Before Hawaii hospitals collaborated to reduce infections from central lines like the one above, it was common for intensive care units to get an infection about every nine days. After the collaboration, the whole state went without such an infection for 134 days. Photo:

The Fight Against Infection

When Hawaii hospitals worked together to reduce infections, they achieved remarkable results.

October, 2014

Hawaii’s rate of central-line associated bloodstream infections – one of the most deadly kinds of infection a patient can acquire in a hospital – was already on par with the national average when hospitals and state officials agreed to participate in a 2009 project to improve practices.

Three years later, the rate had been reduced by 80 percent, giving Hawaii the lowest rate for central-line infections in the country, says Dr. Della Lin, an anesthesiologist and patient-safety consultant who served as a point person for the project.

The changes stuck; Hawaii’s rate is still well below national benchmarks and is now the second-best in the country.

Lin says changing hospital culture and being more open about communication were keys to tackling the problem.

“It was remarkable to watch hospitals go from treating this as something they didn’t really want to talk about to sharing information and saying, ‘Hey this is what happened to us, and this is how we’re looking at maybe doing things better,’ ” she says.

Nationwide, about one out of every 25 patients will pick up infections in the hospitals where they are receiving care. Of the 722,000 patients in the U.S. who got a hospital-acquired infection in 2011, around 75,000 died.

Hawaii began requiring hospitals to report certain healthcare-acquired infections in 2011.

A “central line” is a catheter inserted into one of the patient’s largest veins – usually in the neck, chest or groin – and left in place as a portal to quickly deliver medication. Central-line infections can be especially dangerous because they spread bacteria directly to the bloodstream.

In 2009, Hawaii participated in a project with the Johns Hopkins Hospital in Baltimore, supported by funding from a private donor, to see if Johns Hopkins’ model for reducing hospital-acquired infections could be replicated elsewhere. All 17 of Hawaii’s hospitals with ICUs participated, making Hawaii the only state with 100 percent participation.

“It was a huge opportunity for us,” says Lin.

All the hospitals had to dedicate a team of staff, clinicians and senior leadership to the project for three years, meeting regularly as a group and consulting with experts from Johns Hopkins.

More than a “technical fix,” Lin says the most important step to tackling the problem was for hospital staffers to change their attitudes toward infection – no longer simply accepting that a certain number of infections was inevitable, but to look at each patient as a fresh case in which infection could be prevented.

“A lot of it had to do with expectation,” Lin says. “Our expectation was to reach zero.”

Hospitals worked together to evaluate procedures, then developed a checklist of best practices for every stage of each procedure, from the products they were purchasing, to the process of cleaning the area and inserting the catheter, to how long the lines were left in place, to how they were removed.

The next hurdle was educating clinicians and getting them to follow the new procedures. They learned that one weakness was experienced providers who had “drifted” away from best practices over the years.

“One question was how do we engage this person who’s been doing this for 20 years and might be thinking, ‘Hey, I already know how to do this,’ ” she says.

The collaborative developed an educational video depicting a nurse inserting a central line on a patient and making 12 mistakes along the way. Staffers were challenged to spot the “dirty dozen.”

Finally, the collaborative looked for ways to motivate staff to follow through. They began posting signs in each unit listing the number of days since its last central-line infection.

When the project started, it was common for adult ICUs to go eight or nine days between infections. But the combined efforts had dramatic results.

“We got to a point in the state where we went 134 days without any (central-line) infection in any hospital,” she says.

Hospitals are now working together to see if they can achieve similar results in reducing infection in colon surgeries. The procedure was selected because it’s one of the most widely practiced surgical procedures, and because the colon and intestines are at high risk for infection.

Hawaii’s current rate of surgical-site infections for colorectal surgeries is on par with national benchmarks, according to a 2013 Department of Health report.
“We’re starting to see improvements with that as well,” Lin says.

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