From the 2023 HVPA National Conference
Shirley Bomhoff, Master of Science in Nursing (LSSBB MedStar Health)
Background:
MedStar Georgetown University Hospital, a teaching hospital in the District of Columbia (DC), experienced a sharp increase in central line-associated bloodstream infections (CLABSIs) since the start of the Covid-19 pandemic. This trend was seen nationally during this time, as reported by the CDC. To address this challenge, improve health outcomes, and chart a sustainable pathway for other organizations, MedStar developed resilient and agile improvement methodologies, including data and analytics best practices and a change management program.
Objective:
MedStar aimed to reduce the CLABSI Standard Infection Ratio (SIR) to a Mean Quarterly SIR of 0.41 or less and reducing the overall CLABSI rate of a mean of 0.88 or less at MedStar Georgetown University Hospital and build a sustainable process to continuously improve health outcomes.
Methods:
To address CLABSI rates, MedStar implemented SMART performance improvement (PI) methodology, combining traditional Lean Six Sigma concepts with high reliability, change management, appropriate data visualization and interpretation, and coaching a continuous process improvement mindset. It was essential to be aware and respectful of competing priorities and staffing constraints. The team kept the implementation timeline short while ensuring the execution of a robust and effective PI methodology and involving the bedside multidisciplinary team without adding administrative burden.
Results:
Through this improvement work, MedStar achieved the following results:
MedStar Georgetown University Hospital CLABSI SIR has decreased from 0.884 (Q3FY20 – Q3FY22) to 0.347 (Q14FY22 – Q2FY23) CLABSI Raw Numbers have decreased from a Quarterly Mean of 3.33 to a Quarterly Mean of 1.33
Organization wide CLABSI SIR has decreased from a mean of 0.88 (Q3FY20 – Q3FY22) to 0.34 (Q4FY22 – Q2FY23)
Organization wide CLABSI rate: Results tracking beginning in Q1FY24
Conclusions:
Building on its success, MedStar plans to scale the improvement program across the health system to 8 additional hospitals. To support this effort, MedStar is developing a daily management system to track actionable key process indicators to ensure desired outcomes are maintained.
Clinical Implications:
This initiative significantly reduced patient harm caused by a CLABSI. After testing and then implementing improved clinical processes and structures, the hospital has achieved a significant reduction in CLABSI SIR and Rate. The next steps are to spread these improvements across MedStar Health System to 8 additional hospitals.
