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Building on Our Successes to Leverage Momentum, Gain Buy-In and Foster Accountability
The journey to zero began in 1998 for BJC HealthCare and the BJC Infection Control and Healthcare Epidemiology Consortium. Education had a huge impact in reducing central line-associated bloodstream infections (CLABSIs). The program that was developed was part of a BJC initiative for all system hospitals. The program was developed because these infections were exceedingly high in our institutions. In some facilities, they were double the benchmark provided by the National Nosocomial Infection Surveillance System data (NNIS), now known as the National Healthcare Safety Network (NHSN).1
An educational module was implemented and completed by September 1999 at all BJC HealthCare facilities. The CLABSI rate at Barnes-Jewish Hospital (part of BJC HealthCare), in the Surgical Burn Trauma Unit, pre-intervention was 10.8 per 1,000 line days and the post-intervention rate was 3.7 per 1,000 line days This was a 66 percent reduction in the CLABSI rate which we attributed to the education module rollout. Additionally, our success was attributed to 100 percent accountability at Barnes-Jewish Hospital from the top down. This included the president, vice presidents, the surgical services director and the leadership in the Surgical Burn Trauma Unit including physicians. Education was mandatory and the intervention was fully supported by the physician staff. The robust level of support for this initiative was due in large part to the fact that nurses and physicians were concerned about the current infection rates. We therefore did not have the obstacle of resistance for this initiative.
In 2004, we made a concerted effort to drive down CLABSI rates even further at Barnes Jewish Hospital in the Surgical Burn Trauma Unit by utilizing a deliberate and multi-faceted approach. The staff believed that one infection was a bad outcome and wanted to strive for a zero CLABSI rate in this unit. We leveraged the momentum we had built up from the earlier success with the reduction of our CLABSI rate by 66 percent through the use of an education module. Our use of a process improvement program resulted in a further reduction of the CLABSI rate from 3.7 to 2.8.2 Let me describe this journey...
Assembling the Team
This time we conducted our process improvement using Focus-PDCA methodology: Plan, Do, Check, Act, to further reduce CLABSI in the Surgical Burn Trauma Unit. This scientific process and four-step model of change is an extension of the PDCA cycle sometimes called the Deming or Shewhart cycle.3 Each step has important activities that help you to identify processes requiring improvement, clarifying the current processes, understanding variation and then selecting the solution for process improvement.
Selection of informed and motivated team members is essential for success. You need to organize a team that knows the processes you will be addressing. To this end, we selected members who represented people who work in the Surgical Burn Trauma Unit and understood each of the processes. Our team consisted of clinical nurse specialists, a nurse manager, physicians, a dietitian, a performance improvement consultant and the infection preventionist for this unit.
Mapping out the Process
In order to get a visual baseline of our existing processes, we conducted a brainstorming meeting. In this meeting, we dissected and memorialized the causes of the CLABSI we had experienced on a fishbone diagram (see the November issue of ICT). Our fishbone diagram was complex and we noted that that the most critical items represented on main offshoots of this skeletal outline related to poor and improper technique. More specifically, they clustered around inadequate handwashing and dressings not being changed on time based on best practices recommendations. Other top focal areas included line colonization and contamination, blood left in the line, no stopcocks or caps on the stopcocks, contaminated supplies, length of time that the line was in, number of catheters and lumens, antibiotic usage, education, site selection and staffing acuity in the intensive care unit (ICU).2
The fishbone diagram helped the team sort ideas into useful categories before beginning the flowcharting process for both central line maintenance and central line insertion. The flowcharting step involved creating a mapping framework using sticky notes or other placeholders until we refined the steps which succinctly reflected the process. In doing so, we could visually see and understand the existing process. This enabled us to more readily note unneeded steps and additionally, identify more efficient ways to accomplish tasks. Analyzing all aspects relating to central line maintenance care and insertion lent itself well to flowcharting these processes, and from this, we developed educational pictorials for the staff to reference. Our flow chart for line maintenance is presented in an accompanying image (see the November issue of ICT).2
After mapping out each step in the process, we took photos of each and organized them into a pictorial format to systematically implement this process and facilitate compliance.
