Reducing Central Line-Associated Bloodstream Infections in a Burn Intensive Care Unit: Using a Business Framework for Quality Improvement

Abstract

Central line-associated bloodstream infections (CLABSIs) pose a unique risk in burn patients, with rates of infection 2-3 times that of other Intensive Care Unit (ICU) populations. Here we present a detailed account of our experience in reducing CLABSI rates utilizing a business framework called the Four Disciplines of Execution (4DX). The Burn ICU CLABSI rate had risen to the 90th percentile nationally when compared to other burn units on the National Healthcare Safety Network. We applied the 4DX framework. This is a four-step method which includes creating a Wildly Important Goal, establishing measurable and accomplishable process measures, creating a scoreboard, and using a weekly meeting to provide accountability. Process changes included both physician and nursing practices. The physicians changed the criteria for when to order blood cultures, as well as requiring attending approval for cultures. The nurses engaged in a peer-observation practice improvement for "scrub the hub" and line dressing conditions and improved their own expertise for peripheral IV placement. The multidisciplinary team initiated a daily review of line indications to ensure removal as soon as possible. Overall, the CLABSI rate decreased from 7.39 infections per 1000 line days to 2.29 infections per 1000 line days over 1 year. We subsequently achieved over 635 days without a CLABSI. In conclusion, the 4DX was a successful quality improvement technique in our healthcare context. Because of the simplicity of implementation, we think it is broadly applicable in the healthcare setting.