Types of Interventions

Prevention of central line–associated bloodstream infection (CLABSI), while initially making great strides in 2003, has declined as use of peripherally inserted central catheters (PICCs) has grown tremendously over the past two decades. The convenience of a PICC has led to sicker patients being treated outside the intensive care unit, and there has been little recognition of a trade-off between benefits and risks after PICC placement. For these reasons, CLABSI prevention has become more challenging. This chapter describes the contents of an infection prevention bundle for CLABSI. In the case of CLABSI, the intervention outlines appropriate and inappropriate uses of central lines. Several new tools are discussed, which help doctors and nurses think through which device is most appropriate for any given patient.

Types of Interventions

Infection prevention programs were slow to develop—they were a rarity as recently as the 1950s—but they have become a staple of modern-day hospitals. Great strides have been made in identifying clinician activities that can control or prevent various healthcare-associated infections. This chapter describes the contents of an infection prevention bundle for catheter-associated urinary tract infection (CAUTI). In the case of CAUTI, the so-called bladder bundle sets forth appropriate and inappropriate use of indwelling catheters. A nursing checklist, on paper or as a template in the electronic medical record, is used to track patients’ daily urinary catheter status. Doctors and nurses are asked to rethink when a Foley is called for, what alternatives should be considered, what catheter equipment should be used, and how long the Foley should remain in place.

Taking on Clostridioides difficile

The adaptive approach used in the previous chapters to prevent catheter-associated urinary tract infection (CAUTI) is applied to an initiative to prevent Clostridioides difficile (formerly Clostridium difficile) infection. These two initiatives differ regarding their scope, the members of their teams, and the elements of their bundles. For preventing C. difficile, for example, the most important bundle item is antimicrobial stewardship since the use of broad-spectrum antibiotics vastly increases a person’s risk of becoming infected. Infectious diseases physicians or clinical pharmacists are to examine the circumstances of antimicrobial prescriptions they have filled to see whether they meet infection prevention standards; if not, the prescribing physician will receive prompt feedback. Differences aside, the basic elements of the CAUTI framework apply, from the C-suite’s decision to go ahead with the initiative to the tactics used to sell the C. difficile bundle to the hospital staff.

Joining a Collaborative

When hospitals join in a collaborative infection prevention project, they agree to work within the requirements and discipline of the sponsors. That includes providing baseline and monthly infection rate data to the collaborative leaders and committing some staff members to intense weekly phone talks with the collaborative experts and other coaching sessions. Ideally, a community emerges, both online and in-person. The community members exchange experiences and ideas related to the initiative, socialize, and establish a behavioral norm within each hospital that can help convince resisters, particularly physicians, to change their ways. To make up for the limited attention paid to the problems individual hospitals may encounter, some collaboratives provide a troubleshooting group of expert advisors. The collaborative approach has strong support from federal and state agencies, but some studies have questioned its effectiveness.

The Importance of Leadership and Followership

Leadership in a hospital setting differs substantially from that in a for-profit corporation, regarding both mission and practice; that is evident during a quality improvement initiative. Top administrative and clinical leaders need to continually communicate the value and scientific validity of the project to staff members by all available means—including personal cheerleading. Project managers and team champions have to energize the staff with their own enthusiasm for the initiative, capitalizing on the trust and respect they have earned. What is called for is transformational leadership and substantial emotional intelligence. Leaders on all levels need to devote themselves to helping colleagues become exemplary followers. The major characteristics of the leaders of successful infection prevention projects are described.

The Future of Infection Prevention

The technical advances described in this chapter could markedly aid the struggle to prevent healthcare-associated infection. They range from nanomedicine to oral doses of probiotics and IBM’s Watson computer as diagnostician. The adaptive possibilities include further empowerment of the patient on the one hand and new approaches to bring hard-pressed clinicians emotional relief and improve their interactions with patients on the other hand. Studies have shown that large numbers of physicians have suffered burnout. Many doctors and nurses are not fully attentive in their encounters with patients. Growing numbers of clinicians have begun practicing mindfulness, and a model designed to show how a mindful focus can help clinicians in implementing infection prevention initiatives is presented.

An Effective Strategy to Combat Hospital Infections

Healthcare-associated infection takes a heavy toll on patients, and negatively affects hospitals themselves, both financially and psychologically. Proven technical approaches to prevent infection have often faltered because of the failure of hospital staff to adopt them. This book focuses on these adaptive problems, particularly as experienced during efforts to combat catheter-associated urinary tract infection (CAUTI), central line–associated bloodstream infection (CLABSI), and Clostridioides difficile infection (CDI). It provides a step-by-step description of a model quality improvement intervention, explaining why clinicians neglect or actively oppose such initiatives and how to change their minds. The focus is on preventing CAUTI, which has proven far more resistant to quality improvement efforts than CLABSI. The CAUTI intervention framework is also broadly applicable to a variety of other hospital issues, including preventing falls and CDI. The solutions presented grow out of the extensive research by the clinical authors and their colleagues at the University of Michigan and VA Ann Arbor Healthcare System.

Common Problems, Realistic Solutions

A hospital-wide intervention is rolled out. There are changes in the team leadership and many operational adjustments: supplies ordered, procedures redesigned, nursing assignments altered. Three major types of troublemakers are described: the active resisters, the organizational constipators, and the time-servers. Motivations range from opposition to any kind of change to a personal animus toward the project champions to a determination to do as little extra work as possible. Requests by patients and their families may be used to try to get around bladder bundle items or a member of the project team may approach nurses with a patronizing attitude. The team cheers short-term progress to encourage staff compliance, solicits concrete criticism as a path to improvement, and adjusts the implementation process to allow for special circumstances. Efforts to use the electronic medical record to game the system must be squelched. Unfortunately, these challenges are all too common when implementing an infection prevention initiative—but there are solutions.

Toward Sustainability

After the formal initiative is finished, the project team continues working to secure and perpetuate the progress made in reducing Foley usage and institutionalizing the bladder bundle checklist. Members put into effect plans formulated during the initiative’s early days. The evaluation of catheter use and of infection rates goes on, though the data collection intervals are farther apart. Successes are promoted throughout the hospital, a reminder that the initiative continues. A major mission is to identify backsliders and realign them. Because of the possibility that champions will leave the hospital or be reassigned, current champions are urged to develop their replacements. The team makes sure that the orientation process for new arrivals to the hospital includes prevention information related to catheter-associated urinary tract infection and the hospital’s protocols concerning Foley insertion and removal.

Building the Team

The recruitment of a nurse champion and a physician champion is described in detail. At in-person meetings and via online presentations, team members familiarize themselves with current catheter practices and absorb the new protocols. They decide which medical floor unit will be the first target and pilot project for the initiative. Their criteria: a unit with a track record for cooperating with interventions and that also has a sizable number of Foleys and catheter-associated urinary tract infection cases. The project manager, champions, and other team members work out implementation details—promoting the project’s goals throughout the hospital, coordinating with other ongoing quality initiatives in the hospital, and identifying those people who will need special convincing. The changes will drive staff from their comfort zones, add to their workload, and challenge traditional relationships between nurses and doctors.