Physician Assistant UTHealth Houston / Children's Memorial Hermann Hospital Houston, Texas, United States
Abstract:
Introduction: Central line-associated bloodstream infections (CLABSIs) increase hospital length of stay, morbidity/mortality and healthcare costs. Despite implementation of guidelines, challenges remain to eradicate CLABSIs. In addition, compliance audits were completed by personnel not responsible for direct patient care. Six Sigma is a methodology with proven success to identify and reduce process variation. We hypothesized that an advanced practice provider (APP)-led Six Sigma methodology would engage and train the team on current program standards, identify process variation in central line (CL) care at the Children’s Heart Institute (CHI), and develop initiatives to reduce variation and CLABSI occurrence.
Methods: Process variations were evaluated through a knowledge-attitude-practices survey on CL care (n=25) by nursing in the CHI. Surveys included questions on training, review of line necessity, sterile technique, responsibility of dressing changes, scrub the hub time, frequency of tubing changes, and environmental cleanliness. Additionally, process variations were identified by direct observations of CL dressing changes (n=15). Interrater reliability was measured as a percent agreement among two trained observers.
Results: Our interventions began by engaging and training front-line APPs utilizing Six Sigma methodology. This led to common team goals, education of guidelines, dressing change observations, and development of comprehensive databases to best meet our needs. Data collected was used to establish tracking tools and identify easily modifiable risk factors. A unique CLABSI collection tool was developed by APPs to identify clinically-pertinent risk factors for infection. A second tracking tool was developed to oversee all active CLs across the institution. In combination, these tools allow for a comprehensive understanding of the risk profile of CHI patients with CLs. Survey data showed tremendous variability in training (52%), review of line necessity (62%), sterile technique (8%), responsibility of dressing changes (54%), length of time to scrub the hub when accessing lines (88%), frequency of tubing changes (54%), and environmental cleanliness (61%). Direct observations revealed significant variations with maintaining sterile technique (87%), cleaning processes, dressing application, and overall frequency of maintenance with interrater reliability at 100%. Based on our findings, new education tools and training approaches were developed for all providers to ensure CL compliance. Our team developed process flow maps, insertion and dressing change checklists, CL champions, recommendations for dressing change kits, daily bedside tool for necessity/dressing change review, and multidisciplinary skills workshops.
Conclusion: In a shared practice model for care of complex congenital heart patients, APPs level the playing field and are champions for change. Despite institution-specific guidelines, compliance variation exists. Our initiatives empower front-line providers to identify key elements of process variation and focus efforts to drive change for improved patient care. This approach has proven success in building sustainable culture change by utilizing front-line providers for shared accountability and buy-in to CL care.
