Institutional initiatives are interventions done by an organization to facilitate uptake and implementation of new knowledge by healthcare providers, patients, and caregivers to improve care. Interventions include provision of education and distribution of printed materials, and may include development of organizational protocols, procedures, and activities to standardize care. Institutional interventions were evaluated in terms of effect on chronic pain and prevention of infection in patients with cancer.
Bundy, D.G., Gaur, A.H., Billett, A.L., He, B., Colantuoni, E.A., Miller, M.R., & Children's Hospital Association Hematology/Oncology CLABSI Collaborative. (2014). Preventing CLABSIs among pediatric hematology/oncology inpatients: National collaborative results. Pediatrics, 134, e1678-e1685.
To assess the feasibility of instituting a multicenter effort to standardize central line (CL) care and CL-associated bloodstream infection (CLABSI) tracking while quantifying the impact of standardizing these processes on CLABSI rates among pediatric patients
A CL maintenance bundle was developed using Centers for Disease control and Prevention guidelines and recommendations as well as best practices from previous pediatric CLABSI efforts. These guidelines included (a) a reduction in the number of CL manipulations and entries, (b) the maintenance of a sterile entry to CL (hand hygiene and sterilization of port), (c) and standardized CL care practices (date and time cap, tubing/dressing/needle changes, standardized procedure). Tubing changes were every 96 hours and every 24 hours for blood products and lipids. Staff members audited the CLABSI bundle practice monthly using a standard form and submitted unit profile information. Teams met in two-day learning sessions annually and interacted monthly via webinars.
Cohort comparison study
Teams reported baseline data regarding CLABSI from January 2006 and October 2009. These data were compared to the intervention period from November 2009 to August 2012. CLABSIs were tracked as number per 1,000 CL days per month. CLABSIs occurring more than 48 hours after hospital admission and less than 48 hours prior to hospital discharge were deemed inpatient events and included in measurements.
Across 46 months, precollaborative effort CLABSI rates were 2.85 per 1,000 CL days. During the first 34 months after the intervention, that rate was 2.04 per 1,000 CL days (p = 0.05). The odds for having no CLABSIs per unit per month was 2.59 higher during the collaborative intervention (p = 0.01). The compliance with recommended CL maintenance increased rapidly over the first year from 38% at baseline to 79% by the end of the first year. It remained at a rate of 81%–86% during the remainder of the intervention period.
The 28% reduction during the first 2.5 years suggested the elimination of about 290 CLABSIs over that period with an estimated reported cost savings of about $11 million. It was feasible to implement a standardized CL maintenance care bundle, track CL infections with standardized definitions, and generate benchmark data across a large network of centers. The implementation of a standardized catheter care bundle in a multi-instutituional collaborative effort was associated with reduced CLABSI rates.
Nurses are on the front lines when it comes to CLABSI prevention. This report demonstrated the effectiveness of a multisite collaborative initiative to reduce CLABSI rates. The implementation of a specific care bundle, monthly practice auditing, monthly webinars, and annual education of care teams involved was reported to be effective. This report provides suggested approaches for such initiatives and demonstrates associated improvement in quality and cost reduction.
Gilbert, C.R., Lee, H.J., Akulian, J.A., Hayes, M., Ortiz, R., Hashemi, D., . . . Yarmus, L.B. (2015). A quality improvement intervention to reduce indwelling tunneled pleural catheter infection rates. Annals of the American Thoracic Society, 12, 847–853.
To evaluate the effects of an organizational intervention to reduce pleural catheter infections
Medical records of patients receiving indwelling pleural catheters (IPC) for malignant effusions were reviewed to describe the overall findings and practices from 2009 to 2014. The protocol was then updated to include changes so that all placements occurred within a single location, all patients received perioperative antibiotics within 60 minutes prior to IPC insertion, and full body sterile draping was conducted. A review of all cases was done after six months of follow-up.
Overall, the IPC infection rate was 8.2% prior to the intervention and decreased to 2.2% after the intervention (p = 0.049).
The quality improvement interventions implemented were associated with a significant reduction in overall IPC infection rates.
This study showed that a quality improvement intervention involving a review of practices and related outcomes and an implementation of protocol changes aimed at reducing IPC infection rates was successful because of the overall reduction of infection rates. Principles related to surgical site infection and catheter infection prevention were incorporated into the organizational protocol changes that were made.
Kachare, S.D., Sanders, C., Myatt, K., Fitzgerald, T.L., & Zervos, E.E. (2014). Toward eliminating catheter-associated urinary tract infections in an academic health center. The Journal of Surgical Research, 192, 280–285.
To determine if implementing two interventions would cause a reduction in catheter-associated urinary tract infections (CAUTIs) in an inpatient surgical oncology unit (The first intervention was designed to decrease the use of Foley catheters, and the second intervention was designed to initiate early removal while preventing reinsertion of the Foley catheter.)
