This article appears in the January/February 2013 issue of HealthLeaders magazine.
It isn't every day top health officials in the Obama administration and two national professional societies host an hour-long national webinar to praise your hospital for reducing central line-associated bloodstream infections in its intensive care units, and even send a U.S. Department of Health and Human Services video team in for two days to chronicle the steps you took to achieve success. It's also not every day all this happens after embarrassing data showed your hospital had among the worst CLABSI rates in the state, and that the committee you had charged to deal with all of this had failed.
With changes in your culture and practice, even while facing financial instability, your hospital manages to reverse this surprising and humiliating distinction and becomes a national hero all hospitals are advised to emulate.
It sounds too good to be true. But that's what happened to 511-licensed-bed Hospital of Saint Raphael in New Haven, Conn., which at about the same time in September 2012 merged to become the Saint Raphael campus of 1,519-licensed-bed Yale New Haven Hospital.
"I said, 'We are going to blow up the committee and put a stick of dynamite under this. We are going to start again,' " recalls Alan Kliger, MD, vice president and chief medical officer for the former hospital and now Yale New Haven Health System's vice president and chief quality officer. After he realized how comparatively poor Saint Raphael's rates really were, "we pledged that we would do whatever is necessary to get to zero infections," he says.
HHS, the Association for Professionals in Infection Control and Epidemiology, and the Society for Healthcare Epidemiology of America heard about the success and lauded YNHH Saint Raphael Campus with a first-of-its kind Partnership in Prevention award for "the greatest sustainable improvement in eliminating healthcare-associated infections." Kliger's teams had bested 40 other applicants across the country.
During a public webinar Oct. 15, Howard Koh, MD, HHS assistant secretary for health, called the award "historic" because "reducing healthcare-associated infections is so critically important. We know that HAIs affect not only one in 20 hospitalized patients, but also many more in ambulatory and long-term care settings."
"We must broaden our healthcare system from one focused on treatment, sometimes delivered late, to a system that also is focused on prevention, delivered as early as possible," Koh said, adding that reaching the goal, "involves changing entrenched behaviors for busy professionals and large complex institutions such as hospitals."
Three other hospitals received an honorable mention for their efforts: Denver Health Medical Center; Mayo Clinic Florida in Jacksonville, Fla.; and Shore Health System in Easton, Md.
The Saint Raphael success story had a few false starts. But in picking apart its processes one by one and reexamining everything it did, team members isolated a number of process errors and defects. And improve they did, coming from 3.99 bloodstream infections per 1,000 line days during the first 15 months, between January 2009 and March 2010—one of the state's highest rates—to 0.18 over the past 18 months, between January 2011 and August 2012, one of the state's lowest rates, Kliger says.
To understand Saint Raphael's improvement story, one must look back to 2008 and 2009, when the state of Connecticut launched an HAI reporting program, first by hospital size and then by hospital name.
The infection control department wasn't worried, recalls Diane Dumigan, Saint Raphael's infection preventionist. "We kept saying, 'We are close to the national mean, or we're just a little above, it, or this month we're a little below it.' "
After all, the team had implemented the well-known Institute for Healthcare Improvement "bundle" for infection prevention from 2000 to 2008, such as requiring sterile caps, gowns, gloves, and masks on all inserters, fenestrated patient drapes, chlorhexidine cleaning of skin at the line insertion sites, and using a checklist.
But with the state data out there, "when we started comparing to our colleagues, to our neighbors, we realized we were the outliers. It was an aha moment," she says.
"We were really distressed to see that our infection rate in our ICUs was so high," Kliger says. It was, he acknowledges, embarrassing.
In addition, every additional day an HAI keeps a patient in the hospital increases cost as it delays recovery. These infections were not just hurting patients; they were costing the hospital money.
John Boyce, MD, epidemiologist for the Hospital of Saint Raphael and now the director of hospital epidemiology and infection control for the merged facility, made the patient care decision that the hospital needed to get serious about stopping CLABSIs.
He found studies showing that for each hospital CLABSI, the hospital absorbs an average of $16,550 in excess hospital costs, and if the infection occurs in a patient undergoing hemodialysis, the cost can add an average excess cost as high as $22,240. Very complicated bloodstream infections can be as high as $32,462 as a mean average cost from initial hospitalization, in 2001 dollars, according to studies from the Centers for Disease Control and Prevention.
Finding the problem and fixing it wasn't easy, nor did it happen fast.
