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Creating Systems to Improve ICU Outcomes: Reducing Central Line- Associated Bloodstream Infections and Ventilator Pneumonia in VA ICUs

Infections acquired as a consequence of hospitalization are costly and common. In a 2001 review, which ranked safety practices based on the evidence and potential for impact and effectiveness, practices to reduce hospital-acquired infections ranked highly.¹ The Saving 100,000 Lives campaign of the Institute for Healthcare Improvement and the elimination of payment for infectious complications of hospitalization by Medicare and other insurers represent external efforts that have targeted hospital-acquired infections.²

The VA Inpatient Evaluation Center (IPEC) provides infrastructure to improve outcomes in hospitalized Veterans. IPEC uses information technology to measure variation in outcomes and evidence-based practices, provides benchmarked feedback to both senior and middle-level managers, and creates learning tools for implementation. Organizationally, VA leadership plays a central role in establishing IPEC targets for improvement through an executive board composed of senior regional, national, and local leaders, and a clinical advisory board composed of an ICU director and nurse manager from each of the 21 VA regions.

Reducing Central Line-Associated Bloodstream Infection and Ventilator Pneumonia in the ICU

In the fall of 2005, VA Operations asked IPEC to support the implementation of evidence-based practices (EBP) in the intensive care unit (ICU) to reduce central line-associated bloodstream infections (handwashing, sterile gown and gloves, bed-sized drape, cap and mask, avoidance of the femoral site, early removal) and ventilator-associated pneumonia (elevation of head of the bed, coordinated daily sedation vacation and spontaneous weaning trial, daily weaning assessment, venous thromboembolism prevention, and stress ulcer prophylaxis). The agreement by regional leadership to support these projects as part of VA's commitment to Saving 100,000 Lives, and inclusion of reduction in infection rates in leadership's performance contract created a strong mandate.

To create momentum for this initiative, three hospitals in the field presented their experience in implementing the central line-associated bloodstream infections (CLAB) and ventilator-associated pneumonia (VAP) bundle and reducing infections during a kick-off web-based call. IPEC contacted every nurse manager and infection control practitioner in VA to learn existing use of measures and practices to reduce hospital-acquired infections. To make implementation easy, a website provided tools such as:

1. learning modules that offered CEUs,
2. examples of forcing functions (line cart, checklist for line insertion, and daily goal sheet),
3. adaptable policies and procedures,
4. an annotated bibliography, and
5. guidance for moving practice change.

Lacking a system to track hospital-acquired infections nationally, we developed a data management website where hospitals manually entered infection rates using CDC definitions and adherence to evidence-based practices. Rates benchmarked internally and externally were reported quarterly to multiple levels of leadership. IPEC program managers mentored struggling sites (infections > 75th percentile) who volunteered.

Results

This implementation experience created a template for future initiatives. Facilitators for successful implementation included availability of pilot sites, feedback benchmarked to similar ICUs, leadership commitment, accessible tools to adapt to local circumstances, learning strategies that keep new staff up to date on expected practices and shared expertise across VA hospitals, and a help desk (via the program managers at IPEC) to troubleshoot barriers and mentor. Barriers included use of older frameworks for change (conference room planning rather than rapid tests of change), time constraints, and tapping interest of a physician champion. Given a goal likely to improve patient outcomes based on strong evidence, 260/273 ICUs dropped their infection rates without coaching or participation in a collaborative process. External drivers from regulators and quality organizations and internal drivers such as comparative rates of infections in VA and prioritizing the initiative through inclusion in the leadership performance contract facilitated the interest of VA leadership.

Adherence to both the CLAB bundle and VAP bundle increased. Adherence to composite EBP for CLAB increased from 85 percent in the second quarter of 2006 to 97 percent in 2009. Adherence to composite EBP for VAP increased from 51.6 percent in the second quarter of 2006 to 90.6 percent in 2009, and ventilator days fell by 8,800 from 2007 to 2009. CLAB rates fell (3.8 to 1.8 /1000 line days; p < 0.01) overall as did the rate of ventilator pneumonia (6.8 to 2.8/ 1000 vent days; p < 0.01). Struggling sites lacked a functional team, forcing functions, and system to provide feedback to frontline staff.

References

1. Shojania KG et al. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Rockville, MD: AHRQ Publication No. 01-E058; 2001.
2. Berwick DM et al. The 100,000 Lives Campaign: Setting a Goal and Deadline for Improving Healthcare Quality. Journal of the American Medical Association. 2006;295(3):324-7.