Denise Murphy, RN, MPH, CIC is Vice President and Chief Safety and Quality Officer at Barnes-Jewish Hospital in St. Louis, MO.

1. Has your institution/facility identified a facility-specific “bundle”(products, protocols) to reduce the occurrence of CABSI? What are the elements of that bundle?

Yes—we use the bundle recommended by the IHI (Institute for Healthcare Improvement):

• hand hygiene
• maximal barrier precautions upon insertion
• skin antisepsis with chlorhexidine
• optimal catheter site selection, with the subclavian vein as the preferred site for non-tunneled catheters
• daily review of line necessity with prompt removal of unnecessary lines

2. How did your facility de­termine this bundle, and how was it implemented?
large academic medical center (1300 beds and 6 ICUs) had been following general IHI recommendations since 1999. We became involved in the IHI’s 100,000 Lives Campaign launched in 2005 and subsequently adopted the bundle.

The process began before 2005, however. We’d been looking at the problem of CABSI since 2000, and specifically at 3 areas: education for healthcare workers, aligning our policies with the those of the CDC (Centers for Disease Control and Prevention), and issues surrounding the process of placing and maintaining central lines. We knew that we’d been following recommendations but not consistently, so we had decided to audit the process of care; it was the right thing to do for our patients. We were thus well-prepared to implement the bundle.

The people responsible for overseeing implementation of the bundle were the bloodstream-infection prevention team. They targeted the ICUs first and mapped out 4 steps:
1.   In each ICU, identify 1 or 2 people (e.g., physician, nurse) to champion the cause.
2.   Ensure that the administration is involved also.
3.   Draw up a checklist of every element in the bundle.
4.   Implement the bundle and provide the checklist across all the ICUs.
It took a year before the bundle was implemented in the 6 ICUs. We are currently taking it to the rest of the patient-care units.

3. What are the elements—products and procedures—of your organization’s bundle that have produced positive outcomes?

Every central-line insertion involves 5 steps:
1.   decision to insert
2.   preparation for insertion
3.   insertion
4.   care and maintenance of the line
5.   discontinuation process
           
We want all our patients undergoing this process to have the same experience: the best experience. A static process of merely setting rules won’t ensure that, so we’re performing value-stream analyses to redesign the patient’s experience. Apart from patients, the key stakeholders in this analytic process are the IV team, hospitalists, the anesthesia department, the Lean Six Sigma group, patient care directors, nurse and physician educators, and even a human factors engineer.
In the meantime, staff nurses who are patient-safety liaisons audit compliance with the bundle. Subsequently, every month the Manager of Infection Prevention provides members of the executive team, unit medical directors, and nursing leadership with compliance data and a list of the infections (with risk factors) that have occurred.
           
Any instance of CABSI is treated as a sentinel event. It elicits a rapid response, and we perform a bedside root-cause analysis. The main question is Where did the process break down?

• When there’s a problem, the front-line staff tell us what’s wrong. It’s evident that interruptions, noise, or crowded rooms can interfere with the process, and we currently have a human-factors engineer studying ways to improve this. We’ve discovered some major barriers to a good CVC outcome for patients; for example, staff don’t have the materials needed. This is usually because kits are missing critical items.

• The doctor is interrupted while placing a line. Now we put a big stop sign on the CVC supply cart, then park it in front of the door to the patient’s room. This has cut down on interruptions.

We all know that resources are tight; nonetheless, we ensure that experienced people are involved: IV-team nurses put in PICCs (peripherally inserted central catheters), and the hospitalist procedure team puts in most CVCs. Clinicians are also asking for a better vascular-access coordinating function (similar to air traffic control).
           
We have a policy that CVCs are not to be used for drawing blood samples, but nurses are often pressured to be quick, and some occasionally use the CVC. This is an example of how it’s often the system that’s at fault, not the people working within it. When we discover a situation such as this pressure to be fast, our response is not to be punitive but to communicate and drill down instead and to look for root causes of shortcutting and ways to improve the situation.
           
We also realize that, in the past, nursing schools did not ensure that their students were proficient in starting peripheral IVs; as a result, nurses would ask for a central line to be placed. Our affiliated school of nursing is responding to this, providing simulations so that students, and our hospital nursing staff, get the necessary experience.

a) Can you tell us about site preparation, connectors, flushing protocols, etcetera?
           
The answer is pretty simple: follow the bundle. Use anything (for example, chlorhexidine) where there is good evidence. Use the right catheter and insertion procedure for the given situation. And communicate often to everyone involved with the experience, including the patient.

b) Do you feel that a renewed emphasis on staff education may be necessary to reinforce good practice for antisepsis of valves? of any other elements?
           
Absolutely! Education has too often been scattershot, hit-and-run. Education must be continuous. We have on-line modules that residents must study at the beginning and repeat at the start of an ICU rotation. They’re also observed placing lines and are left alone only when we’re satisfied that it’s being done correctly. To help the process, laminated pictorials of procedures are available. Nurses are trained in every aspect of managing central lines, not just dressing changes, so they can also help provide house staff with the best hands-on training. We’ve also been asking patients about their experiences and, as a result, are developing brochures to explain our efforts.

c) What methods have proven most beneficial for you in improving decontamination of IV ports?
           
We have a vigorous “scrub the hub” campaign going on.

4. What would you consider the reasons for your success in reducing CABSI? What do you feel still needs to be done?
           
Until we instituted the bundle we had been having more than 300 cases of CABSI each year, but this year we’ve had approximately 40. The team approach has been vital to our success. We have knowledgeable, empowered management. We have commitment from our infection-control leaders, because they’ve been educated and understand the problem and are being given solutions. And we have front-line staffers redesigning processes because nobody knows patients like they do.
           
At our hospital we’re still refining our approach to infection prevention, but we have real commitment from administration and staff, which is important. This is continual work that requires a long-term commitment.

5. Is there anything else on this topic that you feel should be mentioned?
           
I feel lucky to be in my position. It’s wonderful to be an advocate for both patients and staff. As with any experience, it must be a partnership between those doing the work at the front line, those supporting and resourcing the work (leadership), and those that the work impacts (our patients). Although it has been somewhat of a rough road at times, increased pressure from external forces, such as accreditation and regulatory bodies, as well as consumer advocates has helped us in patient safety and quality roles to bump patient-care practices higher up on the priority list—for everyone.