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Sustaining Reductions in CRBSI over 5 years in Welsh ICUs

Chris Hancock, Dr Eleri

Davies, Dr Wendy Harrison

Context

• From 2006 to the present the 17 Intensive Care Units (ICUs) in Wales have worked to reduce the incidence of Central Venous Catheter Related Blood Stream Infections (CRBSI) through participation in the 1000 Lives Campaign and other national collaborative programmes.

• Reliable implementation of CVC bundles in all of these ICUs was associated with reduction in rate of CRBSI in the majority within 24 months. This presentation assesses whether this improvement has been sustained 60 months after the launch of the collaborative programme.

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The 1000 Lives Campaign

• 3 million people• All Hospitals, Primary Care and

Ambulance services• Six content areas

– Leadership

– Critical Care/Rapid response

– Medicines

– Healthcare associated infection

– Surgical care

– General medical and surgical care

The Campaign’s aims

• Reduce avoidable mortality by 1000

• Reduce episodes of harm by 50,000

By improving the reliability and reducing the variation in the systems and processes that we use everyday.

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• 1,199 lives have been saved by NHS staff in Wales

• Over 50,000 episodes of harm averted

2008-10 - Two years that made a difference

Problem

• CRBSI is the cause of considerable mortality, morbidity and cost to

healthcare particularly in the ICU

• The Michigan Study (Pronovost et al, 2006) demonstrated that the

introduction of evidence based care bundles and other improvement

techniques was associated with a reduction in mean rate of CRBSI.

• This effect has been demonstrated as having been sustained and

improved upon over a period of 36 months (Pronovost et al, 2010).

• During participation in the Welsh Critical Care Improvement

Programme (WCCIP) 2006 – 2008 many ICUs reported achieving a

zero rate of CRBSI for prolonged periods.

• Has this improvement been sustained.?

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• Overall Median CRBSI rate (per 1000 catheter-days) :

– 2.7 (mean, 7.7) to 0 (mean, 2.3) at 3 months (p ≤ 0.002)

– Sustained at 0 (mean 1.4) during 18 months of f/u

• Decrease in both teaching and non-teaching

hospitals

– Large and small hospitals

• Modestly more effective in small hospitals

– Pronovost et al. NEJM 2006; 355(26): 2725-32

Michigan Study

Michigan Sustainability• Ninety (87%) of the original 103 intensive care units participated,

reporting 1532 intensive care unit months of data and 300 310 catheter days during the sustainability period.

• The mean and median rates of catheter related bloodstream infection decreased from 7.7 and 2.7 (interquartile range 0.6-4.8) at baseline to 1.3 and 0 (0-2.4) at 16-18 months and to 1.1 and 0 (0.0-1.2) at 34-36 months post-implementation.

• During the sustainability period, the mean bloodstream infection rate did not significantly change from the initial 18 month post-implementation period (–1%, 95% confidence interval –9% to 7%). – Pronovost et al. BMJ 2010;340:c309

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Developing a Solution• Two evidence based care bundles, insertion and

maintenance, were developed by consensus amongst the collaborative members.

• VAP bundle, daily rounds and goals, intensivist led ICUs

• The HELICS definition of CRBSI was adopted to ensure compatibility with the European norms

• Documentation for data collection was developed in immediate consultation with the ICU teams.

Process and Outcome• You cannot control outcomes without

controlling the processes that contribute to that

outcome

• Correlation does not necessarily mean

causality BUT

• There does appear to be a strong link between

improving the reliability of evidence based

processes and improvements in outcome.

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Welsh Central Line Maintenance (CVCM) Bundle

• Review necessity of central line every day -and remove promptly if it is not needed.

• TPN should be given via a separate line or a dedicated lumen.

• Access to line must be made using an aseptic technique.

• Entry site to be checked every day for signs of leakage or inflammation.

Welsh Central Line Insertion (CVCI) Bundle

• Wash hands before and after procedure: soap and water or alcohol-based agents.

