Clinical Governance And CPI For Reducing CLABSI Rates In Healthcare Facilities
The Seven Pillars of Clinical Governance
Clinical governance can be defined as the framework which the NHS organizations utilizes to accountability to continuously improve the quality of their services and in order to safeguard the high standards of the care by creating an environment of excellence where the clinical care can flourish. There are 7 pillars of clinical governance, namely clinical effectiveness, risk management, patient experience and involvement, communication, resource effectiveness, strategic effectiveness, and learning effectiveness (O’Brien 2015). On a more elaborative note, clinical governance entails application of best practice evidence while addressing the care needs of a patient with respect to the exact wishes and preferences of the patient and carried out by an appropriately trained and resourced health care professional or the member of the multidisciplinary health care team. The clinical governance helps in enhancing the sense of accountability and responsibility of the care professional so that they take full responsibility of their actions and the safety and wellbeing of the patients in care is nor jeopardized under any circumstances (Uhb.nhs.uk. 2018).
professional development and management, clinical risk and consumer value. The topic that has been selected for this CPI topic is reducing the rates of CLABSI in the unit within 6 months by 50% addresses each of the vital 4 pillars of clinical governance. First and foremost, it has to be mentioned in this context that the solution that is being proposed in project implements evidence based practice in the infection control program, addressing the first pillar clinical performance and evaluation (Van Zwanenberg and Edwards 2018). The intervention also focuses on the developing educational training for the staff to enhance their knowledge of infection control, addressing the second pillar of clinical governance. With respect to the third pillar, clinical risk, the incidences of CLABSI is undoubtedly a vital risk to the safety and wellbeing of the patient population. The last pillar of clinical governance addresses consumer value, where the health care professionals are encouraged to improve their facilities to improving current practice and maintaining the enhanced care standards in the future. The CLABSI intervention that is being implemented also focuses on implementing a sustainable solution that not only improves the current practice scenario but also implements changes that will help in maintaining the improved care standards in the future (Uhb.nhs.uk. 2018).
The CPI project addresses a very important aspect of the health care scenario, the nosocomial infections, especially the central line associated blood stream infections or the CLABSI. It has to be mentioned in this context that the CLABSI pertains to an alarming rate of adverse events and deaths in the health care scenario, especially the critical care units (Afonso, Blot and Blot 2015). The nosocomial CLABSI leads to an alarmed rate of clinical risk for the patients which not only is a massive threat to the health and wellbeing of the patient due to the exacerbation event (Dombecki et al. 2017). Along with that, the impact of the nosocomial infection also leads to enhanced hospital days which in turn becomes an additional financial concern as well. Hence, it is a crucial clinical risk which needs immediate attention to reduce it.
The Importance of Addressing CLABSI Rates
Central line associated bloodstream infections have been reported to cause thousands of deaths in the hospitals (Patel et al. 2018). According to the report shared by CDC, it also causes a considerable reflux in the health care costs both nationally and globally. Many of the
global and national health authorities have identified these catheter associated nosocomial as a global challenge which demands to be added to the public health priorities all across the world (Payne et al. 2018). Close to 4000 incidences of CLABSI is reported every year in the intensive care units in Australia, most of which terminates in tragic mortality (Safetyandquality.gov.au). A recent study by Payne et al. (2018), the more than 55% of the total ICU patients have been reported to have CLABSI infections and at least 30% of the patients outside ICU had developed CLABSI. Hence, it is crucial to develop a goal oriented intervention to reduce the rates of CLABSI,w hich will not only reduce the mortality and adverse event rate due to HIAs and will also improve the consumer satisfaction and reputation of the facility (Zingg et al. 2015).
