I AM Patient Safety 2023 Transparency and Safety in Healthcare
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​​​​​2023 IAPS Transparency & Safety Award Winner, Behavioral Health 6 Spruce Shared Governance Penn Medicine Pennsylvania Hospital

Standing in the back: Molly, Bridget, Helen, Melissa, Thurmond 

Sitting: Chaunae and Violet

Behavioral Health 6 Spruce Shared Governance
Penn Medicine Pennsylvania Hospital

In 2020, many hospitals experienced a surge of high-acuity patients who needed intensive medical care in the turmoil of a challenging pandemic. Throughout the year, WellSpan observed a high number of central line–associated blood stream infections (CLABSI) increasing the risk to patient harm, in addition to increasing the risk of medical complications and a subsequent longer length of hospital stay. A multispecialty team of physicians, nurses, infection prevention experts, and performance improvement specialists gathered to identify opportunities for improvement and develop a plan to bring Zero Harm back to patient care within the walls of the hospital.

The team met weekly   to describe the problem, map the current condition, determine root cause, and implement countermeasures for improvement. It began process observations at the unit level to identify variations in central line insertion techniques, site selection, daily maintenance, and dressing care, as well as conduct daily assessments of all current central lines for discontinuation opportunities. Physicians were observed for insertion technique, and for femoral lines placed in emergent situations, sites were reassessed upon stabilization of condition to ensure appropriate placement.

Each intensive care unit (ICU) nurse was observed doing central line care of 16 touch points. Standard work was developed and the team was trained to it to eliminate any variation in practice. One innovation was the creation of Central Line Pocket cards for insertion and line maintenance, distributed to all appropriate staff across nursing units for quick reference of standard work and best practice tips. An added opportunity was to transition the organization to a chlorhexidine-impregnated central line dressing product. Education was spread to nursing units with a timely rollout. All nursing units implemented a daily focus at shift huddle to identify patients at high risk for hospital-acquired infections (HAIs), highlighting those with central lines in place.  

Another root cause identified was the variation in blood culture ordering and specimen collection. Physicians, nurses, and Lab clinicians worked together to develop appropriate blood culture order sets, education for clinicians, and an audit process to ensure coaching was available in real-time. Nursing collaborated with the Lab   to ensure the appropriate specimen tubes were available on the units and upon request.  The tangible outcomes from all the focus that this team of professionals placed on eliminating hospital-acquired infections brought reason to celebrate. At the 180-day CLABSI-free mark, the hospital president and leaders performed a “line dance” skit and invited all hospital employees to participate. Today, the Zero Harm focus continues by harvesting what is working well, removing variation in processes, and celebrating wins. At the time of this writing, WellSpan has been CLABSI-free for 310 days and has embraced a 28% decrease in overall HAIs.

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