Linking Blood Stream Infections to Intensive Care Nursing

Linking Blood Stream Infections to Intensive Care Nursing Context of Care and Process Jill A. Marsteller, Ph. D, MPP; J. Bryan Sexton, Ph. D, MA; Yea-Jen Hsu, MHA, Ph. D Candidate; Chun-Ju Hsiao, Ph. D, MPH; David Thompson, DNSc, MS, RN Funded by the Interdisciplinary Nursing Quality Research Initiative, a national program of the Robert Wood Johnson Foundation 03 November 2020 Unpublished data—Not for circulation 1

Background p p Central-Line Associated Blood Stream Infections (CLABSI) are among the most common and most serious types of hospital-acquired infections Between 9, 600 and 20, 000 patients are estimated to die from CLABSIs annually in the US The estimated cost of treating CLABSIs ranges from $296 million to $2. 3 billion The risks for CLABSIs are especially great for patients in ICUs, n n p 48% of patients in ICUs have indwelling central venous catheters Approximately 15 million central line days per year in U. S. ICUs CLABSI are most often preventable 03 November 2020 Unpublished data—Not for circulation 2

How was this different from Keystone ICU? Pronovost et al. 2006 NEJM reported results of Keystone ICU project in Michigan ICUs (also New Yorker article) p This project was different because: p n n n Randomized controlled trial Acknowledged the key nursing role Collected contextual measures Team Checkup Tool and interviews w/ teams p NQF nursing quality measures p 03 November 2020 Unpublished data—Not for circulation 3

Study Population 45 adult ICUs in 35 hospitals across two affiliated faith-based health care systems (East n=35 ICUs and West n=10) p The hospitals included in this study represent 12 states and are all community non-profit religious hospitals p Religious hospitals provide health care for one-fifth of all Americans p 03 November 2020 Unpublished data—Not for circulation 4

Adventist-QSRG ICU Patient Safety Intervention Comprehensive Unit-based Safety Program (CUSP) 03 November 2020 CLABSIPrevention Bundle Unpublished data—Not for circulation 5

CUSP p p p Evaluate the culture of safety Educate the staff on science of safety Encourage staff to identify how the next patient might be harmed Assign an executive to adopt the unit a) Learn from one system defect in the work environment per month; b) Implement one teamwork tool every 2 months (daily goals; morning briefing; shadowing; culture check up) Re-evaluate culture 03 November 2020 Unpublished data—Not for circulation 6

CLABSI Prevention p p p Washing hands before inserting a central line Removing unnecessary lines Cleansing the site with chlorhexidine Using full barrier precautions Avoiding the femoral site for line placement (some preference for the subclavian site) 03 November 2020 Unpublished data—Not for circulation 7

Study Design p Phased, clustered randomized controlled trial p ICUs randomized by hospital into intervention (23 ICUs) and control (22 ICUs) conditions for the first seven months (then control became Intervention II) p Analyses: test of the intervention 03 November 2020 Unpublished data—Not for circulation 8

Conceptual Framework 03 November 2020 Unpublished data—Not for circulation 9

Data Collection and Measures Laboratory Confirmed CLABSI and. Line Days p Team Check-up Tool p Nursing turnover, skill mix, RN hours per patient day, PES-NWI p SAQ p Exposure to elements of the intervention p ICU Length of stay p ICU Mortality p ICU Charges p 03 November 2020 Unpublished data—Not for circulation 10

RCT analysis Intervention I group started March 2007 p Control group started the intervention in Oct 2007 p RCT compares post-intervention (Oct-Dec 2007) CLABSI rate, holding baseline (2006) rates constant (zero-inflated poisson regression) p Two groups equivalent at baseline on all measures except two (exposure to CUSP and to partnership with a senior executive) p 03 November 2020 Unpublished data—Not for circulation 11

The Effect of the Intervention: Model 1 03 November 2020 Poisson Intervention status Control group Intervention group System East West ln(Baseline CLABSI rate+1) Logit Volunteer system East West No. of ICU beds 1 -10 >10 Baseline CLABSI count constant Model fit AIC BIC Vuong test IRR (95% CI) P value 1. 00 0. 19 (0. 06 to 0. 58) 0. 004 1. 00 10. 38 0. 95 Coef. (2. 96 to 36. 34) (0. 57 to 1. 58) (95% CI) 0. 000 0. 844 P value 66. 56 (62. 05 to 71. 06) 0. 000 98. 04 -32. 38 -18. 02 (90. 87 to 105. 22) (-34. 63 to -30. 14) (-21. 90 to -14. 14) 84. 2 98. 6 0. 000 Unpublished data—Not for circulation 12

