Using real time process measurements to reduce catheter related bloodstream infections in the intensive care unit

Vanderbilt University, Нашвилл, Michigan, United States
Quality and Safety in Health Care (Impact Factor: 2.16). 09/2005; 14(4):295-302. DOI: 10.1136/qshc.2004.013516
Source: PubMed


Measuring a process of care in real time is essential for continuous quality improvement (CQI). Our inability to measure the process of central venous catheter (CVC) care in real time prevented CQI efforts aimed at reducing catheter related bloodstream infections (CR-BSIs) from these devices.
A system was developed for measuring the process of CVC care in real time. We used these new process measurements to continuously monitor the system, guide CQI activities, and deliver performance feedback to providers.
Adult medical intensive care unit (MICU).
Measured process of CVC care in real time; CR-BSI rate and time between CR-BSI events; and performance feedback to staff.
An interdisciplinary team developed a standardized, user friendly nursing checklist for CVC insertion. Infection control practitioners scanned the completed checklists into a computerized database, thereby generating real time measurements for the process of CVC insertion. Armed with these new process measurements, the team optimized the impact of a multifaceted intervention aimed at reducing CR-BSIs.
The new checklist immediately provided real time measurements for the process of CVC insertion. These process measures allowed the team to directly monitor adherence to evidence-based guidelines. Through continuous process measurement, the team successfully overcame barriers to change, reduced the CR-BSI rate, and improved patient safety. Two years after the introduction of the checklist the CR-BSI rate remained at a historic low.
Measuring the process of CVC care in real time is feasible in the ICU. When trying to improve care, real time process measurements are an excellent tool for overcoming barriers to change and enhancing the sustainability of efforts. To continually improve patient safety, healthcare organizations should continually measure their key clinical processes in real time.

