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What defines high quality care has perplexed the speciality of critical care for many years. According to the Institute of Medicine, quality care is safe, effective (evidence-based), patient-centred, timely, efficient and equitable.1 Whilst these terms are laudable, they do not actually answer the "what is quality?" question and too often we limit ourselves to the measurable rather than focussing on actions that actually impact on local healthcare issues.The science underpinning many quality projects is often enthusiastically extrapolated from a weak evidence-base. As a consequence, many clinicians view quality with a degree of cynicism and suspicion. Concerns are raised that practice is changed purely to improve the measured surrogate rather than deliver any tangible patient-centred outcomes. External bodies may even view the numerical value generated by these narrow metrics as a measure of our global practice and use these data to distribute healthcare funding, a reality in the US health care system today.The measurement and prevention of central line associated bacteraemia (CLAB) has become one of the major quality targets for the critical care community. The frequency, cost, morbidity and mortality of this ubiquitous aspect of modern ICU makes it an attractive proposition for potential improvement. Fortunately, unlike many other quality predecessors, its implementation appears to be supported by high quality evidence from large, well conducted, multicentre trials.2,3 These studies not only describe impressive, sustainable results, but also illustrate a "how-to guide" in order that CLABs can be minimised in other jurisdictions. In this week's NZMJ, Seddon et al demonstrate a significant reduction in local CLAB rates following the introduction of similar multifaceted quality improvement programme.4 At first, the reader may question why we need a further study when international data seems so compelling.The article is important and relevant for a number of reasons. Firstly it demonstrates that a US-healthcare-based CLAB reduction programme can be effective in a large New Zealand hospital. Secondly, it reminds us that a good quality project requires more than just data collection. The planning, education, feedback and local process modifications undertaken by the investigators were, I believe, crucial to ensuring that local practitioners felt engaged by the project. Thirdly, it provides some handy practical solutions to problems faced by others attempting to collect similar data with particular reference to the tally method used for calculation of line days.Seddon et al demonstrate a CLAB rate reduction rate from 6.8 to 0.9 per 1000 line days over approximately 2 years. These data are impressive and comparable with international data but are still greater than the desired zero. A rate of zero implies that all CLABs are preventable and this intolerant approach has been adopted by the Centres for Medicare and Medicaid Services in the United States, where hospitals are no longer reimbursed for CLAB-related expenses. In reality up to 50% of hospital-acquired bloodstream infections may not be preventable5 and a more realistic target of <1 per 1000 catheter days has recently been adopted by the Australian Council of Healthcare Standards.The authors conclude that their paper makes a case for all ICUs in New Zealand to measure CLAB rates and adopt a similar approach to CLAB reduction. This proposition raises two issues; one about measurement and the other about incidence reduction methods.Measurement of CLAB rates requires two metrics, a numerator (numerical value of CLABs) and a denominator (numerical value of line days). These two values are derived from a combination of a microbiologist, intensivist and data collector(s) review. At present there is little or no central resource provided to support this process. If this process becomes a mandatory part of New Zealand ICU practice, then can we be sure that this resource shift will not result in reduced effectiveness or even unintended negative consequences on other areas of healthcare? Equivalent multi-centred quality improvement projects have been supported by Federal or State funding.3,4The second point raised is with regard to the actual methods of CLAB reduction. The authors comment on local changes to the originally described CLAB bundle which included preferential access to internal jugular vein, customised central line pack, consideration of a biopatch and a data focus on "time between CLABs". These changes allowed the process to adapt to the hospital, required local staff to take ownership and be engaged in the project. Local adjustment of the CLAB implementation process to optimise its performance and acceptance in each of our unique hospitals is vital to its success. A centrally dictated intervention is doomed to fail.The assumption that a low CLAB rate equates to high quality critical care is probably naive. However, an appropriately funded national monitoring programme could reduce regional inequality by allowing resources to be focused on environments that have a demonstrable CLAB problem.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

David Knight, Intensive Care Specialist, Department of Intensive Care, Christchurch Hospital, Christchurch

Acknowledgements

Correspondence

Dave Knight, Intensive Care Specialist, Department of Intensive Care, Christchurch Hospital, PO Box 4345, Christchurch, New Zealand. Fax: +64 (0)3 3640099

Correspondence Email

David.Knight@cdhb.govt.nz

Competing Interests

None.

