TriStar Skyline Medical Center is a 353-bed hospital located in Nashville. Even through the pandemic, TriStar Skyline maintained zero central-line associated bloodstream infections (CLABSI) in its trauma ICU for over three years. TriStar Skyline shares its success strategies below.
The TriStar Division-Wide CLABSI prevention strategies are centered around two key concepts: first, put eyes on practice, i.e., trust but verify, rounding every day on every line; and second, make safety huddle count, i.e., right line, right time, right reason. These processes ensure we can answer the following questions: “What is the indication for the line and is it appropriate?” and “Can we de-escalate by removing the line?”
Putting our eyes on practice involves evaluating key points of care such as IV hubs (“Scrub the Hub” and “Focus on Friction”); medication administration; blood draws; hand hygiene and glove etiquette; and catheter insertion sites, including review to ensure dressings are clean and intact.
Safety Huddle includes a review of every line by infection prevention and nursing; a process to stop inappropriate blood culture orders, as well as use of two-person attestation for draws; review of chlorhexidine (CHG) bathing to ensure proper technique, including over dressings and down lines, as well as use of CHG impregnated dressings; universal decolonization in the ICU; and the benefit of a dedicated Vascular Access Team.
The key to Skyline’s successful implementation of these strategies has been interdisciplinary partnership between physician providers, nurses, quality (including infection prevention), education, and other key stakeholders. For example, Tristar Skyline implemented rounding on devices and dressings, specifically from the day of line insertion, during which the infection prevention team collaborates with bedside nursing staff to ensure quality line care is being performed.
Similarly, infection prevention staff partners with the facility’s education department to assist in delivering formal and informal education about HAI reduction to interdisciplinary staff. One tactic has been to utilize the CLABSI bundle during multidisciplinary rounding and education sessions. Another tactic, completed in conjunction with education, nursing and quality, has involved infection prevention offering classes to nursing directors, managers, and charge nurses on the importance of infection prevention and HAI reduction.
The two strategies that have been the most successful in preventing CLABSIs capitalize on the use of technology and systems intelligence. First, TriStar Skyline implemented an alerting structure (Raven) developed by our parent company, HCA Healthcare, for cultures ordered on patients who have a central line in place for two days or greater. When a notification alerts, a multidisciplinary group immediately assembles to review the culture order and ensure aseptic technique is use for the draw.
Another successful strategy is the implementation of PowerBI, an application tool also developed by HCA Healthcare. Within this tool, the care team is able to see the most recent dressing change and CHG treatment; the number of days the line has been inserted; and the indication, the ordering provider, and several additional important resources. Providers, nursing, quality and infection prevention, and administration all have access to the PowerBI tool. Collaboratively, this multidisciplinary team reviews lines twice daily, seven days a week (first during morning safety huddle and again mid-afternoon). The team evaluates the plan for line removal; creates an action plan for same day removal of lines that no longer meet the criteria for an invasive device; and complete loop closure of the plan. Pharmacy and PICC teams join in these discussions, providing additional resources and feedback, as needed.
HAI reduction remained a top priority and continued focus during the pandemic; however, as patient volumes and acuities increased throughout the hospital, so did our central line use. The TriStar Skyline team knew we were potentially at risk for having CLABSIs. Therefore, we heightened awareness by bringing in charge nurses and additional key team members (such as weekend staff, administrative nursing supervisors and administrators-on-call) to help ensure there were no breakdowns in the previously established processes. This additional focus by our team members has been critical in sustaining our success during COVID.
In addition to the multidisciplinary group that reviews lines during daily safety huddle, the TriStar Skyline nursing staff reviews every line during multidisciplinary rounding. These rounds include physician providers, nursing, respiratory therapy, pharmacy, case management, and the patient and family. As each discipline looks at the line from a different perspective, input is varied and challenges us to consider multiple viewpoints, each pointing to the safest, highest quality care of the patient.
The practice at TriStar Skyline is standard across the board for all invasive devices and additionally includes other HAI processes such as ones for clostridiodes difficile (C.diff) . As we streamlined the process for HAI reduction specific to CLABSI, we were able to take successful strategies, adapt and spread them to other HAI prevention processes, for example a two-person review for C.diff specimen collections; daily rounding on foleys (for CAUTI prevention), etc. While we always strive for zero harm, when we do identify a HAI, a drill down is completed within 24-hours; the case is reviewed for opportunities by a multidisciplinary team; findings are shared during safety huddle with facility leaders; and results are disseminated to interdisciplinary staff.