Lean/EBP improvement showcase

Fiscal Year 2016 Organizational Initiative
Central Line Associated Blood Stream Infections (CLABSI) 

In 2015, Salem Health was experiencing an increase in Central Line Blood Stream Infections (CLABSIs), finishing the fiscal year with 15 infections across intensive care (including neonatal) and medical/surgical units. In early 2014 several CLABSIs were analyzed through a root cause analysis approach and interventions were deployed, primarily focused on insertion. CLABSIs continued to occur, and it was determined to be associated with ongoing maintenance of central lines.

Ideally there should be zero CLABSI so having 15 in FY ’15 was a call to action. In addition to preventable harm for our patients, each central line associated blood stream infection costs approximately $45,814, so an annual cost of $687,210.00.

The inter-professional team discovered numerous direct causes to the rate increase. The team concluded that an inadequate system of maintaining the line was the focus for new work. To understand current state, staff went to the Gemba to observe various central line practices, including blood draws, blood administration, flushing the line, dressing changes, and medication administration. Opportunities for improvement were identified and standard work was developed based on evidence. Implementation of these tests of change were accomplished through education and return demonstration by all nursing staff. 

CLABSI piechart 1

The result of the work was divided into four components: 
1. Adherence to maintenance standards.
2. Decreasing device days through introduction of alternatives.
3. Spreading of CHG baths to all patients with CL.
4. Application of new product – alcohol impregnated caps on needleless connector hubs.  

The specific tests-of-change that were implemented addressed the current state failure modes that were determined using Ishikawa diagrams (also called fishbone diagrams.) They included: 1) Initiation of FMEA and process flow for patient device selection, maintenance and documentation, and work-up for source of infection; 2) Implementation of Curos Caps; 3) Operationalize standard work created using current process, organizational policies & procedures, and evidence-based practice; 4) Implementation of Power Glide & algorithm for venous access device selection; 5) Implementation of no IJ or SC lines leaving Critical Care.

CLABSI fishbone

The outcomes for the project are noteworthy. CLABSI standard infection ratios (SIRs) for 1st Quarter 2015 were 0.80. By 4th Quarter 2015 the CLABSI SIR dropped by 60% to 0.18 (p value <0.05). Days between CLABSI dropped from an average of 17 days to 96 days. To sustain the outcome, the multidisciplinary team established ‘regenerate and improve’ targets to audit adherence to standards for units that had a CLABSI in the last 90 days. Once audits are completed 100% of the time for 90 days with no further CLABSI, or for units that have had no CLABSI in the last 90 days, the measure is moved to ‘sustain & operate’. Though auditing continues, fewer are required going forward unless another CLABSI occurs. 

CLABSI bar chart
Organizational focus on CLABSI prevention including adherence to maintenance bundles reduces the confidence as to which intervention caused the reduction of CLABSI. Further research is needed to isolate which intervention was the cause of the reduction seen in CLABSI. 

CLABSI barchart 2
 CLABSI scorecard