Chicago hospital uses hospitalwide huddles to reduce catheter infection rate
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August 1, 2018
How much have you reduced hospital-acquired infections (HAI) at your facility in the past two years? Five percent? 10%? 15%?
If so, you’re a bit behind. In 2016, the Department of Health and Human Services (HHS) put out an ambitious set of goals for HAIs by 2020. This includes reducing catheter-associated urinary tract infections (CAUTI) and central line–associated blood-stream infections (CLABSI) by 50%.
With two years left before the deadline, facilities should consider investing in ways to prevent HAIs—particularly given that CAUTIs can cost up to $10,000 per patient.
Prevention is a challenge, but it can be done. In just two years, Saint Anthony Hospital in Chicago faced down HAIs, cutting its HAI rate by 90% and saving itself $498,000. The hospital even won the Illinois Health and Hospital Association’s (IHA) “Innovation Challenge: Partners in Progress Award.”
How did the facility make such tremendous strides in infection control (IC)? Short answer: daily interdisciplinary safety huddles (DISH).
While most hospitals conduct safety huddles, what makes DISH different is that participation is hospitalwide. Representatives from all different departments (security, nursing, emergency services, IC, etc.) meet every morning for a 15-minute daily briefing.
Alfredo Mena Lora, MD, Saint Anthony’s medical director of IC, says DISH is just one aspect of the facility’s HAI reduction program, but it’s an important part.
“We know that huddles have been proven to improve outcomes and reduce certain variables, whether it’s in surgery or catheter placement,” Lora says. “But a hospitalwide huddle is what I think is novel.”
At DISH, nurse managers report on which patients have indwelling catheters (urinary or central venous). Then it’s decided which patients still need their catheters. If not, the device is expected to be removed within 24 hours. The reason this matters is because the longer a patient has a catheter, the more likely he or she is to develop an infection.
After one year of DISH meetings, Lora became curious. He felt the meeting was making a difference—after all, he saw the catheters being removed. But he wanted to prove it.
“Everything we do, every small quality improvement initiative, as the IC person here I always try to study it to see if there are empirical ways to assess the before and after,” he says. “I knew the meeting was being effective; my objective was to look at the before and after.”
In the summer of 2016, he made a chart of his findings and submitted it to the IHA’s innovations competition. While he’s glad to be recognized, he says winning the award wasn’t the point.
“Our goal wasn’t to win any specific award, but rather our day-to-day quality improvement objectives here in the hospital,” he says.
For an improvement program, DISH is pretty simple and cheap to set up. Saint Anthony started doing DISH meetings in late 2014. While it took a few months to get rolling, Lora says they saw results almost immediately.
They tracked their progress by tracking their device usage rate (DUR). While the definition of HAIs have changed over time, DUR has remained a constant variable for measuring the effects of medical intervention.
“When we reviewed this retrospective, we saw a downtrend after we were assessing the needs of catheters on a daily basis and forcing their removal,” he says. “I do think it promotes quick removal and is pretty cost-efficient and easy to do.”
There are always small challenges in trying a new improvement project, he says. But DISH is very sustainable and it helps correct any kind of challenges they have.
Right now, he’s working on a way to better assess why certain catheters remain. For example, was there a rise in the DUR because there were more sick patients? Because a new physician didn’t know the catheter policies? Or something else?
“Because I’m the infection control physician here, I know why some catheters remain—because some patients are sick and so forth,” he says. “As part of optimizing DISH, I’m looking for better ways to obtain that data moving forward and report it at DISH in a more efficient way.”
While Lora’s DISH study looked at catheter reduction, the huddles have more than one use.
“I think the success of the huddle is that it just morphed into including all the other disciplines,” he says. “Because on certain days we’d need information from other groups or departments in the hospital. Eventually we just decided to include all of them, because it improves communication between all departments.”
“For example, a week ago there was some minor construction that was going to happen,” he continues. “I know about it because of that [DISH] meeting and I implemented immediately whatever I need to do from an IC standpoint. Similarly, if there’s an issue in the OR, all the disciplines go there, so we all communicate.”
The daily huddle gives everyone from nutrition to facilities management a chance to update each other on what they’re doing. Everyone gets something out of this meeting, he says. And what they get is:
- Ability to ask questions and get quick responses
- Knowledge of everything going on in the hospital
- Accountability for finding solutions
“No matter what variable, this meeting does help,” he says. “And that’s part of the reason why we’ve been doing this for three years.”
Prior to DISH, Saint Anthony’s catheter reduction program was similar to what most facilities have: an evidence-based approach, checklists, antibiotic discs, etc. What made DISH successful, Lora says, is how it changed the behavior around reporting and removing catheters.
“We know that in infection control a lot of what we’re trying to control is human behavior,” he says. “We know that a patient that needed a central line for a lifesaving measure needs that central line. Maybe after day three or four they don’t need it. But sometimes it’s more comfortable for the nurses or people to forget that the catheter is there. So, I think that’s one of the human factors that this meeting controls. There’s more checks and balances to removing Foleys and central lines.”
Something he’s noticed in the data is a global drop in catheter use in all of Saint Anthony’s units. The most dramatic changes came from non-intensive care units, especially the medical-surgical units. The only place where the decrease was statistically insignificant was in their ICU.
What this suggests is a lot of ICU patients have catheters but are justified in having them. However, he says without the daily meetings, it was more likely for patients to leave the ICU and have the catheter remain for a few extra days.
“Clinical practice is very busy, so I think sometimes we forget that we can remove these catheters or use an alternative line,” he says. “And I think that’s where we found the dramatic change.”
The boss is watching
Lora says the most important reason why DISH has been so successful was “because our leadership saw the value in this and really helped move everybody to come to this meeting.” Since day one, hospital leaders have attended, which gives people an incentive to not let problems linger.
“If I as the infection control person say, ‘Hey, we talked about removing this catheter yesterday; was there a problem?’ chances are because we have the vice presidents there and senior leadership, most people will come with an answer the next day if the catheter does remain,” he says. “Or try to remove it, which is our ultimate goal.”
He says that DISH is usually attended by at least one senior administrative person, usually the vice president of nursing and the vice president of patient care services. Lora says this creates an air of accountability that’s promoted results and maintained DISH over the years.
“Another brief statement I’ll say on that is my own experience [as the infection control leader],” he says. “I have an IC nurse that goes to these meetings, and it’s somewhat redundant for me to go. But I started going and I saw the value immediately. These meetings don’t last more than five to 15 minutes, plus or minus depending on how many people come up. But the value you get from this meeting is massive because you know everything that’s going on in the hospital. I think the value of the meeting is that though we have leadership supporting and moving this, the value is obvious to everyone, which is why I think everyone enjoys going.”