In 2011, Saint Joseph Mercy Ann Arbor (“Saint Joe's”) in southeastern Michigan was one of four hospitals in its Midwestern region to win the highest level award from HHS and the Critical Care Society for its work in eliminating CLABSI and VAP from its ICUs. The award made visible the results of a complex journey led by a gifted team of nurses and physicians who engaged health care professionals to eliminate HAIs.
Keystone ICU Project
Saint Joe's journey to control VAP and CLABSI began late in 2003 when the CNO gave Denise Harrison, RN, MSN, then Nurse Manager of the surgical intensive care unit (SICU), some information about the Michigan Health & Hospital Association Keystone Center's ICU Project introducing CUSP, which they decided to join. Keystone's aim was to improve patient safety, reduce errors and improve outcomes in Michigan ICUs by getting all ICUs to use the CUSP method to focus on the same thing: eliminating CLABSI and VAP. Harrison quickly realized the scale of the project and enlisted the half-time support of Pat Posa, RN, MSA, a SICU staff nurse with project management experience. They formed a “Keystone Team” with staff nurses from each unit, physicians and others, and rolled out CUSP across the ICUs. By the spring of 2004, Harrison recognized that she needed Posa full-time on the project, so Posa became full-time Project Manager in the new role of system performance improvement leader for all three ICUs. Harrison reflected,
“We saw some Michigan hospitals falter and drop off because they did not dedicate resources to the project. The number one success factor in sustaining our success all these years is Pat's full-time leadership and a dedicated, multidisciplinary team that continues to meet bimonthly for two hours.”
Posa has high regard for the support and expertise of the collaborative:
“Being part of the collaborative has been a phenomenal experience. As we began this journey, it was awesome to people sharing their knowledge so that we didn't have to look up everything ourselves. When some of the hospitals were struggling to get chlorhexidine, Keystone told the hospitals how important it was, and within a month, everyone had it.”
One result of so many Michigan ICUs joining the collaborative was that “ICUs in Michigan no longer compete on safety and quality,” said Posa. Johns Hopkins, the faculty advisors and partner on this AHRQ-funded statewide initiative, openly shared their infection rate data, which encouraged the participating Michigan hospitals to share their own. “By keeping the patient at the center and recognizing that everyone brings something valuable to the table, the sense was that we are all in this together for the patient, so let's learn together.”
Saint Joe's ICUs
Saint Joe's Ann Arbor has 527 beds, 48 of which are ICU beds divided into a medical ICU, a surgical ICU that includes cardiac surgery, and 7 coronary ICU beds. It is part of Saint Joseph Mercy Health System (SJMHS), which includes seven hospitals. SJMHS includes 5 outpatient health centers, 5 urgent care facilities and more than 25 specialty centers in a 5-county area. It is part of Trinity Health, the fourth largest Catholic network of hospitals and health care facilities in the country.
The nurses in each of Saint Joe's Critical Care Units report to a Nurse Manager, who in turn report to Harrison, now Nursing Director for the ICUs. The MICU is staffed by a single private practice of eight pulmonary/critical care intensivists, and Christine Curran, MD has been its Medical Director since 2008. The SICU is staffed by surgical intensivists who are part of General Surgery, and certified in Trauma and Critical Care. Saint Joe's is a Level 2 Trauma Center. Since 2008, Mary-Anne Purtill, MD, has been Medical Director of the SICU.
These two medical directors have been the key physician champions for bringing evidence-based practices into the ICU and taking them house-wide. They work collaboratively and co-lead safety initiatives and their meetings. Curran attributes much of their success to having added to each ICU in 2010 the role of clinical nurse leader “to help focus the team on evidence-based practice every day.”
In addition to the “Keystone Team,” the ICUs have developed educational conferences open to everyone, a Morbidity and Mortality Conference that Purtill and Curran co-chair, and regular meetings with physicians and nurses from ICUs and the emergency department (ED). All of this communication and collaboration contributes to having become, “much more evidence-based and protocol-driven,” says Curran. “Physician engagement is much higher now, there's much more familiarity with what's being done, nurses and doctors are partnering. Pat's been instrumental in all that.”
