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Applying reliability to improve infection rates
CCHMC reduces VAP rates
When staff at the Cincinnati Children's Hospital Medical Center (CCHMC) began working on reducing ventilator-associated pneumonia rates, they armed themselves with more than a bundle. The work was informed by the theory of high reliability — how to make progress and how to sustain improvements.
Uma Kotagal, MBBS, MS, senior vice president for quality and transformation at CCHMC, says they came across a framework that the Institute for Healthcare Improvement (IHI) discussed as part of its Pursuing Perfection initiative. The framework was developed by University of Michigan researchers Karl E. Weick and Kathleen M. Sutcliffe, who had studied other highly reliable industries such as aviation and recorded the characteristics therein. The IHI recognized that this framework could be applied to the health care industry, Kotagal says, "and we found it to be extremely useful to getting great results."
"If you want 99% reliability in a process, then training and reminders won't get you there," Kotagal says. "You'd have to use checklists, force functions, and default functions, etc. So that learning really helped us a lot to think about how do we get ourselves to a place of very high performance.
"When we started to work on the ventilator pneumonia bundle, we worked on understanding those concepts and designing our interventions — for example, using the every-four-hour nursing and respiratory huddle to check on whether we applied all components of the ventilator bundle and hard wiring some of our safety indicators into routine nursing documentation, as well as using alerts to remind us about important components. Those kinds of tools that we used allowed us to get to very high levels of performance on the processes that we were interested in," she says.
They began by adopting the IHI bundle for ventilator-associated pneumonia (VAP) prevention. Of course, that was developed for adult patients. So Kotagal says CCHMC had to modify some of it for its specific patient population. "For example in the NICU, the kids that are on radiant warmers or on incubators couldn't have the head of the bed elevated to the same level. Or some of the medications were not appropriate for prescribing a newborn," she says.
The team researched evidence-based synthesis, systematic reviews, and expert consensus to adapt the bundle to the pediatric world. The program began as an internal collaboration between the hospital's three ICUs — the pediatric ICU, the neonatal ICU, and the cardiac ICU. Each team tested the intervention and came together as a group to learn from each other's experiences. "So what could be learned at one place could be accepted by the other. And that moved us much faster," she says.
Kotagal says a number of interventions were implemented to ensure that the bundle was being followed.
Frequent huddles are now a part of everyday work for the hospital's nurses and respiratory therapists. Often, they meet every four hours but might meet more frequently. And the purpose is to crosscheck the use of the bundled components. They verify that the position of the head of the bed is correct or that a mouth cleaning was performed. "When we first started to do the improvement, we did use these naturally occurring huddles to create force functions that allowed us to be sure that things were going well," she says.
Another built-in check, she says, for respiratory therapists and nurses is that a set of six prepackaged mouth kits is located above each patient's bed to ensure that the kits are being used.
"At the beginning we had a checklist and a separate sheet for documenting all of this. Now we've gone through a fairly extensive sustainability checklist or a control plan and so all of the components of the bundle are incorporated into daily work. It's part of people's evaluation. We also have a mechanism for alerting us if something is out of the ordinary. Statistical signals allow us to pick up something if there's a problem," she says.
"For example, if we run out of a particular kind of tubing because the company stopped making that tubing, then we have a process to notify us that the tubing has changed. So right now it's all part of our work. It's been a couple of years since we hard-wired the changes, and we've sustained very low VAP rates for a very long period of time." Their target this year is to reach 0.5 infections per 1,000 ventilator days. So constant reinforcement and preoccupation with failure, a key characteristic of the high reliability model, have enabled the hospital to anticipate and prevent infections as part of everyday practice, Kotagal says.
Now when an infection occurs, Kotagal says, an abbreviated root-cause analysis is completed. "So now if we have a signal that something is different, we're trying to find out what the cause is. So it's generally not due to deterioration of processes but rather an aberrant cause." Last year they established that a problem occurred with patients being transported off the floor. In one case, the problem was due to running out of the correct ventilator tubing. "So every time we learn something, we put a new process in place to address that," she says.
She references Atul Gawande's new book, "The Checklist Manifesto." "I think that the idea that you get down to sufficient level of detail, that you're not relying on memory, is important. And that is a step up from fuzzy [messages such as], 'Consider treating the patient' or 'You might want to consider this if a patient exhibits these findings,'" she says.
Improvement eliminates the reliance on memory alone. For example, Kotagal explains, clinicians are expected to give antibiotics prior to incision based on evidence. If that doesn't happen, there should be a particular reason, such as the patient is crashing or the patient was already on antibiotics and the surgeon decided not to give an additional dose.
Multiple teams track and report daily and weekly failures. Kotagal says because they are working now at a high reliability rate with the bundles, they can isolate and analyze daily failures. "So we could say today in the ICU a kid didn't get his head elevated and let's figure out what the problem is. And maybe it is that the incubator bed only goes that high or maybe somebody ordered the wrong bed for this patient, not realizing they would be on a ventilator. Always legitimate reasons. And if you're honest and willing to tackle those legitimate reasons without individual blame, then everybody is part of the process solution."
If the team finds a case in which a child wasn't given antibiotics prior to incision, they can go to that particular surgeon and say, "Our records show the patient wasn't given antibiotics. Why was that?" And he or she might say, "We elected not to give antibiotics because the patient already was on antibiotics and I didn't want to give an additional dose."
"By looking at daily failures and sorting them out, we find that we can get to much higher levels of performance, both because the individuals can remember the case and so it builds accountability. And because they can identify problems that we didn't think about that improve our process," she says.
The concept of high reliability also looks at anticipating failures so you can work to solve them beforehand. Kotagal says the hospital is working to apply the high reliability concepts at an organization-wide level through systematic escalation processes, huddles, algorithmic predictions of patient deterioration, analyzing daily failures, and mitigating those failures to reduce harm.