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The Canadian ICU Collaborative: sustaining the gains: a lesson in humility.

"To live for some future goal is shallow. It's the sides of the mountain that sustain life, not the top." Robert M. Pirsig

High reliability organizations build sustainment into their action plans (Carroll & Rudolph, 2006; McKeon, Cunningham, & Detty Oswaks, 2009; Redman, 2008; Wilson, Burke, Priest, & Salas, 2005). The history of high reliability organizations is based in high-risk activity organizations such as aviation and nuclear plants. Health care organizations struggle to become high reliability organizations because of the unpredictability inherent within health care. One of the key messages Carroll and Rudolph cite about high reliability is that change agents must design and redesign as their organization changes. That sensitivity to an organization's needs is parallel to the success of sustaining its goals.

Goal setting is a key component of any improvement charter. It is a solid reminder for team members of their purpose and intent. Within the Canadian ICU Collaborative (Collaborative) a great deal of time is spent establishing approaches for attaining the goals and spreading the successes. We also explore what it looks like to sustain the gains or maintain those goals. However, our improvement initiatives tend to close after a year and we collectively move on to a new initiative. Often, we do not know how our colleagues are collectively fairing in maintaining their goals or sustaining their gains. A recent experience at B.C. Children's Hospital (BCCH) Pediatric Intensive Care Unit (PICU) has prompted us to explore what it looks like to continue with successes. In this article we describe BCCH's PICU's lesson in humility and the strategies they used to continue to get back on track and sustain their gains.

[FIGURE 1 OMITTED]

BCCH's PICU's lessons learned

The PICU at BCCH joined the Collaborative in October of 2004. By the end of the first 12 months they had met and exceeded their goal of reducing central line associated blood stream infections (CLA-BSI) by 50% to 62%. Over the next three years they continued to work on reducing CLA-BSI rates by incorporating the insertion and maintenance bundles into orientation for physician groups and nursing staff. In addition, central line care was highlighted during PICU nursing validation days.

Their successes continued with an overall decrease each year of CLA-BSI. During June 2007, the unit staff was thrilled when they surpassed their previous CLA-BSI-free period of four months; that infection-free stretch lasted for 13 months. Sadly, that stretch ended in April 2008 when the first CLA-BSI was diagnosed. By September 2008, there had been four CLA-BSIs (See Figure One). While staff was disappointed, they understood the patients with the CLA-BSIs were complex with the highest of risks associated with their conditions and treatments and, therefore, out of their control. However, when three more CLA-BSIs were confirmed in October of 2008, a full review was conducted to attempt to identify what could be contributing to the infections.

Root cause analysis findings

Causative factors were identified during the review of the CLA-BSI cases. Extended extracorporeal life support (ECLS) runs, limited line access leading to placement in the groin with subsequent stool contamination, use of positive pressure caps on percutaneous intravenous central catheters (PICC), practices in accessing lines and excessive needleless caps in the central line set-up were identified as potential contributing factors to line contamination. Further investigation through dialogue with physicians, ECLS technicians, OR staff and bedside nurses confirmed for the PICU quality improvement team that there were multiple causative factors that were leading to CLA-BSIs. Those findings were associated with ignorance of best practice, inconsistencies in practice, necessity based on limited options, and complacency by auditors.

Areas of concentration

Based on the multiple causative factors, a multi-pronged approach was developed to increase awareness and refocus all PICU and ECLS staff on the CLA-BSI bundles. This occurred over the next month to promote awareness and move toward zero rates of infection. The major areas of concentration were:

* Education and re-education of PICU physicians, nurses and ECLS technicians of CLA-BSI insertion and maintenance bundles.

* Site-wide exploration of use of positive pressure caps on PICC lines including how this decision was made, best practice recommendations and education.

* Commitment of physician group to change groin line placements as soon as possible.

* Increased auditing of insertion and maintenance bundle compliance via observation and discussion with staff.

