By Eugenia K. Pallotto, MD
Central line-associated bloodstream infections (CLABSIs) are one of the most deadly and costly hospital-associated infections in the U.S. Each year, thousands of patients die and it costs billions to care for patients who develop CLABSI. Many of these infections are preventable and no healthcare system is immune to the problem. We’re all challenged to lower hospital-acquired infections as part of ongoing quality expectations. Seeking zero harm is an important patient safety goal for all hospital populations, especially for our most medically complex infants in the neonatal intensive care units (NICU).
Newborns in the NICU can become quite critically ill when faced with a CLABSI because of their immature immune systems, yet central venous catheters (CVCs) must be used in the NICU to provide both nutrition and life-saving medications.
To curb the growing problem of hospital-acquired infections in the NICU, 17 children’s hospitals from The Children’s Hospitals Neonatal Consortium (CHNC) teamed up in 2011 to form the SLUG Bug (Standardizing Line care Under Guideline recommendations) collaborative.
Our goal was to study ways to reduce infections from the central lines and provide better practice recommendations for neonatal healthcare professionals in care and maintenance of CVCs.
Through efforts of the collaborative, we were able to reduce the level of infections by nearly 20 percent across the participating healthcare organizations. But achieving success took more than just improving technology and procedures, it took multidisciplinary teams working together and culture change.
To get started, the collaborative first needed to agree on what we were trying to accomplish. Once that was determined, we needed to identify how we would know if a change was an improvement over current practices. Finally, we needed to implement changes we knew could achieve improved results.
We used the Plan-Do-Study-Act (PDSA) Cycle as a model to guide us through this process. PDSA is often used by health care organizations, which helps test a change by developing a plan to test (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the test (Act).
The outcome improvement required multiple cycles over a wide range of conditions, and we collected and reported data during this time. Each site implemented the practice changes most needed for their organization based on clinical practice recommendations the collaborative provided. Over time, the implementation of tests of change led to sustained improvement. While PDSA can be a lengthy process, each step along the way is important to help achieve success.
Methods to Reduce Rates
Many hospitals across the country already have evidence-based practices in place to help improve central line infection rates, which include hand hygiene, central line insertion techniques, dressing changes and root cause analysis. But what we quickly found out was that other methods of central line care, include tubing change technique, hub care monitoring, CVC access limitation and CVC removal monitoring, varied widely in local hospital practice. As part of the SLUG Bug collaborative, we focused on these areas and where we could have the most impact.
A design matrix of eight distinct factor/level combinations (test groups) were developed by using four factors: sterile versus clean tubing change technique, hub care compliance monitoring versus not monitoring, CVC line entry access limitation versus not monitoring and CVC line removal tracking versus no tracking policy.
Each healthcare organization selected the practices in one of eight test groups to adopt and/or maintain. Some had practices congruent to the selected test group and did not modify practice, whereas others planned to implement changes.
During the study phase, we incorporated learning sessions, monthly webinars, a listserv and quality improvement advisors to help facilitate a successful project.
SLUG Bug Collaborative Results
During the 12-month study period from January 2013 to January 2014, the collaborative CLABSI rate decreased from a baseline rate of 1.333 to 1.076 per 1,000 line-days, more than a 19 percent reduction.
Among the four infection prevention factors, sterile tubing change decreased CLABSI rates by an average of 0.51. The addition of hub care compliance monitoring produced the strongest effect with an average decrease in CLASBI rates of 1.25 per 1,000 line-days.
The decreased infection rates were also maintained in the six-month sustain phase following the study. In addition, four health care organizations elected to implement the sterile tubing change technique after reviewing the results of the testing, which resulted in a 64 percent decrease in CLABSI rates from the baseline. This was exciting because it confirmed what we already believed that sterile tubing change does indeed have a significant impact on lowering infection rates.
Other outcomes included:
• An estimated 35 CLABSI events were prevented and up to seven lives saved, which is an attributable cost savings of $69,000 per CLABSI averted.
• More than 80 percent of participating health care systems decreased CLABSI rates.
• Healthcare organizations continued to sustain low rates 18 months after the collaborative period.