Institute of Medicine. Crossing the Quality Chasm. Washington: National Academy Press; 2001.http://www.nap.edu/books/0309072808/html/ Accessed July 2011.Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter- related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725-2732.Scales DC, Dainty K, Hales B, et al. A Multifaceted Intervention for Quality Improvement in a Network of Intensive Care Units: A Cluster Randomized Trial. JAMA. 2011;305(4):363-372.Seddon M, Hocking CJ, Mead P, Simpson C. Aiming for zero: decreasing central line associated bacteraemia in the intensive care unit. N Z Med J. 2011;124(1339). http://www.nzma.org.nz/journal/124-1339/4780Bonnal C, Mourvillier B, Bronchard R, et al.Prospective assessment of hospital-acquired bloosdstream infections: how many may be preventable? Qual Saf Health Care 2010;19:1-5.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

What defines high quality care has perplexed the speciality of critical care for many years. According to the Institute of Medicine, quality care is safe, effective (evidence-based), patient-centred, timely, efficient and equitable.1 Whilst these terms are laudable, they do not actually answer the "what is quality?" question and too often we limit ourselves to the measurable rather than focussing on actions that actually impact on local healthcare issues.The science underpinning many quality projects is often enthusiastically extrapolated from a weak evidence-base. As a consequence, many clinicians view quality with a degree of cynicism and suspicion. Concerns are raised that practice is changed purely to improve the measured surrogate rather than deliver any tangible patient-centred outcomes. External bodies may even view the numerical value generated by these narrow metrics as a measure of our global practice and use these data to distribute healthcare funding, a reality in the US health care system today.The measurement and prevention of central line associated bacteraemia (CLAB) has become one of the major quality targets for the critical care community. The frequency, cost, morbidity and mortality of this ubiquitous aspect of modern ICU makes it an attractive proposition for potential improvement. Fortunately, unlike many other quality predecessors, its implementation appears to be supported by high quality evidence from large, well conducted, multicentre trials.2,3 These studies not only describe impressive, sustainable results, but also illustrate a "how-to guide" in order that CLABs can be minimised in other jurisdictions. In this week's NZMJ, Seddon et al demonstrate a significant reduction in local CLAB rates following the introduction of similar multifaceted quality improvement programme.4 At first, the reader may question why we need a further study when international data seems so compelling.The article is important and relevant for a number of reasons. Firstly it demonstrates that a US-healthcare-based CLAB reduction programme can be effective in a large New Zealand hospital. Secondly, it reminds us that a good quality project requires more than just data collection. The planning, education, feedback and local process modifications undertaken by the investigators were, I believe, crucial to ensuring that local practitioners felt engaged by the project. Thirdly, it provides some handy practical solutions to problems faced by others attempting to collect similar data with particular reference to the tally method used for calculation of line days.Seddon et al demonstrate a CLAB rate reduction rate from 6.8 to 0.9 per 1000 line days over approximately 2 years. These data are impressive and comparable with international data but are still greater than the desired zero. A rate of zero implies that all CLABs are preventable and this intolerant approach has been adopted by the Centres for Medicare and Medicaid Services in the United States, where hospitals are no longer reimbursed for CLAB-related expenses. In reality up to 50% of hospital-acquired bloodstream infections may not be preventable5 and a more realistic target of <1 per 1000 catheter days has recently been adopted by the Australian Council of Healthcare Standards.The authors conclude that their paper makes a case for all ICUs in New Zealand to measure CLAB rates and adopt a similar approach to CLAB reduction. This proposition raises two issues; one about measurement and the other about incidence reduction methods.Measurement of CLAB rates requires two metrics, a numerator (numerical value of CLABs) and a denominator (numerical value of line days). These two values are derived from a combination of a microbiologist, intensivist and data collector(s) review. At present there is little or no central resource provided to support this process. If this process becomes a mandatory part of New Zealand ICU practice, then can we be sure that this resource shift will not result in reduced effectiveness or even unintended negative consequences on other areas of healthcare? Equivalent multi-centred quality improvement projects have been supported by Federal or State funding.3,4The second point raised is with regard to the actual methods of CLAB reduction. The authors comment on local changes to the originally described CLAB bundle which included preferential access to internal jugular vein, customised central line pack, consideration of a biopatch and a data focus on "time between CLABs". These changes allowed the process to adapt to the hospital, required local staff to take ownership and be engaged in the project. Local adjustment of the CLAB implementation process to optimise its performance and acceptance in each of our unique hospitals is vital to its success. A centrally dictated intervention is doomed to fail.The assumption that a low CLAB rate equates to high quality critical care is probably naive. However, an appropriately funded national monitoring programme could reduce regional inequality by allowing resources to be focused on environments that have a demonstrable CLAB problem.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

