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Service Delivery Innovation Profile

Nurse-Enforced Protocols and Associated Tools Significantly Reduce Catheter-Related Infections in the Intensive Care Unit


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Summary

As part of a system-wide effort to transform inpatient care and eliminate preventable injuries and deaths, St. John Hospital and Medical Center (part of the Ascension Health System) developed standardized, nurse-enforced protocols to prevent catheter-related bloodstream infections, tools to assist in following these protocols, and an education program for physicians and nurses. Pre- and post-implementation comparisons show that the program has significantly reduced catheter-related bloodstream infections (from 9.6 to 3 per 1,000 central line days) and delayed the onset of infections in those who develop them; the reduction in such infections has led to substantial cost savings.

Evidence Rating (What is this?)

Moderate: The evidence consists of before-and-after comparisons of catheter-related bloodstream infection rates and infection-free catheter days, along with post-implementation data on protocol compliance and estimated cost savings.
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Developing Organizations

St. John Hospital and Medical Center
Detroit, MIend do

Date First Implemented

2004
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Patient Population

Vulnerable Populations > Intensive care unit patientsend pp

Problem Addressed

Nosocomial infections, particularly catheter-related bloodstream infections, are a major, costly, and preventable problem for patients in the intensive care unit (ICU). However, implementation of proven practices for preventing such infections remains highly variable.
  • A common problem: Each year, between 5 and 10 percent of the more than 5 million ICU patients in the United States develop a nosocomial infection. Catheter-related bloodstream infections are among the most common type of nosocomial infection in the ICU,1 and more than 90 percent of them occur with central lines (which are placed in almost one-half of all ICU patients). In the second half of 2003, the catheter-related bloodstream infection rate at St. John Hospital and Medical Center averaged 9.6 per 1,000 central line days, well above the 2002 national average of approximately of 4 reported for medical–surgical ICUs by the National Nosocomial Infections Surveillance System.2
  • A costly problem: Nosocomial infections are a major cause of morbidity and mortality.1 In aggregate, central line infections cause between 14,000 and 28,000 deaths each year3; the cost of one blood stream infection is estimated to be between $35,000 and $58,000.2
  • But largely preventable: Studies suggest that many catheter-related bloodstream infections can be prevented if all nurses and physicians who insert a central line adhere to a single set of evidence-based practices.3 However, hospitals vary in their implementation of these practices.4

What They Did

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Description of the Innovative Activity

To improve the process and outcomes associated with central line administration, St. John Hospital and Medical Center developed a set of standardized protocols (enforced by nurses), tools to assist in following these protocols, and an education program for physicians and nurses. Key elements of the program include the following:
  • Nurse-enforced central line insertion protocols: A protocol for central line insertion was developed based on the Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee Guidelines3 and the Institute for Healthcare Improvement (IHI) Central Line Bundle.5 With support from the ICU nurse manager, nurses monitor adherence to the protocol and have the right to stop the procedure at any time if a physician or resident is not complying. The ICU medical director serves as a contact person if problems occur. The protocol specifies the following practices:
    • Before the procedure: Physicians should practice appropriate hand hygiene (i.e., wash hands or use hand sanitizer); the physician and his or her assistant should use cap, mask, gloves, and gown; a full drape should be used to cover the patient; and the patient's skin should be prepared with chlorhexidine.
    • During and after the procedure: A sterile field should be maintained during the procedure, and a sterile dressing applied afterward.
  • Checklist: The ICU nurse uses a central line checklist (that includes the steps outlined above) to document the procedure, including date/time of insertion, unit, line location, line type, procedure (new line or rewire), whether the procedure is elective or emergent, and whether the patient is intubated. The introduction to the checklist specifies that nurses have the authority to stop line placement if protocols are not followed.
  • Central line cart: To make following the protocols as easy as possible, a central line insertion cart is placed in each ICU; the cart includes packets that contain all necessary supplies for central venous catheter insertion, including the lines, chlorhexidine skin preparation, full drapes, caps, gowns, masks, and gloves.
  • Encouraging early removal: ICU clinicians are encouraged to remove central lines as soon as possible; rounding physicians evaluate the necessity of central lines as part of their daily assessment of the patient. Hospital policy calls for femoral lines to be removed within 72 hours, and lines placed in response to an emergency to be removed within 24 hours.
  • Ongoing education: To educate existing staff on catheter-related bloodstream infections and the protocols/tools, the medical director of infection control led a 1-hour seminar for resident physicians, while other infection control department staff led a similar session for nurses. Infection control department personnel lead monthly sessions for new clinical staff and for rotating resident physicians. Topics covered during the sessions include the following:
    • Problem overview: The session leader reviews the significant clinical and economic costs associated with catheter-related bloodstream infections, including morbidity, mortality, and the impact on hospital finances.
    • Central line alternatives: The leader reviews different types of available central lines, indications for their use, and the infectious and noninfectious risks associated with each.
    • Placement: The leader reviews appropriate sites for central line placement, emphasizing the need to avoid femoral lines when possible (given their association with infection and thrombotic complications).
    • Description of tools and monitoring processes: Attendees learn about the central line protocols, the checklist, and the cart, along with strategies that will be used to monitor and improve compliance.
    • Other topics: Other covered topics include a discussion of possible implementation barriers and how to address them, and the important role of the intravenous (IV) team in central line care.