To do CUSP and evidence-based practice work—initially with CLABSI and VAP—Saint Joe's ICUs and the ICU at the neighboring hospital formed a multidisciplinary Keystone Team. Its members now include the medical director, clinical nurse leader, and a staff nurse from each ICU, as well as a respiratory therapist, infection preventionist, pharmacist, and physician assistant. The staff nurse representing their unit might also be the coordinator or the Chair of that unit's practice council, but not its manager. Purtill said, “We needed nurses from each floor to tell us ideas about implementation and where the barriers were on their floor.” She elaborated on their bimonthly meetings:
“For years we lacked a common language around safety, but we've been creating that in our work together. We are very real with each other. ‘What prevented you from doing this?' ‘What system error didn't allow the individual to get their job done?' Ninety percent of errors are due to systems. Some mistakes are nurses', but the majority are physicians', so you need them both in the room.”
The Keystone Team has evolved to become Saint Joe's primary forum to evaluate and implement evidence-based practices it wants in its ICUs and to create a culture of safety. That work includes prevention of CLABSI, CAUTI, VAP, falls, pressure ulcers, delirium prevention and management, progressive mobility, and sepsis prevention and treatment. It works closely with the nursing governance council on issues impacting nursing. The Keystone Team is also the forum through which some of the principles of process improvement methods such as Lean and Six Sigma have been introduced to ensure consistent outcomes and reduce errors.
Timing has been important to the success of this work. Toy Bartley, RN, MSN, a former nurse educator, and now clinical nurse leader of the MICU, cautions about managing the timing and buy-in of stakeholders:
“When we have a lot of initiatives, we can't introduce two in a row. We have to keep on top of the one we've introduced, get input from everyone involved in the change, assess how it's working, and ask staff how to improve it. They need to own it. If they don't believe in it, it won't work.”
The basic question Keystone team members asked themselves was: how do we convert evidence into behaviors? They used the Keystone/CUSP approach of engaging key stakeholders, bringing front-line clinicians into decisionmaking, understanding change theory, having an executive champion on stand-by and insuring that people understand why they need to change some of the ways in which they do their work.
To make it easy to do the right thing with central lines, each ICU had a line cart with prepackaged equipment and a checklist. Keystone members from each unit had the responsibility of carrying the flag, making sure their unit was complying, collecting data and using the Learning from Defects tool to improve the culture and prevent errors from reaching the patient. Curran said, “In Keystone, we also look at why something is failing. Pat has structured ways of going through this failure analysis and facilitating our coming up with solutions.”
In alignment with the CUSP model, Keystone advocated having an executive adopt each ICU so that there was, in Posa's words, “a linkage with executive management that helped break down barriers and provide appropriate resources.” One of Saint Joe's executives adopted the MICU as his unit. He rounds quarterly, inquiring into their safety concerns. Bartley noted, “He brings our concerns that are out of our control to a higher level so that something can be done about them.” Curran summarized, “Most of our work has been done in the absence of any direct executive involvement. They are very supportive, and they hold us accountable for our ICU outcomes.”
CLABSI Elimination Process
In July 2004, the Keystone Team led the implementation of the CLABSI insertion bundle from Hopkins. CLABSIs dropped from 31 to 13 over the year. This translated to a drop from 7.6 per 1,000 catheter days to 2.12. Posa believed the most important piece of the bundle was the empowerment of nursing staff. “We achieved that when we shared the CLABSI bundle with the chief of the Department of Surgery and Medicine. We got their support that a nurse could stop the line insertion. That was the beginning of culture change.”
This moment in 2004 built upon a more gradual transition over the past 25 years: “Years ago nurses were not given the opportunity to ask questions,” said Bartley. “There were no interdisciplinary rounds, no daily huddles, but now there are. This allows us to be more assertive, to ask questions, and to contribute.”
In 2009, the ICUs implemented a CLABSI maintenance bundle to insure appropriate dressing changes, tubing changes, and scrubbing the hub properly. CLABSIs declined further to 5 per year, and 0.7 per 1,000 line days. In 2010, chlorhexidine was added. By 2011, however, the ICUs were still getting 6 CLABSIs per year. They invested in a disinfection cap on all ports so that it was no longer necessary to scrub the hub for 15 seconds and let it air dry for 10 seconds. Since mid-2011, as of this writing in September 2012, the three ICUs have had no CLABSIs for 14, 9, and 13 months. Harrison summarized the process and the rationale:
“We were always true to the original bundle with which we started, and we added pieces. If we saw rates not going down, we investigated cases and charts. Some hospitals started with a BioPatch, but our thought was that we should do the correct technique from the beginning, and then if there's a problem, add the BioPatch.”
