By Jennifer Larson, contributor
September 27, 2012 - Nurses are often tasked with lowering their unit’s rate of infections, but they can’t do it alone. In fact, organizations that want to significantly reduce their rate of hospital acquired infections (HAIs) may find the most success using a comprehensive approach that combines evidence-based practices and improvements to their culture of safety.
An interdisciplinary team of researchers led by David Thompson, DSNc, MSN, RN, Jill Marsteller, PhD, and J. Bryan Sexton, PhD, recently conducted a randomized clinical trial in 45 intensive care units in 35 hospitals in 12 states. They found that a combination of proven practices to prevent central line associated bloodstream infections (CLABSI), when paired with a program to encourage better teamwork, communication and safety, reduced infections by 70 percent. Thompson called the results “amazing.”
In the study, one group of hospitals used the approach called CUSP, which stands for Comprehensive Unit-Based Safety Program, to support the use of evidence-based bloodstream infection prevention strategies. This program has been shown to improve interdisciplinary collaboration and improve culture across units, noted Thompson. And it can really help in situations where the culture needs to be changed.
“You can take people from that mindset where they’ve worked in a very punitive culture to one where they see, ‘This is a systems-based error and these are the things that we can fix,’” said Thompson, an associate professor at Johns Hopkins University in the School of Medicine.
Funded by the Robert Wood Johnson Foundation’s Interdisciplinary Nursing Quality Research Initiative, (INQRI) this study follows another HAI reduction study that used CUSP. That study, which was not a randomized clinical trial, was conducted several years ago in 103 ICUs in Michigan. The Michigan Keystone ICU Patient Safety Program, which was created by Peter Pronovost, MD, PhD, of Johns Hopkins, used two main components in a protocol used to combat HAIs in the ICU setting: evidence-based interventions to improve compliance with infection-prevention methods and a program designed to strengthen the culture of safety, while also improving teamwork and communication.
The Agency for Healthcare Research and Quality (AHRQ) also recently announced that its nationwide patient safety project utilizing CUSP had made significant strides in reducing certain HAIs. According to AHRQ, more than 1,100 adult ICUS in 44 states participated in the project over a four-year period. The results: an overall reduction in CLABSIs of 40 percent.
“To see a 40 percent reduction is substantial,” noted James Cleeman, MD, senior medical office for AHRQ’s Center for Quality Improvement and Patient Safety. “A reduction of 40 percent in the rate translates into more than 2,000 cases of CLABSI prevented…and over $34 million in excess health care costs avoided.”
Other initiatives are now using CUSP, too, and it can be used for a variety of HAIs, he added, noting that AHRQ is promoting the use of it for HAI reduction beyond CLABSI, such as surgical-site infections and catheter-associated urinary tract infections.
Diane Pinakiewicz, MBA, president of the National Patient Safety Foundation, noted that it’s exciting that these studies have shown that the reduction efforts and strategies not only work but can be replicated.
“The challenge is getting everybody to do it,” she said. “It’s all about re-engineering the culture and accepting and embracing this type of approach.”
Vicki Good, RN, MSN, president-elect of the American Association of Critical-Care Nurses (AACCN), noted that her organization supports efforts for creating and sustaining a healthy work environment because it has an impact on clinical practice and optimal patient outcomes. In fact, a set of healthy work environment standards set forth in 2005 addresses the need for good communication and collaboration.
“A healthy work environment--culture--isn’t just important. It’s essential,” she said. “The culture of the organization becomes the essence of the care delivered. If the culture does not support open communication and teamwork, the safety of our patients will be in jeopardy.”
The results of studies like the INQRI-funded study are promising because they confirm that the consistent application of evidence-based care, along with a consistent set of foundational elements that support safety, works.
Another interesting note about the study is that it utilized a nurse-led intervention, Thompson said. Nurses were charged with educating their colleagues, setting content and developing the interdisciplinary relationships with physicians that were necessary for success.
The success “shows that nurses are assertive, independent and well-educated enough to pull off a quality improvement project such as this, across these many hospitals that participated,” he said.
“The study from Johns Hopkins confirms what the American Association of Critical-Care Nurses has learned from a three-year national awards program to recognize reduction and elimination of HAIs,” said Good, referring to a program that partners the association with three medical societies to recognize successes in HAI reduction.
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