The Importance of Leadership in Effecting Change: A Tale of 2 ICUs

Abstract

ISSUE: A 2005 performance improvement goal for our Epidemiology Department (ED) was to decrease the incidence of catheter-related bloodstream infections (CR-BSIs). The leadership of 2 targeted, high-risk adult ICUs was presented with an initiative, which was met with enthusiasm in one and reservation in the other. PROJECT: A recommendation was made to the 2 ICUs to implement a central line bundle based on a peer reviewed, published study that demonstrated a decrease in CR-BSIs. The bundle consisted of 5 interventions: education on proper technique for central venous catheter (CVC) insertion, use of a CVC supply cart, daily questioning of the need for CVCs, a checklist to be completed by nurses to ensure sterility of CVC insertion, and empowering nurses to stop the procedure if breaches in sterility were identified. The ED brought the lead investigator of the study to our hospital as a consultant to kick off the implementation of the bundle; served as a resource for computer based education on CVC insertion; offered education to nursing and resourced the bundle policy development. Leadership in “ICU-A” was well informed of the initiative, obtained a CVC cart and completed education in March 2005. The unit educator wrote the policy and adapted a CVC insertion checklist, which was implemented July 1, 2005. Conversely, the leadership of “ICU-B” resisted adaptation of the bundle policy. It cited additional work for nurses, not wanting to “police” housestaff, and not wanting to utilize a bundle policy that was not designed specifically for ICU-B. Implementation was delayed until coaxed by hospital administration in October 2005. RESULTS: ICU-A maintains use of the femoral site for CVC below the CDC 10 th percentile. For the 6 months before and after the intervention, its CVC utilization decreased 24%, maintaining in the CDC 10 th -24 th percentile for the last 2 quarters of 2005. In ICU-B, the use of the femoral site for CVC increased 33% in the 3rd quarter of 2005, maintaining in the CDC 11 th -25 th percentile for the last 2 quarters of 2005. CVC utilization continued at the CDC 75 th -90 th percentile for 2005. LESSONS LEARNED: The same education produced 2 different outcomes. ICU-A has had 6 months of success with the bundle, and is now re-evaluating nursing processes to further decrease CR-BSIs. ICU-B strives to achieve compliance. Despite documented, evidence-based practice, it is imperative to achieve unit leadership “buy-in” in order to effect a practice change.