And on a closing note,
I would really like to talk about the results of our CUSP CLABSI initiative.
I think that too often,
as I've said, quality improvement is done for quality improvement's sake.
But when you treat it like vigorous research,
it really does make a difference because you have
the metrics to see what is changed over time.
That is something that you can share with your organizational hierarchy,
your front line staff,
and you know that you've made
a significant difference because you have the data to support that.
So when we look at our results here,
this goes back to our slide and what I think is really interesting these were rates
per 1,000 catheter days and you see how poorly we did.
And what you see through each one of the little peaks and valleys
is how much work it actually took
to not only implement the evidence-based practice bundle,
but the amount adaptive work that had to be done.
So first of all, there was the evidence,
so the vascular access device policy,
that had to be written based on the CDC guidelines so that it was believable.
It also had to read like it was black and white.
There were no gray areas,
it was not subject to interpretation.
We also had our hospital epidemiology infection control and Dr. Pronovost and all of
many other patient safety leaders including myself talk about
what the evidence could do for our patient population,
and why we had to adhere to the bad policy.
So just because you were used to using betadine
doesn't mean that you're using betadine anymore.
You're using chlorhexidine.
Just because you didn't like
a full barrier precaution doesn't mean that you can't use it.
You're going to be held accountable.
So, we had the policy and we saw that it made some difference but would
really made a big difference was reducing the amount of work it took for the physicians,
the PAs, the MPs to get the supplies.
So, developing that line cart and showing them where everything was
kept so they didn't have to go to eight different places to find all of their supplies.
And we thought, "Oh gosh, we're done.
Look how great we're doing.
We hit zero." We're not done.
There's still adaptive work to be done. There's a spike.
There's continuous things that go on.
So, we had issues still with people not wanting to remove the line,
and as you can say, I said, well,
eventually, people started taking them out much sooner.
But as you can see by this log,
it was a couple of years before we had everybody right where we wanted them.
So, we develop a daily goals form.
It asks every day,
can the line come out?
And there are reasons on there.
They're no longer getting the volume that they
need or they don't need the volume that we were giving.
The antibiotics are not being used
anymore or there's only on one empiric or they're on one.
We don't need a triple lumen, we don't need a double lumen.
We can get by with a peripheral line. Then the checklist.
So, we realized that some people were
still skipping steps even though they had a line cart with everything in it,
they were being reminded to get rid of the line as soon as possible.
And you see, we're kind of floating there at just under five per 1,000.
So, that's when the checklist developed in about 2003 and there was
an article written by Peter about this great checklist.
It was to remind all of us that we are
fallible and we need a reminder and that we're doing this as a team.
However, the checklist was not really complied with all the time and that's because
the frontline staff did not really feel
comfortable approaching some of the senior physicians that were placing the line.
Verbal abuse, being screamed at,
it just doesn't sit well.
It makes you not want to go to work if you were the nurse.
So, the next component was we had to empower
the nurses and the only way to empower those nurses was to say,
"I've got your back," which is why
so many people gave them their business cards and said,
"If you have any problems,
give me a call anytime, day or night,
if you have a house office or or
an attending physician who is not complying with the evidence."
And as soon as they got those first few calls and they knew it was happening,
that they were going to be using the daily goals,
they were going to be using the checklist,
they were going to be following the evidence because the nurses were
a big partner in our goal to reduce the CLABSI rates,
and they were definitely a partner the patient as
an ombudsman and a partner of the physician
because they were now their partner when they place the line.
They were keeping track,
and an audit trail to make sure that they actually did what they were supposed to do.
So, lots of hills and valleys and as you can see,
all of that adaptive work and the tools that we developed through
the CUSP program in order to make not only it easier for them to follow the evidence,
but to make sure that we had
a 100 percent compliance or near 100 percent compliance most of the time.
And at the end of the study,
when we did get to zero,
we still, with our back to basics campaign,
we did not need to go to advanced technology like the bio patch or
the chlorhexidine-infused central line dressing
or the impregnated catheters with antibiotics or anything like that.
Just by doing what you're supposed to all the time every
time really made a significant change in CLABSI.
And so, as I said,
we had some units that have gone for years without any CLABSI.
Lastly, I'd like to show what you hopefully will see in your climate scores.
So, culture is important and as you can see, the pre-intervention,
these were the two units that we worked with at
Johns Hopkins to implement the CLABSI initiative with the CUSP program.
And the CUSP program was new.
It was also in the developmental phase,
so pre-CUSP, you see the WICU,
the Weinberg ICU and the surgical ICU,
and we're somewhere down there around 30 some percentile.
So, that's respondents feel that they work in a safe environment.
Is the climate good? Can I speak up?
Do I feel comfortable working here?
Do I feel like I'm giving good care here?
Well, they did not.
They were in the 30 percentile.
And the way the culture is scored is,
anything above 80 percent needs no intervention.
Anything below 60 percent definitely needs an intervention.
60 and 80 is more of a gray area. Maybe, maybe not.
But we do ask that people work on one to two areas of their culture.
And then we see at time two, post CUSP,
we see that the WICU jumped forward and the SICU jumped forward.
And at time two,
by the end of our implementation,
they both were two of the units in the highest percentile.
So, as I said,
that is all because of the Comprehensive Unit Safety Program.
It is the only program that is shown to improve culture over time.
So not only did we kind of
managed to get rid of our central line associated bloodstream infections,
we also improved the place that we work which makes coming to work a much better day.
And again, that's the adaptive component.
It's probably more important than the technical component.
You can follow the evidence.
But if you don't have a culture that supports following the evidence and adhering to it,
you will never have the success that you have with
a team that is willing to work together and respect each other.
Just a few little notes for best way forward.
And that is, anything that we do in quality improvement is not done on a whim.
We are informed by science,
what does the evidence say.
As we're looking at the technical work,
we want to also look at the adaptive work like,
what are we going to need to do to get physicians and nurses on board?
What are we going to need to do to get the senior executives to see this as a priority?
And guided by valid measures,
again, the metrics are really important.
Quality improvement for quality improvement's sake is
never going to be as important as when you can
show a numerator and denominator and show that your rate has gone down.
So, metrics are very important.
Look at your local and your national so you might want to
compare how you're doing nationally with the NSH data or the CDC.
And then compared to local hospitals within your state just to see how you're doing.
And I would say finally,
that the top-down approach,
as we often know,
doesn't always take hold.
And so, when you use a different approach,
like one with the front line providers are making the change,
they are the change agents for and improve culture and reduce defects,
supported by your senior executives,
you really have changed the whole hierarchy of your organization.
And as we have found,
it builds capacity and patient safety,
reduction in adverse events and defects that we see within our systems,
and we have a quicker turnaround on things that need to be fixed,
and we have a much better relationship within the organization as a whole.
David Thompson DNSc, MS, RNAssociate Professor
