Reduction of central line infections in Veterans Administration intensive care units: an observational cohort. Render, ML Corresponding author
Appendix
Table A. Characteristics of VA intensive care units
2006-2009N total / Mean / STD / %
Number of ICU beds / 1774 / 10.01639
1st admission to ICU / 411400 / 102,850 / 694.4
Unadj Hosp Mort ICU / 40783 / 10196 / 124.5 / 9.9%
ICU LOS (days) / 2.92
> 10% pred mort / 107426 / 26856.5 / 923.6 / 26.1%
Medical School Affiliation / 112/123 / 91.10%
Critical Care Fellowship / 83 / 45.40%
Residents during night/ weekend / 134 / 73.20%
ICU Computer Information System / 62 / 34.00%
Physician Staffing Model (Open) / 103 / 56.30%
Admissions by type of ICU
CCU / 27352 / 6838 / 231.8 / 6.7%
MICU / 22133 / 5533.3 / 242.5 / 5.4%
MICU/CCU / 87059 / 21764.8 / 286.4 / 21.2%
Mixed / 169981 / 42495.3 / 117.6 / 41.5%
SICU / 103391 / 25847.8 / 520.5 / 25.2%
Admissions by level of ICU
Level 1 / 256765 / 64191.3 / 912.6 / 62.4
Level 2 / 68261 / 17065.3 / 602.4 / 16.5
Level 3 / 64119 / 16029.8 / 288.6 / 15.6
Level 4 / 22255 / 5563.8 / 644.7 / 5.4
Age (years)
<40 / 7652 / 1913.0 / 200.5 / 1.9%
41- 59 / 128890 / 32222.5 / 3009.4 / 31.3%
60 – 79 / 214463 / 53615.8 / 2838.4 / 52.1%
>80 / 60395 / 15098.8 / 185.9 / 14.7%
Gender (male) / 397477 / 99369.3 / 805.3 / 96.6%
Non-operative (%) / 281721 / 70430.3 / 718.7 / 68.5%
TOP 5 non operative diagnoses
Angina / 25122 / 6280.5 / 858.6 / 8.9%
Arrhythmia / 20491 / 5122.8 / 195.5 / 7.3%
Acute MI / 21690 / 5422.5 / 580.4 / 7.7%
CHF / 16406 / 4101.5 / 152.2 / 5.8%
Pneumonia / 12086 / 3021.5 / 150.0 / 4.3%
TOP 5 operative diagnoses
CABG / 13564 / 3391.0 / 234.4 / 10.5%
PVD Bypass / 11952 / 2988.0 / 87.3 / 9.2%
GI Resections / 12208 / 3052.0 / 122.6 / 9.4%
Renal Neoplasm / 10686 / 2671.5 / 57.3 / 8.2%
Carotid endarterectomy / 10113 / 2528.3 / 128.0 / 7.8%
ICU = Intensive care unit, N = number, STD = standard deviation, Unadj = unadjusted, CCU = cardiac care unit, MICU = medical intensive care unit, MICU/CCU = medical intensive care unit and cardiac care unit, Mixed = mixed intensive care unit, SICU = surgical intensive care unit, Level = complexity of services provided where level 1 provides the greatest range and level 4 provides the least range, MI = myocardial infarction, CHF = congestive heart failure, GI = gastrointestinal, CABG = coronary artery bypass graft surgery, PVD= peripheral vascular disease bypass
Table B. Interventions to reduce central line infections
Kick-off / 2 HR / Create broad knowledge about scope of problem and reversibility and prevention strategies
VA National leader introduces the project and goals. / 10 minutes / National leadership establishes the importance of the initiative to the VA
Expert reviews scope of problem and prevention: The literature / 20 minutes / Create academic credibility for the project
3 groups from ICUs who have successfully implemented the project describe their strategies and results / 60 minutes / Establish feasibility, identify barriers and facilitators, including team members, and forcing functions : line cart, checklist, use of daily goal sheet.
