Evidence-based practice to reduce central line infections.

BACKGROUND: In 2003, through the Greater Cincinnati Health Council nine health care systems agreed to participate and fund 50% of a two-year project to reduce hospital-acquired infections among patients in intensive care units (ICU) and following surgery (SIP). METHODS: Hospitals were randomized to either the CR-BSI or SIP project in the first year, adding the alternative project in year 2. Project leaders, often the infection control professionals, implemented evidence-based practices to reduce catheter-related blood stream infections (CR-BSIs; maximal sterile barriers, chlorhexidine) at their hospitals using a collaborative approach. Team leaders entered process information in a secure deidentifled Web-based database. RESULTS: Of the four initial sites randomized to CR-BSI reduction, all reduced central line infections by 50% (CR-BSI, 1.7 to 0.4/1000 line days, p < .05). At the project midpoint (3 quarters of 2004), adherence to evidence-based practices increased from 30% to nearly 95%. DISCUSSION: The direct role of hospital leadership and development of a local community of practice, facilitated cooperation of physicians, problem solving, and success. Use of forcing functions (removal of betadine in kits, creation of an accessory pack and a checklist for line insertion) improved reliability. The appropriate floor for central line infections in ICUs is < 1 infection /1,000 line days.

An irreplaceable safety culture.

Intensive care unit (ICU) clinicians are sources of errors and of resilience. When they learn how to juggle many competing goals, remain vigilant, and tell safety stories--all in the context of changing technologies and demand--they can create safe settings of care. Other strategies (eg, using computerized tools and implementing safety procedures) are important, but alone they are not sufficient. An ICU needs a safety culture that is rooted in a committed leadership, the acknowledgment that error is inevitable, a reporting system, and continuous learning. The all too common norm, "no harm no foul," is an obstacle. ICU leaders can use a campaign strategy to spread the safety practices that sustain a safety culture. They should attend to the political, marketing, and military aspects of such campaigns and recognize that people's time and attention are limited and built projects from existing ongoing pilots. Pilots can compete for people's attention; it has pull when it exemplifies a moral idea, simplifies work, and gives the health care professional more control and feedback. Under these conditions, the campaign will release individuals' passions and add energy and insight to the campaign itself.

Campaigning for change.

Most organizations must change if they're to stay alive. Change is tough to accomplish, but it's not impossible and can be systematized. The author, who has been involved in change initiatives at scores of companies, believes that the success of such programs has more to do with execution than with conceptualization. The successful change programs he observed had one thing in common: They employed three distinct but linked campaigns--political, marketing, and military. The author cites examples from such companies as Hewlett-Packard, Bristol-Myers Squibb, and Saturn to illustrate how effective such campaigns can be. A political campaign creates a coalition strong enough to support and guide the initiative. Sometimes, coalitions arise from changes to a company's formal structure. But they may come out of the informal structure, or they could stem from a temporary counterstructure. A marketing campaign must go beyond simply publicizing the initiative's benefits. It focuses on listening to ideas that bubble up from the field as well as on working with lead customers to design the initiative. A clearly articulated theme for the transformation program must also be developed. A military campaign deploys executives' scarce resources of attention and time. Successful executives secure their supply lines by, for instance, piggybacking onto initiatives that have already captured people's interests or already exist as bootleg projects. These managers also set up pilot projects that turn into beachheads because the projects expose them to the difficult dynamics they will ultimately face. Successful executives launch all three campaigns simultaneously. The three always feed on one another, and if any one campaign is not properly implemented, the change initiative is bound to fail.