Aiming for zero

Five years ago, when a surgeon told staff at Evangelical Community Hospital in Lewisburg, Pa., that a central line infection (CLI) could contribute to a patient's death, it made them even more determined to find and resolve the problems—both clinical and cultural—that stood in the way of preventing infections.


Five years ago, when a surgeon told staff at Evangelical Community Hospital in Lewisburg, Pa., that a central line infection (CLI) could contribute to a patient's death, it made them even more determined to find and resolve the problems—both clinical and cultural—that stood in the way of preventing infections.

In 2002, those changes included introducing antimicrobial dressing at the insertion site and collecting data on infections. Then the Institute for Healthcare Improvement (IHI) released its catheter-related bloodstream infection (CR-BSI) prevention initiative, which focused on using a bundle of evidence-based interventions in all patients requiring a central line. The plank was part of the IHI's 100,000 Lives Campaign, which ran from December 2004 to June 2006, and is now part of its 5 Million Lives Campaign, which was announced in December 2006.

That program, said Tamara F. Persing, RN, MS, the hospital's infection control practitioner, brought it all together—from educating physicians to initiating a multidisciplinary approach, including the hospital's six hospitalists and a dedicated IV team that assesses all IVs every day. As a result, Evangelical, a 135-bed acute care facility with a 12-bed ICU, went from 6.5 infections per 1,000 line days in 2002 to 0 infections per 1,000 line days in 2006.

The IV team at Evangelical Community Hospital in Lewisburg Pa includes from left James Perle ACP Member Robert Scott MD James Morgan MD N Richard Anderson RN and Tamara F Persing RN MS
The IV team at Evangelical Community Hospital in Lewisburg, Pa., includes, from left, James Perle, ACP Member; Robert Scott, MD; James Morgan, MD; N. Richard Anderson, RN; and Tamara F. Persing, RN, MS.

That's impressive given the national average of approximately 5.3 CR-BSIs per 1,000 catheter-days in ICUs alone, a number that translates to between 14,000 and 28,000 deaths annually, according to the IHI. As other hospitals look to achieve similar results, motivated in part by a new CDC guideline as well as a focus on the issue by the Institute of Medicine and the Joint Commission, they need to address common problems: resistance to change, concern over time demands and costs, and a tendency to believe that infections are inevitable. And they can look to one key to Evangelical's success with this issue: gaining a physician champion. Ironically, for that hospital, the champion turned out to be the surgeon who had voiced concerns five years ago. Today a photograph of him using the proper technique is part of the house-wide educational process on CLIs.

Why bundle?

One key to reducing CLI rates is to focus on the IHI's bundle of prevention components . Programs can adjust these measures to meet their specific needs. For example, UMass Memorial Medical Center in Worcester, Mass., provided carts with all required materials for all ICUs, devised and revised a checklist and created an educational module to train all providers before they did a central line.

The results were good, said Eric Alper, FACP, a hospitalist and former patient safety officer at UMass, who began implementing changes to central line care at the 700-bed hospital with 100-plus ICU beds in 2004. Infections per central line days dropped from 11.2 per 1,000 to 4.5 per 1,000 from 2003 to 2004. “I didn't realize that a number of factors within our control could significantly cut down on CLIs in the hospital, especially in the ICU,” Dr. Alper said.

Avoiding missteps

Making these changes first requires dispelling the notion that CLIs are inevitable. “A lot of people view line infections as the cost of doing business,” Dr. Alper said. Instead, he said, they should view those infections as “failures.”

Once the results start coming in, it's easier to get everyone on board, noted Fran Griffin, RRT, MPA, the IHI's project director on the campaign. “That's when everyone realizes they don't have to sit back and say a certain amount of line infections will just happen,” she said.

Along the way, hospitals need to address behaviors as well as process. Perhaps most challenging is how to empower nurses to confront physicians and others who are not following the rules. The answer is not to focus on the interaction between the nurse and the doctor, advised Sanjay Saint, ACP Member, a hospitalist at the Ann Arbor VA Medical Center and professor of medicine at the University of Michigan, where he directs the patient safety enhancement program. “Instead, focus on what should be done in the best interest of the patient. Once that's done, issues related to ego fall away,” he said.

For example, at Beth Israel Medical Center in New York City, a nurse goes through a 12-step checklist at the front of the bed whenever a central line is to be inserted. “We empower the nurse that if you see the physicians not doing the steps, you can help them but also stop the process,” said Brian S. Koll, FACP, chief of infection control.

Just having a climate of safety can make nurses more comfortable, said Elizabeth A. Pesek, RN, BSN, critical care charge nurse at Overlake Hospital in Bellevue, Wash. “It's not how can you step in and say something,” she said. “It's how can you not?”

Humor can help, too, Ms. Pesek noted. To make a point with one physician who didn't want to wear a cap, she brought in outrageous hats and offered them to the doctor as an alternative. She also used competition to get physicians on board, grading physicians anonymously on a “report card.” It worked. “One cardiologist came and asked, ‘How do I get an A?’,” she said.

The initial extra cost of these programs may also be controversial. At Beth Israel, Dr. Koll knew up front not to expect any additional resources. But advocates point out that a successful program will not only save lives and free up staff to care for other patients but will also benefit hospitals financially. The 257-bed Overlake Hospital calculates that each CR-BSI costs $54,000. Having gone from one CR-BSI per month to zero for eight months running, the hospital estimates it has saved nearly $1 million from CR-BSIs prevented since the project began.

Success can also trickle down. For example, at the 325-bed Columbus Regional Hospital in Columbus, Ind., managers get bonuses based on how they meet quality and safety goals, including prevention of BSIs as tracked and reported on their department scorecards. The hospital, which has gone 33 months without a CLI, is next considering how to reward when there are sustained safety and quality results within their department, noted Jennifer Dunscomb, RN, MSN, clinical nurse specialist.

After zero?

Although hospitals with successful CLI programs want to move beyond the ICU to the operating room or emergency department, facilities that have remained at zero for months or even years may anxiously wonder when an infection will occur.

“You need one type of strategy to get to zero. You need a different type of strategy to stay at zero,” IHI's Ms. Griffin said.

A first step is realizing that some infections might have special causes or that some patients are so sick they're beyond the reach of infection control efforts. Next is to keep on top of new treatment modalities and prevention techniques.

“We can't rest on our laurels,” Ms. Persing emphasized. “It takes continued work. But we plan to keep our rate at zero—forever.”