David Knight, Intensive Care Specialist, Department of Intensive Care, Christchurch Hospital, Christchurch

Acknowledgements

Correspondence

Dave Knight, Intensive Care Specialist, Department of Intensive Care, Christchurch Hospital, PO Box 4345, Christchurch, New Zealand. Fax: +64 (0)3 3640099

Correspondence Email

David.Knight@cdhb.govt.nz

Competing Interests

None.

Institute of Medicine. Crossing the Quality Chasm. Washington: National Academy Press; 2001.http://www.nap.edu/books/0309072808/html/ Accessed July 2011.Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter- related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725-2732.Scales DC, Dainty K, Hales B, et al. A Multifaceted Intervention for Quality Improvement in a Network of Intensive Care Units: A Cluster Randomized Trial. JAMA. 2011;305(4):363-372.Seddon M, Hocking CJ, Mead P, Simpson C. Aiming for zero: decreasing central line associated bacteraemia in the intensive care unit. N Z Med J. 2011;124(1339). http://www.nzma.org.nz/journal/124-1339/4780Bonnal C, Mourvillier B, Bronchard R, et al.Prospective assessment of hospital-acquired bloosdstream infections: how many may be preventable? Qual Saf Health Care 2010;19:1-5.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

What defines high quality care has perplexed the speciality of critical care for many years. According to the Institute of Medicine, quality care is safe, effective (evidence-based), patient-centred, timely, efficient and equitable.1 Whilst these terms are laudable, they do not actually answer the "what is quality?" question and too often we limit ourselves to the measurable rather than focussing on actions that actually impact on local healthcare issues.The science underpinning many quality projects is often enthusiastically extrapolated from a weak evidence-base. As a consequence, many clinicians view quality with a degree of cynicism and suspicion. Concerns are raised that practice is changed purely to improve the measured surrogate rather than deliver any tangible patient-centred outcomes. External bodies may even view the numerical value generated by these narrow metrics as a measure of our global practice and use these data to distribute healthcare funding, a reality in the US health care system today.The measurement and prevention of central line associated bacteraemia (CLAB) has become one of the major quality targets for the critical care community. The frequency, cost, morbidity and mortality of this ubiquitous aspect of modern ICU makes it an attractive proposition for potential improvement. Fortunately, unlike many other quality predecessors, its implementation appears to be supported by high quality evidence from large, well conducted, multicentre trials.2,3 These studies not only describe impressive, sustainable results, but also illustrate a "how-to guide" in order that CLABs can be minimised in other jurisdictions. In this week's NZMJ, Seddon et al demonstrate a significant reduction in local CLAB rates following the introduction of similar multifaceted quality improvement programme.4 At first, the reader may question why we need a further study when international data seems so compelling.The article is important and relevant for a number of reasons. Firstly it demonstrates that a US-healthcare-based CLAB reduction programme can be effective in a large New Zealand hospital. Secondly, it reminds us that a good quality project requires more than just data collection. The planning, education, feedback and local process modifications undertaken by the investigators were, I believe, crucial to ensuring that local practitioners felt engaged by the project. Thirdly, it provides some handy practical solutions to problems faced by others attempting to collect similar data with particular reference to the tally method used for calculation of line days.Seddon et al demonstrate