Inside Duke Medicine

Teamwork, focus on work culture significantly reduce bloodstream infections

 (See the September issue of Inside Duke Medicine for more stories on patient safety.)

If you forget to wash your hands before entering a patient room in the Critical Care Unit of Durham Regional Hospital, you can count on a gentle but firm reminder from Amy Wright, RN, and the CCU team to find some sanitizing foam or a sink.

From Durham Regional to Duke University Hospital to Duke Raleigh Hospital, simple steps like handwashing, combined with innovative approaches to patient safety, have significantly reduced central line catheter-associated bloodstream infections over the last 18 months.

But success didn’t come easy, say nurses, physicians and hospital leaders. The effort required a close look at how care providers work together and how each contributes to the safety of every patient.

“Preventing bloodstream infections is not rocket science. Doing it right is not the hard part,” says Wright. “The hard part is understanding that a CCU is a complicated, fast-paced place with a lot going on, and then realizing that doing these things is important because each patient is important, and that we as a team have to be committed to doing them each and every time.”

Central line catheters are plastic tubes inserted into major blood vessels to allow caregivers to channel medication and other fluids directly into a patient’s bloodstream. Because insertion requires piercing the skin, catheters can serve as pathways for bacteria to enter the body. Central-line infections can complicate or jeopardize a patient’s recovery. In addition, they can increase the cost of a hospital stay by an estimated $34,000-$50,000 per case.

DRH’s CCU has not seen a central line-associated bloodstream infection since January, says Lorrie Jones-Hartley, RN, MSN, CPHQ, the hospital’s chief safety and quality officer and patient safety officer. She gives much of the credit to the Team STEPPS program, an evidence-based program which builds team effectiveness, and the commitment of staff who care for the patients on a daily basis.

At DUH, the 2200, 3200, 4200, PICU, PCICU, ICN, 7200 and 8200 intensive care units have all achieved periods of more than 100 consecutive days without a central line bloodstream infection. As of mid-August, the Intensive Care Nursery had 206 consecutive days, setting a new record for the unit with every additional day.

The hospital record is held by the 7200 Unit, which has gone as many as 311 days without an infection. Neeley Pollard, RN, a 7200 charge nurse, says staff achieved that performance by first committing to improving patient safety and to following evidence-based standards.

As of Aug. 23, DRAH’s ICU had not encountered a central line-associated bloodstream infection for 193 consecutive days – a run that began February.

“We set a goal as a health system to improve – and wow, did we improve,” says Karen Frush, M.D., chief patient safety officer for Duke University Health System. “This takes tremendous work – and true teamwork. Our critical care teams didn’t just reduce the rate. In many instances, we got to zero. That shows we are putting the patient first.”

At heart, the effort really focused on changing the culture of teams caring for some of the sickest patients. “It’s about fostering and growing a culture of safety, which always puts the patient’s needs first,” Frush says.

Targeting central line infections represents an opportunity to have a significant, measurable impact on patient safety, she says. Research has shown that specific procedures implemented and sustained broadly in ICUs can reduce and even eliminate central line infections.

Key safety steps include handwashing; wearing full sterile gowns, gloves and facemasks; fully draping the patient before insertion; cleaning the skin with chlorhexidine antiseptic; avoiding the groin artery when possible; and removing catheters when they no longer are necessary.

The staffs of Duke’s ICUs also were empowered to educate and motivate themselves to reduce central line-associated infections.

“Champions” were recruited to focus on creative ideas. DRH held a Halloween-themed “bundle bash” to reinforce awareness of the protocols. In DUH, units posted the number of infection-free days on break room bulletin boards. At DRAH, the critical care team held a two-day retreat on reducing the infections.

The work has paid off, Frush says, but it’s more than just an effort to change statistics.

“It’s not about achieving a number,” she says. “It’s really about the commitment of each one of us to reducing the harm for each of our patients, each and every day.”