The topic of hospital-acquired infections has recently moved to center stage in health policy debates. Evidence-based practice guidelines for preventing various types of HAIs have been developed by the Centers for Disease Control, in collaboration with other agencies, which serve as the standard of care in U.S. hospitals. However, wide variations persist in their implementation.
The Institute of Medicine in 2001 emphasized the need for evidence-based medicine (standards of clinical care practice) to go hand-in-hand with evidence-based management (strategies for successful practice change) to ensure the consistent and successful implementation of such practices across health care organizations. While much progress has been made with evidence-based medicine, many gaps remain in evidence-based management.
Researchers at Georgia Regents University sought to address this variance. A study funded by the Agency for Healthcare Research and Quality examined the structure and content of communication associated with successful implementation of evidence-based infection prevention practices in two unit-level ICUs within an academic health center. Both units had low baseline adherence to the Central Line Bundle (five evidence-based practices for preventing CRBSIs), and higher-than expected CRBSIs. Periodic top-down communications were conducted over a 52-week period to promote CLB implementation in both units. Simultaneously, the study examined (a) the content and frequency of CLB communication at the unit level through weekly communication logs completed by physicians, nurses and managers; and (b) unit outcomes, such as CLB adherence rates through weekly chart reviews.
Both units experienced substantially improved outcomes, including increased adherence (particularly the fifth CLB component, “daily review of line necessity”), and statistically significant declines in both CRBSIs and catheter days. Concurrently, over time, both units demonstrated a significant decline in “reactive protocol-based communications” (e.g., “wear mask before entering patient room”) among nurses, coupled with a significant increase in proactive risk-reducing communications (e.g., “remove central line,” or “switch to peripheral IVs”) between physicians and nurses.
These changes in communication structure and content were associated with a sustained practice change at the unit level (i.e., daily review of line necessity), which in turn translated to sustained improvement in outcomes, (i.e., significantly reduced catheter use) and CRBSI rates in both units for over two years following the intervention period.
The study underscores the importance of (a) screening each unit for change champions and (b) enabling champions to emerge from within the unit to foster change implementation.
The study was led by Dr. Pavani Rangachari, associate professor and MPH program director at Georgia Regents. Co-authors are Dr. Michael Madaio, Dr. Peter Rissing, Dr. Peggy Wagner,and students Lauren Hall and Sid Roy, all of Georgia Regents, and Mr. R. Karl Rethemeyer of the University at Albany SUNY School of Public Health.
Results of the study have been published in Health Care Management Review.