Each year in the United States, an estimated 2 million health care-associated infections claim nearly 100,000 lives — almost one-third of them from central line–associated blood stream infections alone. This makes HAIs the fourth largest killer in the nation, taking more lives than breast cancer, auto accidents and AIDS combined. What's more, according to a 2009 CDC report, HAIs add as much as $45 billion a year in excess medical costs to our national health care tab, and data show that the average cost per CLABSI in children is $45,000.
These numbers make a compelling human as well as business case for HAI prevention. And the good news is that more than 70 percent of these infections can be prevented — something that Children's Healthcare of Atlanta has achieved throughout the past four years, along with a savings of $23 million. We'll take a closer look at how we made it happen.
In 2005, then Chief Operating Officer Donna Hyland attended a national quality forum in which an emphasis was placed on the morbidity, mortality and cost associated with CLABSIs. Upon her return, she made reducing HAIs and CLABSIs a priority for Children's. The hospital convened a task force — of quality department representatives, performance improvement experts, infection preventionists, care-level clinicians, supply chain representatives and others — which then launched a campaign to increase awareness, educate and reduce harm to our patients.
Hyland, now the CEO of Children's, also voiced her support and shared stories of those close to her who had suffered HAIs to reinforce the human connection behind the numbers. The CEO's presence, stance and support underscored the importance that the executive team placed on this initiative. And, while a movement to tie reimbursement to HAI rate reduction loomed on the horizon, for the leaders of the largest pediatric health care system in Georgia, the primary focus was on the safety of children.
But buy-in on the front lines — and engagement across all disciplines — was imperative to gain traction in the campaign to prevent CLABSIs from occurring. Since 2006, the institution has set aggressive annual goals to reduce CLABSIs by at least 10 percent and now has a five-year goal to reduce them by another 50 percent.
Tools for Change
Children's drew from a wealth of published evidence to identify the best practices and interventions for reducing CLABSI rates. In addition to the guidelines published by the Centers for Disease Control and Prevention, Children's looked to prevention bundles and practices issued by national quality organizations such as the Children's Hospital Association and the Institute for Healthcare Improvement. These procedures address hand hygiene, using full-barrier precautions during the insertion of central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site when possible, and prompt removal of unnecessary central lines.
The task force used these established national guidelines to tailor a road map for the Children's CLABSI-reduction initiative, engaging front-line staff to identify inefficiencies in the hospital's existing care processes, formulate and recommend standardized policies, and implement best practices that set new expectations for performance in all units. These new practices included:
- central line insertion and maintenance checklists;
- daily talks between physicians and staff to assess line removal;
- a standardized dressing change kit; and
- establishment of a consistent day for a dressing change.
In addition, the task force members created tools for real-time CLABSI data monitoring and analysis. Staff members also hold BSI huddles whenever a CLABSI occurs during which they share factors contributing to the infection, identify continued opportunities for improvement and educate the care-level staff.
Results and Lessons Learned
Since the launch of this initiative in 2006, Children's has reduced its bloodstream infection rates by 77 percent. This translates into 550 avoided bloodstream infections with a cost avoidance of more than $27 million. As of June 25, 2012, two of the critical care units had celebrated 806 and more than 1,000 days without a CLABSI.
In addition, the current hand hygiene rate is 98.3 percent — evidence that hand hygiene has become ingrained into the Children's culture.
Changing behavior is rarely easy or fast — something that the Children's CLABSI initiative affirms. But it is doable if health care systems approach the undertaking as a marathon, not a sprint. While the initial push can be easy, organizations can hit the wall and find it a challenge to push through and achieve their ultimate goal of zero harm to patients.
As with any improvement initiative, Children's must continue to analyze the data to find additional opportunities to improve safety — in addition to maintaining and expanding initial gains.
Education Is Key
A vital underpinning of this initiative has been ongoing education of clinicians and nonclinicians about their roles in preventing CLABSIs and — even more fundamentally — teaching that these infections are, in fact, preventable.
Early on, for example, the team engaged the hospital's medical staff governing body and the medical executive committee to support physician practice changes such as hand hygiene and sterile barrier guidelines during line insertion. Area home health agencies are periodically invited to an educational session on central venous line care. A "Days Since Last Infection" sign is displayed in each unit as a daily visual reminder to staff. And to reinforce the importance of proper hand hygiene — a cornerstone of any CLABSI reduction initiative — the hospital's communication department created a "Foam Up" education campaign that targeted physicians, staff and, most importantly, patient families.
Children's also worked closely with vendors like Kimberly-Clark, which has developed meaningful patient and provider education tools on HAIs, available at HAIWatch4you.com and HAIWatchdog.com.
"As pediatric providers, we know that we're not just caring for the patient, we're caring for their families," said John Zetzsche, vice president for quality and medical management at Children's. "We have taken the lead in engaging families in participating in the safety of their child while in our care, and Foam Up gave families a simple and nonthreatening way to hold us accountable."
Renee Watson, R.N., B.S.N., C.P.H.Q., C.I.C., is the manager of infection prevention and epidemiology at Children's Healthcare of Atlanta.
For more information about Children's Healthcare of Atlanta's quality efforts, go to www.choa.org/quality.