You may remember the classic American film, “Field of Dreams,” starring Kevin Costner and James Earl Jones. In the movie, Ray Kinsella (Costner), an Iowa farmer, hears a voice whispering, “If you build it, he will come.” As the story develops, the whispering voice morphs into visions of a need for Ray to turn a portion of his cornfield into a baseball field so star players from yesteryear can return and relive their dreams. After the first player arrives, he asks Ray if he can bring others to the field so they can also play. The player later returns with seven other players and then the story goes on.
When it comes to patient safety related to invasive care, the same concept of “If you build it, he will come” applies, however in a much less favorable way. Specifically, any time you access a patient through a needle stick, Foley catheter, central venous catheter (central line) or surgical procedure, you have the chance of introducing a contaminant, i.e., bacteria, by “building” a pathway for it to enter the body. This contaminant loves company, so it brings seven of its friends and so on and so on.
Over the past several years, most hospitals have learned to use a multidisciplinary care approach to the reduction of unnecessary patient interventions, such as early removal of Foley catheters. As a result, catheter-associated infections dropped proportionally to the rate of Foley- use reduction. However, in the care of patients with central lines, the identification and then removal of unnecessary lines is much more complicated. In many cases, several clinical specialties access these lines for such procedures as vesicant drug administration, dialysis and pheresis, and therefore review of central line removal becomes more complex.
Lean management, based on continuous process improvement, revolutionized the manufacturing industry. Today, it has become an increasingly popular approach in a number of other industries; health care being one of them. Lean uses a combination of techniques, such as “go to where the work is performed” (observation) and the “humble inquiry” when trying to understand if there is an opportunity to simplify a process. Humble inquiry used during observational rounds approaches the perceived problem (in this case, possible overuse of catheters) in the form of respectful questions asked of the caregivers that are designed to build an immediate rapport and to help understand if an opportunity exists to remove catheters.
One member hospital, using this Lean approach, paired a physician with the IV team to identify central lines that had been in place for more than seven days, had not been accessed for 24 hours or where there were multiple central lines in the same patient. Infection prevention literature suggests that a second central line in the same patient increases the probability of an infection tenfold. Armed with that data and using Lean observation and management systems techniques, the physician initially visited with the attending RN to clarify current patient care. Then, as appropriate, the physician discussed the idea of central line removal with the attending physician or hospitalist.
Prior to the start of this process the first week of December 2017, the hospital averaged a central line utilization ratio of nearly 20 percent (UR = # of central lines ÷ # of patients). National 50th percentile for this type of facility is 18 percent. Beginning on Day 1 and continuing through March 2018, the number of central lines inserted decreased from 54 per day to 33 per day. This 39 percent improvement reduced central line utilization to 10 percent, putting them in the top-performing decile nationally.
The hospital wanted to prove that all units and care specialties were participating in the improvement effort. The key impact of central line utilization reduction is “No Line. No Infection.” By tracking central line utilization by unit they were able show that all units contributed to this significant change in performance. The Lean concept of going to where work is performed, combined with management systems and leader rounding, resulted in a desired reduction in central line use and patient safety with a sustained process approach.
So, while the baseball field that Ray built in the middle of his cornfield in Iowa may have provided a celestial opportunity for people to re-live something they sacrificed long ago, for safe patient care, “Don’t build it and they won’t come.”