The Effect of the Intervention: Model 2 Poisson Intervention status Control group Intervention group Volunteer system East West Exposure to ECUSP Partnership with an ICU by a senior executive for the BSI-reduction effort ln(Baseline CLABSI rate+1) Logit Volunteer system East Unpublished data—Not West for No. of ICU beds circulation 1 -10 >10 Baseline CLABSI count constant Model fit AIC 03 November 2020 BIC Vuong test IRR (95% CI) P value 1. 00 0. 31 (0. 10 to 0. 92) 0. 035 1. 00 6. 37 0. 75 0. 87 (2. 33 to 17. 40) (0. 84 to 1. 16) (0. 62 to 1. 22) 0. 000 0. 193 0. 408 1. 03 Coef. (0. 62 to 1. 72) (95% CI) 0. 908 P value 67. 26 (62. 52 to 72. 01) 0. 000 98. 72 -31. 82 -19. 49 (91. 85 to 105. 58) (-33. 88 to -29. 76) (-24. 09 to -14. 88) 84. 8 102. 9 0. 002 0. 000 13

No. of Bloodstream Infections per 1000 catheter-Days Baseline After implementation Median (interquartile range) Overall 1. 89 (0. 72 - 4. 18) 0. 00 (0. 00 - 2. 48) Control 1. 78 (0. 00 - 3. 80) 0. 00 (0. 00 - 2. 89) Intervention 2. 56 (0. 74 - 5. 87) 0. 00 (0. 00 - 1. 50) East 1. 67 (0. 29 - 3. 80) 0. 00 (0. 00 - 2. 48) West 3. 77 (1. 03 - 7. 12) 0. 00 (0. 00 - 5. 66) Intervention status System 03 November 2020 Unpublished data—Not for circulation 14

Quarterly BSIs per 1000 line days Intervention 1 (n=23) Baseline (2006) Mar 07 1 st Q (Apr-Jun 07) 2 nd Q (Jul-Sep 07) 3 rd Q (Oct-Dec 07) 4 th Q (Jan-Mar 08) 5 th Q (Apr-Jun 08) 6 th Q (Jul-Sep 08) BSI rate 4. 48 4. 71 1. 12 1. 83 1. 33 0. 96 0. 88 0. 85 BSI rate reduction from baseline to 6 th quarter 03 November 2020 IRR % of reduction 1. 00 1. 05 5% 0. 25 -80% 0. 41 16% 0. 30 -11% 0. 21 -8% 0. 20 -2% 0. 19 -1% -81% Intervention 2 (n=22) % of reduction IRR 1. 00 BSI rate 2. 71 2. 16 0. 52 0. 83 0. 79 0. 21 0. 19 0. 31 -21% -59% -2% 12% -69% Unpublished data—Not for circulation 15

Challenges of the Design Controls knew they would also be implementing p In interviews, some controls told us they had gotten started early p Controls did not report during control period—so “post” period is actually first 3 mo. s of intervention p Education delivery was better 2 nd time p 03 November 2020 Unpublished data—Not for circulation 16

Staff Use (1) 03 November 2020 Unpublished data—Not for circulation 17

Staff Use (2) 03 November 2020 Unpublished data—Not for circulation 18

Estimated Lives Saved over 2006 ~20% of people acquiring CLABSI will die from the infection p An estimated 35 to 36 people died in 2 systems in 2006 p If rate in quarter ending August 2008 stays the same over a year, only an estimated 12 people would die of CLABSIs June 2008 -May 2009 p p. A 66% reduction Unpublished data—Not for circulation * Preliminary estimates

Estimated Cost Savings p BSIs cost an estimated ~$45, 000 per infection p Reduced BSIs could have saved as much as $5, 850, 000 across the two systems!! Unpublished data—Not for circulation

Conclusions p p The CLABSI evidence-based practice bundle reduces bloodstream infections and zero can be achieved for long periods of time The bundle can be implemented effectively as a nursing-driven protocol for interdisciplinary team management of central line placement and maintenance Despite the promising results there were many barriers to implementation, such as physician engagement; adherence to protocol Difficult to achieve team compliance with monthly reporting by all team members 03 November 2020 Unpublished data—Not for circulation 21

Policy/ Managerial Implications CMS has said it will not pay for CLABSI above the normal IPPS payment for the case starting Oct. 1, 2008 (Deficit Reduction Act of 2005) p Assumes all infections can be prevented p All hospitals will need to implement CLABSI prevention strategies p QI teams need education, attention from and support of senior management, Bo. D p 03 November 2020 Unpublished data—Not for circulation 22