[Show abstract][Hide abstract] ABSTRACT: 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.
Full-text · Article · Sep 2005 · Quality and Safety in Health Care
[Show abstract][Hide abstract] ABSTRACT: To implement sedation and delirium monitoring via a process-improvement project in accordance with Society of Critical Care Medicine guidelines and to evaluate the challenges of modifying intensive care unit (ICU) organizational practice styles.
Prospective observational cohort study.
The medical ICUs at two institutions: the Vanderbilt University Medical Center (VUMC) and a community Veterans Affairs hospital (York-VA).
Seven hundred eleven patients admitted to the medical ICUs for >24 hrs and followed over 4,163 days during a 21-month study period.
Unit-wide nursing documentation was changed to accommodate a sedation scale (Richmond Agitation-Sedation Scale) and delirium instrument (Confusion Assessment Method for the ICU). A 20-min introductory in-service was performed for all ICU nurses, followed by graded, staged educational interventions at regular intervals. Data were collected daily for compliance, and randomly 40% of nurses each day were chosen for accuracy spot-checks by reference raters. An implementation survey questionnaire was distributed at 6 months.
The implementation project involved 64 nurses (40 at VUMC and 24 at York-VA). Sedation and delirium monitoring data were recorded for 711 patients (614 at VUMC and 97 at York-VA). Compliance with the Richmond Agitation-Sedation Scale was 94.4% (21,931 of 23,220) at VUMC and 99.7% (5,387 of 5,403) at York-VA. Compliance with the Confusion Assessment Method for the ICU was 90% (7,323 of 8,166) at VUMC and 84% (1,571 of 1,871) at York-VA. The Confusion Assessment Method for the ICU was performed more often than requested on 63% of shifts (5,146 of 8,166) at VUMC and on 8% (151 of 1871) of shifts at York-VA. Overall weighted-kappa between bedside nurses and references raters for the Richmond Agitation-Sedation Scale were 0.89 (95% confidence interval, 0.88 to 0.92) at VUMC and 0.77 (95% confidence interval, 0.72 to 0.83) at York-VA. Overall agreement (kappa) between bedside nurses and reference raters using the Confusion Assessment Method for the ICU was 0.92 (95% confidence interval, 0.90-0.94) at VUMC and 0.75 (95% confidence interval, 0.68-0.81) at York-VA. The two most-often-cited barriers to implementation were physician buy-in and time.
With minimal training, the compliance of bedside nurses using sedation and delirium instruments was excellent. Agreement of data from bedside nurses and a reference-standard rater was very high for both the sedation scale and the delirium assessment over the duration of this process-improvement project.
Full-text · Article · Jul 2005 · Critical Care Medicine
[Show abstract][Hide abstract] ABSTRACT: ISSUE: Use of central venous catheters (CVC) has been associated with increased incidence of bloodstream infections (BSIs). We set out to decrease the rate of CVC-associated BSI (CVC-BSI) by implementing a multifaceted intervention that included provider education, a standardized insertion checklist, and real-time performance feedback.
PROJECT: Our institution defines CVC-BSI using National Nosocomial Infections Surveillance (NNIS) system criteria. During the year prior to the intervention (October 2001 to September 2002), our 14-bed medical intensive care unit (MICU) had a CVC-BSI rate of 7.6/1000 central line days. Based upon published guidelines, a multidisciplinary team developed a mandatory online tutorial and examination for medical and nursing staff. At each CVC insertion or guidewire exchange, the bedside nurse completed a standardized checklist that identified evidence-based insertion behaviors. The checklists were scanned into a computerized database, allowing rapid data entry. Real-time performance feedback reports were generated, and the MICU staff and physicians were provided unit specific data at the start of each month and 3 weeks later to allow resident physicians, who rotate monthly, to review their data and adjust their practice as needed. This collaborative intervention was designed to be educational and not punitive in nature.
RESULTS: Following implementation in October 2002, the intervention has been used for 701 CVC insertions. The CVC-BSI rate for lines impacted by this study decreased to a 2004 rate of 1.9/1000 central line days. There have been two periods of greater than 200 days each between CVC-BSI. Positive feedback from this intervention has led to its acceptance and continued use for more than 2 years. MICU is proud of the low BSI rate and works to maintain it.
LESSONS LEARNED: Using a standardized intervention aimed at CVC insertion reduces CVC-BSI rates. Development of a successful program requires cooperation and buy-in from physicians as well as nursing staff to effect change. Use of a standardized form provides data for process improvement as well as documentation for the medical record. The observation checklist is available in the electronic medical record. Due to the continued success in the MICU, we started implementing the intervention in all critical care areas in 2004.