The Joint Commission Update for Infection Control
VA programs cuts CLABSIs by >50%
Pull not push does the education trick
The Joint Commission targets central line–associated bloodstream infections in its 2011 national patient safety goals, with NPSG.07.04.01 calling for hospitals to "implement evidence-based practices to prevent (CLABSIs)."
A recently published paper on a 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.
1. Render ML, Hasselbeck R, Freyberg RW. Reduction of central line infections in Veterans Administration intensive care units: an observational cohort using a central infrastructure to support learning and improvement. BMJ Qual Saf 2011: 20:725-732.