Context of the Innovation

St. John Hospital and Medical Center is a 772-bed tertiary care teaching facility in Detroit, MI. The institution has 60 adult critical care beds in four ICUs: surgical, medical, cardiac, and cardiovascular. St. John is part of Ascension Health, the largest Catholic and largest nonprofit health care system in the country. In 2002, Ascension Health articulated a "call to action" to its 67 member hospitals to initiate a comprehensive campaign to eliminate preventable injuries or deaths by 2008. Ascension chose St. John and one other site (St. Vincent Hospital in Birmingham, AL) to be “alpha sites” for addressing nosocomial infections, which was identified as one of eight priorities for the campaign. St. John's clinical leaders were particularly interested in participating because they saw the program as an opportunity to reduce the hospital's above-average catheter-related bloodstream infection rate.

Did It Work?

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Results

Pre- and post-implementation comparisons show that the program has significantly reduced catheter-related bloodstream infections (leading to substantial cost savings) and delayed the onset of infections in those who develop them.
  • Significant decline in infections: The mean catheter-related bloodstream infection rate fell from 9.6 per 1,000 central line days before the intervention (July 2003 to January 2004) to 3 per 1,000 afterward (February 2004 to January 2006).
  • Positive financial impact: A hospital analysis indicated that the program led to 16 avoided catheter-related bloodstream infections in the first 6 months after implementation, yielding a savings of more than $265,000. Additional savings have been achieved since that time, as more infections have been prevented.
  • Delayed onset in those getting infections: For those patients developing a catheter-related bloodstream infection, the average time to onset increased from 5.8 days in 2004 to 13.2 days in 2005.
  • High compliance with protocol: In the first year after implementation, 92 percent of central line placements in ICU patients followed established protocols. Data from after this time period are not available.

Evidence Rating (What is this?)

Moderate: The evidence consists of before-and-after comparisons of catheter-related bloodstream infection rates and infection-free catheter days, along with post-implementation data on protocol compliance and estimated cost savings.

