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

Abstract

Problem: 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. Design: 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. Setting: Adult medical intensive care unit (MICU). Key measures for improvement: Measured process of CVC care in real time; CR-BSI rate and time between CR-BSI events; and performance feedback to staff. Strategies for change: 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. Effects of change: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. Lessons learnt: 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.

Use of bundled interventions, including a checklist to promote compliance with aseptic technique, to reduce catheter-related bloodstream infections in the intensive care unit

“…Miller et al (17) analyzed compliance with an insertion bundle and a maintenance bundle separately and found that only compliance with the maintenance bundle was related to a decreased incidence of CRBSI. Interestingly, the decrease in infection rate in the studies in which the checklist was the primary intervention (18,25) was approximately 45% to 60%, similar to the magnitude of effect observed in the other studies.…”

A Clinical Predictive Model for Catheter Related Bloodstream Infections from the Electronic Medical Record

“…Wall et al studied the impact of process measure interventions in the reduction of catheter related bloodstream infections in the intensive care unit [14]. An interdisciplinary team developed a standardized, nursing checklist for CVC insertion.…”

“…These infection control process measures allowed the ICU team to directly monitor adherence to evidencebased guidelines. After two years, the investigators reported a persistent and historically low catheter related bloodstream infection rate, demonstrating that multifaceted programs ensuring maximal adherence with evidence-based infection control guidelines are effective in reducing the incidence of catheter related bloodstream infections in the intensive care setting [14].…”

Reducing Iatrogenic Risks

“…With rigorous adherence to infection control techniques, coupled with simulation-based training, such infections can be nearly eliminated. [76][77][78] An analogous transformation must occur in approaches to ICU-acquired delirium and weakness. Although these conditions may occur in the absence of specifi c modifiable risk factors ( Fig 3 ), ICU provider teams must recognize the important role that modifi able risk factors play and use process improvement methods to achieve reductions believed unimaginable today.…”

“…64 Morris et al,65 safety. 76,77 A fi ve-step checklist reduced the central line-associated bloodstream infection rate to near zero across 108 Michigan hospitals. 77 A similar approach applied to ABCDE interventions may yield analogous benefits in preventing ICU-acquired delirium and weakness.…”