'Owning' the problem drives CLABSIs to zero

Saving a few lives and a cool quarter mill

There has been so much hoopla about driving central line-associated bloodstream infections (CLABSIs) down to zero with checklists and bundles, that a unit that fails to achieve such success may take it somewhat personal. After a period of struggle, nurses on a surgical intensive care unit (SICU) at a large academic medical center did just that, deciding to "own the problem" until they cut bloodstream infections to zero and saved more than $200,000 during a six-month period.

Ultimately, culture change in a given unit may be as big a factor as any checklist or infection prevention tactic, said Michael Anne Preas, RN, BSN, CIC, infection preventionist at the University of Maryland Medical Center in Baltimore.

"It was truly a back-to-basics effort – these were just best practices at a granular level, led by the unit themselves," she said recently in Baltimore at the annual educational conference of the Association for Professionals in Infection Control and Epidemiology. "The nurses on the unit took ownership of best practices and drove the change. When you have one of your own in the lead, and are reminding each other and encouraging each other to do your best, everybody gets on board, and that is what we saw."

Preas played a key role in the project, but credits the culture change within the unit for making a change that will endure.

"Until the staff actually owned doing that work, they were struggling with their [infection] rates," she said. "We are using this as a business case to make sure that the units are well staffed, so that they can do the work of infection control. I'm the one who got the publicity for being the germ cop, but really this whole concept of going around and saying 'You're doing this correctly or incorrectly' [has diminishing returns]. One IP can make an impact, but can't make the difference in the way the unit can by changing their own internal culture."

Morale was not so high at the outset, as the unit staff were coming to terms with the thought that maybe there was little more they could do for their patients. "We had a CLABSI rate [in this unit] that was significantly higher than the national average," she said. "They had many best practices in place — they used the standard central line cart for all of the placement of their catheters. They used sterile barrier precautions when they inserted these lines and used a checklist."

When infections continued to occur, there was some thought that the patient severity of illness in the SICU was too high to overcome with interventions.

"Frankly, the staff in this particular SICU believed that they could not get to zero," Preas said. "They felt that their patients were too sick and that they were doing everything they could and this was the best it was going to be. So we kept having conversations with them and eventually last spring we had a meeting and this particular unit decided they were going to take over and own infection control in their unit."

To address the problem of higher-than-average CLABSI rates on the 19-bed unit, the hospital appointed dedicated infection control nurses (ICNs) to oversee central line catheter insertions. The effort was conducted in partnership with the director of medical surgical nursing. An ICN was present during every central line insertion and trained to call out breaks in technique, breaches in hand hygiene and to perform daily assessment of central line dressings, looking for signs of infection. The nursing staff came up with clever reminders for best practices and created incentive programs to keep the team motivated and engaged. They also removed excess clutter from patient rooms and hallways so it would be easier to clean them.

To kick off the intense focus, staff huddled for a five minute education session on best practices every day, eventually extending this time to cover other infection control issues. "What was so exciting was that almost immediately we began to see no CLABSIs," she said. "Over a 25-week time period this unit had a zero CLABSI rate after they implemented the infection control nurse role within this unit."

The initiative took place from July to December 2010. The SICU sustained a rate of zero for a 25-week period, eliminating 14 CLABSIs and saving several patient lives when compared to the same time period in the previous year, she reported. The average cost of a CLABSI is estimated to be $18,432. By eliminating 14 CLABSIs, the team saved $258,048, less $44,000 for a nurse's salary for six months, resulting in a net savings to the hospital of $214,048.

"When you base that on an attributable mortality of about 20%, they essentially saved two to three lives," Preas said. "We are just thrilled about it, though the unit is not completely at zero. They have had a few CLABSIs since that time frame, but this project has changed the culture in this particular unit. The nurses know that they are the ones that make the difference in terms of preventing infections. It is really a business case [argument] for application of resources to prevent CLABSIs."