Seven Years, Zero CLABSIs: How a California Hospital Did It
May/June 2013
Seven Years, Zero CLABSIs: How a California Hospital Did It
By Alan Reder, MA
Figure 1: A nurse on the PICC team at Sutter Roseville Medical Center uses ultrasound, maximum barrier precautions, and a device bundle including a specific catheter stabilization device, IV connector, and other technology. This approach has eliminated central-line associated bloodstream infections for more than seven years.
Courtesy of John Milne, Sutter Health
Joint Commission executives Mark Chassin, MD, FACP, and Jerod Loeb, PhD, have an uncomfortable question for hospitals: If airlines and chemical plants can maintain superb safety records despite huge potential hazards, why can’t you?
Chassin, the Joint Commission’s president, and Loeb, who is executive vice president for healthcare quality evaluation, raise this question almost every time they speak or write about so-called “high reliability organizations” (HROs). The term describes organizations that maintain long-term records of safety and quality in environments rife with the threat of catastrophe. Hospitals lag well behind other industries in meeting this challenge, Chassin and Loeb note. There are some good reasons that hospitals lag behind, such as the increasing severity and acuity of hospital patients’ illnesses and the corresponding complexity of the care they require. But none of this is to say that hospitals can’t do better.
Some hospitals already are doing much better. An impressive example is occurring at a hospital near Sacramento, California—Sutter Roseville Medical Center (SRMC) in Roseville. Since SRMC adopted an innovative central IV catheter bundle in January 2006 and handed ownership of central lines to its vascular access team, no SRMC patient has suffered a central line-associated bloodstream infection (CLABSI) attributable to central catheters placed by the team.
That is a span of more than seven years. During that time, there has been an intense public-private effort to minimize CLABSIs. While the data suggest that hospitals have improved on this front, many struggle just to reduce their CLABSI rate to benchmark levels set by the CDC’s National Healthcare Safety Network (NHSN). Some hospitals have completely eliminated CLABSIs for long time spans, but it appears none has come close to SRMC’s sustained record of zero.
This publication first reported Sutter’s accomplishment in 2008 (Martin and Harnage), when it had gone just over two years with zero CLABSIs. Five years later, it’s clear there’s something special about the combination of factors that have led to SRMC’s success. It’s time to take a fresh look at this achievement, including what healthcare leaders from around the country think about it.
The Sutter Approach: Tangible Aspects
SRMC believes its zero CLABSI rate is due to a combination of tangibles, such as the hospital’s central line bundle, and intangibles such as its organizational culture. What follows is a review of those elements, with comments from Sophie Harnage, RN, BSN, VA-BC, who heads Sutter’s vascular access team and was the prime mover behind its central line bundle; Barbara Nelson, PhD, RN, chief nursing executive at SRMC; and Gordon Hunt, MD, chief medical officer (CMO) for Sutter Health, the parent health system.
The story begins with the bundle itself. Some of its elements are fairly standard and some are not, but it is the synergy among them that is crucial. “In a nutshell, our approach is to take no chances,” says Harnage. “If your bundle addresses many of the ways bacteria can infect a central line, but it doesn’t address all of them, then some unlucky patients will be the victims of bacteria that find those unprotected entry points. As much as possible, we tried to address every possible source of bacterial ingress, so there was no falling between the cracks.”
The bundle has seven key practices and device technologies:
1. Maximum barrier precautions kit, as recommended by the CDC. Proper use supported by education. Maximal barrier precautions are fairly standard nationwide, but “the kit ensures that everything you need will be available when you place a central line,” says Harnage.
2. PICC placement in the upper arm with the basilic vein as the vein of choice. Ultrasound-guided placement of central catheters. Harnage: “This is simply a matter of following guidelines, which state this site has fewer skin bacteria and therefore lower risk of bloodstream infections. And ultrasound makes placement more accurate, which helps lower complications.”
