU Volume median (IQR) | 595 (337,909) | 578 (244,1077) | .80 |
| ICU LOS median (IQR) | 4026 (1978,5824) | 4228 (1645,6725) | .82 |
| ICU Mortality  % (sd) | 5.9% (2.9%) | 7.1% (3.6%) | .19 |
| Medicare/Medicaid % (sd) | 68.4% (9.6%) | 68.4% (10%) | 1.0 |
| Emer.Dept Admit % (sd) | 72% (14%) | 67% (20%) | .2 |
| Female % (sd) | 49.7% (5.6%) | 50.3% (7.7%) | .83 |
| Charge weight mean (sd) | 1258 (1004) | 1295 (1110) | .94 |
| SAQ: mean (sd) | 3.60 (.29) | 3.67 (.28) | .21 |
| BSI & VAP Projects % | 68% | 60% | .54 |
| BSI Rate per 1000 days | 2.3 (2.5) | 4.4 (5.8) | .26 |
| VAP Rate per 1000 days | 3.4 (3.5) | 4.7 (5.9) | .73 |

**Notes:**
The Collaborative and Took Kit groups were equivalent at baseline in their QI initiatives and hospital characteristics.

## BSI ResultsRelative Risk = 1.14 (95% CI 0.93, 1.40), p = .20 

**Notes:**
The Tool Kit group had a 14% greater risk of a Catheter-related Bloodstream Infection, however, the p-value was nonsignificant (p=.20).

## VAP ResultsRelative Risk = 1.28 95% CI (1.03, 1.57), p = .023 

**Notes:**
The Tool Kit group had a 28% greater risk of a Ventilator-associated pneumonia, statistical significance at p = .02.

## Safe Critical Care:  QI Interventions

- Adoption of bundles for patient care
- Interdisciplinary team rounding
- Rounding form/checklist
- Empower nurses to encourage physician compliance
- Unit champions
- Nurses empowered to stop procedure if break in sterile field
- Checklist implementation
- Kit changes & cart
- Checklist in kits
- Standards of Practice revised
- Order set protocols

- Alcohol gel dispensers
- Hand wash campaign
- Evaluate performance and practices
- Audits & surveillance
- Difference between standard audits and peer group observation
- Case reviews of BSI and VAP
- Reporting bundle compliance
- Feedback reports
- Monthly ICU newsletter
- Encourage staff feedback

**Notes:**
This slide shows some of the quality improvement strategies that were used by the Collaborative Group.

## Webcast Seminars

- Collaborative Group participated in more data topic seminars (52% vs 22%)
- and rated them as useful (78% vs 54%)

**Notes:**
There were 10 web seminars offered during the study period, 5 were on clinical topics and 5 were on data topics, including BSI/VAP data collection, SAQ survey findings, quality improvement methodology, and use of statistical process control methods.  Both groups attended over half the clinical topics but the Collaborative Group had greater participation in the data topics (Collaborative 52% vs Tool Kit 22%, p = .001).  Respondents were requested to also answer whether the seminar was useful to their ICU improvement project.  For respondents who attended the seminar, the usefulness rating was high for the clinical topics (Collaborative 88% vs Tool Kit 85%).  For the data topics, the Collaborative Group usefulness rating was 78% vs the Tool Kit rating of 54%.  

## Usefulness of Tools

- A greater proportion of the Collaborative Group accessed the BSI and VAP
- Tools, accessed the SPC methods tools, and found the tools useful.

**Notes:**
A set of 14 tools were produced during the study period, 9 clinical process tools such as checklists, algorithms, protocols, and flowsheets; and 5 tools related to data monitoring and quality improvement such as easy-to-use statistical process control spreadsheet templates, quality improvement tools, and Meditec computer tools.  The Collaborative Group accessed a median of 9 tools and the Tool Kit group a median of 7 (p=.06).  Within the clinical tool set, a greater proportion of the Collaborative group accessed the BSI checklist (p=.057) and the VAP daily assessment tool (p=.014).  A greater percentage of the Collaborative Group accessed the SPC tool for BSI (p=.001), SPC tool for VAP (p=.001), and the QI tool kit (p=.043).  The chart shows the usefulness rating of the tools.  If the clinical tools were accessed, 75% of the Collaborative group found them useful and 55% of the Tool Kit group found them useful.  If the data tools were accessed, 70% of the Collaborative group found them useful versus 47% of the Tool Kit group.  The Collaborative group reported higher rates of implementing the tools; once implemented, both groups report a very high rate of sustaining their implementation (86%-100%).  

## BSI Bundle Process

- 82% of the Collaborative Group implemented all components of
- The CVC Bundle compare to 56% of the Tool Kit Group (p=.027)

**Notes:**
This chart shows the evidence-based quality improvement interventions that were recommended for prevention of BSI.  The Collaborative group had a higher rate of implementing each intervention.   The follow-up questionnaire also asked the sites to self-report on their use of the interventions as a bundle, i.e., credit only if all interventions implemented.  82% of the Collaborative group implemented the bundle vs 56% for the Tool Kit group (p=.027).  

## VAP Bundle Process

- 76% of the Collaborative Group implemented all components of
- The CVC Bundle compare to 64% of the Tool Kit Group (p=.30)

**Notes:**
This chart shows the evidence-based quality improvement interventions that were recommended for prevention of VAP.  The Collaborative group had a higher rate of implementing each intervention.   The follow-up questionnaire also asked the sites to self-report on their use of the interventions as a bundle, i.e., credit only if all interventions implemented.  76% of the Collaborative group implemented the bundle vs 64% for the Tool Kit group, this difference was not statistically significant (p=.30).  

