Reducing central line associated blood stream infection in medical intensive care: leadership and standardization

Purpose:
To develop sustainable strategies for reducing incidence of central line associated BSI to fall under the NDNQI mean for Academic Medical Centers by July 2011 through 1)developing staff leadership and 2)implementing standard evidence based central line insertion and maintenance bundles.

Significance:
CLABSI burdens our entire healthcare system, both providers and payers. Estimates quantify CLABSI as costing $300 million to $2.3 billion a year, on top of a mortality rate of 10% to 30%. CMS designates it as a "Never Event" and has a policy of non-payment for this condition. (Ranji SR et al, 2007)

Strategy and Implementation:
Effective leadership and administrative support built the foundation for successful practice changes. Yale-New Haven Hospital joined the state-wide BSI prevention collaborative. The hospital-wide steering committee partnered with unit based teams and the epidemiology department to implement new standard process bundles (insertion and maintenance checklists) hand-in-hand with a vigorous evaluation methodology. In MICU, one assistant manager, a frontline nurse, and an attending took ownership of CLABSI as team leaders. The team leaders worked with the steering committee to develop the standard hospital tools. Following, they engaged RN and MD staff on the MICU, educated on new processes, tracked data, and adjusted implementation per results. Metrics include: hospital-wide epidemiological data, days since last event, and direct-observation audits. If an infection did occur, the team does a thorough case review to determine causation and follows up with providers who cared for the patient.

Evaluation:
The MICU achieved and is sustaining a significant reduction in incidence of CLABSI. The unit went 151 days with no infection in early 2011 and performed better than the NDNQI benchmark mean 4 out of the last 5 quarters. MICU had zero CLABSI in calendar year 2010 quarter 1 and 2011 quarter 1.

Implications for Practice:
Improved quality care for patients with central lines using standard bundles leads to reduced BSIs. All ICUs within YNHH and the 2 other hospitals within the YNHH System can benefit from collaboration to standardize best practices to reduce infection rates, improve care and reduce loss of revenue.