3. Central line kit. The to-be-expected supplies include swab sticks with a mix of chlorhexidine gluconate (CHG) and isopropyl alcohol and CHG skin prep. But Sutter also adds catheter stabilization devices and a foam disk that surrounds the catheter insertion site and secretes CHG for up to seven days. Harnage: “These devices are highly regarded in the literature. For instance, the disk is an excellent defense against infections caused by bacteria on the patient’s skin.”
4. Zero fluid displacement IV needless connector. This is another example of Sutter looking beyond the ordinary. Few central line bundles address IV connector type. Yet positive- and negative-pressure connectors, which are widely used, are both associated with high rates of CLABSIs. Many experts believe this is because both connector types cause blood reflux (backflow of blood into the connector when tubing or syringes are connected or disconnected) if the nurse doesn’t perform the proper maintenance routine (called a clamping sequence). The blood coats the connector’s interior and is hard to completely flush away because these connector designs have complicated fluid pathways and internal moving parts—in other words, many surfaces to which the blood can stick. Blood is a breeding ground for the bacteria that cause CLABSIs.
Many of these connectors also have uneven septum surfaces that are hard to disinfect because, again, the unevenness creates surfaces where bacteria can hide. Harnage explains, “We decided to implement a connector that did not have any of these design issues and was better designed in several other ways to prevent CLABSIs. It also doesn’t require nurses to remember a clamping sequence. Nurses are often confused about which sequence to use with a positive versus a negative connector, because each one requires a different sequence. If you get it wrong, you get blood reflux and a greater risk of infection.”
5. Reinforcement of protocol for disinfecting IV connector hubs. It is crucial that the hubs be disinfected before nurses access the lines to administer fluids. Most hospitals, including SRMC, use an evidence-based manual technique to accomplish this. But if nurses don’t perform the several-step technique exactly as prescribed or fail to comply altogether—a known risk when nurses feel pressured for time—infection-causing bacteria can enter the line. Harnage: “Manual disinfection can be a problem because nurses are always incredibly busy. So we teach our nurses about why this protocol must be done properly and then reinforce compliance through supervision.”
6. Updated central catheter flushing protocol. Central venous catheters must be flushed properly and regularly to remove fibrin—the material in blood that is the biggest concern, infection-wise—from the catheter’s intraluminal surface. If fibrin remains, it can lead to the formation of biofilm. Bacteria that shear off of biofilm and enter the patient’s bloodstream are a primary cause of CLABSIs.
SRMC’s policy is to verify all catheter lumens for patency before use. Central lines are flushed with saline-only every eight hours and PRN (exception: ports and dialysis catheters, which are flushed with saline and heparin). Harnage: “A policy is only effective if everyone follows it. We reinforce compliance with this policy by putting a brightly colored reminder card on every medication cart at every nursing station. The card includes flushing directions for each type of catheter we use.”
7. Regular monitoring of central lines. SRMC’s vascular access team monitors all central lines daily. “Daily monitoring allows us to get on top of complications and any other negative situation before it’s a big problem,” Harnage explains. “It also helps us make sure that the maintenance aspects of our bundle are being followed.”
Barbara Nelson, PhD, RN, the chief nursing executive at SRMC, points out, “there’s no magic to how we designed the bundle. It was about science. We looked at potential causes of contamination and took evidence-based steps to address those.” She also notes that it was important, when selecting devices for the bundle, to choose technology with “forcing functions”—design features that make it easy to do the right thing and hard or impossible to do the wrong thing.
The safety feature that prevents you from turning on a microwave oven while the door is open is an everyday example of a forcing function. One example from the Sutter bundle is the zero displacement IV connector, which makes it impossible to perform the wrong clamping sequence because there is no “wrong” sequence. The connector is also designed to be easy to flush clear of blood in the fluid pathway because the pathway is straight, with no blood-trapping dead spaces or internal moving parts. Another device example is the CHG-dispensing foam disk. The nurse merely puts the disk in place. The disk does the rest.
Besides the bundle, the other tangible aspect of Sutter’s central line approach is its dedicated vascular access team (Figure 2). The team places all PICC lines and when requested—which is often—assists physicians with centrally inserted central lines. The team also takes full responsibility for all central lines, including responsibility for bundle compliance by all clinicians. Harnage: “Everyone in infection control these days feels it’s important that nurses be empowered to stop physicians if they see noncompliant actions. At Sutter, we’ve gone beyond that by collaborating with physicians on central line insertion. It makes life easier for them and helps us make sure that the every central line is inserted and maintained exactly according to protocol.”
