Appendix 9: Back to Basics
Central line-associated blood stream infections (CLABSIs) kill 31,000 patients a year, nearly as many deaths as breast cancer. Most of these infections are preventable, and you are part of the cure.
Large, small, academic and community hospitals across the country have demonstrated that achieving and sustaining zero CLABSIs for more than a year is possible in many clinical areas. Your clinical area can achieve this zero rate, too.
There is no single therapy that wipes out these infections. It takes the concerted efforts of many people and a variety of tasks to reach zero. Based on the experiences of the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, site visits, and interactions with hospitals, we know significant reductions are achieved when the following 12 tenets are in place:
- A senior leader commits to a goal of zero.
- A senior leader holds unit-level leaders (not Infection Prevention staff members) accountable for CLABSI rates. This means expecting unit leaders to present both infection rates and weeks without an infection to senior leaders and boards of trustees and expecting unit leaders to investigate every infection and report what they found (e.g., where the line was placed and whether insertion or maintenance was the mode of the infection) to senior leaders and boards of trustees.
- Infection preventionists work closely with unit-level teams to train, monitor, investigate infections, and improve performance. Infection preventionists are the in-house experts; rather than have their role solely focus on data collection, tap into their expertise to aid your efforts.
- Unit physicians and nurse leaders “own” the goal of reducing CLABSI rates.
- Providers avoid placing catheters in the groin whenever possible.
- Hospital managers make it easy to comply with the Central Line Insertion Checklist. This means having a line cart (or kit) that meets staff members' needs, is readily available in each unit where lines are inserted, and is consistently stocked with all of the needed supplies.
- Clinical leaders standardize catheter insertion and maintenance practices across the hospital. Variation among units is acceptable if standardization is mindful rather than mindless. Mindful variation is driven by evidence, theory, or a rationale that supports the care variation; mindless variation is driven by power, position, or arbitrary factors.
- Clinical leaders create and enforce a policy that empowers nurses to stop a line insertion (or any potentially harmful act), and senior physicians serve as role models by supporting this empowerment.
- Unit leaders and infection preventionists investigate all CLABSIs as defects. Each investigation should examine whether the checklist was used appropriately, where the catheter was placed (e.g., the operating room), and whether the infection resulted from insertion or maintenance practices. Based on their results, investigators can then develop a plan to prevent future infections.
- Unit nurses review and audit catheter maintenance policy and practices.
- Clinical leaders and infection preventionists build CLABSI prevention training into physician and nurse orientations. Clinical leaders should ensure each new rotating doctor on a unit receives this training if the hospital employs residents or other rotating doctors.
- Infection preventionists post the quarterly rate of CLABSIs and the weeks without an infection in clinical units where infections are measured and report these data to senior leaders. All unit staff should know their CLABSI rates and weeks without an infection.