• Four healthcare systems continued to lower CLASBI rates with implantation of sterile tubing change.
Culture Change is the Key to Success
The SLUG Bug collaborative was one of the first to utilize orchestrated testing to identify specific components of care bundles that contributed to outcome improvements. But it took more than procedures and techniques to reduce CLASBI rates. It took teamwork, collaboration and what I believe is the most important thing, culture change.
The easy part in any organizational change is coming up with the technical tasks, but the reality is everyone from clinical staff to hospital leaders need to believe and care about the mission at-hand if you want to achieve your goals. You can have the best technology and procedures in place, but if the culture hasn’t shifted to support initiatives, change isn’t going to happen.
It’s important to get all multidisciplinary team members involved in the CLASBI prevention efforts from the start, which includes the nurses, the people ordering the central lines, the staff placing the central lines and maintaining them, as well as parents and/or other family members.
Transparency and communication are necessary for any workflow changes. Sharing results from the quality performance report and helping staff understand the importance of performing procedures consistently across patients is the key to success. This process continually needs be reinforced to ensure everyone is on the same page and working toward the same goal.
Empower staff to be a part of the solution and reinforce positive practices. Encourage frontline stakeholders to speak up when a break in practice occurs.
In one instance, we had achieved low infection rates, but infections started to spike back up again. It was the frontline nurses that spoke up, rallied the troops and said we needed to do something different.
The SLUG Bug collaborative was developed and implemented by a multidisciplinary group of experts from CHNC member hospitals, which included representatives from neonatal nursing, neonatal advanced practice nursing, neonatal physicians, and statistical and process improvement experts. It’s been motivating to work together, learn from one another and bring back those new ideas to the individual teams.
While the study found that low CLASBI rates can be sustained in NICUs with high device use, you don’t have to be part of the SLUG Bug collaborative to achieve lower infection rates. Each individual system should continue to examine evidenced-based infection prevention practices.
Look at all parts of your organization and see what’s working and what areas need improvement.
It takes more than one person to achieve low rates, so make your data and results visible and put systems in place that foster team work. Most importantly, collaborate with your peers. Engagement, transparency and vigilance all contribute to a team’s success.
More information on the SLUG Bug collaborative and the orchestrated testing can be found in the whitepaper, “Improving Care for Medically Complex Infants: Accomplishments and Future Direction of the CHNC Collaborative Initiatives for Quality Improvement,” which was posted online May 1, 2017.
Neonatologist Eugenia K. Pallotto, MD, is medical director of the Neonatal Intensive Care Unit (NICU); medical director of ECMO; and professor of pediatrics at the University of Missouri-Kansas City School of Medicine.
Grover TR, Pallotto EK, Brozanski B, Piazza AJ, Moran S, McClead R, Mingrone T, Morelli L, Smith JR. “Interdisciplinary teamwork and the power of a quality improvement collaborative in tertiary neonatal intensive care units.” J Perinat Neonatal Nurs. 2015 Apr-Jun;29(2):179-86.
Pallotto EK, Piazza AJ, Smith JR, Grover TR, Chuo J, Provost L, Mingrone T, Holston M, Moran S; DNP, Morelli L; LNCC, Zaniletti I, Brozanski B. Sustaining SLUG Bug CLABSI Reduction: Does Sterile Tubing Change Technique Really Work? Pediatrics. 2017 Oct;140(4). pii: e20163178. doi: 10.1542/peds.2016-3178.
Pallotto EK, Chuo J, Piazza A, Provost L, Grover T, Smith J, Mingrone T, Moran S, Morelli L, Zaniletti I, Brozanski B. Orchestrated Testing: An Innovative Approach to a Multicenter Improvement Collaborative. Am J Med Qual. Oct. 19, 2015.
Piazza A, Brozanski B, Provost L, Grover T, Chuo J, Smith J, Mingrone T, Moran S, Morelli L, Zaniletti I, Pallotto EK. SLUG Bug: Quality improvement with orchestrated testing leads to NICU CLABSI reduction. Pediatrics. 2016 Jan; 137(1):1-12. 23.