A3 for Central Line-Associated Blood Stream Infections

Abstract

SESSION TITLE: Quality Improvement 1 SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: An estimated 30,000 central line associated blood stream infections (CLABSIs) occur in U.S. Intensive Care Units (ICUs) each year. Patient mortality rates associated with CLABSI range from 12-25% and the cost of CLABSIs ranges from $3,700 to $36,000 per episode of care. To address this issue, we collaborated with hospital management to create a multidisciplinary team to enhance the care of patients with central venous catheters (CVCs) by using A3. A3 is a problem solving and continuous improvement approach first employed by Toyota and based on Edward Denning’s PDSA (Plan-Do-Study-Act).We implemented an A3 problem solving methodology in order to systematically reduce CLABSI among the medical and surgical ICUs. METHODS: A review of CLABSI related events across the various adult ICUs was performed. Initial and target states were established. The goal was to achieve a zero CLABSI rate by standardizing workflow for insertion, implementing strict guidelines for maintenance, and emphasizing early removal of CVCs. Gap analysis was used to identify multiple areas for improvement, which fell into five major categories: workflow, education, documentation, assessment and visual management. During subsequent monthly meetings, multiple small experiments were developed and implemented. Some of the products of these experiments include the creation of standardized central line insertion and maintenance checklists, a CVC insertion and maintenance audit tool, and a decision algorithm for line insertion and maintenance. RESULTS: We reviewed a total of 14,960 ICU patient days. Mean patient-days per month was 298 (range 210-379). Following the implementation of insertion and maintenance checklists in ICUs, we were able bring down our CLABSI Rate (CLABSI events /1000 patient days) from 2.25 to 0.00 to achieve our target goal of zero. CLABSI rates were reduced by 100% among adult ICU patients (p<0.001). Despite emphasis to reduce the use of central lines by early removal and consideration of alternative access, the device utilization ratio (defined as device utilization days divided by patient days) remained relatively constant (mean 0.30; range 0.23-0.39). These rates were sustained over the next nine months and checklists are permanently embedded in ICU work protocol. CONCLUSIONS: Our data demonstrates the effectiveness of the A3 approach for improving quality and safety among the different ICUs. Using this methodology, we were able to serially introduce several interventions that acted synergistically to eliminate CLABSI in the ICU. CLINICAL IMPLICATIONS: A3 provides an effective appraoch to problem solving and can be used in clinical setting to decrease and sustain lower CLABSI rates. DISCLOSURE: The following authors have nothing to disclose: Sikander Zulqarnain, Anton Dela Cruz, Gem Snagg, Raymonde Elysee, Jacqueline Syrus, Samir Fahmy No Product/Research Disclosure Information