The opening pictorials focused on performing hand hygiene and donning clean gloves, while other pictorials addressed how to clean and prepare the central line site for the new dressing and ensuring that the catheter is anchored, among other practices.
Part of our ongoing process involves ensuring that nurses consistently perform dressing changes. If the nurse forgets the proper way to change a central line dressing, the pictorials are available at the patient’s beside for the nurses to reference. In addition to central line site maintenance, the nurses assist the physician who inserts the central line. They also document in the medical record that the hand hygiene protocol is being followed and the procedure was performed properly. This is true whether the medical record is a paper record or an electronic one.
In terms of the line maintenance process we defined in these pictorials, this is the nurse’s role and is the process improvement highlighted in this article. It involves the basic steps for all nurses to follow including an agency nurse or traveling nurse who enters the Surgical Burn Trauma Unit. Nurses can therefore easily reference the protocol and conveniently and independently address any questions regarding how a central line dressing is done.
Visual Reminders: Keeping the Process Visible to Clarify and Reinforce Process
To foster learning and optimize compliance with the process, we placed these pictorials in strategic locations that we believed would have maximum visibility. As for the central line maintenance pictorials, we placed them on a small ring on a hook by the computer in all patient rooms. They were laminated so they could be easily cleaned during the terminal clean that we conducted in between patients who occupied the room. Therefore, if a nurse needed a refresher or had any questions about the process, they could readily find the answer by looking at the step-by-step process whether it related to a dressing change, where to dispose of soiled supplies, etc.
The central line insertion pictorials were laminated and attached to the procedure carts used for central line insertion. These pictorials displayed the products that the physician or nurse practitioner would need to insert a central line. This enabled nurses to better support inserter and as required, point out consistency of practice. In addition, these pictorials were placed in residents’ manuals. Each resident was responsible for reviewing the pictorials as they moved through the rotation every five to six weeks throughout the Surgical Burn Trauma Unit. Although the number of pictorials was kept to a 12-slide minimum, of the 12 insertion pictures, three were related to hand hygiene, washing with soap and water, or using alcohol foam.2 This was impressive at a time when the healthcare team was just beginning to focus on our hand hygiene guidelines.
A Comment on Implementing and Sustaining Cultural Change
Sustaining the gain and keeping the rates down to zero requires a multi-faceted approach. Part of our success in doing so has to do with education as well as other performance-improvement activities. Providing metrics and feedback to the team every month is also essential to success. If you have a problem in your intensive care unit, you may want to engage in deliberate observations to see first-hand what is going on. Another way to get to root causes is to pointedly ask nurses what they think is causing a central line infection in their unit.
Many behaviors will help implement and sustain cultural change. One critical success factor in the ICUs is being on the unit with the nurses continually and developing relationships. When a care unit in your facility goes a month without a CLABSI, celebrate that success, because you may have had a CLABSI every single month before that. So celebrating successes, however small they are, is very important for staff morale. Our continued success was due to in part to monitoring, collecting metrics, transparency in feeding back the rates to the staff and celebrating successes in CLABSI reduction.
Jeanne E. Zack, PhD, RN, CIC was an infection control specialist at Barnes Jewish Hospital at the time of this performance improvement initiative. She is currently the infection prevention and control manager for Missouri Baptist Medical Center in St. Louis, part of BJC HealthCare. Zack expresses special thanks to the leadership and staff of the Surgical Burn Trauma Unit at Barnes Jewish Hospital; without their continued dedication to their patients and their efforts to reduce CLABSIs to zero, this performance-improvement initiative would not have been possible.
1. NNIS: www.cdc.gov/ncidod/dhqp/nnis.html NHSN
2. Coopersmith C. Zack J and Ward, M. The impact of bedside behavior on catheter-related bacteremia in the intensive care unit. Arch Surg, 2004: 139: 131-136.
3. The Balanced Scorecard Institute. www.Balancedscorecard.org