CLABSI prevention bundles have been introduced by many health care facilities to reduce the instance of Central line associated blood stream infection in intensive care units (Reyes, Bloomer and Morphet 2017). Although, the contents encompassing the different CLABSI prevention bundle are different, the most commonly reported had been the combination of a systemic change and an educational intervention. In this case, we are introducing the use of chlorhexidine gluconate impregnated washcloths while insertion and management of catheters as one part of the prevention bundle (Hansen et al. 2014). Although, it has to be mentioned that the lack of training with respect to using a chlorhexidine impregnated washcloths often leads to unprecedented results which does not meet the expected goals as mentioned by the authors the lack of training and skill enhancement of the existing staff in using the chlorhexidine impregnated washcloths properly. There is mounting evidence that indicates that the implementation of a systematic staff education plan involving a particular infection control regime specifically designed for preventing CLABSI results in reducing the incident of infection by 20 to 30%. Hence, main intervention of the bundle will be an educational training to enhance the knowledge of the staff regarding using the washcloths (Blot et al. 2014).
The first and foremost internal stakeholder for the infection control scenario would be the
The Proposed CPI Approach
nurses of the intensive care unit which had been selected for the CPI project. Nurses are the primary point of contact for the patients and they carry out the most of the patient care, including insertion, removal and management of the catheters for the patients. The registered nurses in this case will be the most impactful stakeholder that will be utilized in this case will be the registered nurses employed in the post-surgical ward.
The pharmacists will also be a very important stakeholder inn this scenario as they will be managing the supply and usage maintenance of the chlorhexidine washcloths in the intensive care units.
The medical officer will be the monitoring and supervisor head of the intervention program and the medical officer can also be participating in the training and workshops to enhance staff knowledge regarding the CLABSI prevention.
The safety risk coordinator will overlook whether the intervention program is not affecting the patient safety in the ward selected and whether the care services or programs are going smoothly.
The consumer voice will be the representative of the patients and their family members to share the perception, doubts, preferences and grievances of the patients and family members to the scenario.
The nurse manager will have one of the most fundamental roles in ensuring the smooth completion of the entire project. The nurse manager will monitor and supervise the entire educational program and will also supervise the compliance of the staff to the educational intervention being provided on the infection control using chlorhexidine washcloth.
CPI or the clinical practice improvement can be defined as a tool or a framework which is utilized by the health care scenario in planning, implementation and evaluation of a change that has been implemented in the health care scenario to improve care standards to minimize any clinical risk. According to the research evidence, CPI tools have been considered as a continuous cycle of improvement that attempts to implement a change which enhances patient safety, wellbeing or improves the care practices or the quality of the services that is being provided to the patients that are seeking care from the facility (Taylor et al. 2014).
The vital or integral part of a health promotional CPI project is the CPI tool which in this case is the PDSA cycle. It has to be mentioned in this context that the integration of the PDSA cycle with the CPI is one of the most abundantly used tools to implement and manage practice improvement strategies in the health acre scenario. Furthermore, it also needs to be acknowledged that the project needs to be completed in a time bound manner and the PDSA tool will also be an excellent help to complete the project within the set time. As discussed by Knudsen et al. (2018), the PDSA cycle helps facilitates optimal resource allocation, better staff management and also avoids the chances of wastage of resources such as time, equipment, and money. The PDSA cycle will also be essential for facilitating a teamwork approach and achieve better outcomes, hence, the PDSA cycle has been selected as CPI tool for the project. There are four elements of the PDSA cycle, plan, do, study and act (Kadu and Stolee 2015).
Internal Stakeholders and Their Roles
Plan: The first month will be devoted to extensive research associated with central line blood stream infection prevention strategies as evidenced in the literature that has been published before and pooling of the all the relevant data to arrive at a conclusion regarding the possible intervention bundle being implemented. Followed by this, more systematic research will be carried out on the chlorhexidine washcloth implementation challenges in the health care units and possible intervention recommendation that has been employed. Then based on the research, staff education will be prioritized specifically for Chlorhexidine washcloth use in the care units. Workshop committee will be formed to provide the educational intervention to the selected staff along with a schedule on which the intervention will be provided.
Do: The project will commence from 2nd January, 2019 and will proceed till 2nd of July involving the post-surgical rehabilitation unit nurses as the target group for the intervention. The educational workshop will be arranged twice a week for first two months and for the follow up 4 months the workshop will be reduced to once a week format. The educational class will carry out for 45 minutes for every setting and post each of the classes the individuals will be given a small test.