Education and re-education of PICU and ECLS staff. While trying to uncover the contributing factors leading to the increase in CLA-BSIs, staff disclosed a number of discrepancies in practices and knowledge of best practice. Some of the deviations from recommended practice were attributed to a large influx of new nursing staff in the unit who adopted different care practices in their previous work environments and a gap in education of new staff and ECLS technicians in the prevention of nosocomial infections. As a result of this knowledge, the previous reducing CLA-BSI marketing campaign was reviewed and adapted to reflect the highlighted deviations from practice. Presentations to all PICU staff and ECLS technicians were conducted reviewing the CLA-BSI bundle and highlighting the identified gaps in practice. Old resource tools were updated and new ones created to capture the significance of correct line placement (See Figures Two and Three). Changes to practice and policy and procedure were made by the ECLS team to reflect correct accessing of the ECLS circuit. Using suggestions from Michie et al.'s (2005) cultural domains as a guideline, one-on-one discussions were conducted by the quality and safety leader and clinical resource nurses with both day and night staff to support them in their efforts to adhere to the CLA-BSI bundles. These proved to be invaluable experiences, as staff disclosed their values and beliefs around the bundles components and their ability to adhere to them. Many misconceptions were clarified during these discussions, which highlighted the need for clear communication in change and validation of understanding. Another invaluable lesson was making assumptions that staff who were orientated in one practice area within the centre all practised within the same parameters.

Use of positive pressure caps. Adoption of needleless caps within the central line set-up was initially a struggle within the PICU, as it was a significant change in practice. The PICU specifically avoided the use of positive pressure caps on their central line set-ups because most of them were being continually infused. In addition, great variability existed among the literature, conference presenters, and BCCH clinical experts regarding a higher risk of infection associated with the use of positive pressure caps (Yebenes et al., 2008).

Sometime during the summer of 2008, positive pressure caps became a recommended practice for PICC lines at BCCH based on a widely accepted practice with the community vascular access programs. The PICU was ignorant of the change as they rarely had patients with PICC lines, so the sitewide change notice seemed irrelevant compared to other practice issues. However, after reviewing the patients with nosocomial infections, it became obvious the use of positive pressure caps on PICC lines in PICU had likely contributed to some patients acquiring a CLA-BSI. Due to the PICU's minimal use of PICC lines, the PICU nurses believed the new caps were the responsibility of the intravenous (IV) team as they conduct daily audits of the PICC lines and change PICC dressings. The IV team thought the PICU staff was changing the positive pressure caps. This discrepancy in practices and knowledge deficit led to the creation of a site-wide committee charged with reviewing central line practices. After two meetings, the committee, which included policy development and practice leaders, educators, infection control practitioners, quality and safety leaders and IV team members, agreed with the PICU's request to have a moratorium on positive pressure caps in the PICU until the PICU was CLA-BSI-free for three months. This timeframe was suggested so the PICU could return to its desired education baseline around CLA-BSI bundles and then introduce the new practice of positive pressure caps on PICC lines. The result was a focused rollout about the correct use of positive pressure caps on PICC lines. To date no CL-BSIs have occurred in patients with PICC lines since the education.

Placement of short-term central lines. The review of CLA-BSIs identified one infection directly attributed to stool contamination. Femoral lines were usually avoided in PICU because of the risk of contamination. When this particular case was discussed, the physician group determined that there was no alternate choice at time of admission for line placement. They all agreed the line could have been changed later to another location. They also discussed the fact that suspected contamination means a central line is to be removed and not rewired. The physician group's commitment to replace a line at risk of contamination was communicated to staff through posters, shift change announcements, one-on-one discussions, the communication book and the PICU community of practice.

Auditing. Measurement is the most important aspect of identifying gaps in practice. It is also a significant time commitment. The compliance with the insertion bundle was much easier to audit based on the tool and the process of the insertion itself, which is usually controlled. Measurement of the maintenance bundle posed significant challenges. The PICU team returned to weekly audits of the central line setups. In addition, weekly discussions with staff about CLA-BSI maintenance bundle compliance were conducted by the quality and safety leader. The PICU team recognized the need for this based on the increase in infections.

[FIGURE 4 OMITTED]

The efforts to highlight the importance of compliance were shared by frontline leaders (nursing and physician) and nurse champions over a one-month period. Continued weekly follow-up was the responsibility of the quality and safety leader and clinical resource nurses.

Results of intervention

After their focus on getting back to basics of CLA-BSI prevention, the PICU at B.C. Children's Hospital celebrated zero infections from November 2008 to April 2009. (See Figure Four). The interventions were declared a success and the experience considered a lesson in humility.

