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7 ensuring adaptation and ownership

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Luciana Martins
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18 views

7 ensuring adaptation and ownership

Uploaded by

Luciana Martins
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Ensuring adapta-on and ownership

in change implementa-on – a case


study

Debbie Xuereb
Senior IPCN
Mater Dei Hospital – Malta
@XuerebD
[email protected]
Mater Dei Hospital

2
What are “Care Bundles”?
• Collec-on of evidence based clinical interven-ons
(usually 3-5)
• Care bundle provides a means to ensure that the
applica-on of all the interven-ons is consistent for
all pa-ents at all -mes thereby improving outcomes

• Developed by Dr. Peter Pronovost in Michigan USA


– Checklist for inser-on and management of Central
Venous Catheters to ensure that key interven-ons
recommended by the CDC 2002 guidelines were
implemented every -me a CVC was inserted
Pronovost’s Results
• 103 ITU’s in 67 hospitals data was
included in the study results

• Rate of catheter-related blood stream


infections per 1000 catheter days
decreased from 2.7 at baseline to 0 at 3
months after implementation
• In 2010 invited to participate in IMPLEMENT
project
• EU funded project
• Look at process of implementation of CVC
bundles in European hospital
WP4
Culture
Understanding hospital organisa-onal culture relevant to IPC

Iden-fying effec-ve interven-ons in EU hospitals

Implementa-on of Care Bundles to


Implementa-on
reduce infec-ons in intensive care
Before we started
• Lack of wriZen CVC policy
• Various shortcuts in proper a[re, skin
disinfec-on and draping
• Lines kept in far too long
• Sub-op-mal hub disinfec-on when accessing
lines
• Inadequate CVC dressings
• Major issues when pa-ents transferred out of
ICU with CVC

9
Focus groups
• We wanted to beZer understand our
organiza-onal culture in the ICU

• Look at a[tudes, beliefs, percep-on, what are


the ‘rules of behaviour’, shared values

• Iden-fy the boZle necks and plan for them

• 3 focus groups
Focus groups results
• Audits
– “incriminate the par-cular individual”
• Documenta2on
– “this is not an integral part of our work”
– “nurses should focus on pa-ent care rather than filling extra
documenta-on”
• Short-cuts
– “there is nothing wrong in taking short cuts as long as nothing bad
happens”
• Teamwork
– “(nurses) will politely point out (mistakes) with junior doctors (but)
they would not dream to do so with senior consultants; once biZen,
twice shy ”
• Accountability
– “when doctors start to follow infec-on control policies, then come to
talk to us about accountability”
KoZer’s 8 steps model for change
Create sense of urgency

• High BSI incidence ITU patients >48hrs

Patients BSI rate


Patient BSI
staying per 1000
Days episodes
>48hrs pt-days

2009 661 6091 44 7.2


2010 857 6377 42 6.59
EU average (2007) 4.2
Form a powerful coali-on
• Leads from infec-on control and ICU
• Mul-disciplinary
• Close collabora-on – knew who to pick
• Champions
• Trust within team and outside
• Energe-c, mo-vated
Form a vision for change

• Visit to a collaborating
hospital in Ireland

• Invest time in planning

• Standardisation
Change Process
• Using feedback from focus groups modified
the Pronovost template to fit into our culture

• Nurses were not required to oversee doctor's


performance or stop an inser-on
• Informal feedback from link nurses iden-fied
non-compliant staff
– Referred to champions
Documenta-on
• Modified approach to
documenta-on

• Easy on documenta-on
• Tick sheet

• Filled by doctor
• signed by both doctor and
nurse

• If not all form filled, s-ll


counted as a level of
compliance
CVC maintenance
• Line maintanance checklist introduced
• Hub scrub with chlorhexidine alcohol x 15
seconds emphasised
• Daily review of central line necessity
• Review of line necessity before transfer to
ward
– If essen-al, ICN informed
– Went to ward to ensure correct access prac-ces

18
KoZer’s 8 steps model for change
Communicate vision
• Several seminars, outside hospital, in evening
• Invited unit nurses and doctors
• Leaders from UK and Ireland as invited
speakers
• Shared our plans
• Asked for feedback
Empower ac-on
• Remove obstacles - provide necessary items
(wipes, dressings, disinfec-on solu-ons)

• Foster ownership
• Training of intensivists on inser-on
• Introduc-on of inser-on checklist
Involve and engage stakeholders
Gown Gloves

22
Nurse Training
• Onsite competency training for
ICU nurses in small groups

• Training on mannequins

• Competency assessment

• Small onsite groups

• See one, do one


Create quick wins
KoZer’s 8 steps model for change
Build on the Change

MRSA BSIs likely source - MDH - 2011


CVCs outside ITU
• Review of line necessity before transfer to ward
– If essential, ICN informed
– ICN visit ward to ensure correct maintenance practices

• Different challenges than ITU

• Lines not present as frequent as in ITU

• Competency issues noted

• Handled by different hcw – nurses and junior doctors


Hospital wide roll out
• Hospital wide training on CVC maintenance for
>350 nurses

• Introduced training on CVC accessing for all


foundation year doctors

• Introduced a tracking system of all CVC lines


inserted in op theatres

• Continue follow-up of pts with CVC on ward by


ICN and link nurse
2014 – No line related MRSA
bacteraemia

S-PUL, 1, 11%

S-SST, 1, 11% S-SSI, 3, 34%

UO, 2, 22%

S-UTI, 2, 22%

29
Make it s-ck
ICU-acquired BSI rate/1000 ICU bed days
8

0
2009 2010 2011 2012 2013 2014 2015 2016
What worked?
• Promote team work
‘teambuilding was great - together from start as a
team – posi7ve energy’

• Staff were involved from start and given


opportunity to feedback and change
“you involved the actual users and listened to our
feedback”
What worked?
• We allocated -me – effec-ve change doesn’t happen
overnight
“we had undisturbed planning 7me”

• Never stop talking about it; show passion

• Celebrate success

• If you have funding, specific budget that would really help

• Its hard work; be pa-ent


Thank you
@XuerebD
[email protected]

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