Change Strategy and Implementation

Introduction and analysis

The hospital is an acute care hospital facility. It has indicated a commitment to protecting patients and medical personnel from adverse health care events even as it promotes value, quality and safety in the delivery of healthcare. Preventing hospital acquired infections (HAI), particularly central line-associated bloodstream infection (CLABSI), is a priority for the facility since it is a preventable concern. CLABSI is a concern because it is a HAI that develops within 48 hours of a central line placement. Many of the CLABSI incidences are preventable through proper management strategies, surveillance, and aseptic techniques. Besides that, CLABSI is a concern because it is associated with prolonged hospital stay with higher cost burden as each case requires approximately $30,000 in additional health care costs (Webb et al., 2016).

The CLABSI performance data for the hospital facility is presented based on standardized infection ratios (SIR), a measure of the progress made in reducing CLABSI compared to the predicted performance given the trends and measures in place. The SIR figure is calculated as the ratio of CLABSI events (observed number of infections) to the number of predicted events for the summarized time period. The predicted CLABSI events is estimated based on risk adjusted national baseline data. The risk adjustment takes into account the state and county averages, and the fact that this is an acute care hospital that treats sicker patients than others (Laitenbach et al., 2018).  Change Strategy and Implementation Essay Discussion Paper

A review of the facility-specific CLABSI SIR figures reported for 2020 reveals that the SIRs are all greater than 1. This indicates that the number of actual infections is greater than the number of predicted infections for all patient populations in the ICU, wards and NICU. To be more precise, the CLABSI SIR reported for the whole facility is 1.15 with the figure reported for ICU being 1.16, wards being 1.14, and NICU being 1.16 (see Table 1). Further analysis of the figures reveals that there were 15% more CLABSI cases than had been predicted for the whole facility with 16% more cases reported in the ICU, 14% more cases reported in the wards, and 16% more cases reported in NICU. The higher than expected CLABSI events in the whole facility and across all patient populations indicate that the facility has applied inadequate measures to reduce the CLABSI events.

Table 1. Summary of SIR using facility-specific CLABSI data reported for 2020 by patient population

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Intervention (proposed change)

The high SIR figures show that CLABSI is a concern in the facility. To be more precise, the facility is underperforming in its efforts to reduce CLABSI events. To address this concern, a change proposal is presented to implement prevention guidelines during central line insertion. The change has eight key components. Firstly, using a checklist. Secondly, replacing central lines placed during emergencies within 48 hours. Thirdly, promptly removing the central line if not required. Fourthly, preferring subclavian vein and avoiding the femoral vein during central line placement. Fifthly, using ultrasound guidance during placement to avoid mechanical complications. Sixthly, using 2% chlorhexidine skin preparation to clean and disinfect the skin before central line insertion. Seventhly, applying strict aseptic techniques using full-body drape and maximal sterile barrier precautions during insertion. Finally, hand hygiene by washing hands with alcohol based foams/gels or soap and water (Meddings, Chopra & Saint, 2021).

In addition to the insertion guidelines, there is a need to apply maintenance guidelines with three main components. Firstly, assessing the need for the central line on a daily basis. Secondly, replacing administration sets every 96 hours, except for lines used for blood products and lipids. Thirdly, disinfecting the connections, injection ports and catheter hubs before accessing the line (Weber, 2020). Applying the central line insertion and maintenance guidelines is expected to significantly reduce CLABSI incidences in the hospital.

Implementation strategy

A multifaceted implementation strategy that incorporates elements from other strategies has been identified as appropriate for successfully implementing the change. The multifaceted approach takes into account the characteristics of the organization and environment. The first element is the presentation of research evidence presented in peer-reviewed publications to show that the change is appropriate for achieving the desired outcome. The second element is the recruitment of opinion leaders who are recognized as influential persons capable of promoting the change implementation by convincing other stakeholders to support the change. Varying the opinion leaders is important for increasing acceptance of the change and avoiding the impression that only one opinion leader support or mandates the change. The third element is reminders that prompt medical personnel to apply the central line insertion and maintenance guidelines. This is a behavioral approach that is effective if few prompts are presented in the form of posters in health care stations. Too many prompts presented at the same time could become counterproductive. This element utilizes the communication processes that work best in the organization, but minimizes frequent, repetitive formats, as the targeted staff would quickly begin to ignore them (Bemker & Schreiner, 2017).

The fourth element is feedback with audits of clinical performance data and feedback from medical personnel helping to show the effectiveness of the intervention and if additional changes are required. The feedback must be objective as the analysis is based on observation, measurable and fact-based information. The fifth element is educational (interactive) approaches that tailor educational items that are based on assessment of potential barriers and focus on teaching the medical personnel the new guidelines and challenging negative attitudes. The potential barriers must be clearly identified and stakeholders moved through the barriers. This is achieved by consulting successful change agents who may have already encountered and overcome these barriers. The final element is the use of the organization’s quality management process as this creates common language and familiarity that improves communication and minimizes resistance (Garcia-Dia, 2019).

References

Bemker, M., & Schreiner, B. (Eds.) (2017). The DNP Degree & Capstone Project: A Practical Guide. DEStech Publications, Inc.

Garcia-Dia, M. (2019). Project Management in Nursing Informatics. Springer Publishing Company.

Lautenbach, E., Malani, P., Woeltje, K., Han, J., Shuman, E., & Marschall, J. (Eds.) (2018). Practical Healthcare Epidemiology (4^th ed.). The Society for Healthcare Epidemiology of America.

Meddings, J., Chopra, V., & Saint, S. (2021). Preventing Hospital Infections: Real-World Problems, Realistic Solutions (2^nd ed.). Oxford University Press.

Webb, A., Angus, D., Finfer, S., Gattioni, L., & Singer, M. (2016). Oxford Textbook of Critical Care (2^nd ed.). Oxford University Press.

Weber, D. (2020). Mayhall’s Hospital Epidemiology and Infection Prevention (5^th ed.). Lippincott Williams & Wilkins.

Change Strategy and Implementation Essay Discussion Paper