EM: This area has had a lot of focus over the years due to the severity of outcomes with central line-associated bloodstream infections. The Pennsylvania Healthcare Cost Containment Council, together with the Jewish Healthcare Foundation, found that Dr. Rick Shannon from Allegheny General Hospital had developed and implemented a business case analysis for certain nosocomial infections in his ICUs. He was successful at reducing his central line-associated bloodstream infections from being a significant part of their ICUs down to zero, and along the way he also tied in some financial analysis. That was PHC4’s rationale for developing this grant – they wanted other hospitals to try to duplicate this successfully, because it can benefit patients, hospitals and insurance companies.

EM: Hamot chose to apply because we felt this was something that we would be able to demonstrate, as well. Our ICUs are a reasonable size – we have about 46 beds – and, since November 2004, we have had an infection control database system called MedMined, which is a virtual surveillance interface system with data mining capabilities that let us track in real time positive cultures indicative of a central line bloodstream infection. We use this as an aggregate database to keep all of our data for ICU patients, house-wide. There are only two hospitals in Pennsylvania that actually use that system – Butler Memorial also has MedMined. We have not yet been notified of the exact amount of the grant, but we will be using it for staff support and data tracking. They were initially going to award ten grants in the amount of about $15,000, but they’ve only issued six grants. The money is really not the issue here. It’s demonstrating that we’re able to do this.

EM: We had to agree that zero should be the baseline – that we should be able to reduce our bloodstream infections to zero. We had to have support throughout the levels, from administration all the way down to nurses on the floor, and also have support of our financial department to tie in data in the end. We currently have a central line team that will be involved with this project and focus solely on caring for patients that have central lines. Our infection control department is completely involved with data collection and analysis. We have physician support, as well as critical care committees and patient care committees that are involved with this project. The concept put into place at Allegheny General was developing central line kits, or having all the supplies necessary in a type of central line bundle, and following guidelines from the latest recommendations for the care and placement of central lines. We’re tying that into this project, as well. We’re trying to attack this from all different sides, and at the end we will have the financial analysis.

EM: Historically, we have tracked our rates of central line bloodstream infections, so that will be our starting point – to know if we’re going to be making any long-standing interventions that will actually affect our rates. We’re going to focus on hand hygiene and campaigns to re-educate on how to prevent infections. Making sure that we’re 100 percent compliant with maximum barrier precautions, which means the way a patient is prepared to have a central line and also involves the person placing a central line – usually a physician or a certified nurse infusionist. They need to have gloves on, they need to have a gown on, they need a mask on. We provide those materials every time, so that shouldn’t be an issue. We use a CHG or a skin antiseptic that is recommended for the care of central lines. So, some of these things we already do, but we want to focus on them. Also recording whether we are actually placing catheters in the appropriate sites. The risk can change if a patient has a catheter that may not be in an appropriate area, or is left in that area too long, so we’re going to be looking whether we are removing these lines at a proper time interval and, if not, why. What processes are potentially causing infections that we can actually be preventing? What processes can we fix or change? We have some key steps we’d like to take, but we also assume that along the way we’re going to discover things we can do that will also positively affect our outcome.

EM: We have a critical care committee and a patient care committee, which involve our chief medical officer and some of our hospitalists and intensivists. We have had really great feedback and input from our physicians in those areas and they’re going to help us guide the care and recommendations. We have at least two committee meetings a month that discuss this topic – that’s where the critical questions are asked, where things can start to be put in place, and where presentation of results and follow-up can ultimately happen. Our medical staff is also very engaged in the project and always willing to engage in conversations about it, outside of the formal committee meetings. We have about seven intensivists, but there’s a lot of other physicians who will be consulted – the patient never has just one physician attending to their care. Not everyone is going to be dealing directly with central lines, but issues like hand hygiene can apply to everyone, even if they might not have direct contact with a particular device. We would like to affect everyone who enters the ICU, so we’re not particularly focused on just one group of physicians or one group of caregivers.

EM: Sure. While we do have great physician buy-in, putting things into place – compliance – comes into mind when you talk about changing a process, because people are used to doing something a certain way, by habit. We do have protocols for central lines. There are general practices that I’m sure vary from physician to physician – not large variance, but there are always small variances. We’re trying to address those issues head-on, so we don’t have any compliance problems if we do change a step in a process. When you’re doing a change in an organization this size, you’re always going to have some lag time before it all comes together.

EM: We are tracking, real-time, all patients that have a central line and doing targeted surveillance for development of bloodstream infections. We’ll be recording what interventions are taken as we go along, and we’ll be tracking our rates. We’ve made our goal zero, and we won’t be happy until we’re down to zero. We are well below CDC’s benchmark rate for nosocomial infections. It’s hard to say what intervention is going to give what percent of reduction, so we haven’t tried to estimate that. Even a reduction in one bloodstream infection would actually be a huge victory.

EM: Yes. The PHC4 and Jewish Healthcare Foundation grant had the stipulation that the data would be presented and "owned" by those organizations. Ultimately, the goal is to demonstrate that successful projects can be replicated at other facilities.

EM: We haven’t historically, in the infection control department, done financial analysis like this. Nationally, there have been studies that have identified a central line bloodstream infection, on average, as producing an extra cost of around $15,000. If we reduce our numbers even by the slightest, it’s helping the patient, it’s helping the hospital, it’s helping the payer. Hospitals save money on supplies, on staffing, being able to have more patients and improving outcomes.