How They Did It

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Planning and Development Process

Key elements of the planning and development process included the following:
  • Selection as Ascension alpha site: In February 2004, Ascension Health accepted St. John’s proposal to become an alpha site for reducing nosocomial infections.
  • Project startup: The medical director of infection control talked to the ICU director and the vice president of medical affairs to confirm that the project would be largely based on the IHI bundle.
  • Development of tools and education program: A multidisciplinary team including the medical director of infection control, the ICU medical director, the IV nursing manager, and the ICU nurse managers developed the protocols and checklist (based on the IHI bundle) and the appropriate content for the cart. The medical director and manager of infection control worked together to create the educational program.
  • Pilot testing and expansion to all ICUs: The protocol was initially piloted with one physician, one nurse, and one ICU patient, and then spread throughout the pilot ICU and later to all ICUs.
  • Program expansion throughout facility: After an analysis indicated that catheter-related bloodstream infections were still too common in patients receiving central lines outside the ICU (e.g., in the operating room, emergency department, and medical–surgical general units), the protocol was spread throughout the facility.

Resources Used and Skills Needed

  • Staffing: The program requires no new staff, as existing personnel incorporate it into their daily routines.
  • Costs: The program requires no additional expenditures.
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Funding Sources

St. John Hospital and Medical Center
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Tools and Other Resources

Protecting 5 Million Lives From Harm. Getting Started Kit: Prevent Central Line Infections, a How-to Guide. Institute for Healthcare Improvement, 2007. Available at: http://www.ihi.org/knowledge/Pages/Tools
/HowtoGuidePreventCentralLineAssociatedBloodstreamInfection.aspx


Information about implementing the IHI's central line bundle is available at: http://www.ihi.org/knowledge/Pages/Changes/ImplementtheCentralLineBundle.aspx

O’Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep. 2002;51(RR-10):1-29. [PubMed]

Adoption Considerations

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Getting Started with This Innovation

  • Ensure physician and nurse support: Clinicians and clinical leaders often need to be educated about the magnitude of the catheter-related bloodstream infection problem before they will support prevention efforts.

Sustaining This Innovation

  • Monitor the impact of the program: Ongoing tracking of infection rates will determine whether the program is working and help to ensure ongoing clinician compliance with the protocols.
  • Monitor protocol compliance by auditing checklist: Adherence to protocols may decline if not monitored on an ongoing basis.
  • Conduct a financial analysis to demonstrate return on investment: Documenting realized cost savings will help to ensure ongoing institutional support of the program.

Additional Considerations

  • Create an accessible location for supplies: The central cart is critical to program success, because it ensures that packages of appropriate supplies are easily available to clinicians.
  • Assign responsibility for protocol monitoring to nurses: Empowering nurses to stop the procedure is a powerful way of ensuring compliance with sterile procedures.

More Information

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Contact the Innovator

Mohamad Fakih, MD, MPH
Medical Director, Infection Control
St. John Hospital and Medical Center
22101 Moross Rd
Detroit, MI 48236
Phone: (313) 343-8320
E-mail: mohamad.fakih@stjohn.org

Innovator Disclosures

Dr. Fakih has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Berriel-Cass D, Adkins FW, Jones P, et al. Eliminating nosocomial infections at Ascension Health. Jt Comm J Qual Patient Saf. 2006;32(11):612-20. [PubMed]

Footnotes

1 Burke JP. Infection control: a problem for patient safety. N Engl J Med. 2003;348(7):651-6. [PubMed]
2 O’Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep. 2002;51(RR-10):1-29. [PubMed]
3 Protecting 5 Million Lives From Harm. Getting Started Kit: Prevent Central Line Infections, a How-to Guide. Institute for Healthcare Improvement, 2007. Available at: http://www.ihi.org/knowledge/Pages/Tools
/HowtoGuidePreventCentralLineAssociatedBloodstreamInfection.aspx
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4 Berriel-Cass D, Adkins FW, Jones P, et al. Eliminating nosocomial infections at Ascension Health. Jt Comm J Qual Patient Saf. 2006;32(11):612-20. [PubMed]
5 Institute for Healthcare Improvement. Implement the Central Line Bundle. Available at: http://www.ihi.org/knowledge/Pages/Changes/ImplementtheCentralLineBundle.aspx
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: October 14, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 14, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: July 14, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.