On July 7, the Steven and Alexandra Cohen Children's Medical New York, announced an important celebration: Its 20-bed pediatric intensive care unit (PICU) became the first in New York State to go an entire year without a central-line infection. And, it became an important milestone in a movement to use teamwork to promote patient safety.
"We're not the first unit that's done it [for a year]. There are three or four others. But it's still quite an achievement, and we're going to go for two years now," says Peter Silver, MD, chief of critical care medicine at the medical center, formerly known until this past spring as Schneider Children’s Hospital.
The achievement was part of a collaborative effort among PICUs, coordinated by the National Association of Children’s Hospitals and Related Institutions (NACHRI), to eliminate pediatric catheter-associated bloodstream infections (CA-BSI). The goal was to take what was in the literature about targeting infections and enforcing it in the PICUs, Silver says.
When the PICU started its project to eliminate CA-BSI in September 2008, the infection rate was 4.7 infections per 1,000 central line days, and it was experiencing a central-line infection every 28 days," Silver says. The initial goals was to reduce the infection rate by half, while doubling the time interval between infections.
For adult inpatient populations, efforts to reduce the incidence of CA-BSI in adult patients have been successful mostly by improving insertion techniques and using the chemical antiseptic, chlorhexidine. "We weren't that lucky in pediatrics because what our collaborative found was that 10% of the infections were associated with the catheter going in, and 90% were associated with how you took care of that catheter along the way—how you kept it sterile," Silver says.
To combat infections in pediatric populations meant focusing on the catheter maintenance procedures. The improvements included a 30-second scrub of the catheter port—what they called "scrub the hub"—with a special cleansing solution for each entry into the catheter to either administer a medication or sample blood and a new protocol for changing the catheter dressing.
But for the new patient safety procedures to work, it meant that the PICU staff need to develop a new way of staff communication to promote good patient care. The use of catheters became a topic for discussion on daily rounds with both nurses and physicians, and became a part of an open conversation among team members. "We transformed our culture," Silver says.
"Several years ago, if I were to put a central line in the patient, I would go to the bedside, and I would do it myself. Now we have a dedicated nurse observer who stands there with a checklist of all the things that I as the physician inserter must follow," says Silver. This includes hand washing, or wearing the proper mask, cap, and gown.
"Everybody on the medical team has a voice, and everybody has the right in the interest of patient safety to use that voice—actually has the obligation to use that voice to speak up in order to what is right for the patient," he says.
The results of the team approach have produced results: From July 7, 2009 to July 7, 2010, Cohen Children’s Medical Center had zero infections for 2,574 central-line days. The national average is 2.9 infections per 1,000 central line days.
And, to keep the central-line infection issue front and center in the unit, a sign is posted in the unit that says how many days it has been since our last central line infection, Silver says.
"That's the greatest thing," Silver says. When nurses come back to work after a vacation, "it's the first thing that they look at: Are we still there? Parents even look at it."
"We have over 100 staff members, from all parts of our team, who are responsible for that achievement, and it only takes one mistake to bring it back down to zero," he says. “Everybody is focused on doing everything in their power to make sure that avoidable mistakes do not happen—especially on their watch."