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Facility Identifies Four Ways to Lower Infection Rates

Heather Comak, May 4, 2009

To prevent central line–associated bloodstream infections (CLABSI), Swedish Medical Center (SMC) in Seattle has found sharing information with staff members and simplifying techniques has made all the difference.

SMC is a participant of Institute for Healthcare Improvement's (IHI) campaigns, which has featured CLABSI prevention as a part of its past two campaigns. Its efforts have spread beyond ICUs and now include central lines placed by anesthesiologists and interventional radiologists.

By incorporating the following four techniques into its practice, SMC has at one time gone 12 months without reporting a CLABSI in some of its ICUs, and has currently not had a CLABSI in four months.

Staff education
Before 2005, when the more organized effort to prevent CLABSI began, the facility would often fail to keep up with educating staff members, says Will Shelton, M(ASCP), CIC, director of epidemiology and employee health at Swedish Medical.

"As the education wore off, our compliance would go down and the rate [of infection] would go back up, and so the rates were constantly this yo-yo up and down," says Shelton.

Learning from the IHI's model, which involved bundling education with several prevention techniques, such as hand hygiene, optimal catheter selection, clorhexadine antiseptic, and, in SMC's case, an antimicrobial bio patch on the site, it was able to post weekly infection and compliance rates for staff members to see.

In addition, the facility implemented one-on-one meetings with nurse managers for those staff members whose patients were not in compliance.

The graphs were very powerful, says Caroline Truong, RN, BSN, critical care clinical supervisor, because staff members could clearly see the efforts' effects.

"We've seen tremendous dedication from the managers, nurses, the charge nurses, and the physician champions," says Shelton about the one-on-one education of complying with the bundle of actions recommended by the IHI.

Use of bundles to create a checklist
Like many efforts to prevent CLABSI, SMC created a checklist that used the recommended techniques from the IHI. However, it went a step further and had a manufacturer create all of the supplies necessary for inserting a central line in one package so whoever was completing the insertion did not have to search in different places for these supplies.

Additionally, SMC empowered the ICU nurses to speak up when they saw a physician not completing the checklist in the required manner by enlisting a physician sponsor so they felt more secure.

"There's only so much that nursing can do by themselves," says Truong. "We needed to partner with the physicians and let them know that nurses would be giving them that feedback to stop the procedure if the checklist was not followed."

The director of infectious disease wrote a letter to all staff members informing them that the facility was instituting the central line bundle insertion and that nurses would be intervening if steps were not followed.

"We gave the nurses a script too so it wouldn't be uncomfortable," says Truong. "Basically, we made all the obstacles in the past; we tried to make things easier so there'd be no excuse for not having it done unless someone was being a silent partner and seeing something go wrong but not say anything."

To further the nurses' commitment to stepping in when a checklist was not being followed, Truong had the nurses sign an "Act Boldly" statement during annual evaluations to reinforce the message.

"Act Boldly" is a slogan that the American Association of Critical-Care Nurses created as a means of empowering critical care nurses to "act deliberately and powerfully" to give better patient care.

"We have a discussion with our staff to speak up and act boldly if they see an opportunity for improvement, especially if they witness a potential or actual risk to patients or staff," says Truong.

Recognize the need for flexibility
To come up with the best policy to outline SMC's CLABSI prevention tactics, Shelton and Truong's team received permission to have a rogue policy that could be changed instantly at the suggestion of staff members.

This practice is contrary to how policies and forms are normally approved and signed off on at the facility since most forms are dated and approved by a higher committee, says Shelton.

As staff members gave feedback about the policies and checklists being created to prevent CLABSI, Shelton and Truong could instantly make changes, especially if staff members thought something on a policy or checklist was not working.

Leadership support and collaboration
Shelton says SMC' leaders are quality-focused. Support for joining the IHI's initiative always came from the top down. His team had convinced leadership earlier that taking on these types of quality initiatives was a step in the right direction by improving the quality of life for ventilator-associated pneumonia patients, which also saved the facility a significant amount of money.


Heather Comak is a Managing Editor at HCPro, Inc., where she is the editor of the monthly publication Briefings on Patient Safety, as well as patient safety-related books and audio conferences. She is also is the Assistant Director of the Association for Healthcare Accreditation Professionals. Contact Heather by e-mailing hcomak@hcpro.com.

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