Texas Health Resources

Arlington, TX
3355 staffed beds

14 hospitals

STEEEP

Effective - Use of IHI bundles have standardized the care of patients at risk for VAP and CLASBI.

Safe - Both hospital-acquired VAP and CLABSI are now rare occurences at the health system.

Timely - Dedicated nurse-led PICC teams are available to insert central lines so patients do not have to wait for physicians to perform the task.

PPE

Eliminate Defects - Care providers perform root cause analysis on each case of hospital-acquired VAP and CLASBI so they can learn about the likely causes of infection and eliminate them. This information is shared systemwide on a secure Website.

Reduce Process Variation - Reducing process variabilitySupply Chain Management replaced all central line insertion and maintenance kits to make sure the full drapes, cleansers and other supplies were available.

Team Members

Michael  J. Deegan, MD
Executive Vice President, Chief Clinical and Quality Officer
Linda Gerbig, RN
Vice President, Performance Improvement
Marcie Williams, RN
Vice President, Safety & Risk Management
Faye Sheppard, RN
Director of Risk Management 
Edward Goodman, MD
Physician Champion, Infection Prevention COPIC
Sue Sebazco, RN
2009 Chair, Infection Prevention COPIC
Lynda Doell, RN
2009 Co-Chair, Infection Prevention COPIC
William A Brock, MD
Physician Champion, Critical Care COPIC
Margaret Markey, RN
2009 Chair, Critical Care COPIC
Brett Thetford, RN
2009 Co-Chair, Critical Care COPIC

Culture Change Stops Infection

The Problem

Hospital-acquired infections are a dangerous problem for providers.  A study in the Archives of Internal Medicine, released in February 2010, showed that in 2006, hospital-acquired sepsis and pneumonia caused 48,000 deaths and cost $8.1 billion in treatment.  But long before this study came out, senior leadership at Texas Health Resources, a 14-hospital system headquartered in Arlington, saw hospital-acquired infections as something that had to be eliminated.

The Solution

In the mid-2000s, Texas Health Resources piloted and then spread systemwide two bundles from the Institute for Healthcare Improvement, one to prevent ventilator-associated pneumonia (VAP) and another to prevent central line-associated blood stream infections (CLABSI). At the same time, the hospital system enacted a vigorous campaign on hand hygiene.

The Results

The Background
For Texas Health Resources, the desire to work on infections started at the top.  “Our CEO and the board decided that quality and patient safety had to be attended to in a much more robust way,” says Michael Deegan, MD, executive vice president, chief clinical and quality officer. Part of their approach was to hire Deegan in 2003. He, in turn, put senior quality officers in place at each hospital—it is the Texas Health Resources version of chief medical officers. And while the system already had councils in place to work on operational problems, called Operational Performance Improvement Councils, Deegan and other leaders also charged those councils with solving clinical care problems, changing the group names to Clinical and Operational Performance Improvement Councils (COPICS). Texas Health Resources has 14 such councils, which bring together department leaders from each hospital in the system.


The VAP and CLASBI projects needed the work of the COPICs for both critical care—including ICU department heads—and infection prevention. One big obstacle:  The staff’s belief that some amount of infection would always occur. “It was a paradigm shift when we started talking about a zero rate,” says Sue Sebazco, RN, director of infection prevention and employee health at Texas Health Arlington Memorial Hospital.  A member of the COPIC for Infection Prevention, she saw a change over time.  The system’s nurses and doctors became convinced: They saw both clinical studies in journals and Texas Health Resources’ own pilot data, showing that using these bundles could eliminate infections. “We have a whole new cadre of clinicians who believe now,” says Sebazco. “As the years go on, we have even sicker patients at a higher risk for infection, but we don’t use that as an excuse anymore.”  In fact, the COPIC she served on changed its name from “Infection Control” to “Infection Prevention.”


Another hurdle was getting all system hospitals to use the bundles, says Deegan. “Each of our 14 hospitals brings its history and culture, and the staff want to believe their approach is better than anyone else’s,” he says.


In the case of the VAP bundle, it was piloted at one hospital, because an ICU physician and a nurse leader there wanted to test its merits. After the system’s quality officers saw the bundle’s benefits, Texas Health Resources rolled it out to all hospitals, a process that took two years. The expertise of two hospital quality officers who were intensivists was leveraged to help doctors adopt the bundle, while nurses were educated through members of the critical care COPIC. In the VAP bundle, some of the changes are minor—elevating the head of the patient 30 to 40 degrees to stop fluids from pooling--and others required bigger changes. One such measure, called a “sedation vacation,” directs clinicians to use breathing tubes for a shorter period of time, and thus use less sedation medicine.  “That was the hardest part of the bundle for staff to accept,” says Deegan. 


One of the big changes for staff in using the CLASBI bundle involves fully draping the patient when the central line is inserted, and asking everyone, including family, to leave the room. “You are bringing the surgical field to the bedside, which can sometimes be frightening to the patient,” says Amanda Johnson, RN, who works on the peripherally inserted central catheter (PICC) team at Texas Health Arlington Memorial Hospital.  “But the patient may find it uncomfortable to have her head covered and want to know why a family member can’t stay and hold her hand.”  While this change sometimes means that nurses need to explain the situation to the patient, Johnson feels confident that the measure contributes to fewer infections.


During the same time the bundles were adopted, Texas Health Resources kicked off a campaign for hand hygiene, Clean In/Clean Out, complete with CEO Doug Hawthorne demonstrating proper hand washing technique at several meetings.  Anonymous observers who are trained in a methodology from the nuclear power industry check compliance. But it’s not just the measurement that shows the health system’s commitment, everyone is involved.  Johnson notes that she often sees supervisors washing their hands, which reinforces the practice for bedside nurses. 


Principles of Performance Excellence


Manage Organizational Variability
Texas Health Resources hospitals share data with COPICS and hospital presidents on hospital-acquired VAP and CLASBI occurrences and in 2008 required that the caregivers themselves perform root cause analyses (RCA) on each occurrence.  The RCA process is a partnership among Infection Control, Critical Care, Peri-operative Services, Performance Improvement and Risk Management. Clinicians receive coaching from risk managers on how to perform the RCA, but it’s vital the care givers do it themselves. “It’s hard to take high-level people away from the bedside,” says Sebazco, “but we learn a lot.” These RCAs provide timely information about the causality of the event and are posted on a secure Web site so all system members can benefit from the lessons learned. In the RCAs, caregivers usually discover that they did not perform the entire bundle, says Deegan, so it’s a good way to isolate circumstances that led to an infection event. The RCAs have helped staff see infections not as random events, but process failures.


Reduce Process Variability
 In addition to using bundles, the hospital system created PICC nursing teams at its hospitals. These specially trained clinicians are available to insert central lines for 12 hours each day. Having fewer clinicians that perform this vital task allows for the bundles to be closely followed. These teams also educate bedside nurses in the care of the insertion site. This is necessary, notes Johnson, as the methods for keeping the site sterile are always being updated. But the practice also empowers bedside nurses, says Johnson, to improve care for their patients and really make a difference in their patients’ outcomes.


Continual Improvement
Texas Health Resources continues to monitor and measure occurrences of hospital-acquired VAP and CLASBI. After the successes in reducing these infection rates, the system is turning its attention to lowering the incidence of C.difficile infections from indwelling catheters.