Beyond Bundles: Enlisting Healthcare Infection Prevention Performance Improvement Champions to Promote Patient Safety in Critical Care

Background:   Healthcare organizational strategies aimed at reducing CLABSI and VAP are variably successful and frustrated by poor long-term adherence. Most described approaches do not involve direct care providers and variably leverage translation of evidence-based infection prevention strategies into practice.  We hypothesized that clinicians acting as healthcare infection prevention (IP) performance improvement champions (HIPPIs) would achieve sustained adherence to bundled process measures and improve infection prevention in clinical practice.

 

Objective:   To assess the effectiveness of a HIPPI champion-led program for CLABSI and VAP prevention training through prospective auditing.

 

Methods:   A multidisciplinary team of infectious diseases, pulmonary, surgical physicians and critical care nurse HIPPIs organized to improve patient safety in the areas of CLABSI and VAP prevention during Quarter 4, 2007, at an urban academic community medical center.  Mandatory web-based CLABSI and VAP prevention training modules for critical care clinicians were developed and implemented during Q1 & 2, 2009. Validated pre/post-tests measured acquired knowledge.  Behavioral translation with CLABSI-VAP bundle adherence was prospectively assessed by auditing provider compliance with a validated paper-based tool through two rapid PDSA cycles over a 6-month period.  The tool was modified between cycles to improve fidelity. HIPPIs provided education using “teachable moment” interventions when IP opportunities were observed. CLABSI & VAP infection rates were monitored before and during interventions to assess initiative impact. 

 

Results:   CLABSI (N=311) and VAP (N=342) training yielded significant pre/post-test knowledge gains:  CLABSI (pre-M=75.9%, post-M=90.9%, t= -18.362, p<0.0001); VAP (pre-M=77.7%, post-M=91.5%, t=-15.133, p<0.0001).  Greater compliance with CLABSI bundle was observed compared to VAP bundle. Cycle 1 translation audits (N=44 observations) indicated frequent omissions in recording CL-site date (41%), and ventilator weaning and sedation vacation trials in eligible patients (39%). Cycle 2 (N=21 observations) measurements identified improvement opportunities in performing ventilator weaning (29%) and sedation vacation (28.5%) trials in eligible patients.  VAP and CLABSI rates were significantly lower by the end of the intervention period. 

Conclusions:   HIPPI championing of bundle adherence improves knowledge translation of knowledge particularly for VAP Bundle prevention.  HIPPI auditing coupled with educational reinforcement may be an effective tool for sustaining translation of IP bundles thereby increasing patient safety.