Linking Blood Stream Infections to Intensive Care Nursing Context of Care and Process

1. Linking Blood Stream Infections to Intensive Care Nursing Context of Care and Process Jill A. Marsteller, PhD, MPP; J. Bryan Sexton, PhD, MA; Yea-Jen Hsu, MHA, PhD Candidate; Chun-Ju Hsiao, PhD, MPH; David Thompson, DNSc, MS, RN Funded by the Interdisciplinary Nursing Quality Research Initiative, a national program of the Robert Wood Johnson Foundation Unpublished data—Not for circulation

2. Background • Central-Line Associated Blood Stream Infections (CLABSI) are among the most common and most serious types of hospital-acquired infections • Between 9,600 and 20,000 patients are estimated to die from CLABSIs annually in the US • The estimated cost of treating CLABSIs ranges from $296 million to $2.3 billion • The risks for CLABSIs are especially great for patients in ICUs, • 48% of patients in ICUs have indwelling central venous catheters • Approximately 15 million central line days per year in U.S. ICUs • CLABSI are most often preventable Unpublished data—Not for circulation

3. How was this different from Keystone ICU? • Pronovost et al. 2006 NEJM reported results of Keystone ICU project in Michigan ICUs (also New Yorker article) • This project was different because: • Randomized controlled trial • Acknowledged the key nursing role • Collected contextual measures • Team Checkup Tool and interviews w/ teams • NQF nursing quality measures Unpublished data—Not for circulation

4. Study Population • 45 adult ICUs in 35 hospitals across two affiliated faith-based health care systems (East n=35 ICUs and West n=10) • The hospitals included in this study represent 12 states and are all community non-profit religious hospitals • Religious hospitals provide health care for one-fifth of all Americans Unpublished data—Not for circulation

5. Adventist-QSRG ICU Patient Safety Intervention CLABSI-Prevention Bundle Comprehensive Unit-based Safety Program (CUSP) Unpublished data—Not for circulation

6. CUSP • Evaluate the culture of safety • Educate the staff on science of safety • Encourage staff to identify how the next patient might be harmed • Assign an executive to adopt the unit • a) Learn from one system defect in the work environment per month; b) Implement one teamwork tool every 2 months (daily goals; morning briefing; shadowing; culture check up) • Re-evaluate culture Unpublished data—Not for circulation

7. CLABSI Prevention • Washing hands before inserting a central line • Removing unnecessary lines • Cleansing the site with chlorhexidine • Using full barrier precautions • Avoiding the femoral site for line placement (some preference for the subclavian site) Unpublished data—Not for circulation

8. Study Design • Phased, clustered randomized controlled trial • ICUs randomized by hospital into intervention (23 ICUs) and control (22 ICUs) conditions for the first seven months (then control became Intervention II) • Analyses: test of the intervention Unpublished data—Not for circulation

9. Conceptual Framework Unpublished data—Not for circulation

10. Data Collection andMeasures • Laboratory Confirmed CLABSI andLine Days • Team Check-up Tool • Nursing turnover, skill mix, RN hours per patient day, PES-NWI • SAQ • Exposure to elements of the intervention • ICU Length of stay • ICU Mortality • ICU Charges Unpublished data—Not for circulation

11. RCT analysis • Intervention I group started March 2007 • Control group started the intervention in Oct 2007 • RCT compares post-intervention (Oct-Dec 2007) CLABSI rate, holding baseline (2006) rates constant (zero-inflated poisson regression) • Two groups equivalent at baseline on all measures except two (exposure to CUSP and to partnership with a senior executive) Unpublished data—Not for circulation

12. The Effect of the Intervention: Model 1 Unpublished data—Not for circulation

13. The Effect of the Intervention: Model 2 Unpublished data—Not for circulation

14. No. of Bloodstream Infections per 1000 catheter-Days Unpublished data—Not for circulation

15. Quarterly BSIs per 1000 line days Unpublished data—Not for circulation

16. Challenges of the Design • Controls knew they would also be implementing • In interviews, some controls told us they had gotten started early • Controls did not report during control period—so “post” period is actually first 3 mo.s of intervention • Education delivery was better 2nd time Unpublished data—Not for circulation

17. Staff Use (1) Unpublished data—Not for circulation

18. Staff Use (2) Unpublished data—Not for circulation

19. Estimated Lives Saved over 2006 • ~20% of people acquiring CLABSI will die from the infection • An estimated 35 to 36 people died in 2 systems in 2006 • If rate in quarter ending August 2008 stays the same over a year, only an estimated 12 people would die of CLABSIs June 2008-May 2009 • A 66% reduction Unpublished data—Not for circulation * Preliminary estimates

20. Estimated Cost Savings • BSIs cost an estimated ~$45,000 per infection • Reduced BSIs could have saved as much as $5,850,000 across the two systems!! Unpublished data—Not for circulation

21. Conclusions • The CLABSI evidence-based practice bundle reduces bloodstream infections and zero can be achieved for long periods of time • The bundle can be implemented effectively as a nursing-driven protocol for interdisciplinary team management of central line placement and maintenance • Despite the promising results there were many barriers to implementation, such as physician engagement; adherence to protocol • Difficult to achieve team compliance with monthly reporting by all team members Unpublished data—Not for circulation

22. Policy/ Managerial Implications • CMS has said it will not pay for CLABSI above the normal IPPS payment for the case starting Oct. 1, 2008 (Deficit Reduction Act of 2005) • Assumes all infections can be prevented • All hospitals will need to implement CLABSI prevention strategies • QI teams need education, attention from and support of senior management, BoD Unpublished data—Not for circulation