In March, Riverside Methodist Hospital in Columbus, Ohio, part of OhioHealth, received a Best Practice Award from the Ohio Patient Safety Institute. The award recognized the hospital for its success in reducing external ventricular drain infections. EVDs are inserted into patients in neurological critical care units to relieve increased intracranial pressure and hydrocephalus when there is abnormal accumulation of fluid around the brain. While a cost-effective treatment, it does carry the risk of device-related infection. In October 2007, Riverside Methodist Hospital decided to attack this problem head-on and create standards to reduce infections, which resulted in the elimination of EVD infections for 32 months and counting.
Adapting current tools
One of the first obstacles to meeting the goal of reducing EVD infections was limited literature on EVD infection reduction. The team at Riverside Methodist Hospital turned to evidence-based practice for preventing central line-associated blood stream infections, as both this procedure and EVD placement involve inserting a line into a sterile body site. "You have to trust your instincts and knowledge base" when faced with limited literature, says Jo Henman, MPH, CIC, infection control program supervisor at OhioHealth.
The team identified similarities between EVD infections and CLABSIs and adapted tools that were successful in reducing CLABSIs for the EVD reduction initiative. "Step back and look at your process. Look at the data to see where the gaps are," Ms. Henman says. "Then look at other successes you've had. Can you take tools from those successes and apply them to this situation?" For example, Ms. Henman says maximum barrier precautions used to prevent CLABSIs were also used when placing EVDs. This practice requires the clinician wear a gown, sterile gloves, a mask and a cap. Another practice borrowed from central line best practices was having a nurse monitor placement at the bedside. This person's sole job is to use a checklist to ensure all appropriate processes occur when the clinician places the line in the patient.
Following best practices that hospital clinicians and staff were already familiar with from previous work reducing CLABSIs helped the team implement EVD reduction standards quickly and safely.
Putting standards to the test
Riverside Methodist Hospital began implementation by educating and training nursing staff on changes in standard practice. For example, Ms. Henman says previously physicians changed the dressing for the EVD but that task became nurses' responsibility to facilitate the quick changing of dressing when necessary. The nurse was at the bedside continually and could more easily ensure the dressing was occlusive (air- and water-tight), whereas physicians are often in other parts of the hospital and may be delayed reaching the patient. This practice was adapted from standards for CLABSIs, in which nurses also change the dressing. The hospital also helped speed the process of changing the EVD dressing by creating a standardized kit that had all the materials needed to change the dressing.
Ms. Henman and the unit's educator — who is responsible for teaching staff new procedures and how to use new products — made weekly rounds on patients with EVDs to ensure the dressing was occlusive and that the checklist for EVD reduction was completed. If the dressing was wet or the checklist was incomplete, Ms. Henman and the educator would speak with the bedside nurse to identify barriers and work to improve the process.
Building a team
The key to the success of the EVD infection reduction initiative was the collaboration between team members in the unit and infection prevention staff, according to Ms. Henman. At Riverside Methodist Hospital, a multidisciplinary team of nurses, physicians and management developed the interventions. Having front-line people create the processes they will use increases their buy-in and engagement in the initiative.
One challenge in gaining buy-in was convincing staff and physicians that reducing infection was possible. "It's so ingrained that infections with this device were inevitable that sometimes it was hard for them to believe that if you do these actions, you can truly prevent infections," Ms. Henman says. Team members began to believe in their ability to reduce infections once they implemented standards and began seeing results.
When clinicians and staff truly believed they were capable of eliminating infections they became more engaged in the initiative and worked together with infection control staff to achieve their goal. "It's about building partnerships with the staff on the floor," Ms. Henman says. "That's where the real success comes from, when infection [preventionists] partner with nurses and work together." She suggests building these partnerships by being visible and spending time with the units, such as by doing weekly rounds. "Nurses begin to see you as a partner and as somebody who can help knock down barriers to make their job easier, not someone who is coming to tell them what they're doing wrong," she says.
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Adapting current tools
One of the first obstacles to meeting the goal of reducing EVD infections was limited literature on EVD infection reduction. The team at Riverside Methodist Hospital turned to evidence-based practice for preventing central line-associated blood stream infections, as both this procedure and EVD placement involve inserting a line into a sterile body site. "You have to trust your instincts and knowledge base" when faced with limited literature, says Jo Henman, MPH, CIC, infection control program supervisor at OhioHealth.
The team identified similarities between EVD infections and CLABSIs and adapted tools that were successful in reducing CLABSIs for the EVD reduction initiative. "Step back and look at your process. Look at the data to see where the gaps are," Ms. Henman says. "Then look at other successes you've had. Can you take tools from those successes and apply them to this situation?" For example, Ms. Henman says maximum barrier precautions used to prevent CLABSIs were also used when placing EVDs. This practice requires the clinician wear a gown, sterile gloves, a mask and a cap. Another practice borrowed from central line best practices was having a nurse monitor placement at the bedside. This person's sole job is to use a checklist to ensure all appropriate processes occur when the clinician places the line in the patient.
Following best practices that hospital clinicians and staff were already familiar with from previous work reducing CLABSIs helped the team implement EVD reduction standards quickly and safely.
Putting standards to the test
Riverside Methodist Hospital began implementation by educating and training nursing staff on changes in standard practice. For example, Ms. Henman says previously physicians changed the dressing for the EVD but that task became nurses' responsibility to facilitate the quick changing of dressing when necessary. The nurse was at the bedside continually and could more easily ensure the dressing was occlusive (air- and water-tight), whereas physicians are often in other parts of the hospital and may be delayed reaching the patient. This practice was adapted from standards for CLABSIs, in which nurses also change the dressing. The hospital also helped speed the process of changing the EVD dressing by creating a standardized kit that had all the materials needed to change the dressing.
Ms. Henman and the unit's educator — who is responsible for teaching staff new procedures and how to use new products — made weekly rounds on patients with EVDs to ensure the dressing was occlusive and that the checklist for EVD reduction was completed. If the dressing was wet or the checklist was incomplete, Ms. Henman and the educator would speak with the bedside nurse to identify barriers and work to improve the process.
Building a team
The key to the success of the EVD infection reduction initiative was the collaboration between team members in the unit and infection prevention staff, according to Ms. Henman. At Riverside Methodist Hospital, a multidisciplinary team of nurses, physicians and management developed the interventions. Having front-line people create the processes they will use increases their buy-in and engagement in the initiative.
One challenge in gaining buy-in was convincing staff and physicians that reducing infection was possible. "It's so ingrained that infections with this device were inevitable that sometimes it was hard for them to believe that if you do these actions, you can truly prevent infections," Ms. Henman says. Team members began to believe in their ability to reduce infections once they implemented standards and began seeing results.
When clinicians and staff truly believed they were capable of eliminating infections they became more engaged in the initiative and worked together with infection control staff to achieve their goal. "It's about building partnerships with the staff on the floor," Ms. Henman says. "That's where the real success comes from, when infection [preventionists] partner with nurses and work together." She suggests building these partnerships by being visible and spending time with the units, such as by doing weekly rounds. "Nurses begin to see you as a partner and as somebody who can help knock down barriers to make their job easier, not someone who is coming to tell them what they're doing wrong," she says.
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