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Available from: Kathie Wilkerson, May 19, 2015
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    • "1999). Second, despite contacting authors to obtain the actual checklists, although a number did provide these (Wall et al. 2005; Lobo et al. 2005; Costello et al. 2008), a few studies were excluded because of a lack of response from the authors. Despite these limitations, this study has a number of strengths. "
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    ABSTRACT: Central venous catheterization is a complex procedural skill. This study evaluates existing published tools on this procedure and systematically summarizes key competencies for the assessment of this technical skill. Using a previously published meta-analysis search strategy, we conducted a systematic review of published assessment tools using the electronic databases PubMed, MEDLINE, Education Resource Information Center (ERIC), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica, and Cochrane Central Register of Controlled Trials. Two independent investigators abstracted information on tool content and characteristics. Twenty-five studies were identified assessing a total of 147 items. Tools used for assessment at the bedside (clinical tools) had a higher % of items representing "preparation" and "infection control" than tools used for assessment using simulation (67 ± 26% vs. 32 ± 26%; p = 0.003 for "preparation" and 60 ± 41% vs. 11 ± 17%; p = 0.002 for "infection control", respectively). Simulation tools had a higher % of items on "procedural competence" than clinical tools (60 ± 36% vs. 17 ± 15%; p = 0.002). Items in the domains of "Team working" and "Communication and working with the patient" were frequently under-represented. This study presents a comprehensive review of existing checklist items for the assessment of central venous catheterization. Although many key competencies are currently assessed by existing published tools, some domains may be under-represented by select tools.
    Full-text · Article · Jan 2014 · SpringerPlus
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    • "Providing feedback on surveillance data to ICU staff has been associated with a reduced rate of hospital-acquired infections [14]. Such feedback is a useful complement to other strategies particularly feedback regarding adherence to good practices of CVC care [8,15,16]. The published CLABSI guidelines provide recommendations for implementing a checklist to ensure compliance with evidence-based practices and for empowering nurses to ensure compliance with the checklist (self-report method) [17]. "
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    ABSTRACT: We analyzed the impact associated with an intervention based on process control and performance feedback to decrease central line-associated bloodstream infection (CLABSI) rates.This study was conducted from March 2011 to September 2012 in five adult intensive care units (ICU) located in two Belgian tertiary hospitals A and B, with a total of 53 beds. This study was divided in three phases: P1 (baseline), P2 (intervention) and P3 (post intervention).During P2, external monitoring of five central venous catheters (CVC) care critical processes and monthly reporting (meetings and feedbacks reports posted) of performance indicators (CLABSI rate, CVC utilization ratio, compliance rate with each care process, and insertion site) to ICU workers were performed. The external monitoring of process measures was assessed by the same trained research nurse.A Poisson regression analysis was used to compare CLABSI incidence density rate per phase. Statistical significance was achieved with 2-sided p-value of <0.05. For the analysis, we separated the five ICU in hospital A and B when appropriate. Significantly improved total mean compliance was achieved for hand hygiene, CVC handling and CVC dressing. CLABSI rate declined from 4.00 (95% confidence interval (CI): 1.94-6.06) to 1.81 (0.46-3.17) per 1,000 CVC-days in P2 with an incidence rate ratio (IRR) of 0.49 (0.24-0.98, p = 0.043). A better response was observed in hospital A where the nurse participation at the monthly meeting was significantly higher than in hospital B (p < 0.001) as the percentage of feedbacks reports posted in ICU (p < 0.001). The decline in the CLABSI rate observed during P2 in comparison with P1 was independent of the insertion site (femoral or non-femoral; p = 0.054). The overall CLABSI rate increased to 2.73 (1.17-4.29) per 1,000 CVC-days with IRR of 0.67 (0.36-1.26, p = 0.212) in P3 compared to P1, but a high nursing turnover was observed in both hospitals. Our intervention focused on external auditing and performance feedback resulted in significant reduction in rates of CLABSI. Investigation continues regarding the most effective way to sustain CLABSI prevention practices and to improve the culture of safety in healthcare.
    Full-text · Article · Dec 2013
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    • "Mode of delivery of education not specified – eight studies (Price et al. 2002; Rosenthal et al. 2003; Gnass et al. 2004; Misset et al. 2004; Berriel-Cass et al. 2006; Goeschel et al. 2006; Young et al. 2006; Capretti et al. 2008). . Ten studies also used other interventions in addition to education, such as the use of a bundle (including a checklist) (Frankel et al. 2005; Wall et al. 2005; Berriel-Cass et al. 2006, Pronovost et al. 2006; McKee et al. 2008), a stepwise intervention (Bhutta et al. 2007), or other additional interventions (Bishop-Kurylo 1998; Rosenthal et al. 2003; Tsuchida et al. 2007; Lobo et al. 2005). "
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    ABSTRACT: Up to 6000 patients per year in England acquire a central venous catheter (CVC)-related bloodstream infection (Shapey et al. 2008 ). Implementation of Department of Health guidelines through educational interventions has resulted in significant and sustained reductions in CVC-related blood stream infections (Pronovost et al. 2002), and cost (Hu et al. 2004 ). This review aimed to determine the features of structured educational interventions that impact on competence in aseptic insertion technique and maintenance of CV catheters by healthcare workers. We looked at changes in infection control behaviour of healthcare workers, and considered changes in service delivery and the clinical welfare of patients involved, provided they were related directly to the delivery method of the educational intervention. A total of 9968 articles were reviewed, of which 47 articles met the inclusion criteria. Findings suggest implications for practice: First, educational interventions appear to have the most prolonged and profound effect when used in conjunction with audit, feedback, and availability of new clinical supplies consistent with the content of the education provided. Second, educational interventions will have a greater impact if baseline compliance to best practice is low. Third, repeated sessions, fed into daily practice, using practical participation appear to have a small, additional effect on practice change when compared to education alone. Active involvement from healthcare staff, in conjunction with the provision of formal responsibilities and motivation for change, may change healthcare worker practice.
    Full-text · Article · Jan 2010 · Medical Teacher
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