The primary lesson learned from this experience was to not take success for granted. The PICU staff committed to improve on regular auditing and highlight CLA-BSI bundles during orientation of nurses, residents and ECLS technicians. The struggle with maintenance auditing remained a concern for staff and the quality improvement team. After reviewing the literature, the PICU is considering trialing direct observation of compliance with cleaning of catheter hubs and injection ports before they are accessed and using this measurement as part of the reporting of the CLA-BSI bundles compliance (Marschall et al., 2008).

In addition, staff requested better communication around results. While CLA-BSI results are reported monthly to staff through graphs depicting the incidence and rates, staff was honest in saying there was too much information on the graph. They wanted to hear about infections in a more consistent manner. To date, infections and time between infections are reported in a monthly quality summary for staff to review. Also, notices of success are posted on the PICU's community of practice, and monthly reviews of any infection through a formal reporting system have begun. In addition, the quality improvement committee felt the information obtained from the review of the CLA-BSI infection was beneficial to learning more about our practices. As a result, a commitment has been made to hold a review of each nosocomial infection at interprofessional morbidity rounds in an effort to learn and improve in a timelier manner.

Conclusion

Sustainment of any improvement is challenging in our complex health care environments. In addition, the rapid changes many intensive care units are experiencing stress the ability of staff to actualize multiple practice changes. BCCH's PICU's example of losing its 13-month zero-CLA-BSI rates and watching it increase steadily over a period of months was an example of how assumptions of adoption of a practice can catch a team unaware. In their example, BCCH had significant cultural and operational changes that influenced their PICU's adherence to the CLA-BSI bundles. Michie et al. (2005) outline multiple cultural domains with specific questions to better understand how a unit staff's cultural values and beliefs influence their acceptance or resistance to evidence-based practices. It is imperative change agents within organizations are sensitive to their practice environments' own cultural domains on an ongoing basis in order to sustain change.

References

Carroll, J., & Rudolph, J. (2006). Safety by design: Design of high reliability organizations in health care. Quality and Safety in Health Care, 15(Suppl. 1), i4-i9.

Marschall, J., Mermel, J., Classen, D., Arias, K., Podgorny, K., Anderson, D., et al. (2008). Strategies to prevent central line-associated bloodstream infections in acute care hospitals. Infection Control & Hospital Epidemiology, 29(Suppl.), S22-30.

McKeon, L., Cunningham, P., & Detty Oswaks, J. (2009). Improving patient safety: Patient-focused, high-reliability team training. Journal of Nursing Care Quality, 24(1), 76-82.

Michie, S., Johnston, M., Abraham, C., Lawton, R., Parker, D., & Walker, A. (2005). Making psychological theory useful for implementing evidence based practice: A consensus approach. Quality and Safety in Health Care, 14, 26-33.

Pirsig, R. (n.d). Thinkexist.com. Retrieved on Feb 26, 2009, from http://thinkexist.com/quotation/to_live_for_some_future_goal_is _shallow-it-s_the/12283.html Redman, R. (2008). Practice environments: High reliability organizations: Implications for nursing development. Research & Theory for Nursing Practice, 22(3), 165-167.

Wilson, K., Burke, C., Priest, H., & Salas, E. (2005). Education and training: Promoting health care safety through training high reliability teams. Quality and Safety in Health Care, 14, 303-309.

Yebenes, J., Delgado, M., Sauca, G., Serra-Prat, M., Solsona, M., Almirall, J., et al. (2008). Efficacy of three different valve systems of needle-free closed connectors in avoiding access of microorganisms to endovascular catheters after incorrect handling. Critical Care Medicine, 36, 2558-2561.

By Tracie Northway, RN, MSN, CNCCP(C), and Cathy Mawdsley, RN, MScN, CNCC(C)

Tracie Northway is the Quality and Safety Leader for Critical Care at B.C. Children's Hospital. Cathy Mawdsley is a Clinical Nurse Specialist in the ICU at London Health Sciences Centre.
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Author:Northway, Tracie; Mawdsley, Cathy
Publication:Dynamics
Date:Sep 22, 2009
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