Sustaining Zero CLABSIs (Transcript)
May 8, 2012
Operator: Excuse me, everyone, we now have our speakers in conference. Please be aware that each of your lines is currently in a listen-only mode. At the conclusion of the presentation, we will open the floor for questions, and at that time instructions will be given if you would like to ask a question. I would now like to turn the conference over to Barbara Lucas.
Barbara Lucas: Good afternoon, everyone, and welcome to our National CLABSI Content Call. I have the privilege of introducing today your speaker Dr. Barbara Brown, who is the vice president with the Virginia Hospital and Healthcare Association. Dr. Brown heads up VHHAs organizational workforce, data sharing, community health, and HIPAA initiatives, and prior to joining VHHA, she served as the divisional head of risk management for a multistate malpractice insurer and also is associate director of a health services research institute as well as editor of a national nursing journal. Her clinical background is as a pediatric nurse practitioner and neonatal intensive care nurse. And she is a frequent contributor to national publications in the area of health care research and nursing journals. Dr. Brown received her BSN from the Medical College of Virginia, Virginia Commonwealth University, her MSN from the University of Pennsylvania, and her PhD in health services administration and research from Virginia Commonwealth University. This afternoon she will be speaking with us about Virginia’s experience on the National CLABSI Collaborative in getting to zero and sustaining success. Dr. Brown, we welcome you to the call.
Dr. Barbara Brown: Thank you, Barbara, I appreciate it. This story I have to tell is not really my story, but it is the story of 55 wonderful nursing units within the Commonwealth of Virginia who were willing to take on a challenge and really did a great job with it and learned to share. And it is my hope that with this presentation you will understand the challenges and the successes that we had during the national collaboration and what we did to reduce and sustain the CLABSI rate at a low level and sort of how we went about implementing CUSP.
Everyone has a journey. I don’t know that your journey would be like ours, but we are hoping that some of the lessons learned from our journey could help you. Now why did Virginia get chosen to do this? Sometimes I ask myself the same question. We were able to maintain our data submission rates well above others in this national project. We then were able to demonstrate sustained drops in our CLABSI rates in both the two cohorts going forward. And we were able to demonstrate the adoption of CLABSI reduction strategies and could pinpoint where the CUSP steps were working and where we still need to put more emphasis.
A little bit about our unit, we have two cohorts. The older cohort started in February of 2010, and they finished this March. The second cohort started in March 2011, and they are now a little bit more than a year into the project. Unlike other States, we did emphasize that this was a project for more than just ICUs. So our first cohort had 64 percent ICUs; the second cohort had 50 percent ICUs. And part of the reason was that we saw more non-ICU units coming in was that our hospitals in the second cohort were trying to address CLABSI and had seen some success in their ICUs but had particular units in their hospitals where a central line infection was still occurring. So it was felt that it was time to move forward. Also there have been changes in CMS reporting of central infections. And emphasis now at this particular patient safety issue is reported by all hospitals in all units across the United States.
Every State faces similar challenges to running a CLABSI collaborative. And if we look on slide 5, there are three particular ones and I think not only were these the ones that we face but they are probably similar to what you and your teams are facing. The first is getting the data submitted from your team. There are two types of data: CLABSI data, team checkup data. We found that our ICUs could easily get us the CLABSI data for two reasons. One, they had to submit it to the State anyway, so they were tracking it. And, two, the nurses could often delegate to someone not on their unit to submit this data, whether it be an ICP or a secretary, so it didn’t take a nurse to really change her timeframe in working with patients to get it in.
The Team Checkup Tool was just as important, and as you get towards the end of the collaborative perhaps more important than the rate if the rate at that point is down because it tells you where to direct your energies in getting the bundle adopted. This was more difficult to get in. But I think in the long run it was probably more productive because it has lasting value for other types of problems, and we’ll talk about those later. We found that reducing the CLABSI rate and improving safety is one the technical changes and that usually took about 6 months to get a good response to. And the second is the CUSP values and changes in behavior that change culture. And that takes a little bit longer. The nursing barriers were pretty much removed by 6 to 8 months. But the physician barriers continue, and some units are still dealing with physician barriers.
Sustainability, some units will always have problems with inspections, and every time they think they have been able to address this challenge, another one shows up. In particular, we find that those units now, based on the data coming into us, that are most likely to have problems are pediatric units, ICUs, oncology units, pediatric oncology, pediatric ICU, general oncology units, and very large metro units where there are various different groups of physicians working with patients. And we will talk about that a little bit more.
