National Patient Safety Awareness Week

Like most acute care hospitals, Saint Francis Hospital Bartlett struggled with central line blood stream infections. In July 2008, we completed the first phase towards a focused reduction program in the intensive care unit. This unit was selected as the pilot area because it offered a consistent group of physicians and nurses maintaining those lines. During the months of January and February we evaluated our insertion kit, the number of steps and time it took to gather the appropriate materials, our culture of communication between physicians and staff, and the use of safety checklists. It was necessary to gather the preliminary information in order to determine the areas in the process that offered the greatest opportunity for improvement. Each change was preceded by staff education which encompassed the purpose of the change, supporting evidence for the change and instruction on how it would be monitored for effectiveness. We developed an all inclusive kit consistent with evidence based bundles as well as adding a time out checklist and providing a new central line procedure cart to stop the running back and forth for supplies. The most beneficial change came when we brought infection control to the bedside for monitoring and teaching. Once a week infection control rounds evaluated each patient’s risk for infection.Prior to completing all our changes, we recorded three central line blood stream infections between January 1, 2008 and June 30, 2008. After implement the changes, we had ZERO central line blood stream infections. The changes worked well until December 2008, at which time we encountered a total of three central line blood stream infections. We believed this was an isolated incident, however 2009 brought about more disappointment in our performance. In 2009 we encountered one to two infections per month for a total of 11 central line blood stream infections for the year. We continued with our established practices and conducted mini root cause analysis of every infection. During this process numerous external and cultural factors were reviewed for trends, and opportunities of improvement were identified. Our findings were discussed with both bedside staff and administrative team. In October 2009 we initiated the “clinical huddle”. This is a daily multidisciplinary reporting meeting to review every patient in house. Although time consuming it has proven effective in reducing our length of stay and infection rates. The year end summary data shows the placement of 364 central lines, with 3114 device days and an infection rate of 3.53 per 1000 patient days. So far, 2010 has shown a total of 82 central lines placed, 420 central line days and ZERO infections. Our plan is to maintain our established practices, while continuing our evaluations and identifying opportunities for improvement.

Karen Smith
Director of Clinical Quality
Saint Francis Hospital - Bartlett
TN