The increased attention to patient safety in healthcare facilities has been driven by regulatory agencies, advocacy groups, litigators and most importantly, the patients themselves. This attention has been welcomed by infection preventionists who focus on the improvement of patient safety through prevention of healthcare-associated infections (HAIs). A leading cause of HAIs in the intensive care unit (ICU) is catheter-related bloodstream infections (CRBSIs). Approximately 80,000 CRBSIs occur annually in U.S. ICUs and are associated with as many as 28,000 patient deaths.1 These infections are estimated to have a mean attributable cost of $18,000 and an associated excess length of stay of 12 days.2 Historically, these infections resulted in additional reimbursement by the payment systems. However, in October 2008, the Centers for Medicare and Medicaid Services (CMS) eliminated reimbursement for reasonably preventable adverse outcomes of care, including CRBSIs. Currently, many healthcare facilities are struggling to quantify their CRBSI rates in an effort to understand the problem and begin to implement prevention strategies.
A major challenge facing healthcare providers is translating the evidence-based practice guidelines into bedside practice. Despite the published evidence that supports the consistent use of the guidelines and the reported success stories of the Institute of Healthcare Improvement 100,000 Lives Campaign, the Keystone Project and others, adherence rates vary considerably. This variable compliance has led to considerable interest from professionals who specialize in human factors research. Gurses and colleagues3 at the University of Maryland Medical Center performed a qualitative study in two surgical ICUs to assess compliance with evidence-based practice guidelines for the prevention of urinary tract infection, surgical site infection, ventilator-associated pneumonia and CRBSI.
Gurses and colleagues3 suggest that consistent compliance with guidelines may be viewed as a systems property of ICUs. Human factors research looks at the ICU as a holistic work system, evaluating both the physical layout of the unit as well as the culture that is embedded in the unit. The ICU culture may support work processes because “that is how it has always been done,” as opposed to embracing evidence-based practice guidelines. One of the underlying tenets of human factors research is the belief that in order to improve processes of care, it is necessary to begin looking at things differently, and in effect, questioning the status quo.
Human factors research views the attitudes and beliefs of the healthcare providers as behavioral in nature. Attention to behavioral factors is critical for assessing the “readiness” of the providers to consider alternative processes of care. Among the questions to ask: Where have they worked before and for how long? How were they trained to perform a certain skill? In many instances, skills were acquired through the “see one, do one, teach one” concept.
Through in-depth interviews with 20 healthcare providers and observations, Gurses and colleagues3 concluded that the concept of systems ambiguity explains non-compliance with guidelines aimed at preventing CRBSIs in ICUs. This article focuses on two types of identified ambiguity – expectation and exception.
Expectation ambiguity examines what providers believe is expected of them. A study finding was that the presentation of CRBSI data as a rate per 1000 line days – 4.6/,1000 line days with a target of <4.0/1,000 line days — was not particularly relevant to the nurses. As a result of this finding, the data was communicated as a raw number of CRBSIs in conjunction with a real-time discussion of each infection during multidisciplinary rounds. The nurses could then relate the infection to the patient still in the unit and review care processes that may have contributed to the incident. Additionally, it was noted that the physicians working in the unit were not necessarily oriented to the best practices for inserting central venous catheters. At the time of the study, an insertion checklist was not in use and the majority of physicians had been educated about insertion technique by several mentors. To address this disparity in practice, a Web-based training module was developed and mandated for residents and fellows inserting central venous catheters. Nursing staff can access the list of compliant physicians on the hospital Intranet. Recently, a post-test was added to the tutorial to ensure the desired level of competency.
In order to identify where breakdowns in compliance or “failure modes” exist, it is useful to utilize The Advisory Board’s concept of a “dress rehearsal,” published in their report, Putting Perfection into Action4 (see accompanying illustrations, originally presented by the Advisory Board’s Nursing Executive Center™ a research program serving CNOs and their leadership teams). This process involves mentally mapping and physically walking through each new practice to be introduced into the clinical environment. The rehearsal can preemptively mitigate concerns such as supply availability and compatibility with existing workflow patterns.
In the first illustration of an ICU floor plan, if you look in the upper left-hand section of the schematic labeled “1,” you will note that the process focused on is the method in which the physicians were inserting a line. In this particular sample problem, the physicians stated the supplies that they needed. Given that there are eight distinct supply areas across the unit (depicted by black circles in the schematic), there was quite understandably, a fair amount of confusion as to where to access the correct supplies. To ensure that physicians accessed the right line for a particular procedure, a relatively simple strategy was to centralize supplies. To best accomplish this, it was determined if a line insertion tray existed for each procedure. Catheter manufacturers now recognize that insertion trays need to include best practice items such as chlorhexidine skin prep, fenestrated full-body sterile drape, etc. Some intensive care units have taken the approach of using a line cart that will have insertion trays stocked along with other supplies that may be needed (e.g., sterile gowns that are not in the tray).
In another example on the same schematic labeled “3,” opposition to policies is assessed. What is the root cause? Can you anticipate that there is going to be some non- compliance? In this example, the physician is being resistant to using a full-drape policy for central line insertion. Physicians may question why this practice is important at the bedside and may not implement use of the drape until the data from the randomized controlled trial conducted by Raad, et al.5 is made available to them. Highlighting the published literature can help physicians understand the rationale for and acceptance of the practice.
Gurses and colleagues3 identified exception ambiguity as a potential barrier to compliance with evidence-based practice guidelines. It is important to note that there will be patient situations that exempt the use of some recommended practices. For example, although the subclavian site is the preferred location for the placement of central venous catheters, it may not be feasible as a site for all patients. In the above example, PICU intensivists consider patient specific factors that may exempt the use of best practices. In respect to CRBSI reduction practices, a patient specific criteria in place in many institutions is the exclusion of chlorhexidine skin preparation in children less than two months of age. Exclusion criteria need to be clearly stated and communicated to the care providers; for the chlorhexidine exclusion it should be noted on the insertion checklist.
In summary, successful translation of evidence-based practice guidelines to the bedside requires addressing the “work system” as well as the behavioral patterns of the providers. Additionally, ongoing communication and collaboration are crucial to identify and clarify ambiguity in the care processes. These practices should be endorsed by the highest levels of management and continually promoted and influenced throughout the organization. Lastly, a measurement system and ongoing feedback to the care providers should be in place to monitor and further refine a healthcare facility’s progress as they strive to get to zero catheter-related bloodstream infections.
Joan Hebden, RN, MS, CIC is the director of infection control at the University of Maryland Medical Center in Baltimore.
1. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. New Eng J Med. Dec. 28, 2006, No. 26, Vol. 355:2725-2732.
2. Perencevich EN, Stone PW, Wright SB, et al. Society for Healthcare Epidemiology of America. Raising standards while watching the bottom line: Making a business case for infection control. Infect Control Hosp Epidemiol. 2007 Oct;28(10):1121-33.
3. Gurses AP, Xiao Y, Seidl K, et al. Systems ambiguity and guideline compliance: A qualitative study of how intensive care units follow evidence-based guidelines to reduce healthcare-associated infections. Quality and Safety in Health Care 2008; 17:351-359, 2009.
4. Case profile of Keystone ICU Collaborative (Michigan Hospital Association). Putting Perfection into Practice: Achieving and Sustaining Zero-Deficit Quality Goals, The Advisory Board Company (2007), pages 15-16. For the complete report or more information, visit The Advisory Board Company at www.advisory.com.
5. Raad II, Hohn DC, Gilbreath BJ, et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol. 1994;15(4 Pt 1):231-238.