Grantee Profiles
David Thompson, Jill Marsteller, and Bryan Sexton
Keeping Patients Safe: David Thompson, Jill Marsteller, and Bryan Sexton Spotlight Nurses Role in Preventing Infections in the ICU
Johns Hopkins Team
Although new reports show that hospital intensive care units (ICUs) have seen dramatic drops in the rate in dangerous staph superbugs due to better procedures, there are still widespread concerns about other forms of bacterial infections that can arise in these settings. INQRI researchers David Thompson, Jill Marsteller and Bryan Sexton are showing promising results from the first randomized controlled trial to reduce central-line-associated blood stream infections among ICU patients. Their research, which was implemented in hospital ICUs in 12 states (including WA, OR, CA, HI, TN, TX, IL, and FL) is a critical step in showing that substantial reductions in infections can be widely achieved, particularly when nurses lead patient safety efforts.
Central line catheter insertions are the most common procedure in hospitals. But all too often, they can have serious and even deadly consequences. Occasionally these lines can cause infections if bacteria spread to the line and enter the patient's bloodstream. According to some estimates there are 80,000 catheter-induced bloodstream infections each year, causing up to 28,000 deaths at an average cost to the health system of $45,000 per patient.
Such infections represent a major battle in the larger war being waged against medical errors in hospitals today.
On the frontlines of that battle stand Johns Hopkins University's Thompson, a critical care nurse and clinical outcomes researcher; Marsteller, a health services researcher; and Sexton, an industrial psychologist. As part of the Robert Wood Johnson Foundation-funded INQRI project, the Johns Hopkins team is studying how adhering to a simple set of best practices can help keep ICU patients safe and foster a culture that curbs errors Thompson says are "imminently preventable."
Their work builds on the work of Dr. Peter Pronovost of Johns Hopkins, a leader in patient safety, who developed a package of interventions, including a line-insertion checklist, which has proven to be a highly effective tool for reducing infections.
What makes Thompson, Marsteller, and Sexton's work unique from similar efforts is that this team relied on nurses to drive the program in their ICUs, and they achieved even better results than previous studies. Also, unlike other studies, theirs was managed like traditional clinical research with much more attention paid to rigorous data collection and review than many quality improvement research studies.
Some of the components of the program include back-to-basics reminders such as having everyone who touches a central line wash their hands with soap and water; or ensuring that patients be fully covered by a sterile drape (except for a small hole where the line is inserted); or removing unnecessary lines from patients that can spawn infections. ICUs that have embraced this nurse-driven protocol have in many cases completely eliminated bloodstream infections among their patients for several months at a time.
Just as important as implementing steps to keep ICU patients safe, the research team is examining the role nurses who work in teams with physicians and other health professionals play in reducing bloodstream infections. The project, which took place in 35 hospitals within Adventist Health (located in the West) and the Adventist Health System (located in the Midwest and Southeast), will measure nurses' role in preventing such infections by looking at factors such as staff turnover, the skill mix of nurses involved in patient care, how many nurses are at the patient's bedside delivering care, and how these measures affect bloodstream infection rates and patient length of stay. The study will also examine the culture that supports patient safety and good teamwork in the ICUs.
"This is so much more than a checklist," says Thompson, adding that the project demonstrated the importance of nurses as leaders of safety improvement. "Unless you have hospital-supported nurse empowerment to ensure the checklist is used, you are not going to succeed. So there's an element of improving the teamwork and safety culture within the ICU and allowing nurses to be assertive patient advocates."
Another lesson learned is how important it is for nurses to identify a physician champion early who will facilitate implementation of this program. "While this is a nurse-driven protocol, engaging physicians early on seemed to be key in the success of some sites," says Marsteller.
Once the project is complete, the Hopkins team hopes the research will guide hospital executives and policymakers as they craft solutions to prevent medical errors and will further the health care system's understanding of the role nurses play in preventing deadly infections. The team already is participating in another phase of the project. A number of states have agreed to participate in an Agency for Healthcare Research and Quality-funded collaborative called On the CUSP: STOP BSI (blood stream infections). "At the same time participating ICUs will be learning about how to create the right environment for improving their care and making patients safer in many ways, not just with respect to infections," Marsteller says.
The Hopkins team hopes to replicate its work in one of these states, further supporting findings on the benefit of nursing-led interdisciplinary evidence-based practice and to continue to assess the National Quality Forum (NQF) nursing measures' impact on infections.