• Use barrier precautions: gown and gloves must be worn; as much as possible of the patient should be covered with sterile drapes.

• Sterilise skin with chlorhexidine in alcohol and wait until the skin is dry.

• Avoid the femoral site unless it is the last resort.

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Intervention

• Care bundle compliance on an individual patient and then whole ICU basis was measured and calculated as a percentage at each site on each day of the programme.

• Data was then uploaded and stored on a web based database, generating reports and charts to aid local improvement.

• Bundle compliance became more consistently reliable when embedded within the routine ICU documentation.

• Documentation was generated for all CVC lines containing physiological and microbiology information which was returned to WHAIP for analysis.

National Aggregate CVC Bundle Compliance

Feb-07Dec-07Oct-07Aug-07Jun-07Apr-07Feb-07Dec-06Oct-06Aug-06Jun-06

90.00%

60.00%

30.00%

_X=97.11%

566

113

3

66

5

11

I Chart of CVC bundle

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Strategy for Change

• Collaborative programme methodology

• National learning events

• Multidisciplinary teams

• Feedback on progress

• Share experiences

• Service improvement techniques

• Peer support.

IHI Collaborative Model

1000 Lives Plus© 2004 Institute for Healthcare Improvement

IHI Breakthrough Series(6 to 18 months time frame)

Select Topic

(develop mission)

Planning Group

Develop Framework & Changes

Participants (10-100 teams)

Prework

LS 1

P

S

A D

P

S

A D

LS 3LS 2

Supports

Email (listserv) Phone Conferences

Visits Assessments

Monthly Team Reports

Dissemination

Holding the

Gains

Publications

Congress

etc.

A D

P

SExpert Meeting

AP1 AP2 AP3*

LS – Learning Session

AP – Action Period

*AP3 –continue

reporting data as

needed to

document success

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Measurement –Bundle Compliance• Monthly nationally

aggregated CVC bundle compliance increased to 97% at 10 months and has remained greater than 95% with minimal variation from months 10-60.

Mar

-11

Dec-1

0

Sep-1

0

May-

10

Jan-1

0

Sep-09

May-

09

Jan-0

9

Sep-08

May-

08

Jan-0

8

Sep-07

100.00%

80.00%

60.00%

40.00%

20.00%

0.00%

Month

Perc

enta

ge

_X=96.70%

UB=100.00%

LCL=91.85%

All Wales ICUs

September 2007 - March 2011

Aggregated CVC Maintenance Bundle Compliance

Measurement -CRBSI• Surveillance of CRBSI rate per 1000 CVC

days commenced in September 2007

• Did not cover months 0-18 of the collaborative programme.

• Months 19-30 all Wales mean monthly CRBSI rate - 1.042

• Months 30-60 dropped to 0.553

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A care bundle approachJun-11Jan-11Aug-10Mar-10Oct-09May-09Dec-08Jul-08Feb-08Sep-07

2.5

2.0

1.5

1.0

0.5

0.0

Month

_X=0.553

UCL=1.665

LB=0

Sep-07 Sep-08

All Wales HELICS defined Catheter Related Bloodstream Infection (CRBSI) Rate

Per 1000 ICU catheter days

September 2007 - June 2011

Effects of change

• Significant and sustained reduction in CRBSI across all Welsh ICUs

• Major change in culture and attitude on the part of ICU clinicians.

• Whereas once CRBSI was regarded as an inevitable side effect of critical care it is now regarded as an adverse event that demands investigation.

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The Model for Improvement (MFI)

• “Just trying harder is

the worst quality

improvement plan of

all.” - W. Edwards Deming

Limitations

• Evaluation of this project would have been greatly enhanced by the measurement of baseline CRBSI prior to commencing the collaborative programme.

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Message

• Large improvements in patient safety outcomes can be sustained over long periods of time by bringing about culture change from within and embedding this change in everyday clinical practice.