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Four “C’s” to Conquer CLI:

This paper details Sturdy Memorial Hospital's comprehensive and collaborative strategies implemented from 2002 to 2007 to effectively prevent central line infections (CLI) in its ICU. The Sturdy Excellence Program emphasizes evidence-based interventions, daily surveillance, and rigorous documentation. Aimed at promoting accountability and enhancing patient outcomes, the program involved multidisciplinary communication and routine performance evaluations while maintaining compliance with CDC standards. The initiative reflects a commitment to quality improvement and maintaining a zero tolerance approach to CLI, ensuring ongoing progress in healthcare delivery.

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Four “C’s” to Conquer CLI:

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  1. Four “C’s” to Conquer CLI: An Integrated Approach to Performance Enhancement Elaine C. Killough, RN, MSN, CCRN, CS Sturdy Memorial Hospital Attleboro, MA

  2. www.cdc.gov/nicdod/dhqp/images/Fig_CLABSI_ICU accessed 05/31/08

  3. Sturdy Memorial Hospital • 128-bed community hospital • 14 bed medical-surgical ICU • Open unit with primary intensivist coverage • Admits ~700 patients/year • Mean LOS 4.8 days

  4. Central Lines (2007) • 265 lines managed • 74.9% Multi-lumen catheters • 14.3% Dialysis catheters • 10.9% SwanGanz catheters • 73.6% placed in the ICU • 93.3% placed by intensivist • Site Selection • 46.7% IJ • 45.0% SC • 8.3% Femoral

  5. Frequency: Line Placement 2004 - 2007

  6. ICU Line Days 2004 - 2007

  7. CLI: SMH ICU 2002 - 2007

  8. Sturdy Excellence Program • Integrated quality and service improvement goals • Validity supported by evidence • Measurable outcomes • Unit/department-based • Regular reporting to Quality and Service Enhancement Committee • Review and feedback from administrative and multidisciplinary resources • High emphasis on progress and accountability

  9. An Integrated Approach Sturdy Excellence Program Senior and Risk Management/ Quality Improvement Unit Management Prevent CLI Infection Control Physicians ICU Nursing

  10. SMH ICU: CLI Prevention Practices: 2004 • Developed a formalized program of daily surveillance • Established system for auditing related documentation and dressing changes per existing protocol (record review) • Provided parameters for identification of suspect lines and clarified expectations for physician response • Worked on development of comprehensive program for 2005

  11. SMH ICU CLI Prevention Program: 2005 - 2007 • Adopted evidence-based interventions as standard of care • Developed total management program: Comprehensive Collaborative Current • Partnering with QSEC to review and evaluate program effectiveness • Goal: To remain at or below the CDC median occurrence rate

  12. A Comprehensive Approach • Prior to placement: Conservative decision-making as to appropriateness of intervention. • Inclusive documentation tool: • Identifies accountable personnel. • Validates implementation of evidence-based standards at insertion. • Describes line maintenance per hospital standard, including description of insertion site, documentation of dressing changes. • Documents problems identified and resolution. • Documents analysis and review if line is suspect.

  13. A Comprehensive Approach • Line maintenance documented each shift in the electronic record. • Daily assessment/data collection by CNS or unit leadership staff: • Insertion site • Intactness/quality of the dressing • All program elements are reviewed and reinforced in orientation for all new staff including temporary personnel.

  14. A Collaborative Approach • Proactive, facilitative approach with MDs not familiar with standards • Problem-solving related to difficult sites or persistent patient problems • Regular review of documentation tools by IC RN • CNS/IC RN analysis of occurrences • Dissemination of findings to staff • Collaborative problem-solving

  15. A Collaborative Approach • Nursing education involvement in all changes in program/protocol • QSEC review of documented performance progress and goal achievement; dialogue to provide feedback, identify problems, and suggest solutions.

  16. Keeping Things Current • Problems identified are addressed immediately. • Bi-weekly reporting to management on all process elements. • Monthly reporting of process compliance and outcomes in staff meetings and through e-mail. • Reports to QSEC available on unit; feedback shared as it is received. • Annual review of program.

  17. CLI: SMH ICU 2002 - 2007

  18. CLI: SMH ICU Cases of CLI in 20 Months! (Since September, 2006)

  19. SMH ICU: CLI Prevention Practices: 2008 Incorporated a “Zero Tolerance” Approach into Our 2008 CLI Prevention Sturdy Excellence Goal

  20. The Fourth “C”…….. • Continued excellent performance. • Consistent goal-achievement. • Commitment to improving patient outcomes.

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