Published in the April 2006 issue of Today’s Hospitalist
When it comes to reducing infections from central lines, having the community work as a group and focusing on the little things can make a big difference in seeing results.
That’s one of the lessons learned by the Greater Cincinnati Patient Safety ICU Collaborative, which halved the rate of central- line infections in ICU and OR patients at several Cincinnati hospitals. One of the keys to the program’s success was tackling seemingly simple tasks “how physicians get equipment for a central line, for example “and improving them.
Marta Render, MD, an intensivist who led the initiative, says that instead of undertaking a massive quality improvement project that would take years to complete, the coalition decided to take an approach that called for much smaller “and fasterpaced ” changes.
“One of the things we like to ask is, ‘What can you do by Tuesday?’ ” she explains. “We don’t want to measure you for seven weeks, we want to see what you can do next Tuesday.”
Building a better central-line tray
Dr. Render says the project took a fairly simple approach: Observe physicians inserting central lines, determine whether their technique met evidence-based practices, make changes to help those physicians follow best practices, and conduct more observation. The cycle repeats itself until the changes lead to success, which in this case meant fewer central-line infections.
During the observation phase, Dr. Render’s team spotted immediate problems with the supplies that physicians were using. Central-line insertion trays contained surgical drapes that were too small to prevent infection, and they contained both povidone iodine and chlorhexidine. Recent evidence has suggested that chlorhexidine may help reduce centralline infections more effectively than povidone iodine.
As a result, the collaborative worked with several manufacturers to modify their central-line trays. One company created a supply kit with a full body drape, while another took povidone iodine out of its tray, added a retractable safety scalpel and replaced standard syringes with safety needles. (See the box on the next page for more information.)
Focusing on simple tasks
Dr. Render says the decision to give physicians only the tools they need to properly insert a central line is a “forcing function” that helps ensure they do the right thing. “You make it easy to do it right,” she explains, “and you make it hard to do it wrong.”
“You create an accessory pack that has the sterile gown, the cap and the mask and the large drape all together, so the doctor doesn’t have to go into the supply cabinet and go looking for the right stuff,” says Dr. Render, who is director of the VA’s Inpatient Evaluation Center.
The team’s work didn’t stop at creating a central-line tray that reflects the latest evidence. The collaborative also reviewed how well physicians were meeting evidence-based guidelines when it came to inserting lines.
“We told them that we expect a large drape, a sterile gown, and a cap and mask,” she says.
Part of that process included focusing on basic tasks like how to unroll a large surgical drape and keep it sterile. While that might seem overly simple for physicians, Dr. Render notes that the reality is that the bed-size drape requires two people to keep it from touching the floor or other nonsterile surfaces.
One of the keys to success in opening a large surgical drape, the team discovered, was getting help from a nurse. “You can’t do it yourself,” Dr. Render says.
A gradual implementation
When it was time to introduce its new approach to physicians, the team took a similarly incremental approach and rolled the initiative out to one doctor at a time. That may seem slow, but Dr. Render says the approach helped disseminate the initiative with little arm-twisting.
She notes that the collaborative posted infection rates in the ICU to let everyone know that changes were being made, and that the entire initiative received a fair amount of publicity in the local media. That attention alerted physicians to expect something new in the area of hospital-acquired infections.
The best publicity, however, came from individual physicians. Because physicians learning the new techniques in the ICU performed line insertions in other parts of the hospital, they helped spread the word throughout the hospital.
Dr. Render says that physicians would come to her office asking why they didn’t have the same tools available. “You let the people doing the work spread the practice,” she explains, “as opposed to making an elaborate plan.”
The role of the checklist
A critical part of the rollout was a checklist that allowed the team to teach and monitor physician compliance with the new techniques.
To encourage nurses to use the checklist, the team taped it directly to the central-line supplies. Nurses would note which steps physicians were following “whether they used a large drape, a sterile gown, etc. “and which they were ignoring. When a patient’s lines become infected and a physician didn’t follow the new procedure, the doctor heard about it.
“We pointed out that their line is infected,” Dr. Render says, “and that they used only two of the five protections for the patient. You know that they’re never going to do that again.”
Both small and large hospitals participating in the project saw a reduction in infection rates in as little as three months. Those numbers were closely related to an increase in physician adherence to evidence-based practices from 30 percent to 95 percent.
While hospitals were able to slash their infection rates quickly, Dr. Render says that it was the result of a lot of planning and preparation that was largely transparent to the physicians.
“This doesn’t take forever,” she explains, “but that ramp-up time of getting it right first is a really critical element that we in health care haven’t learned very well.”
Another important aspect of the initiative, she adds, was changing the attitudes of physicians and other clinicians. “I’ve had very experienced doctors say to me, ‘I never have a line infection, I don’t need to do this,’ ” Dr. Render says.
Part of the problem is that everyone has heard what constitutes “normal” when it comes to central-line infection rates. “Our infection rates were in the normal range,” Dr. Render says, “and that’s the problem with the normal range. It doesn’t tell you anything about best practice, it only tells you what most people are doing.”
She notes that many of the clinicians at the hospital told her that they didn’t understand why they were tackling central line infections, as their infection rates weren’t particularly high.
That’s why she opts for an approach that is relatively fast and easy to deploy. “We are trying to push the rock uphill, and it keeps falling down on top of you,” Dr. Render says. “We want them to take a pebble and carry it to the top of the hill. Although you walk up the hill a lot of times, you’ll eventually have a rock, and you’ll have never been smashed.”
Edward Doyle is Editor of Today’s Hospitalist.
Central-line supplies to help reduce central-line infections
The Greater Cincinnati Patient Safety ICU Collaborative worked with two medical supply companies to reinvent their central-line trays. The following two manufacturers now offer their products to all hospitals:
- Medline offers a Central Line Bundle that contains a full body drape, hand disinfectant, a chlorhexidine preparation, a central line insertion checklist and other quality checks. For more information, call 800-633-5463.
- Edwards Lifesciences offers a custom central-line kit it calls the Health Alliance Safety Kit Upgrade that contains chlorhexidine applicator, a curved suture needle, safety needles, a positive pressure valve to reduce blood clots and a retractable scalpel. For more information on the product, call 800-243- 6245 and refer to custom kit #3K20H1879. You’ll be directed to your local Edwards representative.