The first intervention was the development of a hospital-wide guideline outlining the indications for Foley catheter use. There were six defined reasons for the use of a Foley catheter in a patient. If the patient did not meet one of these criteria, then Foley catheter use was not recommended. The second intervention included two measures. The first was aimed at the early removal of the catheter by designing a daily electronic query sent to the attending physician regarding continuing use of the Foley catheter, and the second was direct personal contact with the primary medical team to determine the medical necessity of continued Foley catheter use. They also focused on the prevention of catheter reinsertion by following a developed algorithm for the healthcare team.
This study design was a pre/post design with preintervention data obtained in a retrospective manner followed by the authors obtaining postintervention data.
There was a significant reduction in the use of Foley catheters after the interventions were put in place (P < 0.0001). There also was a significant reduction in CAUTI rates for patients who did require a Foley catheter after interventions were put into place, from 4.6 to 0 (P = 0.03). For patients who required a Foley catheter and had a diagnosed CAUTI during the postintervention time period, none of the Foley catheters were reinserted. The preintervention group had four patients with positive CAUTIs who had a Foley reinserted.
Even though the study was limited to one inpatient surgical oncology unit, the findings support other similar studies of best practice indicating use of Foley catheter insertion criteria as well as algorithm guidelines for care after catheter removal. Because infections can be detrimental in the oncology population, healthcare teams working with these patients should explore the literature surrounding the prevention of CAUTIs and ways of implementing best practices.
Oncology nurses need to be diligent with hand hygiene, not only among themselves but with other members of the healthcare team. They also need to adhere to Foley catheter bundles, including the daily verification of continuing need for the catheter, the use of catheter securement devices, keeping tubing below the level of the bladder, keeping the bag off of the floor, and providing perineal care at least twice per day. If the institution does not have a catheter bundle, nurses need to lead the initiative to implement one. This study demonstrated successful institutional approaches for protocol implementation and ongoing auditing and interventions with care providers.
Martinez, J.M., Leite, L., França, D., Capela, R., Viterbo, L., Varajão, N., . . . Santo, A. (2015). Bundle approach to reduce bloodstream infections in neutropenic hematologic patients with a long-term central venous catheter. Acta Medica Portuguesa, 28, 474–479.
To use a bundle approach to reduce central line–associated bloodstream infections (CLABSI) in patients with hematologic malignancies and neutropenia with long-term central venous catheters (CVC)
Between 2010 and 2012, a bundle of interventions was introduced and outcomes were compared with the results from six months prior to the intervention. Interventions were the use of a different catheter (a neutral pressure mechanical valve connector versus a positive pressure mechanical valve connector), changing needless connectors twice weekly instead of weekly, and the replacement of a chlorhexidine solution to clean needless connectors rather than a solution with 70% alcohol. If blood cultures were obtained, patients were put on broad spectrum antibiotics. All patients were receiving prophylactic co-trimoxazole, itraconazole, and environmental neutropenic precautions.
Blood cultures were obtained for the presence of a fever for more than one hour or other signs of infection from peripheral veins and CVC lines.
With the intervention, a 71% reduction in both CLABSIs (risk ratio [RR] = 0.29, p < 0.014) and overall bloodstream infections (RR = 0.28, p < 0.001) occurred. The reduction of gram-positive bacteria was most pronounced.
The institutional protocol changes related to catheter selection and IV access system care were associated with a reduction in CLABSIs.
The changes implemented here were associated with the reduced incidence of CLABSIs within 72 hours. The authors suggested that changing from a positive pressure valve catheter to a neutral pressure type catheter may have been most relevant, as positive pressure valves tend to develop a biofilm and cannot be cleaned well with routine flushing.
Tzadok, R., Shapira, M.Y., Moses, A.E., Or, R., Block, C., & Strahilevitz, J. (2015). Reduction in incidence of invasive fungal infection in patients receiving allogeneic stem cell transplantation using combined diagnostic-driven approach and itraconazole oral solution. Mycoses, 58, 694–698.
To determine the effectiveness of using antifungal therapy in conjunction with the diagnostic driven approach (DDA) in the management of invasive fungal infection (IFI) among patients undergoing allogeneic bone marrow transplantation (BMT)
Two strategies, DDA and antifungal prophylaxis, were used to diagnose and treat early IFI among allogeneic BMT patients. Two segments of 20 months included a preimplementation period in which medical records and laboratory statistics were used from admission up to six months. The intervention was the implementation of a DDA and the provision of antifungal prophylaxis. Prior to implementation, no routine antifungal prophylaxis was administered and the diagnosis of IFI was based on European Organization for Research and Treatment of Cancer (EORTC) criteria, including galactomannan assays. Antifungal agents were administered based on assay results. With the implementation of a new protocol, antifungal prophylaxis was given to those with graft-versus-host disease (GVHD), those treated with corticosteroid therapy, those with severe aplastic anemia, those undergoing cord blood transplantation, and those in which the standard diagnostic workup was deemed to be less effective. All patients were managed in high-efficiency particulate air (HEPA)-filtered rooms and housed in areas with limited access.
