[MUSIC] In this video, we're going to talk about some of our lessons learned from working with thousands of hospitals across the country towards translating evidence into bedside practice. Our model for translating evidence into practice includes four steps. Summarizing the evidence, identifying local barriers to implementation, measuring performance. And then finally, ensuring that all patients receive the evidence-based interventions that they should. And we've talked in past videos about the four Es, the important steps of engaging different stakeholders, educating them. Having a clear plan for execution, so they know what we're asking them to do. And then a clear plan for evaluation and feedback to important stakeholders to evaluate how well our improvement interventions are ensuring that patients receive the therapies they should and improving patient outcomes. We've used this model in a number of large-scale collaboratives. In a statewide effort called the Michigan Keystone ICU Program, implementation in more than 100 ICUs was associated with dramatic reduction in central line associated bloodstream infections. In a subsequent study with thousands of hospitals across the US, bloodstream infection reduced by over 40%. And the number of hospitals that were able to achieve a zero incidence of bloodstream infection in any quarter more than doubled. We've used this model for translating evidence into practice for the prevention of ventilator associated pneumonia in a large number of ICUs around the country. And we've also begun to explore how this model may work for prevention of venous thromboembolism and surgical site infections in patients undergoing colorectal surgery. At Hopkins, for example, prevention of bloodstream infections was perhaps one of the most important stories in our journey towards improving patient outcomes. We've shared in detail some of the strategies that we used to identify those evidence-based therapies that we wanted to focus on. We explored how we identified local barriers by talking to front-line staff and walking the process. We talked about how we standardized care and created independent checks by implementing a central line insertion cart. And creating a checklist to help ensure that patients receive the evidence-based therapies they should. And the results were quite dramatic. Across our entire healthcare system, bloodstream infections dropped dramatically. And essentially, we helped to create a culture whereby providers who thought that these complications were inevitable truly began to understand that these complications indeed were largely preventable. We then worked with hospitals in the state of Michigan, over 100 ICUs. And they achieved equally impressive reduction in bloodstream infection rates. And then we went on to conduct a national effort called On the CUSP: Stop BSI Program, with over 1,000 ICUs in 45 states. These results were particularly impressive and important. Because for decades, hospitals had been focusing on prevention of central line associated bloodstream infections. But yet when we introduced this model for translating evidence into practice in this collaborative program, hooking up hospitals to help begin to learn from each other. These hospitals demonstrated a further reduction, 43% reduction in central line associated bloodstream infections as a result of these efforts. And in addition, the number of ICUs that were actually able to achieve a zero rate of infection in any quarter more than doubled. This model has also been used to prevent ventilator associated pneumonia, a common and perhaps the most lethal healthcare associated infection for patients who are in the ICU and on mechanical ventilation. We've talked about how this model for translating evidence into practice was applied for central line associated bloodstream infection. But I wanted to share a couple of thoughts about how the lessons learned from the implementation and adaptation to the prevention of VAP rolled out over time. Like bloodstream infection, there are a number of guidelines that outline effective strategies for prevention of ventilator associated pneumonia, like elevating the head of the bed. Minimizing the amount of sedation that patients receive, or evaluating with objective measures every day whether patients could be liberated from the ventilator. But like bloodstream infections, we found that many times, patients didn't receive the evidence-based therapies they should. We talked to front line staff, we walked the process. And we enlisted important stakeholders to help us better understand why is it that patients aren't receiving the evidence-based therapies they should. Not surprisingly, we found out that lack of awareness was a significant barrier to the adoption of evidence-based intervention. And even more important in our investigation was that providers told us that care of patients within the ICU is exceedingly complex. And oftentimes, when we're taking care of a patient in the ICU, we're much more focused on those things that are readily apparent, like the treatment of septic shock or the treatment of heart failure. And oftentimes, we weren't thinking about providing therapies that may prevent a complication several days or even weeks from where we are right now. So ventilator associated pneumonia and the interventions to prevent it essentially were an invisible risk for many ICU providers who are taking care of these critically ill patients. So to address this issue, we needed to do a better job, just like in bloodstream infections, of really focusing on the evidence-based therapies that we thought were the most important and that had the lowest barriers to implementation. We also needed to standardize the system and create independent checks. And to do that, we adapted our previously successful daily goals form. Essentially, it's a one-page checklist that covers those therapies that we need to make sure happen every day on every patient within the ICU. And we adopted the daily goals to include those evidence-based therapies for the prevention of ventilator associated pneumonia. Of course, we encouraged hospitals to measure performance and make sure that we got that performance feedback to our front line staff. And we also navigated the four Es. We engaged important stakeholders within the organizations, within our own organization. And we coached organizations to create these interdisciplinary teams within their own ICU. We went about the process of educating staff to help them really make sure that they understood what we were asking them to do. We had a clear plan for execution. Essentially, it was routine care. But we wanted to make sure that we incorporated these checklist into the care of patients every day within the ICU. And then finally, that evaluation piece, making sure that providers knew how well they were performing as an ICU ensuring that patients received the therapies they should. And how often patients were developing these lethal complications. For prevention of venous thromboembolism, again, we modified our model. Similar to bloodstream infections, there are clear recommendations about what we should be doing. But oftentimes, providers weren't aware of those evidence-based recommendations. There were also some concerns expressed, particularly by our surgical colleagues, about the risks associated with aggressive pharmacologic VTE prophylaxis. And many providers told us that the system was too complicated. Current guidelines required providers to consider not just the patient's current medical condition, but also any other risk factors that that patient may have, as well as the type of procedure or the reason why the patient is hospitalized. Essentially, providers said that it was too difficult to navigate this complex system and to remember all the things that they should to create a plan for prevention of venous thromboembolisms. To simplify that system and to create those independent checks, we had to make it easier for providers to do the right thing. So we embedded this decision support algorithm within the electronic medical record. And we required it for all patients who are being admitted to our hospitals. Providers had to go through this easy to navigate tool identifying what the patient's risk factors were, and then helping to ensure that they ordered the most appropriate therapy. We also needed to do a better job of engaging particularly our surgical colleagues. And one of the things that we clearly recognized with engagement was that we had to have a surgeon at the face of this intervention. That was exceedingly important to help ensure that the surgeons believed that these interventions were safe and that they were appropriate for their patient care population. Overall, the results were pretty dramatic. We saw significant improvements in the percent of patients that were receiving venous thromboembolism prophylaxis, or appropriate prophylaxis. And we saw dramatic reductions in the number of patients who developed preventable venous thromboembolisms. We've also begun to explore how this work may apply to other healthcare associated infections, including surgical site infections. We'll talk more about this in another video. So the lessons learned from these efforts working with hospitals across the country for the prevention of healthcare associated infections and other preventable complications is that many of these complications, including most healthcare associated infections, are largely preventable. They need to be viewed as defects within our systems. Because oftentimes, these patients aren't receiving the evidence-based therapies they should to prevent these complications. To be successful, we need to focus on the systems of care, and not focusing on individuals. Without a doubt, our front line staff care a lot about our patient outcomes. They want patients to do well, and they're trying their hardest. To be successful, we need to focus on the systems to make sure that every system is perfectly designed to achieve the results that it does. We need to make it easier for providers to do the right thing. And when we can do that, patients will have better outcomes. And finally, this work is far more complex that simply implementing a checklist that's completed during the time of central line insertion. Or a daily goals form to make sure that patients receive the evidence-based therapies they should. These tools, such as checklists and protocols, they work, and they're useful, but they only work if providers use them. To be successful, we need to do a better job of engaging our front line staff to identify and to fix our local defects.
