The evolution of knowledge exchanges enabling successful practice change in two intensive care units

Abstract

Many hospitals are unable to consistently implement evidence-based practices. For example, implementation of the central line bundle (CLB), known to prevent catheter-related bloodstream infections (CRBSIs), is often challenging. This problem is broadly characterized as "change implementation failure." The theoretical literature on organizational change has suggested that periodic top-down communications promoting tacit knowledge exchanges across professional subgroups may be effective for enabling learning and change in health care organizations. However, gaps remain in understanding the mechanisms by which top-down communications enable practice change at the unit level. Addressing these gaps could help identify evidence-based management strategies for successful practice change at the unit level. Our study sought to address this gap. A prospective study was conducted in two intensive care units within an academic health center. Both units had low baseline adherence to CLB and higher-than-expected CRBSIs. Periodic top-down quality improvement 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 communication related to CLB through weekly "communication logs" completed by unit physicians, nurses, and managers and (b) unit outcomes, that is, CLB adherence rates through weekly chart reviews. Both units experienced substantially improved outcomes, including increased adherence to CLB and statistically significant (sustained) declines in both CRBSIs and catheter days (i.e., central line use). Concurrently, both units indicated a statistically significant increase in "proactive" communications-that is, communications intended to reduce infection risk-between physicians and nurses over time. Further analysis revealed that, during the early phase of the study, "champions" emerged within each unit to initiate process improvements. The study helps identify evidence-based management strategies for successful practice change at the unit level. For example, it 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.