The Sutter Approach: Intangibles
Intangibles have also contributed mightily to SRMC’s elimination of CLABSIs. The most obvious of these is the patient-prioritizing culture at Sutter Health System. SRMC’s bundle is notable in part because it includes devices that are not common in central line bundles even though their association with lower CLABSI rates is evidence-based.
Devices have upfront costs. These costs can more than repay themselves by helping the institution avoid much greater infection-related costs. Still, not all facilities are willing to make these kinds of investments. SRMC stands out in its willingness to spend on patient safety.
“Generally speaking if you’re getting a good result, that’s probably because you have the right culture in place,” says Sutter’s CMO, Hunt. “I think that’s true at Roseville and in the Sutter system at large. It requires an organization-wide recognition that the reason we exist is to provide the best possible care to patients and just as importantly, devoting resources to it.”
Hunt believes that healthcare is an industry where doing the right thing is also the smart thing. “From a business standpoint, it’s foolish to compromise the thing that people come to you for,” he says. “These initiatives save money, but they don’t necessarily save money for us. Money saved from preventing CLABSIs might save money for the insurer, the government, or us. Our approach is that ideally we’d like to break even on patient safety initiatives but that can’t be the driver.”
SRMC’s zero CLABSI rate also owes something to Sutter Health’s metrics-driven goal of maximizing quality. Hunt, who heads the effort, says, “CLABSIs and ventilator-associated pneumonia were two clinical areas where metrics showed how we were doing and if there were clear areas where we could make a difference. We saw remarkable reductions in those infections after we undertook initiatives to minimize them, and Roseville’s CLABSI rate reduction is the most impressive example of that.”
Another intangible is a non-punitive environment where the emphasis is on learning from mistakes rather than punishing the one who admits them. The literature refers to this as a “just culture,” as opposed to a “blame culture.” Clinicians are encouraged to report their near- misses as well as actual errors, so the institution can determine if a system- or process-related problem made the slip-up more likely. “We see sharing about a near-miss as a gift to us,” says Nelson. “What safeguard can we put in place so that won’t happen in the future?”
A just culture is crucial to quality improvement, says Hunt, “The non-punitive atmosphere allows you to see things you wouldn’t otherwise see, because it allows people to disclose them without fear of punishment.”
What Other Experts Say
Sutter’s successes have caught the attention of some of the key movers and shakers in patient safety. Here, by topic, are comments from independent infection control expert William Jarvis, MD, and senior leaders at the Joint Commission, Institute of Healthcare Improvement (IHI), and federal Agency for Healthcare Research & Quality (AHRQ):
The SRMC central line bundle. “Prevention of CLABSIs is a lot less expensive than paying to treat CLABSIs,” says Jarvis. “If we really care about patient safety (and they are not just two words we use), then implementing prevention interventions, particularly ones such as these evidence-based measures implemented at Sutter, should be a priority.” He adds that the success of Sutter’s bundle demonstrates “that many if not most of the CLABSIs that occur at hospitals worldwide are preventable.”
Don Goldmann, MD, chief medical and scientific officer at the Institute for healthcare Improvement, is particularly taken with the aspects of SRMC’s bundle that help ensure compliance: putting items in kits and on carts, using reminder cards, education on bundle elements, etc. “It’s important to incorporate evidence-based practices in a way that it’s hard for clinicians not to do them,” he says. He also advocates “random safety audits conducted by the care team during bedside rounds. The audits make it possible to avoid hiring a nurse who looks over everyone’s shoulders.” (That may not apply to SRMC, however, where the vascular access team’s ownership and daily monitoring of central lines could make audits somewhat redundant.)
Figure 2. Sophie Harnage (at far right) and her team have achieved more than seven years without a bloodstream infection in central IV lines placed by the team. Among factors in their success have been an overall hospital commitment to patient safety, along with reinforcing education for nursing staff about proper maintenance protocols for IV lines.