Study: The outcome measurement will be carried out on the basis of CLABSI rate assessment. The medical officer and the nurse manager will lead a monthly assessment of the total number of CLABSI incidence to assess the impact of the intervention being implemented.
The progress of the project will be evaluated with respect to best practice principles, timeliness, involvement of stakeholders, and clinical governance. The monitoring committee will collectively discuss project’s benefits and drawbacks, and decide if the project needs to be continued, replicated or ceased.
The first set of intervention that will be provided to the nurses of the post-surgical unit will be given by the infection control medical officers and head registered nurses. The educational session will be an interactive presentation, and after each session the participants will be given an informative pamphlet for future reference. The participants will have to sit through integrative tests or open question answer sessions to analyse the extent of improved understanding and will be given the opportunity to improve the gaps left behind in anyone’s understanding of the education. Each participant will be allowed to go through a bi-monthly one-to-one discussion with the trainers to clear any doubts or misconceptions regarding the implementation of the intervention, the chlorhexidine impregnated washcloths.
Defining CPI and Its Benefits
seminar workshop where each participants will be given the opportunity to practice whatever is being taught to the nurses and apply the theoretical knowledge. The demonstrative workshop will be supervised by the medical officer and the head RN and it will not involve any patients. It will be a simulation activity allowing the nurses to implement their learnings in the controlled and supervised environment before being able to implement them to the patients.
There are a number of different challenges that the project will encounter while implementing the series of change in the practice. First and foremost, the project co-coordinators will have to encounter staffing issue as the most fundamental challenge. It has to be mentioned that the nurse to patient ratio in the health care facilities is already very limited, and the additional educational might require additional staffing which can jeopardize the patient care in the facility (Rodda et al., 2017).
Another very important challenge that the project will encounter is the resource limitation. It has to be mentioned in this context that limited amount of time, finance, and resources to arrange the educational intervention will be a considerable challenge which has the potential to resist the successful completion of the project (Powell et al., 2015).
Along with that the lack of interest among the staff and the resistance to change implementation will also be a very important source of challenge for the project. As discussed by Reed and Card (2016), the nurses of the post-surgical units often are already suffering from emotional and physical exhaustion, burnout and extra workload due to short staffing. The additional pressure of a 6 month long educational intervention might not avail a welcoming reception from the staff on which the change will be implemented.
Additional possible challenges to successful completion of the project includes Change champions, feedback, compare data, and lack of flexible organizational culture in the facility.
Evaluation of a project result is last but the most vital aspect of the project which decides whether or not the project has yielded reliable and fruitful results and whether it should be implemented in a large scale format throughout the facility. In this case, the evaluation of the project will involve a varied range of parameters to ensure optimal efficacy and relevance of the evidence. The parameters for evaluation that will be utilized in the project includes audits such as chart audits and evaluation audits of the rate of CLABSI incident in the unit every month, incident data analysis using software for pooling and segregating the data being analysed and lastly training evaluation of the staff that had been targeted for the project to ensure optimal skill enhancement in the staff (Reed and Card 2016).
The PDSA Cycle as a CPI Tool
Along with that, this project will also be assessed with respect to best practice principles, timeliness, appropriateness, involvement of stakeholders, participant’s experience on intervention, and clinical governance. In case the data gathered meets all of the criteria successfully, it will be considered that project had met the aims and objectives and it is worth being replicated on a large scale. In case some of the criteria are not met in the project as per the data, it will be considered that project had not met the aims and objectives and it is not worth being replicated.
References:
Afonso, E.P., Blot, K. and Blot, S., 2015. Prevention of hospital-acquired and central line-associated bloodstream infections in the intensive care unit through chlorhexidine gluconate washcloth bathing: a systematic review and meta-analysis. Intensive care medicine experimental, 3(S1), p.A446.
