During the long-running effort to minimize catheter-related bloodstream infections (CRBSIs), experts, government agencies, and healthcare organizations have offered a wealth of ideas. Most are technical recommendations that advocate particular technologies or best practices that can make a critical difference in preventing infections. But technical recommendations must be instituted by human beings in an organizational environment. The culture of any healthcare organization that implements a change to decrease CRBSIs ultimately determines the success of that initiative.
Take the example of White Plains Hospital (WPH), a community hospital in White Plains, NY. Since July 2011, we’ve achieved more than a 70% decrease in CRBSIs after implementing use of a disinfection cap packaged with a flush syringe to increase compliance with cap use. The key to successful implementation was our hospital’s culture, the structures and processes developed as part of our Magnet® journey, expertise of our infection-control director, and engagement of our staff nurses. (As chief nursing officer, I also played a role.) This article describes how these factors came together to improve patient safety.
Organizational culture sets the tone
WPH prioritizes patient safety and accountability over virtually all else, and the steps we took to reduce CRBSIs reflect this. Our nursing team is aligned with the hospital’s priorities, which guide our nursing practice councils. Our nurses believe they “own” all I.V. lines, even when physicians place them. We want nurses to regard our CRBSI rate as a call to action and, more crucially, to recognize the vital role they can play in preventing infections.
As much as possible, we’ve used carrots instead of sticks. Our Magnet journey engaged frontline staff to develop professionally, with the reward of successful patient outcomes. Each nursing unit “owned” its outcome metrics; no sticks were needed. Given our hospital’s culture, our nurses knew they needed to have a passion for their work and for patients’ welfare. We were on our way to a frontline nursing staff that was in sync with the hospital’s mission. True to that mission, our executives fully supported our Magnet journey and the empowerment of our nurses to fully own their practice outcomes. The executives also knew sudden widespread change could be disruptive. (See How the Magnet process helped by clicking the PDF icon above.)
What our data review showed
In January 2010, we undertook a data collection project on peripherally inserted central catheters (PICCs), because their use was growing at WPH. The data showed an unacceptably high CRBSI rate in patients with PICCs.
To identify potential causes, our PICC team and infection-control staff interviewed nurses. When we examined our protocol for manually disinfecting I.V. connector hubs before line access, we found technique variations and occasional noncompliance were common. This was hardly surprising; the widely used “scrub-the-hub” method (scrubbing the hub site for 15 seconds and letting it dry for 30 seconds) is notorious for practice lapses. It requires meticulous execution and is somewhat time consuming. Inevitably, some time-pressed nurses take shortcuts—scrubbing for only a few seconds or skipping the drying time. These shortcuts increase CRBSI risk.
The search for an engineered solution
Our hospital’s patient-safety-oriented culture and the nursing division’s engagement gave us the freedom to add budgeted upfront costs to solve this problem. I empowered the director of infection control, Saungi McCalla, to seek an engineered solution—a device that could compensate for possible deficiencies in the scrub-the-hub method and, ideally, improve connector-hub disinfection. McCalla recommended a specific disinfection cap she’d seen in a demonstration at a conference of the Association for Professionals in Infection Control and Epidemiology (APIC). On her return from the conference, McCalla and the clinical team reviewed the disinfection cap and the evidence showing its effectiveness. The cap appeared to address problems with manual disinfection and offer more protection against bacterial ingress because it’s designed to stay in place between line accesses. It bathes the connector hub in alcohol and protects it from contamination caused by touch and airborne bacteria.
Because of the evidence regarding this cap and other features not available in other caps, the consensus was to conduct a trial of the device on the nursing units to get feedback from nurses (the end users). The cap is available both as a stand-alone device and as part of a kit that includes a flush syringe. The infection-control liaisons told me compliance was likely to be far better if we acquired the kit, because the swab cap would be at hand when nurses perform the final flush on the I.V. line.
The infection-control liaisons were the champions and educators on each unit. They conducted a 2-week trial of the kit; at the end of the trial, they were responsible for feedback and a recommendation from their unit council. The decision was unanimous: The swab-cap kit would be efficient for our nurses and would increase compliance with central-line maintenance. Our infection-control and product-evaluation committees approved the kit for adoption, on the condition that postimplementation data showed infections were reduced significantly enough to justify the added cost. In July 2011, use of the kit was implemented hospital-wide.
We now place the cap on all central lines, including PICCs, peripheral I.V. lines, and tubing components (such as Y-sites), to create closed systems. A financial evaluation 6 months after implementation showed we were saving a projected $583,230 annually by avoiding CRBSIs in an estimated 10 patients.
Interplay of factors
Several factors came together to enable WPH to reduce CRBSIs successfully.
- Our culture made a device solution possible. Not all hospitals would have allowed a device solution because of the initial costs, even if those costs were modest (as ours were). While some hospitals have reduced CRBSIs through best practices alone, that leaves them dependent on the scrub-the-hub method—a shaky proposition at best.
- Our openness to frontline nurses’ input led us to acquire the cap in kit form, which most likely improved compliance. Acquiring a device doesn’t help unless it’s actually used.
- The formal shared decision-making structure we created for the Magnet process promoted the nurses’ input.
- Building a nursing staff with a passion for the hospital’s mission was a necessary condition.
If we’d isolated one of those factors and claimed it was more important than the others, I think we would have failed. And that’s the point of the story.
Leigh Anne McMahon is senior vice president of patient care and chief nursing officer at White Plains Hospital Center in White Plains, New York.