Now about our particular data submission, as you can see from slide 6, Virginia’s Cohort 3 maintained a submission rate of 91 to 97 percent. I think the cohort overall throughout the United States did well at 70 percent. But because we were diligently addressing this and feeding it, I think it was a little bit more on our radar screen. Cohort 6 is doing well in submitting. Again, it is something that has moved into other areas of importance. For example, in our State, CLABSI rates are on many hospital dashboards as well on the dashboards for the Virginia Hospital and Healthcare Association. And now all the hospitals see these types of reports.
In addition, hospital boards are now often getting reports of CLABSI rates and other patient safety issues, so that there is constant feedback and interest into what these rates are. And the third is when it comes to submitting this particular data, it's very easy to do. In care counts, it was a numerator and a denominator and it was very easy to do. It wasn’t complex, say, for those of you experienced in submitting through NHSN, a little bit more difficult. Now Virginia team report was a little bit of a different story. We started out with less enthusiasm for this report from both cohorts. Towards the end, due to my feedback, everyone pulled theirs up. And what the important message I tried to convey is, “We don’t understand how to improve this process or this program unless you can share with us what is working and what is not working.” And this was an easy tool to use, although it did require more time to submit. I'm hoping that Cohort 6 will be able to do as well as Cohort 3 has done, who has just finished.
As you can see, Cohort 6 is still struggling with the submission of the checkup tool. But they look a hair bit better than other units in the same cohort nationally. And I think what I see is that this particular type of infection is no longer a front-burner issue because of the successes. And what we have talked about as a group at our final and midterm meeting is that CUSP is not just for CLABSI. It is a way of standardizing care. And in our final meeting, we worked on what else in our daily nursing processes needs to be standardized.
So what did we do specifically to keep our submission rates high? The first was that I reviewed the care count submission reports, and then I shared them with the entire cohort within our State so that they could see where they stood in terms of submitting the needed information. When I didn’t hear from a particular unit over a two-quarter time, I then would follow up within administratively. I did follow up with individual leads within each unit when I saw we were missing data. I also reported back to the group who was missing data and for how much. And, more importantly, I think was to recognize those who did manage to meet the deadlines and did a lot of effort to show what the issues were.
There are several barriers whenever you ask busy nurses to change what they are doing. And some of them are easily resolved. Some of them are not. On slide 10, if I had to list what the barriers were, what I came up with for care counts training issues. If somebody really had a problem with getting in, we quickly got them their password. And I would walk them through the submission if they didn’t understand how to do it. Very nice for us is that HRET and MHA had designed a process that was very easy to use, so once someone had done the submission, it was “Oh, it's not that big of a deal. I can do it.”
Another issue is staff changes on the unit. It is difficult to know when the staff changes if you're not informed. And that did make a difference. If I saw a unit that was very good about submitting data, and all of a sudden I got nothing, likely there was someone who had changed a position. And another issue was units not knowing how to use the Team Checkup Tool. For example, if they didn’t have a CLABSI event in the quarter they were reporting on, they would say “Well, no, we didn’t go through a ‘How will the next patient be harmed?’” because there was a misunderstanding that you would only do that if you had a CLABSI event.
And on one of our calls, Sentara Potomac Hospital shared that the way that they were dealing with that was when they made rounds to say to the group and then discuss what is it about this patient that makes it likely they will be harmed? It's not the same wording, but for that particular group of nurses, it was easier to address the issue of how will the next patient be harmed.
So what did we see happening over time? We did see that CLABSI rates, as you can see on slide 11, we started out about 50 percent above the national goal. We finished at 40 percent under the goal, although for us being under one was not what we were really going for. We were going for zero, so we’re coming close to that.
In terms of our second cohort, they started a little bit lower. Again, I think the emphasis is on reducing these types of patient harm events, and they have not been able to go quite as low. But I think the issue here is the easy stuff. The low-hanging fruit has been addressed. And now we are left with the more insidious cultural issues that are very frustrating to nurses and sometimes very difficult to resolve.
One of the things we needed to remind people and to realize that when you're trying to reduce any sort of infection rate is the trend is not smooth, and we found that our rate didn’t just go in a linear cycle down. We had quarters where it bumped up. For example, on slide 13 you can see for our Virginia third cohort we had a bump up in second quarter and third quarter of 2011. So it took us at that point back to the drawing board to say “Okay what's different now? Where have we missed something?” You know the easy response for the second and third quarter was “Well, it was the intern’s fault. We had a lot of new nurses.” But that really was too easy, and so we needed to reeducate, ask for administrative assistance and back up in our changes, and to look at the barriers to getting the job done again and address them.
