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CLABSI reduction projects with a twist
Improved education leads to dramatic results
There have been nearly 200 studies about central line-associated bloodstream infections (CLABSI) published since the start of 2011. Many of them talk about similar methods for reducing infection rates — using kits and bundles, putting up posters to remind providers of protocols and pathways, or giving clinicians pocket reminder cards. But with an increased emphasis on hospital-acquired infections evident in Medicare rules (see related cover story), finding novel approaches to reduce infections like CLABSI has taken on new urgency. Two recent efforts have shown new ways to achieve spectacular effects — in one case leading to nearly six months without a single CLABSI case.
At the University of Maryland Medical Center, the 19-bed surgical intensive care unit (SICU) had a troubling rate of CLABSI. While the national benchmark was 2.7 per 1,000 central line days, in 2010, the unit had 5.5 per 1,000 line days. The goal was to reach 2.3 for the 2011 fiscal year.
To do this, the team decided to use an infection control nurse (ICN) five days a week to assist with insertion and removal of central lines, provide education to staff, and audit practices such as hand hygiene, contact isolation precautions, and dressing surveillance. The facility chose ICN bedside nurses who were considered leaders and would help empower the nursing staff as a whole to stop insertions or removals that were considered aseptic or in breach of any part of best practices. They, in turn, were trained by infection control practitioners on how to ensure those best practices were followed.
When the effort was instituted in July 2010, an ICN was expected to be present at every central line insertion, get blood cultures from peripheral veins rather than from central lines, check dressings daily, and make sure that central lines were removed and replaced within 24 hours of admission to the SICU. The ICN was also responsible for enforcing a zero-tolerance policy for breaches in hand hygiene and isolation precautions, and that needleless access ports were scrubbed for 15 seconds with 70% alcohol prior to use. All nurses on the unit received training, watched a video, and completed the post-assessment quiz.
The results were better than anyone expected: For 25 weeks, there were no central-line infections. Since that streak was broken, another streak of 15 weeks without infection has developed.
Cindy Rew, RN, nurse manager for the SICU, says people became very invested in the run without infections. People talked about it in the halls, asked about it over lunch, and when the streak hit 20 weeks, there was a facilitywide celebration attended by the hospital CEO and chief medical officer.
"Before we did this, we were using the bundles, but with very sick, very complex patients, it was not enough," Rew says. "We weren't going to sit back and accept this, though." Education to ensure everyone did the same thing, the same way, using simulators, helped to bridge the gap. "Everyone learned something," Rew says.
Giving nurses an education in proper central line insertion techniques was another key to the success, she says. Knowing what was supposed to be done meant they could speak up if they saw something that was outside the protocols.
Rew also credits the assistance and leadership of her colleague Michael Anne Preas, RN, the infection control professional who developed many of the strategies. Preas was in charge of a lot of the education at the facility, and presented the results at a conference of the Association of Professionals in Infection Control.
At the conference, she outlined some of the savings achieved by reducing the infection rate, estimated at more than a quarter of a million dollars over six months, or more than $200,000 after taking into account the cost of the infection control nurse.
Rew says she and Preas both knew that something had changed when that streak of 25 infection-free weeks broke. "Everyone wanted to know who the patient was and what happened," says Rew. "Everyone wanted to know how it happened so that we could make sure it wouldn't happen again. Before, another infection wouldn't mean anything to anyone. It would have passed by unnoticed. Now that's changed."
Next up is an initiative on catheter-associated urinary tract infections (CAUTI). Preas says she wouldn't be surprised to see that rates for that and other infections are already on the decline. Hand hygiene is up at the facility overall, and other organizations have seen a carry-over effect from one infection control project to another. "The best practices we implemented for CLABSI will easily transfer to CAUTI and other efforts," says Preas.
VA rolls out CLABSI reduction project
In the British Medical Journal's Quality and Safety publication in August, a U.S. Department of Veteran's Affairs (VA) project on CLABSI reduction used the requisite bundles, but focused on education and spreading the word in a manner appropriate to each VA facility1. The result was a decline from 3.8 CLABSI infections per 1,000 line days to 1.8 per 1,000 line days.
Marta Render, MD, one of the researchers on the project, said the focus had to be on learning because the VA is a "gargantuan system. We had to think about how to get learning out to people who needed it. We did not want to have to push this out to everyone, but have them pull it in."
The project focused on projecting a need — which encourages people to want to help — and encouraging them to find what works for them to achieve the shared end goal, says Render. Many facilities had some or all of what they needed in place; others needed to get better at data collection. Some needed help in creating a team in the ICU. In each case, Render and her team were there to coach and talk them through strategies. But what they did in the end was specific to their own needs and their own facilities.
To spread the knowledge, they developed web-based tools and kits, including the critical development of the daily goal sheet. "It is a great tool that changed the way we work together," Render says.
If a patient was on pressors and the physician wanted that patient off, the sheet would include goals that led to that end — pushing two liters of fluid but not more. The physician knows to go back and check that goal sheet and ask how the patient is doing and reevaluate the goal if necessary. "The nurses will keep track, and we create the expectation that certain things will happen. We give people permission to speak up if something doesn't seem right. Even the residents know what the expectation is."
Once implemented and data collection started, Render and the team worked with outliers, conducting structured interviews and setting achievable goals — find a team leader in the next week, check the data the next day. Then the team would follow up on those goals, finding out what went wrong if the goal was not achieved and suggesting potential solutions.
Render thinks that building buzz around the topic also helped. They would print and leave around the ICU scholarly papers about CLABSI reduction. The physicians would inevitably pick them up and read them.
She also says that concentrating on getting a single champion on board helped many facilities get great results. The team leader would take one amenable physician and do training with him or her, then another. It made the process seem exclusive and special. "Pretty soon people would clamor for the training."
The results were initially rolled out in ICUs, but have since been spread to other inpatient units and VA community living centers. CAUTI and ventilator-associated pneumonia are next on the list.
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