Since 2008, the insertion bundle has gone house-wide, first to the ED, and then to anywhere a central line is inserted. During 2008–2009, Saint Joe's began using the maintenance bundle in the non-ICU areas.
To take these bundles house-wide, St. Joe's created a multidisciplinary task force on translating evidence into practice. They worked with the nursing practice council that coordinates unit work, education, quality activities, and nursing protocols. They worked with the educators' committee, product value committee, and each floor unit to understand how to integrate bundles into their floor processes. Posa described who was involved:
“Nursing did a lot of the driving in non-ICU units. We had physician champions and residents as well. We engaged middle management and front line staff on the ‘whys,' the behaviors we needed in place: best practices for line insertion; a checklist to ensure every intervention was completed; and to speak up if best practice not being followed.”
They found that the infrequency of central lines on the floor did not warrant the expense of a line cart, so the task force modified the toolbox another hospital had created. They found a bag in which all of the equipment could fit and be available in case something was contaminated and met with central supply about how to restock it. Cheat sheets were added to the central line bag. They recapped the pre-procedure discussion process between nurse and physician and reviewed the role of the nurse in seeing that all the bundle interventions and steps were complied with. Resistance was considerable, as Harrison described:
“The Keystone project is about standardizing work, and the biggest issue was to get physicians, respiratory therapists, and nurses to follow the new evidence-based guidelines. For a nurse to speak up if a physician broke sterility was huge. We worked with each of them individually, invited them to the team, and showed them data and outcomes. Some of them are now the biggest advocates.”
CUSP and the Culture of Safety
In the Keystone Team, interventions to prevent infection went hand-in-hand with working on their culture of safety. Each ICU examined their culture of safety and created action plans to address it. They began by educating all staff on the science of safety. Posa said,
“Human errors will happen. You have to put in processes to prevent them from reaching the patient. Then you put in a Learning from Defects process so that you see errors as opportunities to do things better. You understand why they are happening and what we can do to prevent there being a next time. While you are doing that, you're also improving teamwork.”
Bundle compliance and developing a culture of safety were challenged by high turnover rates. Attending physicians changed every week, interns and residents every 2 weeks. Both of these terms have now doubled. The Keystone Team and ICUs overcame this challenge with more emphasis on teamwork and communication. The clinical nurse leaders “dog the initiatives, talk about it in huddle, work with the intensivists,” said Harrison. “They are the change agents responsible for coordinating care at the bedside in their unit.”
In the MICU, daily huddle begins at 1:00 P.M., the best time at Saint Joe's for this forum to ensure that everyone is on the same page with regard to the goals for each patient. They share observations and discuss strategies. They use the Learning from Defects tool to ask why something didn't work, and what could they do differently next time. Bartley said, “It's amazing how we see everyone contributing from their own expertise.” That includes Environmental Services, one of whose members asked, “When you don't post the right contact precautions outside the door, we are not going to clean the right way.” Bartley continued, “It was eye opening for some of us. She was very nervous as she talked, but then she found that, ‘they are listening to me.' That's a powerful experience.” One of the solutions was to make sure that staff put the right isolation precaution sign and the correct protective gear on the yellow caddy outside the rooms of patients who are in isolation.
Multidisciplinary rounds are held every morning. Bartley coordinates rounding, oversees practice and communicates with those who cannot attend. “I feel like a spider in the middle of a web. I collaborate with the charge nurse about incoming patients in order to plan for staffing, update the nutritionist on patients needing tube feedings, alert the case manager about patients who are moving to a different unit or outside the hospital to plan for discharge papers, keep the social worker updated on patient and family issues, collaborate with the respiratory therapist on ventilator and therapy changes that were discussed during rounds.”
Debriefings or specialized huddles are held when a pressure ulcer develops or someone has a fall: How did it happen? What can be done to prevent it from happening again? Goals of the day for each patient are written on a white board that also shows when a central line was started. During shift handoffs, nurses overlap briefly to have direct conversations about the patient at the bedside. Interns and residents go through orientation before they come to the ICU. They participate in simulation training facilitated by the ICU Medical (MICU). Bartley orients and educates staff about MICU practices, evidence-based practices, bundles and proper use of equipment.
