The Importance of a Physician Champion in Implementing Practice Change

Abstract

ISSUE: In Surgical Trauma ICU (SICU), the rate of central line related bloodstream infections (CRBSI), as defined by CDC, was at or above the National Nosocomial Infection Surveillance System(NNIS) mean for several sucessive quarters. There is strong evidence that use of full sterile barriers and chlorhexidine skip prep during insertion of central lines reduces the risk of infection. In an effort to facilitate best practices, a “Barrier Kit” was designed with all necessary supplies and was to be provided to each physician by nursing personnel assisting. These are available in all clinical units. A Central Venous Catheter Insertion form was created to monitor several aspects of central line insertion including use of maximum sterile barriers and chlorhexidine skin prep. These were designed to allow physicians to use them as the procedure note as well. If the physician chose to document the procedure elsewhere, the nurse could complete monitoring information. To facilitate ussage, Materials Management attached a form to each central line kit before delivery to patient care units. Medical Staff and nursing were educated. Compliance with completion of the form was poor and documentation of appropriate barriers and skin prep was less than 100% on completed forms. PROJECT: In April, 2005, the new medical director of SICU accepted the challenge of reducing this infection rate. First, she created a policy on the insertion procedure and presented it for approvel by appropriate medical staff committees. Included in the procedure, nursing personnel assisting the physician were to remind the physician inserting the line if policy was not being followed and complete the form if the physician chose not to. In SICU, if a physician didn't comply, she was to be notified and would discuss policy with that physician. Medical Directors of all units were encouraged to adopt a similar procedure. In SICU a cart was stocked with frequently used central line kits and all needed supplies. She supported a trial of a timed release chlorhexidine gluconate dressing in SICU, and when complete, use of the product on all central lines in the facility. RESULTS: In the four preceeding quarters, the average CRBSI rate in surgical ICU had been 6.8%. In the two quarters following her intervention, there were no CRBSI in the unit. LESSONS LEARNED: Physician involvement and willingness to provide feedback to other physicians is vital in process improvements that require a change in physician practice.