## Collaborative Qualitative Results:  Challenges - Physicians

- Challenges
- Resistance
-     Use of barriers
-     Use of checklists
-     Site of insertion
- Multiple private MDs, Involvement
- Resistance to change vendors

- Solutions
- MD buy in, approval from MEC
- Hire Physician champion
- Intensivists
- Nurse empowerment
- Physician involvement in case review
- New order sets

**Notes:**
This slide shows some of the qualitative data from the teleconference Collaborative Meetings.  Challenges presented by physicians were resistance to BSI/VAP recommended practices, private physicians did not have incentive to become involved in hospital practices, and resistance to standardize.  Solutions shared by the Collaborative groups, including strategies for physician buy in, improving leadership in the ICU, and creating new order sets.

## Collaborative Qualitative ResultsChallenges - Staff

- Challenges
- Commitment
- Empowerment
- Resistance to tools
- Resistance to change in behavior

- Solutions
- Champions
-      Enlist
-      Hire
- Storyboard with examples so staff could conceptualize their roles
- Holding each other accountable is painful at times

**Notes:**
This slide shows some of the qualitative data from the teleconference Collaborative Meetings.  Challenges presented by staff were time commitment, empowerment, and resistance to change.   Solutions shared by the Collaborative groups, including enlist of champions, storyboards to illustrate staff roles, and accountability.  

## Collaborative Qualitative ResultsChallenges - Data

- Challenges
- How to
- Data collection tools
- Access to data

- Solutions
- Meditech/PCM documentation of protocols
- Design tools
- Monitoring

**Notes:**
This slide shows some of the qualitative data from the teleconference Collaborative Meetings.  Data collection, measurement and using quality improvement methods were challenges cited by the participants.  The data and method tool kits were in response to the needs of the Collaborative, including strategies design of new informatics nursing documentation, embedding checklists as clinical and data collection tools, standardizing implementation of NNIS definitions (numerators and denominators), and tracking and monitoring processes and outcomes. 

## Findings from Surveys

- ICU Staffing is variable
- Most HCA ICUs are multipurpose
- diagnostic diversity requires task and workload diversity
- diverse demands on education and training requirements
- Intensivists available in 63% of HCA ICUs but with variable models of care delivery
- Documentation is nearly split between paper and computer
- Significant variability in the extent of ICU participation in quality improvement

**Notes:**
Implementing this study across the federation of HCA hospitals pointed out the “real world” variation in care delivery across the health care system.  We found that ICUs vary in their patient populations and hospital staffing, in models of care delivery, in use of informatics, and in deployment of quality improvement.

## Findings from Surveys

**Use of the NNIS definitions **
**98% for BSI **
**96% for VAP  **
**Difficulty obtaining IC denominator data **
**48% for BSI rates **
**23% hospitals reported having months where BSI rates could not be reported due to incomplete denominator reporting.**
**30% for VAP rates **
**13% hospitals reported having months where VAP rates could not be reported due to incomplete denominator reporting. **
**31% use Infection Control software for surveillance**

**Notes:**
Whereas virtually all the ICUs and Infection Control Personnel report using the NNIS definitions for BSI and VAP, there were significant issues in the implementation of data collection.  One of the accomplishments of the initiative was standardization of measurement and mandatory reporting of hospital acquired infection data.  

## SAQ ResultsVariation in Safety Climate

- SAQ ResultsVariation in Safety Climate

**Notes:**
This chart shows the variation in Safety Climate across the HCA hospitals.  

## SAQ Survey: findings

- Overall Safety Climate is positively correlated with QI Measurement  	r = .39
- SAQ and Hospital Size
- Safety Climate and QI support varies with hospital size.
- Smaller hospitals show more positive safety climate.
- Smaller hospitals show need for administrative support in resources and measurement.
- Larger hospitals give more empowerment to the team.
- ICU teams provided with resources and training by the administration have more positive perceptions of safety climate.

## Conclusions

- Monitoring outcomes such as hospital acquired infections is complicated and time consuming.
- While there was a trend for improvement and better outcomes for the Collaborative group, there was appreciable variability and the pattern of results varied over time
- These differences were associated with the Tool Kit group participating in fewer educational opportunities and making less use of Tool Kit elements than the Collaborative group.
- The Collaborative group paid greater attention to the methodological seminars and measurement tools.
- Once sites engaged in these resources they found the information and tools useful and sustained their use.
- The Collaborative group used more improvement strategies and more complete implementation of BSI and VAP evidence-based interventions.

## Conclusions

- “Real world” studies bring to the surface the variation across hospitals and ICU settings.  Whereas clinical, methodological, and informatics tools (Tool Kits) offer standardized core support, the solutions and approaches for tool, quality improvement, and patient safety implementation remain context dependent.  A Collaborative seems to provide a social network that reinforces personal effort despite resistance and workload pressures, shares and facilitates problem solving, and fosters accountability for behavioral change; in such a way that the participant can tailor it all to their home organization.
- Our preliminary results support the ability of a participatory collaborative and support tools to decrease the incidence of catheter-related blood stream infections and ventilator-associated pneumonia in a diverse population of ICUs.