One of the specific things that helped us reduce our rates the second time around was sharing what people had learned in the first time of trying to do this project, so areas in our State where we saw hot spots. For example, one unit by the second quarter of last year really accounted for 25 percent of all the CLABSIs in a 6-month look back. So they were contacted and we said, “Tell us what's going on. Where are your successes? What is your journey?” We said “Okay, when you apply this, what can you find out?” And in many cases people had addressed this but addressed it in different verbiage. So once we talked about what do you see happening and got more of a history, like a patient tells a caretaker more, you can figure out more what's going on. I think we found we would have much better information.
Specifically, we asked what was done, and then we asked our units to share their journey, not necessarily their success but their journey, with their colleagues on the phone. As we started to do this, if you look on slide 15, the team presentations really helped others learn and said “Oh well, they have a problem similar to mine. What are they doing?” For example, one unit reported that they really were seeing changes in the insertion site of the central lines. We started out with subclavian, now many of the units were moving to internal jugular. Anatomy makes a difference.
In the original carts were small barrier protection. When the IJs started to go in what was noticed was that the infections changed, many more candida issues and mouth bacteria. So in observing the patients, it was realized that a larger barrier would be needed because the patients with an ET tube drool on the site of the injection, or by the position of their, head saliva is able to get down into and under the barrier -- one simple example. That particular finding was very helpful to the rest of the cohorts because they, too, were seeing changes.
In looking at what they saw in the technical difference, we noticed that for some hospitals it was very difficult to address removing the femoral lines within 24 hours. And some of that was education and some of that was the need to keep other lines open because of treatment processing going ahead. And we found that some of the education was that, well, the patient came up to the unit with the femoral line in and had been admitted for more than 24 hours. We were able to clarify it is 24 hours after they hit your unit. So that helped in terms of letting people understand what that criteria meant.
In looking at reducing CLABSI using our data, things that went well were the hand hygiene. I think most of us were rather shocked when we saw when we first started out that 44 percent were following the recommendations for hand hygiene. I'm happy to report at the end we’re up to 99 percent. Chlorhexidine use was well implemented as we started and got even better. We are finding now that chlorhexidine baths are being used in some other ways also with patients that maybe were not considered.
For example, one of our units reported using chlorhexidine when there is a urinary catheter in males in. And another unit is using chlorhexidine with babies that are of a particular maturity and size, again, to reduce the infection. Full patient barrier was primarily a nursing and physician education piece, and it did not take long to get that in place.
Now in looking at some of the areas that made some difficult transformations. Avoiding the femoral, that largely was a physician-nurse discussion and then administrative backing to give the nurses the strength to say, “You need to move this line.” It was convenient to have particularly in our younger patients but also particularly for a patient wearing a diaper not a good option. Removing unnecessary lines was a physician and nurse issue in terms of nurses putting that into their daily process to add, “Can this line be removed?” Many of the teams started using their computerized medical records to cue the nurse. But unfortunately implementing that took 6 months or more because they had to get into the queue with other changes that people wanted in the electronic medical record. It worked, but it takes time to get it implemented.
Reducing the rate, it's a whole lot easier when you have an excellent team checkup tool submission. You share the data on the coaching calls, and you know where the opportunities are. I think I can honestly say people used this information and took it forward. Now if you look at the challenge two on page 19, here's where the nurses on the units had less control in terms of implementing CUSP. Senior executive rounds, we’re still not seeing a consistent buy in among our administrative staff. The identified defect has improved, but again, knowing when to apply it and going to that particular modality when there is an issue often isn’t done mainly from what we can see on the reports, lack of time, and competing initiatives.
Learning from the defect, that is culture change and it's difficult to implement. Sharing the findings, I think our units do a better job with this. And, again, time sometimes keeps the unit from sharing with others or even a shift on a unit sharing from others. And if there are other ways that other units recognized and States have found to address this issue, Virginia would really like to hear from you.
Improving our patient safety work was related to three things. One, with the Team Checkup Tool counts high, we could count on our data. We knew that we weren’t just measuring an average in terms of -- someone described average to me as being your temperature at your belly button when your head is in the oven and your feet are in the freezer. When we had 80 to 90 percent reporting, then we knew we had a good sample on which to base our assumptions for recommendations for change and pulling information from our hospitals.
We did share our data on the coaching calls. And I think of all the calls that were done, the units in Virginia have found this to be the most helpful. To assist groups that couldn’t get on the call when the calls are finished, I sent them the summary of the call with the top five or six points so that people know what was addressed and hopefully it encourages them either, one, to listen to the taped call; two, contact me with questions; or, three, contact me to get in touch with a particular unit or a spokesperson for that unit that reported.
