Measured, Steady Approach Key to Cohen Children’s Progress in Preventing CLABSI
When it comes to making progress in some of the more challenging hospital-acquired conditions (HACs) SPS is working to prevent, everything comes back to the fundamental SPS theory of change—using quality improvement methods such as PDSA cycles; sharing what we learn with each other; and adopting, measuring, and increasing reliability to the SPS Prevention Bundles to lower rates of harm. Cohen Children’s Medical Center has seen marked improvement in preventing central line associated blood stream infections (CLABSI) in their institution by using this theory of change and applying it to their specific institutional needs.
Cohen’s team, led by Fiona Levy, MD, Chief Quality Officer; and Kathy Albert, DNP, RN, BC, CRRN, CPHQ, Director, Quality, Performance Improvement & Transformation, began by insisting that the eradication of CLABSI infections was possible and that PDSA cycles be rapidly implemented and tested, deploying the SPS CLABSI Prevention Bundle throughout the entire hospital. However, when they found that their success was limited with this vast approach, they decided to analyze the highest at-risk population and start efforts there, progressing through the hospital once progress is achieved.
For Cohen, one of the specific areas of focus is the hematology/oncology patient population.
“When you have populations with complex medical conditions, it’s easy to say ‘well, this is a tough population – of course the rates are going to be higher.’ But, SPS has allowed us to use the national data to break down barriers and silos internally and shine a tougher light on the processes we were using that just weren’t working,” said Dr. Levy. Dr. Levy then challenged the Hematology Oncology CLABSI team to create and implement a novel CLABSI prevention bundle that went on to dramatically decrease CLABSI rates.
And it is all about saving lives. Take, for example, a male patient in the high-risk hematology/oncology population at Cohen. This patient was 18 years old and diagnosed with AML, with significant developmental delays. Because of the specific bundle that Cohen used and followed with vigilance, the patient understood what would happen each shift change: he would hit his call bell and ask for (Chlorhexidine) wipes and his bath and was ready for his fresh clean clothes and bedding change.
Due to other complications, this patient was unable to be cared for on the hematology/oncology unit, so adherence to the prevention bundle was critical within every area of the hospital. And it worked. He had four courses of chemo with the same line and never had a CLASBI, despite mouth sores, diarrhea and decreased white blood cells, all of which increased his risk. The staff and his physician are vehement that if he hadn’t been part of the bundle process, he would not have gotten through without a CLABSI. The Cohen team believes the SPS prevention bundle truly saved his life.
Another key for the Cohen team is comprehensive engagement – from the patient and family to housekeeping and the pharmacy.
“The staff is engaged,” said Albert. “They know what they have to do and how important it is. They are proud ambassadors because they are transformed and have become believers in the process.”
Examples of this engagement include:
- Working with families to limit clutter, food and other items they bring so that rooms can be cleaned thoroughly as required. It is also important that family limit visitors by keeping people with colds and other health issues out of the room.
- Relying heavily on the housekeeping team to not only keep the room clean but also serving as eyes and ears of the care team. For example, they know that if the patient’s central line is on the floor they need to let the nurse know. And, they are very proud of the role they play in keeping patients safe.
- Developing an SOP for any of the high-risk patients (Download: SOP 1 and SOP 2) and making it simple. The SOP consisted of a card with instructions and a photo or graphic illustrating the instructions in a box-like format. This card is laminated and every patient has it hanging next to the line. That way, when the patient leaves the area for a test or procedure – the card goes with them so that all departments understand the protocol.
Finally, every CLABSI gets a root cause analysis, which includes input from the care giver, infection control and physician. The analysis includes a failure mode effect analysis to determine any weakness in the process. However, when the analysis is complete, the team does not jump in and make whole-scale, full institutional changes. They do small tests of the recommended changes – one patient, one nurse, one situation. Then, the team analyzes the results and if it’s successful, they build out from there.
As Dr. Levy shares, “Being in SPS has been an enormously successful opportunity for our hospital. Working with other providers of pediatric care is so empowering and you don’t feel so lonely on the journey. What SPS is doing is incomparable and unparalleled in the industry as a whole. The labor of love that went into designing SPS from the beginning is benefitting our patients and staff alike. It’s not anecdotal change – it’s data-driven – and it’s truly transformative work.”