Quality Improvement Initiative in a Community Hospital to Reduce Central Line Device Utilization Rate.

Background The intensive care unit (ICU) in a community hospital in southwest Minnesota saw a steady increase in central line-associated bloodstream infections (CLABSI) and an increase in the utilization of central lines. The baseline CLABSI rate was 11.36 at the start of the project, which was the highest in the last five years. The corresponding device utilization rate (DUR) was 64%, which increased from a pre-COVID pandemic rate of 45%. Aim The aim of this project was to decrease the ICU DUR by 37.5% from a baseline of 64% to 40% within six months without adversely impacting staff satisfaction. Methods A multidisciplinary team using the define, measure, analyze, improve, and control (DMAIC) methodology reviewed the potential causes of the increased use of central lines in the ICU. The team identified the following major causal themes: process, communication, education, and closed-loop feedback. Once the root causes were determined, suitable countermeasures were identified and implemented to address these barriers. These included reviewing current guidelines, enhanced care team rounding, staff education, and the creation of a vascular access indication algorithm. The team met biweekly to study the current state, determine the future state, evaluate feedback, and guide implementation. Results The pandemic saw a surge in the number of severely ill patients in the ICU, which may have caused an increase in the DUR. The project heightened the awareness of the increased DUR and its impact on the CLABSI rate. The initiation of discussion around this project led to an immediate decline in DUR via increased awareness and focus. As interventions were introduced and implemented, the DUR continued to decrease at a steady rate. Post implementation, the DUR met the project goal of less than 40%. The team continued to track progress and monitor feedback. The DUR continued to meet the goal for three months post implementation. Since the start of the project, there have been no CLABSI events reported. This effort has positively impacted safety and patient outcomes. Conclusions Through a defined process, the central line utilization rate in our ICU was decreased to 37.5% to meet the target goal and has been sustained.

Pseudomonas infection reduction in the ICU: a successful multidisciplinary quality improvement project.

Pseudomonas aeruginosa infection causes high morbidity and mortality, especially in immunocompromised patients. Pseudomonas can develop multidrug resistance. As a result, it can cause serious outbreaks in hospital and intensive care unit (ICU) settings, increasing both length of stay and costs. In the second quarter of 2020, in a community hospital's 15-bed ICU, the P. aeruginosa-positive sputum culture rate was unacceptably high, with a trend of increasing prevalence over the previous 3 quarters. We performed a multidisciplinary quality improvement (QI) initiative to decrease the P. aeruginosa-positive rate in our ICU. We used the Define, Measure, Analyze, Improve, and Control model of Lean Six Sigma for our QI initiative to decrease the P. aeruginosa-positive sputum culture rate by 50% over the following year without affecting the baseline environmental services cleaning time. A Plan-Do-Study-Act approach was used for key interventions, which included use of sterile water for nasogastric and orogastric tubes, adherence to procedure for inline tubing and canister exchanges, replacement of faucet aerators, addition of hopper covers, and periodic water testing. We analyzed and compared positive sputum culture rates quarterly from pre-intervention to post-intervention. The initial P. aeruginosa-positive culture rate of 10.98 infections per 1,000 patient-days in a baseline sample of 820 patients decreased to 3.44 and 2.72 per 1,000 patient-days in the following 2 post-intervention measurements. Environmental services cleaning time remained stable at 34 minutes. Multiple steps involving all stakeholders were implemented to maintain this progress. A combination of multidisciplinary efforts and QI methods was able to prevent a possible ICU P. aeruginosa outbreak.

Intensive care unit adaptations in the COVID-19 pandemic: Lessons learned.

The coronavirus disease 2019 pandemic had deleterious effects on the healthcare systems around the world. To increase intensive care units (ICUs) bed capacities, multiple adaptations had to be made to increase surge capacity. In this editorial, we demonstrate the changes made by an ICU of a midwest community hospital in the United States. These changes included moving patients that used to be managed in the ICU to progressive care units, such as patients requiring non-invasive ventilation and high flow nasal cannula, ST-elevation myocardial infarction patients, and post-neurosurgery patients. Additionally, newer tactics were applied to the processes of assessing oxygen supply and demand, patient care rounds, and post-ICU monitoring.

Reducing Ventilator-Associated Events: A Quality Improvement Project.

BACKGROUND: Mechanical ventilation is lifesaving therapy in intensive care units but can increase patients' risk for ventilator-associated events. These events are associated with longer intensive care unit and hospital stays, more ventilator days, and increased mortality rates. LOCAL PROBLEM: To meet internal and national benchmarks, the number of ventilator-associated events in a 15-bed intensive care unit needed to be decreased. METHODS: A multidisciplinary team used the define, measure, analyze, improve, and control framework in this quality improvement project at a community hospital. Evidence-based guidelines for preventing ventilator-associated events were incorporated into interventions, which included discussion of ventilator settings in daily rounds, additional evening rounds, and staff education. The team reinforced education, defined roles in the care of patients receiving mechanical ventilation, and implemented communication strategies between departments. Preimplementation data from the calendar year 2018 were compared with postimplementation data from the calendar year 2019. RESULTS: The ventilator-associated event incidence rate decreased from 25.58 per 1000 ventilator days in 2018 to 5.29 per 1000 ventilator days in the third quarter of 2019. The goal rate (≤ 18.00 events per 1000 ventilator days) was sustained for the year 2019. DISCUSSION: The lower rates of ventilator-associated events met internal and national benchmarks after the implementation of interventions. Safety was enhanced for patients who may have had unexpected outcomes related to a ventilator-associated event. CONCLUSIONS: The creation and implementation of clear, specific communication and processes for successfully managing patients receiving mechanical ventilation decreased the rate of ventilator-associated events.