Cambridge Health Alliance undertook an Agency for Healthcare Research & Quality-sponsored 15-month safety improvement program to reduce infections in the ICU at its Cambridge and Everett hospitals. The effort – involving an assessment of potential problems, increased staff education, use of proven best practices, leadership buy-in and more – resulted in a dramatic reduction in urinary tract infections as well as central line-associated bloodstream infections (CLABSI).
Specifically, the “working toward zero” philosophy at the health system resulted in just one CLABSI throughout 2019 and zero catheter-associated urinary tract infections (CAUTIs).
Hospitals tackling infections usually employ the comprehensive unit-based safety program (CUSP) method developed by the U.S. Department of Health & Human Services’ Agency for Healthcare Research and Quality. CUSP offers a series of toolkits to educate staff and build teamwork to get everyone on board – from frontline nurses to ancillary staff – in the effort to improve care.
The Cambridge and Everett CUSP teams consisted of the chief nursing officer, associate CNO for critical care, associate CNO for professional practice, ICU nurse managers, ICU educator, front-line staff nurses, infection preventionists, medical director of critical care, critical care doctors, and infectious disease physicians.
They first worked to define the problem, pinpointing the hospitals’ relatively high use of urinary catheters and central line devices, the lack of practice standardization, and the fact that previous safety practices and improvements were not regularly sustained. The team then determined the baseline rates of catheters and central lines, and developed an action plan to reduce them.
To improve the caregiver-patient link they instituted the “AIDET” communications framework, which is a process from the Studer Group that stresses five communications behaviors: Acknowledge, Introduce, Duration, Explanation, and Thank You. To improve nurse-to-nurse communication, they instituted a standard process for each patient handoff. CAUTI and CLABSI “prevention bundles” were developed to ensure standard protocols relating to decision-making, insertion, assessment and documentation, line care, removal, and more. A whole host of other detailed, step-by-step, repeatable processes were laid out and re-emphasized in ongoing team education programs.
Developing a culture of safety in a do-no-harm environment was established by creating modality bundles for CAUTI and CLASBI. This was the framework for the nursing staff in the ICU to consistently follow a strategic process that resulted in measurable outcomes.
Lynette M. Alberti, R.N., Cambridge Health Alliance’s Senior Vice President and Chief Nursing Officer, said, “While achieving zero harm may seem impossible, it is not. This work is an important step in our journey to becoming a high-reliability, zero-harm organization.” That statement has been the driving force behind the facility’s effort to build a culture of safety.
Perhaps the biggest improvement at Cambridge was a re-emphasis on the “culture of safety,” meaning that anyone on the team – but especially the front-line nurses – can question at any time the need, or continued need, for line/tube insertion. “Safety Bedside Shift Reporting” with the patient has become a new standard of practice and a key driver of reducing harm events in both hospitals. “Multidisciplinary rounding” means the team gathers and gets to talk openly about how the central lines and catheters are being employed.
Patricia Noga, R.N., MHA’s VP for Clinical Affairs, said the path Cambridge Health Alliance took for its improvement project is similar to what is occurring at other hospitals across Massachusetts.
“The sort of improvements in care that Cambridge Health Alliance showed in this project is contingent on a committed team ensuring that each step for every patient is given the team’s unwavering attention and best practice implementation,” she said. “It’s easy to waver from tried and true processes but CHA’s results show that creating a culture where all voices are listened to and respected ensures that everyone is more apt to stay on the path towards improvement.”