Culture Change Key To Safety, Quality Improvements

Janice Simmons, for HealthLeaders Media , July 22, 2010

This training occurred about the same time when the PICU jointed with a nationwide collaborative effort, coordinated by the National Association of Children?s Hospitals and Related Institutions (NACHRI), in 2008 to eliminate pediatric catheter?associated bloodstream infections (CA-BSI). The initial goal was to reduce the infection rate by half, while doubling the time interval between infections.

"There were a lot of parts of the central line initiative that required a culture change," Silver says. Reducing the incidence of CA?BSI in adult patients have been successful mostly by improving insertion techniques. But with pediatric CA?BSI, the insertion of the central line is the cause of only 10% of infections, with the remaining 90% linked to "maintenance procedures" of the line.

The key to combating the infection in pediatric populations meant focusing on those maintenance procedures. The necessities of the catheter itself became a topic for discussion on daily rounds—and part an open conversation among nurses and physicians caring for the patient.

The PICU began using a dedicated nurse observer—with a checklist—who would accompany the physician inserting the catheters. The nurse would observe if safety precautions—such as hand washing or use of caps, gowns, and masks--were being implemented. If there was noncompliance with a checklist item, the nurse could stop the procedure until it was corrected.

Empowering the nurse did take some adjustment, Silver says. "Some of my physician colleagues didn't at first like it much that they would be challenged. But, we changed that culture, and now it's not even an issue.

Now, when a doctor goes in to put in a central line, "they'll go find the nurse—they seek them out," Silver adds. And similarly, nurses can report on how the central line looks--if it's functioning well or if there are concerns that it should come out.

"You have to create a sense of mutual responsibility—where you share the success. I could have talked to the entire group all of the time about how much a central line infection costs and what the mortality risk is, but that has very little impact because we deal with critically ill children," says Silver.

"It's really a matter of working on communication and creating the environment where people realize that everyone is responsible for everything that goes on with a patient—for creating the mindset that a central line infection is not acceptable," Silver says. "It's really letting everybody know that this is really important."

Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at

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