Getting Started / 15 minutes / Basics of rapid action cycle, team members, feedback, contacts for problems
Questions and Answers / 15 minutes
Measurement
Web Based database / Available March 2006 / Allow roll-up of data from the ICUs but eliminate double entry of data, create feedback process with benchmarking
Review of outcomes in semi annual ICU updates with regional and hospital leadership based on IPEC data / Biannual / Involve leadership at multiple levels, Create competition within a region
Continuous learning
Commercial learning module for central line associated blood stream infections provided CEU for any nurse nationally / Available March 2007 / Create benefit for RN for learning, create a system to allow updating of knowledge as staff changes
Toolbox on web with adaptable measurement tools, policies and procedures (for sustaining change) to eliminate need to re invent the wheel from scratch for the local project teams / Available January 2006 / Learn from each other within the system
Performance measurement
Establish goals for ICUs annually to continue to drop the infection rates / FY 2008 / Influence leadership commitment and prioritization
Mentoring / January 2007
Identify ICUs that have not improved and help them move the dot / Husband resources only for those that cannot make progress independently
Table C. Questions asked of mentored site in initial semi structured interview
Barriers / What makes this project difficult?
Data collection / Do you have an infection control practitioner who is assisting with the data defintiions
Data collection / Who enters the infection and adherence data in the website
Data collection / How are line days collected
Equipment / How big is the drape that you use on your central line insertions
Equipment / Do you use a needleless system ? What kind?
Equipment / Do you have a line cart? Who stocks it? What is in it?
Feedback / Do you report the infection rates and adherence in monthly nursing staff meetings
Feedback / How do physicians learn about the CLABSISI rate in the ICU
Feedback / Do you post your central line infection rates and adherence to bundle practices
Feedback / Do you post a chart or a graph, How big is the chart. Where is it posted
Feedback / Do you report infection rates to the nurse executive monthly? To the critical care committee? How does the executive leadership committee learn of your CLABSISI rates
Feedback / What was your CLABSISI rate last month?
Forcing function / Do you have a line cart? What is in the line cart?
Forcing function / Do you use a checklist during central line insertion
Forcing function / Does someone complete a checklist for central line insertion during the central line insertion, who? 24/7 or during administrative hours
Forcing function / Does the team use a daily goal sheet when they round
Leadership / How does leadership learn about your progress on the CLABSI reduction project
Leadership, Team / Do you have the supplies that you need for central line insertion to perform the bundle
Learning / Did you establish a goal for the project ? and what was your timeframe for that goal?
Learning / How many nurses in the unit have taken the self study module
Learning / Can you describe the most recent test of change or PDSA cycle that your team performed
Learning / How do you / did you begin the improvement project ? When did you begin it?
Physician Champion / Is there a physician that is helping you get physician collaboration
Team / Can you tell me who are the members of your quality improvement team to reduce CLABSI SI
Team / What are their roles in the ICU
Team / Do the nurses participate in rounds
Team / Are advances in grade or steps possible because of participation in a QI project in your hospital?
Team / How is this project supported? dedicated time for staff for quality improvement, a system to capture time, or pay for time spent on quality improvement ?
Table D. Comparison of VA CLABSI to National Healthcare Safety Network reported rates; standardized infection rates (January to June 2009)
Observed CLABSI Rates VA ICUs 2009 Jan- June / NHSN CLABSI Rates 2006 - 2008ICU / NHSN Group / CLABSI / Line Days / CLABSI RATE / PRED CLABSI / SIR / CLABSI / Line days / CLABSI Rate
Mixed LVL 1 / Med /Surg teaching / 23 / 16783 / 1.37 / 35.38 / 0.65 / 1474 / 699300 / 2.11
Mixed LVL 234 / Med surg < 15 beds / 33 / 23007 / 1.43 / 34.41 / 0.96 / 1130 / 755437 / 1.50
Medical / Medical ICU / 12 / 9510 / 1.26 / 21.88 / 0.55 / 2097 / 911476 / 2.30
Surgical / Surgical ICU / 53 / 34645 / 1.53 / 79.87 / 0.66 / 1683 / 729989 / 2.31
Medical / CCU / Med/CCU / 48 / 25448 / 1.89 / 51.08 / 0.94 / 876 / 436409 / 2.01
VA ICUs OVERALL / 169 / 109393 / 1.54 / 222.63 / 0.76
LVL = level, NHSN = National Healthcare Safety Network,CLABSI = central line associated blood stream infections, CLABSI rate = CLABSI divided by line days * 1000, Pred CLABSI = predicted VA CLABSI rates; NHSN CLABSI rate divided by 1000 times VA line days. SIR = Standardized infection rate; observed number of CLABSI divided by the predicted CLABSI
Figure A. Data management website and example report built from data on website