At first, the team did what most hospitals normally do when they discover they have a problem: They formed a committee, in this case a multidisciplinary quality improvement group, in 2009.
But a year later, "we looked at our infection rates again, and they were exactly the same as they were before. We'd made no real progress," Kliger says. It was a big surprise. They'd had the entire recommended CLABSI bundle in place, "but it hadn't solved the problem."
In October 2010, Kliger disassembled the old committee and started a new and much larger group that included "basically any discipline that touched the process. And we looked particularly at our challenges to find out who were the people who were getting infections at our institution.
"We did a thorough root cause analysis on every infection we found," he says, and what that revealed is that the IHI bundle and all the things it was doing "were insufficient."
This root cause analysis led to the creation of four subcommittees, each one dealing with a specific step in the process: central line preparation and insertion, line access, line maintenance, and line removal. Each committee identified key issues that impaired improvement. For example, the line removal group looked at gaps in knowledge about how long lines should stay in, while the line access committee looked at failure to "scrub the hub."
Over three short months, there was a flurry of activity, starting with the launch of a retraining in basic infection control practices and peripherally inserted central catheter lines, for physicians, nurses, and others, Dumigan and Kliger say.
Kliger says that the reeducation was incredibly basic and simple, focusing on things like " 'How do you get a gown on properly and tie it properly without contaminating yourself?' and 'How do you put gloves on?'—the nuts and bolts of sterile technique."
Were providers touching things in between without thinking about it?
"Yes," Kliger replies.
Teams also were eased into a requirement that they fill out an expansive checklist and make it part of their routine for every patient with a central line.
These checklists include the name of the person inserting the catheter, the name of the nurse who is observing, the type of catheter that was being inserted, how many minutes it took the inserter to do it, how many times they stuck the patient, and whether there were any breaks in technique.
Nurses were encouraged to write on the bottom of the checklist any comments about the insertion process, "such as 'had to remind resident to put on a sterile cap' or 'another doctor entered the room and had to tell him to put on garb if he was going to stay in the room,' " Dumigan says.
All nurses who insert PICCs were trained in insertion techniques. Nurses with the checklists were trained to know when something wasn't quite right about the process and to recognize breaks in insertion techniques. "They had the ability to stop procedures," Dumigan says.
The teams established a policy that required the placement of "avoid entering" signs outside the patient's door when a central line activity was under way to help prevent distractions for caregivers.
The teams established systems for rounding daily to reduce infections by looking at the dressing.
In March 2012, the hospital hired a simulation lab to continue on-site training of central line practices.
One surprising finding, Boyce explains, is that a few of what were thought to be infections were actually instances of contamination. In drawing blood for culture to determine infection, staff was often drawing it through the catheter instead of through a vein, which the CDC had recommended.
That practice was ingrained especially in teams that worked with patients undergoing hemodialysis, because it was often tough to find a vein.
"We worked very hard with our phlebotomy team to make sure they knew the best technique to obtain these cultures by venipuncture," Dumigan says. "If the phlebotomists couldn't obtain a blood culture, they would call the IV team to assist them, and this over time eliminated blood cultures taken from catheters."
"Our IV team was able to obtain blood cultures from veins 61% of the time when our phlebotomists couldn't," she says.
Initially, dialysis teams were resistant, Kliger says. "When we said we needed to stop drawing blood from these central lines and only draw from peripheral veins, the physicians and nurses taking care of those patients said, 'No, no. For years we've been using those catheters because our patients don't have any peripheral veins.' They said, 'We're sorry, we're not going to do that.' "
"But we did find that for the vast majority of them, we could preserve our policy and get blood for culture from veins. Eventually, our nephrologists and dialysis nurses changed their minds."
Boyce says that false positives due to contaminations were reduced in subsets of patients from around 2% prior to the venipuncture process switch to 0.5%, an average excess cost saving of about $3,300 per contaminated blood culture, according to previous studies. "We found we could save hundreds of thousands of dollars a year in a hospital our size just by not having as many contaminated blood cultures, so that's a win-win."
Kliger says at last check, the reductions have been sustained, and there have been no CLABSIs at all in recent months. The Saint Raphael Campus is now working with Yale New Haven Hospital to help it change practices there as well, Kliger says.
The process changes were all great, Kliger says, but he says that what really made the difference wasn't adding steps to the bundles or some other tricks that they employed.
"We were successful because we changed the culture."
Reprint HLR0213-9
This article appears in the January/February 2013 issue of HealthLeaders magazine.