Blot, K., Bergs, J., Vogelaers, D., Blot, S. and Vandijck, D., 2014. Prevention of central line–associated bloodstream infections through quality improvement interventions: a systematic review and meta-analysis. Clinical Infectious Diseases, 59(1), pp.96-105.
Dombecki, C., Vercher, J., Valyko, A., Mills, J. and Washer, L., 2017. Implementation of a Central Line-associated Bloodstream Infection (CLABSI) Prevention Bundle for Adult Hematologic Malignancy and Bone Marrow Transplant Patients. American Journal of Infection Control, 45(6), p.S103.
Kadu, M.K. and Stolee, P., 2015. Facilitators and barriers of implementing the chronic care model in primary care: a systematic review. BMC family practice, 16(1), p.12.
Knudsen, S.V., Laursen, H.V.B., Bartels, P.D., Johnsen, S.P., Ehlers, L.H. and Mainz, J., 2018. Can Quality Improvement improve the Quality of Care? A systematic review of effects and methodological rigor of the Plan-Do-Study-Act (PDSA) method. Bmj Quality and Safety.
O’Brien, K., 2015. Clinical governance and patient safety. Core Topics in Obstetric Anaesthesia, p.219.
Patel, P.K., Gupta, A., Vaughn, V.M., Mann, J.D., Ameling, J.M. and Meddings, J., 2018. Review of Strategies to Reduce Central Line-Associated Bloodstream Infection (CLABSI) and Catheter-Associated Urinary Tract Infection (CAUTI) in Adult ICUs. Journal of hospital medicine, 13(2), pp.105-116.
Payne, V., Hall, M., Prieto, J. and Johnson, M., 2018. Care bundles to reduce central line-associated bloodstream infections in the neonatal unit: a systematic review and meta-analysis. Archives of Disease in Childhood-Fetal and Neonatal Edition, 103(5), pp.F422-F429.
Powell, B.J., Waltz, T.J., Chinman, M.J., Damschroder, L.J., Smith, J.L., Matthieu, M.M., Proctor, E.K. and Kirchner, J.E., 2015. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implementation Science, 10(1), p.21.
Reed, J.E. and Card, A.J., 2016. The problem with plan-do-study-act cycles. BMJ Qual Saf, pp.bmjqs-2015.
Reyes, D.C.V., Bloomer, M. and Morphet, J., 2017. Prevention of central venous line associated bloodstream infections in adult intensive care units: A systematic review. Intensive and Critical Care Nursing, 43, pp.12-22.
Rodda, S.N., Hing, N., Hodgins, D.C., Cheetham, A., Dickins, M. and Lubman, D.I., 2017. Change strategies and associated implementation challenges: An analysis of online counselling sessions. Journal of gambling studies, 33(3), pp.955-973.
Safetyandquality.gov.au. 2018. Implementation Guide for Surveillance of Central Line Associated Bloodstream Infection. [online] Available at: https://www.safetyandquality.gov.au/wp-content/uploads/2016/04/Implementation-Guide-for-Surveillance-of-Central-Line-Associated-Bloodstream-Infection-2016-Edition.pdf [Accessed 22 Nov. 2018].
Taylor, M.J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D. and Reed, J.E., 2014. Systematic review of the application of the plan–do–study–act method to improve quality in healthcare. BMJ Qual Saf, 23(4), pp.290-298.
Uhb.nhs.uk. 2018. The main components of clinical governance. [online] Available at: https://www.uhb.nhs.uk/clinical-governance-components.htm [Accessed 20 Nov. 2018].
Van Zwanenberg, T. and Edwards, C., 2018. Clinical governance in primary care. In Clinical Governance in Primary Care (pp. 17-30). CRC Press.
Zingg, W., Holmes, A., Dettenkofer, M., Goetting, T., Secci, F., Clack, L., Allegranzi, B., Magiorakos, A.P. and Pittet, D., 2015. Hospital organisation, management, and structure for prevention of health-care-associated infection: a systematic review and expert consensus. The Lancet Infectious Diseases, 15(2), pp.212-224.