Our teams model CUSP on the call in that they shared what defects they identified, shared how they implemented the learning from defect process, and shared what they learned from the drill down. And when they were asked to report, one of the issues that were emphasized is that this is not a grade. This is not about telling people how great you are. This is to share your journey: The good, the bad, and the ugly. And I take my hat off to the units in Virginia because they were willing to do that. And there were some important lessons learned regarding that.
For example, we talked about how to encourage senior executive roundings. And one very astute ICP down at Sentara Care said, “I give my exec talking points so he knows where to discuss things with the group as he moves through the units.” Don’t expect that execs know what to say. And as a result, this is a hospital that gets good administrative support because the administrator feels comfortable coming on to the unit and discussing the issues.
We have engaged nurses as patient advocates. Our units in the western part of the State, Carillion Health System, found that by engaging the nurse practitioners that were on the care teams that they acted as advocates for patients and for CUSP in terms of “Well let's try this. Let's move this in” and reminding their peers as they rounded can we take this line out. Patient and family education assistance in preventing infections in special populations. For example, if you have a NICU of course you want the parents in there, the grandparents want to come, so you need to teach several groups about hand washing and hand washing when they leave the unit, taking off gowns, taking off things that could get infected and them putting on gowns coming into the unit. And just telling the parent is not enough. It needs to be reemphasized and follow up given.
Model checklists, many of our units have used a checklist that they put either with the cart or have posted somewhere to assist people in remembering what needs to be done. Rolling out the project across various disciplines. One of our units, and this again was in the western part of the State, said “If you wait for everybody to be available, you will never get started. You go with what you have and you grow from there.” And that had worked with them. They also said “We needed a team member on nights.” Again something very simple that helps them with implementing CUSP that was adopted by other units.
We also enabled this particular project to consider other approaches to patient safety that weren’t necessarily only tied to CUSP CLABSI. For example, if you look on page 22, one of our hospitals in Woodstock, Virginia, Shenandoah Memorial, it's a small hospital. They chose to address CLABSI throughout their hospital. And over the years they had developed a Good Catch Program. Hospital leadership gives a good catch, and it’s a baseball mitt with a ball in it, to staff who identify and correct patient safety near misses. For example, wrong medication from a contract pharmacy was caught before given to a patient. One nurse noted that patients who needed wheelchairs would try unassisted and fall. So now they have a system where a wheelchair assistant is booked, and these patients are met at the sidewalk to bring them in. One nurse noticed that a stretcher-locking mechanism was failing on their stretchers and by addressing that prevented patients from falling. Programs like this encourage nurses to speak up and other folks in caretaking areas to speak up. And now this particular hospital is getting more reports of near misses so that the systems can be addressed. It is just one of the many successes that we've seen in our State.
Using the Team Checkup Tool data, we find we still are addressing five barriers. Time, time is the biggest issue. And I would say with time also comes interruptions. Physician buy in, one unit in South Hill, Community Memorial Healthcare Center, finally posted a sign in their unit that said “Our unit, our rules,” and with administrative backing would not allow a physician to choose to use a different approach than the bundle for inserting a central line. Physician leadership, physicians are as busy as nurses. And often the attendings may be unwilling to address this issue or address a particular intern or resident who is choosing to be more independent in their choice of how they will insert a line. The same can be said for attending communication among attendings in terms of getting the support for nurses. One that we were able to adjust very successfully was CUSP confusion. In our first cohort, we realized that we had not given a good roadmap as to where hospitals should be at a certain time with their data collection, setting up their team and so forth. We have tried to address that in the second cohort. I would like to say we've done better, but I think it took just about as much time.
Nursing buy in, nursing has a lot of turnover in many of these units. And each new wave of nurses can be another challenge to implement a CUSP process. One of the ways that has been suggested to use, and this is on the national Web site, is we had one unit start to survey nurses as to their knowledge about central lines and preventing CLABSI. It is a five-question survey done on Survey Monkey so no one has to compile data because it's already done for you. For those of you that have used that system, it’s on the national Web site. I encourage you to take a look at it to see if you could use it. And that was from Riverside Regional Medical Center.
What else works? The data was robust. I cannot emphasize that enough. It takes a lot of time on the part of the State leader as well as the MHA staff to compile these numbers. I will say I was very lucky in having responsive units that were willing to use them. We shared the data. And the breakthroughs were shared. When a team had an “Ah ha” moment, they shared it with the others.
