Reducing Blood Culture Contamination and Sustaining the Gain Baylor Regional Medical Center at Plano Finance Pillar 1 Baylor Regional Medical Center at Plano
Rationale for Project Selection Blood culture contamination is a long standing, difficult challenge most hospitals face. In publications, research has found contaminated blood cultures resulted in an additional $3,000 - $5,000 in average cost per case. Contaminated blood culture cases have additional charges associated with unnecessary antibiotics, extended length of stay, returns to the Emergency Department (ED) or physician s office for additional testing. AIM Statement Original AIM Statement: In order to prevent waste and rework, and to improve physician satisfaction, we will reduce blood culture contamination rate from 3.6% to 2.0% within four months (August 2007) through a transparent approach to best practices. NOTE: The time bound portion of the AIM statement was perpetually revised until the goal rate of 2% was met and sustained. Improvement beyond that has continued through diligent attention to the process.
Team Membership Role Executive Sponsor Team Leader Members Facilitator Member Ellen Pitcher, CNO/COO Allen Stanton, Director Laboratory Aubre Tijerina, ED Supervisor Raquel Facunla, Phlebotomy Supv Mohiuddin Faruk, Phlebotomist Anthony Arris, ED Technician Kim Newman, Infection Control Practitioner Pat Cooper, Director Healthcare Improvement 5 Modeling Opportunity Opportunity Opportunity
Prioritization Rate 10.5 9 7.5 6 4.5 Blood Culture Contamination Rate by Category 76% 4.3 41% 3.8 100% 90% 80% 70% 60% 50% 40% Analysis of Key Leverage Point: Forty-one percent of blood culture contamination rate was attributed to the ED. Thus, ED was targeted as the primary site for improvement work. 3 1.5 2.5 30% 20% 10% 0 ED Contamination Rate Line Contamination Rate Lab Contamination Rate Category Category definition ED Contamination Rate: ED staff draw their own blood cultures. Line Contamination Rate: RN draw cultures from indwelling lines. Lab Contamination Rate: Lab staff draw cultures from all other patients. 0% Metrics Leading indicator: Lagging indicator: Financial metric: Each occurrence of a contaminated blood culture Blood culture contamination rate (%) Dollars wasted due to blood culture contamination 8
Lessons Learned Break the problem down; Do Improvement Cycles Keep the data FRONT and CENTER. Enlist a Champion for each area. Persist! Recognize that when you think you have the problem solved, you probably don t! Match skill sets to the task. Use competition among team members to get better results overall. Buy Pizza! Find best practices and discourage (or ban!) other methods. Show others how you accomplished your goal! 9 Where We Started 10
Where We Started Getting Started First, we (laboratory) had to put our own house in order.
Rapid Cycle Improvements prior to multidisciplinary team formation: Lab Driven Process Plan: Do: Educate and retrain lab staff on appropriate technique to prevent blood culture contamination. Jan 2006 One-on-one observation of phlebotomist to evaluate effectiveness of education and training. Mar 2006 Check: Supv retrained each phlebotomist who had a contamination rate over 2% in any given month. May 2006 Act: Distribute monthly blood culture contamination rates. Jul 2006 Act: Post blood culture contamination rates by phlebotomist on communication board. Jan 2007 Spread: Provide feedback to ED on their contamination rates and each occurrence. Apr 2007. Starting to See What is Possible
Anchoring the Line Multidisciplinary Performance Improvement Team s 1 st Intervention Plan: Do: Improve competency of staff in E/D to perform BC technique appropriately. Trained all E/D nursing staff on proper scrub prep and collection technique. April 2007 Established Supertrainers (E/D techs) 1 st Qtr 2008 Station phlebotomist in ED during peak hours. 4th Quarter 2008 Check: Significant positive impact realized from phlebotomist presence in ED. Blood culture contamination rate decreased from 3.42% in Sept 08 to 2.95% in Dec 08. Act: Blood culture contamination rates posted on ED communication boards to increase awareness and provide staff feedback. Jan 2009
Leading Indicator Frequency of Contaminated Blood Cultures 8 7 6 5 Frequency 4 3 2 1 0 1/1/2009 1/15/2009 1/29/2009 2/12/2009 2/26/2009 3/12/2009 3/26/2009 4/9/2009 4/23/2009 5/7/2009 5/21/2009 6/4/2009 6/18/2009 7/2/2009 7/16/2009 7/30/2009 8/13/2009 8/27/2009 9/10/2009 9/24/2009 10/8/2009 10/22/2009 11/5/2009 11/19/2009 12/3/2009 12/17/2009 12/31/2009 1/14/2010 1/28/2010 2/11/2010 2/25/2010 3/11/2010 3/25/2010 4/8/2010 4/22/2010 5/6/2010 Contaminated blood cultures are identified and tracked on a daily basis, the above graph reflects frequency of occurrence on a bi-weekly basis. Multidisciplinary Performance Improvement Team s 2 nd Intervention Plan: Do: During non-phlebotomist hours, centralize blood culture collections to ED techs and charge nurses. Apr 2009 To verify competency, an ED tech, who was a former phlebotomist, checked-off all ED techs and ED charge nurses through training and direct observation of their collection process. Check: Blood culture contamination rate cut in half to 1.71% by April 09, then to 1.52% in Jun 09. Act: Limiting the number of staff collecting specimens and enhancing their skill set continued to drive down the blood culture contamination rate.
