Zero' heroes are those that speak up for safety
Key to driving rates down is empowering staff
Empowering nurses and other clinicians to speak up when they perceive a patient safety problem may be the most important component of emerging new programs designed to drive infection rates to zero, emphasizes Sara Cosgrove, MD, hospital epidemiologist at John Hopkins in Baltimore.
A program designed at Johns Hopkins to reduce catheter-related bloodstream infections (CR-BSIs) has led to striking results there and statewide in Michigan, where it was adapted in 77 intensive care units.
"We had a dramatic and sustained decrease in our bloodstream infections in all of our adult ICUs," Cosgrove recently said in San Francisco at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. "The surgical ICU has had no infections since 2005 and that proves that at least in some units it is possible to get to zero. The strongest predictor of clinical excellence was caregivers feeling comfortable speaking up if they perceived a problem with patient care. We saw that in our own units when we empowered nurses to speak up and they saw it on a much wider level in Michigan."
Based on the overarching principles of "engagement, education, execution and evaluation," the program has infection prevention implications beyond CR-BSIs. Describing the evolution of the program at Hopkins, Cosgrove said one of the first realizations was that there are existing Centers for Disease Control and Prevention guidelines to prevent CR-BSIs. "There are evidence-based guidelines that tell us what is going to work to decrease infections," she said. "When I started thinking about this about four years ago, I really thought that if these exist, why don't people follow them? Why do we still have problems with catheter-associated bloodstream infections?"
The next realization was that the guidelines need to be made accessible and actionable at the individual unit level. "If no one knows about them and if no one has the tools to implement the guidelines in their own unit, then we are not going to get anywhere," she said. "So I think the next step is what kind of tools can you provide people to make implementation of evidence-based guidelines work at the unit level?"
Creating a culture of safety
The other key piece in such efforts — and probably the most critical component — is the transformation to a culture of safety at the institutional and unit level. "You can provide [staff] with as many guidelines and tools as you want but if people don't care that this is a problem — if they are really not saying, 'We're hurting patients. This is a defect and we need to fix it' — then you are not going to be able sustain your intervention," she said.
It is important to identify an intervention that is associated with improved outcomes in a specified setting like the ICU. "Select the strongest interventions and convert them to behavior," she said. "If you know there is evidence to do something, you need to figure out a way to get people to do it. The best candidate interventions are those that have a low barrier to implementation, don't cost a lot of money and have good strong evidence."
Don't lose sight of the need for evidence-based practices or you will run afoul of workers demanding the data to justify the practice changes. "That one is particularly critical if you are at a place where people like to argue, like Hopkins," Cosgrove observed. "If you don't have the evidence in the literature to back up what you are telling people to do, they will get really upset."
It is also important to develop measures to determine the outcome of the interventions. "We found that this is critical," she emphasized. "They can either be process measures — where you see how well people are doing with guidelines and so forth — or they can be outcome measures where you look at rates of catheter-associated bloodstream infections. But you need to be able to measure what you are doing after your interventions."
After deciding what measures will be used, assess the baseline performance of the unit. The program should include independent checks of key processes to ensure that patients reliably receive evidence-based interventions with standardized care. "You want health care providers to learn from mistakes," Cosgrove said. "Look at each infection that develops as a learning opportunity. What could have been changed with that patient?"
Applying such principles to the prevention of CR-BSIs, Cosgrove and colleagues distilled the CDC guidelines down to five key actions:
- Remove unnecessary lines.
- Clean hands prior to the procedure.
- Use maximum barrier precautions.
- Clean skin with chlorhexidine.
- Avoid femoral lines.
Of course educating staff is important, so Cosgrove and colleagues created an institutional vascular access device policy and web-based educational program to increase provider awareness of the evidence-based infection control practices. All physicians were required to complete a 10-question test successfully before they were allowed to insert a central venous catheter in the institution. A series of lectures for nurses and doctors were provided to reinforce these evidence-based practices.
"We often think let's make a policy and everyone is going to do what we say," she said. "But we found that implementing a policy alone was not enough to decrease CR-BSIs."
Enter the line-insertion cart, a practical method to bring all the equipment needed for central catheter insertion to the bedside. "The cart has all the essential materials for placement of a central line in the same place so [staff] would not have to go to one shelf to get the chlorhexidine and down the hall to get a sterile full-body drape," she said. "It was all right there and easy for them to grab to help them do the right thing without thinking too much. We also created a BSI insertion checklist that the bedside nurse could fill out to make sure the people placing the central lines were behaving themselves."
In addition, caregivers were reminded to ask each other every day, does this patient still need to have a catheter in place? "[If not], efforts were made to remove the catheter," she said. "This, I think, was significant because the whole team got involved in deciding whether or not a patient needed the catheter. We also implemented a checklist [that included such items as] was the patient draped appropriately, did people wash their hands?"
A critical component was the aforementioned decision to authorize nurses to stop the catheter insertion procedure if a violation of the guidelines was observed. "We empowered nurses to stop 'take off,'" she says. "That means if they saw the inserter of the catheter doing something wrong, breaking sterile technique, they had the power to say, 'No, you need to stop.'"
Driving the infection rate from 11.3/1000 catheter days to 0/1000 catheter days in one ICU resulted in an estimated 43 CR-BSIs prevented, saving 559 additional ICU days and $1.8 million in additional costs per year. Instances of CR-BSIs have remained low and have prompted careful tracking by unit care teams. Information on identified CR-BSIs now is systematically collected and shared with units on a weekly basis. When CR-BSIs do arise, they bring about focused, multidisciplinary attention.
Cosgrove adds that colleagues have expressed disbelief that "bloodstream infections could get to zero in an ICU because our patients are sicker and our ICU stays are longer. I think that this is a commonly held feeling and is something that has to be overcome. 'Approximating' zero catheter-associated bloodstream infections is possible regardless of the size of the unit or the acuity of its patients. It requires more than just the existence of a policy or a guideline to make this happens. This is an educational and a simplification process that — most critically in my mind — includes the empowerment of staff to create a culture of safety."
Empowering nurses and other clinicians to speak up when they perceive a patient safety problem may be the most important component of emerging new programs designed to drive infection rates to zero, emphasizes Sara Cosgrove, MD, hospital epidemiologist at John Hopkins in Baltimore.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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