As we go forward, we see challenges in keeping CLABSI reduction in patient safety on the unit’s radar. We have continued the calls. And the second year we go to every other month. I think we lose something with that. But at the same time, I do see it keeps the submission rates up as long as there is feedback. Try to make it easy for the teams to stay in touch, either through me or through the coaching calls. Maintaining a common site to share best practices, resources, frequently asked questions, national updates. I often refer the teams to the national site so that they can get additional tools and other options and information to assist them in their patient safety journeys not only for central lines but for other patient harm.
And we’re hoping that by moving this into our Hospital Engagement Network, which many of you are probably working on also, that we will be able to sustain this. In Virginia, our QIO has indicated that they will move forward as it is also written into their eleventh scope of work. And we really appreciate the support from them.
One of the things we have tried to drive home in our final meeting is that CUSP doesn’t start and end. It really is a foundation on which units can build their patient safety process. Some of them will implement it in slightly different ways. But each of them has the opportunity to apply this process to another issue. Our final meeting focused on applying CUSP to doing cranial taps at the bedside. And one of the things we were able to discuss is this is not necessarily just for one project. It is a way of standardizing an approach to a highly variable issue in which patient harm occurs.
It takes away the variation. It may take time to figure out what specific steps work. But it really does reduce the incidence of harm, and isn’t that what we went to nursing, medical school, and hospital administration to do? Patients don’t ask much of us except three things. Cure me. Be nice to me. Don’t harm me. Working with CUSP has enabled us to really focus on that third piece of no harm. If any of you have any questions, I think we could open up the lines now, and I'll be happy to address them or give you a contact within the State of Virginia who can help you a little bit more.
Operator: Thank you. At this time, ladies and gentlemen, we will open the floor for questions. If you would like to ask a question, simply press the star key followed by the one key. That’s star, one on your touch tone phone now. Questions will be taken in the order in which they are received, and if at any time you would like to remove yourself from the queue just press star, two. Again to pose a question, that’s star, one on your touchtone phone now. And we are holding for questions. There are currently no questions in the queue currently.
Deborah Bohr: Hi, Barbara, this is Deb Bohr. Thank you for an excellent presentation. I do have a question for you. For those teams that are in sustainability, I think it's great that they're keeping the calls going. My question has to do with the Team Checkup Tool. Are they going to use that themselves on a voluntary basis, whether it's every other month or quarterly or at some frequency to be capturing those data?
Dr. Barbara Brown: At this point, I don’t know that they will, mainly because just like the units reported to us, they're being pulled off to submit other data through competing efforts. And so our hope is that when they identify a variable process that they can think in terms of CUSP to remove the variability in the choice of intervention. And that’s I think the best we can hope for. As far as an outcome, we will be tracking the central line infections as well as other issues of harm. And I think from our findings there as we work with hospitals within the Hospital Engagement Network, we will suggest CUSP as a method for addressing the variability that may cause central line infections, urinary catheter infections, ventilator-associated infections, obstetric disasters, falls, and pressure ulcers.
Deborah Bohr: Great, thank you very much. And it sounds as though the learning from defects has really been ingrained and so that that’s a tool that even if folks aren’t using the Team Checkup Tool, they're using other aspects of CUSP. And it sounds like they've really internalized and are using those tools to continue the good work, so thank you.
Operator: Thank you. And, everyone, there are no questions in the queue currently.
Mari Franks: Well, terrific. Well, this is Mari Franks from HRET and, again, I just want to thank you, Barbara, for telling the story from Virginia. And I know Barbara Lucas has been your coach throughout the collaborative and a great thank you to you, too, Barb, as well. Barb, do you have any questions or comments for Barbara?
Barbara Lucas: Well I would just like to take this opportunity to thank all of the teams from Virginia for their great participation. As a coach from MHA, we learned a tremendous amount from Virginia’s experience. And I really want to salute Barbara Brown for her leadership with the State of Virginia because they really taught all of us a lot and gave us the opportunity to share their experiences nationally as well.
Dr. Barbara Brown: Well, thank you very much I enjoy the congratulations and thanks goes to the actual nurses who implemented the process and were willing to step forward and share. And for that I will be forever grateful; so will their patients.
Mari Franks: Absolutely. Are there any questions in the queue operator?
Operator: There are no questions in the queue at this time.
Mari Franks: Well, with that, if there are no other questions or comments from the National Project Team, Barbara, do you have any last-minute comments or are we going to end the call a few minutes early?
Dr. Barbara Brown: I think we will end it a few minutes early. Again, I give the credit to the teams in Virginia. I was just the facilitator. They did the work.
Mari Franks: Terrific. Well, thank you again, everyone, and we look forward to speaking with you soon. Have a great afternoon.
Operator: Thank you. This does conclude our teleconference for the day. You may now disconnect.