a CLAB rate reduction rate from 6.8 to 0.9 per 1000 line days over approximately 2 years. These data are impressive and comparable with international data but are still greater than the desired zero. A rate of zero implies that all CLABs are preventable and this intolerant approach has been adopted by the Centres for Medicare and Medicaid Services in the United States, where hospitals are no longer reimbursed for CLAB-related expenses. In reality up to 50% of hospital-acquired bloodstream infections may not be preventable5 and a more realistic target of <1 per 1000 catheter days has recently been adopted by the Australian Council of Healthcare Standards.The authors conclude that their paper makes a case for all ICUs in New Zealand to measure CLAB rates and adopt a similar approach to CLAB reduction. This proposition raises two issues; one about measurement and the other about incidence reduction methods.Measurement of CLAB rates requires two metrics, a numerator (numerical value of CLABs) and a denominator (numerical value of line days). These two values are derived from a combination of a microbiologist, intensivist and data collector(s) review. At present there is little or no central resource provided to support this process. If this process becomes a mandatory part of New Zealand ICU practice, then can we be sure that this resource shift will not result in reduced effectiveness or even unintended negative consequences on other areas of healthcare? Equivalent multi-centred quality improvement projects have been supported by Federal or State funding.3,4The second point raised is with regard to the actual methods of CLAB reduction. The authors comment on local changes to the originally described CLAB bundle which included preferential access to internal jugular vein, customised central line pack, consideration of a biopatch and a data focus on "time between CLABs". These changes allowed the process to adapt to the hospital, required local staff to take ownership and be engaged in the project. Local adjustment of the CLAB implementation process to optimise its performance and acceptance in each of our unique hospitals is vital to its success. A centrally dictated intervention is doomed to fail.The assumption that a low CLAB rate equates to high quality critical care is probably naive. However, an appropriately funded national monitoring programme could reduce regional inequality by allowing resources to be focused on environments that have a demonstrable CLAB problem.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

David Knight, Intensive Care Specialist, Department of Intensive Care, Christchurch Hospital, Christchurch

Acknowledgements

Correspondence

Dave Knight, Intensive Care Specialist, Department of Intensive Care, Christchurch Hospital, PO Box 4345, Christchurch, New Zealand. Fax: +64 (0)3 3640099

Correspondence Email

David.Knight@cdhb.govt.nz

Competing Interests

None.

Institute of Medicine. Crossing the Quality Chasm. Washington: National Academy Press; 2001.http://www.nap.edu/books/0309072808/html/ Accessed July 2011.Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter- related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725-2732.Scales DC, Dainty K, Hales B, et al. A Multifaceted Intervention for Quality Improvement in a Network of Intensive Care Units: A Cluster Randomized Trial. JAMA. 2011;305(4):363-372.Seddon M, Hocking CJ, Mead P, Simpson C. Aiming for zero: decreasing central line associated bacteraemia in the intensive care unit. N Z Med J. 2011;124(1339). http://www.nzma.org.nz/journal/124-1339/4780Bonnal C, Mourvillier B, Bronchard R, et al.Prospective assessment of hospital-acquired bloosdstream infections: how many may be preventable? Qual Saf Health Care 2010;19:1-5.

Contact diana@nzma.org.nz
for the PDF of this article

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