A significant reduction in the cases of IFI (p = 0.051) was observed overall. The incidence of mold infection (aspergillosis) decreased substantially in the protocol period (p = 0.054). However, no change was noted in the survival rates and breakthrough fungal infection in the pre and post intervention phases.
The implementation of a clinical management protocol helped diagnose and treat early fungal infection and was associated with an overall reduction in the incidence of IFI.
Nursing role is vital in identifying the key sign and symptoms of infection and to highlight them to decrease the rates of fungal infections, hence minimizing the mortality and morbidity rates overall. This study demonstrated that a standardized approach to prophylaxis was associated with reduced fungal infections.
Vanderway, J., Vincent, C., Walsh, S.M., & Obrecht, J. (2017). Implementation of a pathway for the treatment of fever and neutropenia in pediatric patients with cancer. Journal of Pediatric Oncology, 34, 315–321.
Implement a pathway to achieve Time To Antibiotics (TTA) in less than 60 minutes form presentation for outpatient evaluation of FN in pediatric patients with cancer. Other endpoint was to improve bedside nurses’ understanding of fever, neutropenia, and importance of Rapid Time To Antibiotics (RTTA).
Implementation of Clinical Pathway for RTTA in less than 60 minutes
Inservice and poster board used to educate nurses about fever and neutropenia. Knowledge measured with pre- and post-tests.
TTA was tracked using retrospective chart review to determine pre-pathway metrics.
Retrospective chart review using electronic health record filters was used for pre-pathway data collection. A computerized spreadsheet was used for post-pathway data collection.
Nursing knowledge was tested using a 9-item Fever and Neutropenia Questionaire. A bulletin board with key FN concepts and an in-service by APNs were sources of education.
Nurses had a mean score of 7.5 correct answers for the pre-education questionnaire and an 8.92 mean score for post-education (p = 0.0002).
Improvement in nurses knowledge of FN was improved with education and TTA was improved with a clinical pathway. The study included a very small sample of pediatric patients and nurses from one cancer center, resulting in limited application to other settings.
Based on literature review and limited findings of this QI project, clinical pathways and nursing education are successful ways to improve care of patients with FN. Recommendations for implementing in other settings will need larger studies demonstrating success with these interventions to demonstrate applicability.
Vicente, M., Al-Nahedh, M., Parsad, S., Knoebel, R.W., Pisano, J., & Pettit, N.N. (2017). Impact of a clinical pathway on appropriate empiric vancomycin use in cancer patients with febrile neutropenia. Journal of Oncology Pharmacy Practice, 23, 575–581.
To determine the appropriateness of vancomycin prescribing, based on consistency with guideline (IDSA and NCCN) recommendations before and after implementation of FN clinical pathway. Secondary endpoint was to determine influence of comorbidities with inconsistent vancomycin use based on guideline recommendations.
Using IDSA and NCCN guidelines for prescribing vancomycin in adults patients with cancer with FN and a risk assessment tool for adverse clinical outcomes a pathway was developed to increase compliance with guidelines. 337 patient records were analyzed to evaluate effectiveness of FN clinical pathway at academic medical center. Patients admitted with FN and no allergy to beta-lactam were included. Four groups were evaluated: pre-pathway vancomycin use consistent with guidelines, post-pathway vancomycin use consistent with guidelines, post-pathway vancomycin use inconsistent with guidelines and post-pathway vancomycin use inconsistent with guidelines. Vancomycin use was defined as use for at least 48 hours to exclude those receiving it for procedural prophylaxis.
Evaluate appropriate prescribing of vancomycin based on consistency with guideline recommendations pre- and post-implementation of a FN clinical pathway.
Antimicrobial usage report generated from electronic medical record. Hematopoietic Cell Transplantation Comorbidity Index (HCT CI)
The rate of vancomycin use, inconsistent with guideline recommendations in the pre-pathway implementation time frame, was significantly greater (n = 74, 35.9%) versus use in the post-pathway implementation time frame (n = 5, 11.4%; p = 0.001). No comorbidities or specific HCT CI scores were predictive of vancomycin without indication on multivariate analysis.
Implementation of a guideline-based pathway for FN in adult patients with cancer can significantly improve adherence to guideline recommendations for antimicrobial (vancomycin) use
Use of clinical pathways can improve compliance with guidelines for managing at-risk patients, leading to better outcomes.