This report describes the work of Iowa Health-Des Moines to integrate graduate medical education and quality improvement as part of the Alliance of Independent Academic Medical Centers National Initiative, Improving Patient Care Through Graduate Medical Education.

Julie A. Gibbons, RN, BSN, Nurse Epidemiologist
Lisa A. Veach, MD, Hospital Epidemiologist, Infectious Disease Physician
Richard A. Sidwell, MD, Program Director, General Surgery Residency
Anne E. Modrzynski, MD, Surgery Resident
Piper L. Wall, DVM, PhD, Staff Scientist
Douglas B. Dorner, MD, Senior Vice President, Medical Education and Research; Director of Medical Education/ACGME Designated Institutional Official
Mark W. Purtle, MD, Vice President of Medical Affairs

Improve resident physician knowledge of infection prevention and compliance with Central Line Bundle and decrease central line-related bloodstream infection (CLBSI) in adult critical care units by May 2009.

• Compliance with central line insertion checklist
• Central line infection prevention knowledge
• Central line infection prevention knowledge of surgery residents 
• Central line-related bloodstream infections

A new infection prevention education program for resident physicians was implemented with a one-hour didactic class on preventing device-related infections and a central line insertion simulation for first and second year surgery residents. This was part of a larger, eight-hour class that focused on preventing infections in acute care. The seven-hour, didactic portion of the program was for all resident physicians. 

• Used a team approach for central line insertion simulation education, having a nurse present during the simulation
• Implemented consistent use of a central line insertion checklist
• Revised the checklist to meet our needs and are in the process of building the checklist into a  procedural note
• Revised the pre- and post-class tests to better assess resident knowledge; several questions were modified for increased clarity 
• Revised the Preventing Infection in Acute Care classes based on the feedback from both residents and program directors, making the classes even more program specific

Lessons Learned:

• Improving resident physician knowledge and compliance with proven infection prevention guidelines was identified as a priority for 2007. We narrowed our focus to preventing central line infections in the adult critical care units to better manage the project and bring about change more rapidly. 

• Understand your checklist and know that:
  • There may be a learning curve
  • There may be a Hawthorn effect with regard to physician residents using all bundle elements
  • The checklist can empower nurses to question deviances from the bundle elements and advocate for the patient
• Make education programs very specific to the program specialty.
• Involve the program director with the project early on. They know where the problem areas are, how to start testing, and can provide support. We had the full support of the surgery program director and when we added the internal medicine program, this program director was also supportive. 
• Find an interested champion, ideally one who is passionate about the initiative and can lobby their peers. Although we did have a passionate nurse epidemiologist on the team, preventing central line infections when our rates were already low was not seen as the “ideal” project by the residents.
• Position key people in correct roles. The hospital epidemiologist, who is highly respected, was very instrumental in the entire project. The surgery program director also participated as the instructor for the central line insertion simulation and placed priority on resident attendance and completion of the pre- and post-class tests.
• Revise the Preventing Infections in Acute Care class and test for the 2008-09 resident class to better meet the needs and assess the knowledge of the residents.

Barriers:

• Determine how the data will be collected. Determining the total number of central lines inserted in the ICU was a barrier for us as billing and ICU procedural codes cannot currently be used to identify the number of central lines placed. From November 2007 through January 2008, only 24 checklists were turned in, but a central supply inventory utilization inquiry for all central line kits reported a net of 31 kits charged to the ICU.

Next Steps:

• Analyze current cases in real time. Two most recent cases met definition for CLBSI, but patients had numerous co-morbid factors and the bloodstream infections were possibly incubating on admission. Third and fourth quarter 2008 cases increased from prior quarters (zero infections in quarters 1 and 2,       2008!), but overall yearly rate decreased from 1.84 per 1,000 central line days in 2007 to 1.1 in 2008.
• Provide data feedback to all involved as more infections are occurring.