What Does Competition Do? Multidisciplinary Performance Improvement Team s 3 rd Intervention Plan: Do: Provide real-time individual feedback to ED staff on contaminated specimens. May 2009 Lab began providing copy of blood culture bottle on any contaminated specimen to nurse manager. Check: Blood culture contamination rate 1.15% in May 09. Act: ED Supervisor hardwired process of discussing each contaminated case with staff member responsible for drawing specimen. Internal Spread: Blood culture collection technique included in skills fair for all ED techs and nurses to verify competency. September 2009
Had to Buy Pizza More Often! Have We Made Progress?
Rapid Cycle Improvements prior to multidisciplinary team formation: Lab Collaborating with Nursing Internal Spread: Take improvement work to nursing units. Plan: Do: Revise line draw policy to reduce line associated blood culture contamination rates. May 2007 NOTE: Line draws are blood cultures taken from indwelling lines by nurses on the inpatient units. Kick-off the Scrub the Hub campaign. Require cap change on lines prior to drawing specimen. Check: Line blood culture contamination rate decreased from 6.5% in May 2007 to 3.1% in July 2007. Act: Educated M.D. s on CDC recommendations, began enforcing requirement to obtain written MD order for all line-drawn specimens. March 2008 Lagging Indicator Blood Culture Contamination Rate 6.0 Lab driven rapid cycle improvements Multidisciplinary team form ed 5.0 4.0 3.0 2.0 1.0 0.0 7/1/2006 9/1/2006 11/1/2006 1/1/2007 3/1/2007 5/1/2007 7/1/2007 9/1/2007 11/1/2007 1/1/2008 3/1/2008 5/1/2008 7/1/2008 9/1/2008 11/1/2008 1/1/2009 3/1/2009 5/1/2009 7/1/2009 9/1/2009 11/1/2009 1/1/2010 3/1/2010 5/1/2010 Blood Culture Contamination Rate Target Phlebotom ist stationed in ED Centralized collection to ED clerks & charge RN Provide real time feedback Actual Target Blood culture contamination rate has been sustained at lower than 2.0% since January 2009!
Financial Metric Cost Avoidance Attributed to Decreasing Blood Culture Contamination Desired $1,200,000 $1,000,000 $800,000 $600,000 $400,000 $200,000 $0 Jul-06 Sep Nov Jan-07 Mar May Jul Sep Nov Jan-08 Mar May Jul Sep Nov Jan-09 Mar May Jul CostAvoidance Sep Nov Jan-10 Mar May -$200,000 Cumulative Cost Avoidance An estimated cost avoidance of $997,091 from FY 07 07-FY10 NOTE: A conservative rate of $3,000 per case was used to estimate cost avoidance. Comparative Data Blood Culture Contamination Rates Desired 3.5% 3.0% BC Contamination Rates 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% Jul '09 Aug '09 Sept '09 Oct '09 Nov '09 Dec '09 Jan '10 Feb '10 Mar '10 Apr '10 May '10 FY'10 Plano National Benchmark Level 3 BHCS BRMCP is performing significantly below national benchmark and BHCS performance.
Spread Internal Spread: Lab improvement work to reduce blood culture contamination rates was spread to the Emergency Department and inpatient nursing units. External Spread: Presentation of improvement work on blood culture contamination rates to Lab Council in September 2008 and May 2010. Offered to go on the road to any lab or ED who may be interested in hearing our story about sustaining the gain. Presented poster session at IHI in December 2010. How Does this Affect Your Peers?
From Beginning to End Lessons Learned Break the problem down; Do Improvement Cycles Keep the data FRONT and CENTER. Enlist a Champion for each area. Persist! Recognize that when you think you have the problem solved, you probably don t! Match skill sets to the task. Use competition among team members to get better results overall. Buy Pizza! Find best practices and discourage (or ban!) other methods. Show others how you accomplished your goal!