CUSP work was understood as such by some at Saint Joe's, but this work was largely carried out under the umbrella of safety and Keystone, sort of “mushed together,” in Posa's words. “‘Culture of safety' pulls on all the components of CUSP.”
Bartley concurred, “When I think of CUSP, it's all the things we do to make the patient safe: eliminating BSI, CAUTI, UTI, VAP—it's comprehensive, like its name. It's about learning from defects. It's a way of thinking that leads to more exploration of other things.”
Posa and other members of the Keystone Team immerse themselves in emerging evidence in caring for critically ill patients. They bring research and ideas to the group and ask if members want to pursue them. Posa is also deeply involved in a two-way flow of evidence-based practice at Saint Joe's parent organization, Trinity Health and her counterparts in sister hospitals.
When the Michigan grant and work with Johns Hopkins ended, Keystone formed an advisory board of ICU nurses and physicians from across the state. Posa said, “We and other hospitals implement evidence based practices for treating sepsis, preventing delirium and progressive mobility, and then push it up to Keystone, after which it is implemented statewide.”
Through these various conversations, in 2004, the Keystone Team had begun discussing the new Surviving Sepsis Campaign's guidelines for bringing down the very high mortality rates from sepsis, and led the introduction of the sepsis bundle into the ICUs and ED in 2006. Any patient with an infection can become septic, and sepsis comes in three degrees: uncomplicated sepsis, severe sepsis, and septic shock.
Harrison noted that, “we have been working on sepsis a long time, but we had to get CLABSI and VAP down as they are so often the causes. Then we moved to sepsis screening in the ICUs, the ED, and the floor. Many sepsis patients don't start off in the ICU, so it's critical that every unit screen for sepsis.” Still, there were struggles over accepting a protocol “as better than my clinical judgment.” Once again, data showing the reductions in morbidity and mortality carried the day. Purtill highlighted how Saint Joe's was reframing its thinking about infections.
“At first, we focused on CLABSI and VAP. Now we're thinking about the bigger ticket of sepsis. Any form of infection can lead to sepsis, which is why our focus has also included sepsis, not just infection prevention. In the last year, we have saved 116 lives at Saint Joe's through early identification and evidence-based management of patients with sepsis.”
Critical Moments in Culture Change
Posa marked the beginning of culture change as occurring when nurses were supported by the Department of Surgery and Medicine in 2004 and encouraged to stop line insertion when the CLABSI bundle was not being followed. Another moment occurred in 2008 when a policy was developed that allowed nurses to draw blood and give fluids to patients who met criteria for severe sepsis. Until then, the nurse had to ask for an order to draw blood and ask to give fluids, and the physician might not be responsive.
Early 2010 witnessed a third moment in which it became mandatory to move a patient to the ICU—which then took over their care—if she or he met certain criteria. Drawing on the Surviving Sepsis Campaign, Keystone team members initially set forth guidelines on screening for sepsis and on the set of evidence-based treatments. When many physicians did not respond, they undertook a lengthy educational effort, including the CUSP material on the science of safety. Poor response sent them deeper into the literature and the recognition that instituting this care had to be made mandatory. They carefully crafted a best practice policy for automatically moving a septic shock patient to an ICU bed. That meant that the patient would now be under the management of an ICU physician. “We had to develop a medical staff policy that did not allow them to ignore evidence-based practice by forcing them to institute care,” said Purtill, who first proposed the measure. “We saw a pretty dramatic reduction in mortality, so we stuck with it.”
Getting approval from the Collaborative Practice Team for Critical Care was fairly easy as many of the developers were part of the Keystone Collaborative. The Medical Executive Committee signed off after doing its own extensive, independent review. In the policy's first full year, nearly 80 percent complied, and that has since risen to 90 percent. Compliance has been aided by the fact that patients do better by earlier admission to the ICU, they return to their regular physician when released and mortality for the patients who were cared for in the ICU dropped to 13 percent from 36 percent.
For more information about Saint Joe's, visit their website at www.stjoeshealth.org.