Courtesy of John Milne, Sutter Health
Using a dedicated vascular access team. “If the program is going to be implemented outside the ICU, the IV team is essential,” Jarvis feels. William Munier, MD, MBA, director of the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research & Quality, believes teamwork in healthcare improves patient outcomes. It’s a concept AHRQ also promotes through its TeamSTEPPS® program. He says that teams “create a virtuous cycle where success breeds success.” The Joint Commission’s Jerod Loeb agrees: “Healthcare is a team sport. Outcomes are better when teams play together.”
Non-punitive atmosphere. Munier and Loeb, like Sutter Health’s Hunt, believe in just culture principles. “If a nurse sees a problem and knows the last nurse who said something was fired or called on the carpet, she may not be as willing to speak up,” Loeb says. “Not having a culture that supports internal reporting increases medical error risk tremendously.”
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Sutter Roseville Medical Center uses the following devices in its central line bundle:
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Before leaving the subject of SRMC’s accomplishment, it’s important to make a distinction about it. In their signature piece on high reliability in the journal Health Affairs (2011), Loeb and his Joint Commission colleague Chassin write that “health care quality and safety today are best characterized as showing pockets of excellence on specific measures or in particular services at individual health care facilities … What has eluded us thus far, however, is maintaining consistently high levels of safety and quality over time and across all health care services and settings.”
The success at SRMC is in fact “a pocket of excellence.” SRMC has achieved high reliability in preventing CLABSIs. This is not the same as saying that SRMC is a high reliability organization, even though it and parent system Sutter Health appear to have the attributes in place that Chassin and Loeb feel are crucial to reach that level. (Those attributes include leadership that is committed to high reliability; a safety culture based in trust, reporting, and dedication to improvement; and robust process improvement methods.)
So maybe we should revise the question that opened this article: If SRMC has eliminated CLABSIs for seven years and counting, why can’t other hospitals? William Jarvis is not alone in believing CLABSIs are completely preventable. The noted Johns Hopkins professor and physician Peter Pronovost, MD, has also been pushing hospitals to aim for zero since the early 2000s. The Centers for Medicare and Medicaid Services and many private insurers no longer reimburse hospitals for treating CLABSIs because they believe these infections should not occur.
SRMC is the obvious proof that they are right. Safety for patients with central lines will take a giant leap forward if other hospitals follow SRMC’s lead.
Alan Reder is a freelance writer who lives in Elcho, Wisconsin. His previous work includes numerous books and articles on management and healthcare issues. He may be contacted at areder@frontier.com.
References
Brewer, K. (2011). How a ‘just culture’ can improve safety in health care. American Nurse Today, 6(6). Retrieved from http://www.medscape.com/viewarticle/746089.
Chassin, M. R., & Loeb, J. M. (2011). The ongoing quality improvement journey: Next stop, high reliability. Health Affairs, 30(4), 559-568.
Harnage, S. (2012). Seven years of zero central line-associated bloodstream infections. British Journal of Nursing (Intravenous Supplement), 21(21), 1212–1218.
Harnage, S. (2012). Sustaining a zero CLABSI rate. Hospital Pharmacy Europe, Nov./Dec., 43-45.
Jarvis, W. R., Murphy, C., Hall, K. K., Fogle, P. J., Karchmer, T. B., Harrington, G., Salgado, C., et al. (2009). Health care–associated bloodstream infections associated with negative- or positive-pressure or displacement mechanical valve needleless connectors. Clinical Infectious Diseases, 49(12), 1821-1827.
Martin, D., & Harnage, S. (2008). A new bundle for preventing CRBSIs. Patient Safety & Quality Healthcare, May/June. Retrieved from http://www.psqh.com/mayjun08/crbsi.html.
Traynor, K. (2011). Long-term elimination of ICU infections requires specific steps. Pharmacy News, Oct. 1, 2011. Retrieved from http://www.ashp.org/menu/News/PharmacyNews/NewsArticle.aspx?id=3611.