Not making a splash

A note this week from Dr. Michael Howell to the doctors, nurses, and respiratory therapists in the ICUs.

All –

(For those I haven’t met, I’m the Director of Critical Care Quality and one of the ICU docs.)

Yesterday marked 150 days without a single reported splash exposure in any of the nine adult ICUs. Previously, that would have been absolutely unbelievable.

Most of you will have noticed the box in the upper right corner of the Portal that lists the number of days since an employee injury. You’ve probably noticed that it’s always zero, meaning that one of our colleagues is hurt every day. Many of us were fairly agitated by that, and for almost the past year, we’ve been working on improving the safety not just of our patients, but of our staff and providers.

As our first target for improvement, we sought the elimination of exposure to blood borne pathogens by splashes. If you or a friend has ever gotten blood in your eye, you know it’s unpleasant, shocking, and scary. Some of our colleagues have, in fact, even been exposed to HIV and hepatitis this way. We know that nearly all exposures from splashes should be preventable by using personal protective equipment. And yet, before we started our work, someone got splashed with blood or body fluids about every week or two in our ICUs.

Because you reported splashes and were open and honest in talking about them, we learned a lot about things that we weren’t that cognizant of before, and we’ve been able to really reduce splashes’ occurrence. A few examples:
· ABGs and accessing arterial lines are especially risky procedures. In January 2009 alone we had *five* splashes from this mechanism.
· Glasses don’t offer adequate protection. Many people have gotten blood in their eyes (or mouth) while wearing their own eyeglasses.
· Splashes happen at unexpected times: disconnecting a Foley, flushing a PICC line, suctioning an ET tube, and being in the room while someone else was doing as ABG – people have been splashed in all of these ways.

Now, though, it’s been five months since a splash occurred. That’s amazing: If we’d done things like we used to, we would have expected ten of our colleagues to have gotten blood splashed in their eyes during this time period. Instead, no one did. For those of you who like rates, during the last six months we’ve seen a seasonally-adjusted splash rate that has fallen by more than 75%. (Yes, splashes seem to vary by season, though we’re not yet sure why.)

Finally, when I last wrote about this, in July, I made a particular appeal:
I want to make a special request of those of you who are more senior, with lots of ICU experience: please watch out for your junior colleagues, and if they are forgetting to wear a mask with visor, please remind them. Remember also that you set an extraordinarily powerful example with your own practice. By not wearing a mask, you may unconsciously be training your more junior colleagues to put themselves at risk.

Now, I want to say “thanks.” I’ve seen you not just wearing masks and visors as part of daily work, but also coaching more junior staff and coming up with ideas on how to further reduce splashes. Many of you have sought me out to talk about this issue, and at least one of you handed me a mask when I walked into a particularly and unexpectedly “active” room (as we euphemistically say in critical care) and forgot to put on eye protection. (Thanks in particular for that – I later found blood spatters on the visor …. yikes.)

Keep up the good work,
Michael

P.S. Now, as we get ready to enter our second year of this work on ICU staff safety, it’s time to start thinking about what’s next. We will continue to focus on splashes, but my sense is that we’re ready to begin other work in this arena, as well. I’d love to hear thoughts, advice, and suggestions.