What Is a CLABSI and How to Prevent It

00;00;01;01 - 00;00;41;29
Tom Haederle
Many of us do a root cause analysis when an adverse event such as the health care associated infection - or HAO - occurs, and we apply interventions to prevent future HAIs from occurring. But what if the interventions still don't work? Today's guest, an attending physician of infectious disease at a Flushing Queens hospital, is here to share how his organization flipped the order of performance improvement tools to achieve desired outcomes.

00;00;42;02 - 00;01;12;19
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. The AHA’s Healthcare Associated Infection Antimicrobial Resistance Project is a funded partnership with the Centers for Disease Control and Prevention. Through the project, the AHA has been listening to the field share its challenges and successes with infection prevention and control. NewYork-Presbyterian Queens in Flushing recently celebrated having no CLABSI’s in more than one year.

00;01;12;22 - 00;01;29;20
Tom Haederle
Dr. Nishant Prasad, attending physician and program director of Infectious Diseases, shares how they re approached CLABSI prevention by deeply examining structure and process. He's in conversation with Marie Cleary-Fishman, AHA's vice president of Clinical Quality.

00;01;29;23 - 00;01;50;19
Marie Cleary-Fishman
Well, Dr. Prasad, thank you so much for being here today. We really appreciate the time and effort you're putting into this, and we're really interested in learning more about your CLABSI work at your hospital at the NewYork-Presbyterian Queens in Flushing I understand. Could you tell us what that acronym stands for?

00;01;50;22 - 00;02;17;00
Dr. Nishant Prasad
Sure. And again, thank you for having me. So a little bit of explanation. Like you said, is a central line associated bloodstream infection. So those invasive catheters that we put into patients to give them medications at the hospital can sometimes be associated with infections that get into the blood from those catheters. So that's what a CLABSI would be considered, when one of those infections occurs.

00;02;17;02 - 00;02;28;22
Marie Cleary-Fishman
Thank you for sharing that. And then let's talk a little bit about your focus in 2017 and why you decided to focus on CLABSI. What was your driving force for that?

00;02;28;24 - 00;03;13;23
Dr. Nishant Prasad
Yeah, so it actually started well before 2017 because we identified times of events of concern. Prior to that, I would say before 2017, we had set the processes in place to try to address our concern, but we didn't have our initial process as well structured as it should have been. And it's really 2016-ish that we figured out how we should approach our concerns with potential associated bloodstream infections at our hospital.

00;03;13;25 - 00;03;22;00
Dr. Nishant Prasad
And once we started utilizing that process is when we really started to see the positive effects.

00;03;22;03 - 00;03;41;19
Marie Cleary-Fishman
So just to summarize that a little bit, so would you say that what really made this more successful this time around was that you identified those processes, maybe looking at structure and process to really get to the outcome you were looking for. Was that sort of the crux of the difference for this effort?

00;03;41;22 - 00;03;49;24
Dr. Nishant Prasad
Yes, You restated it very, very, very appropriately. I actually don't have anything to add to that.

00;03;49;26 - 00;04;16;17
Marie Cleary-Fishman
You've got lots to add. But yeah, so my question, having been in quality for a very, very long time at this point in my life, you know, we know that so many interventions have been around and we've tried those. What performance improvement tools? PDSA Cycles? What kinds of things did you focus on this time and what made that different this time around than the previous times you may have tried?

00;04;16;19 - 00;04;45;25
Dr. Nishant Prasad
Right. So that's a wonderful question because it's really the big change that we made. You know, we were all taught as part of, you know, addressing health care quality initiatives that you have to do, you know, an investigation and a root cause analysis. Right. And then you got to talk to the people where that, you know, that event occurred and and try to figure out what could we have done to prevent that occurrence.

00;04;45;28 - 00;05;07;05
Dr. Nishant Prasad
That's what we were all taught. The change that we made and that's what we initially did before 2016. And unfortunately for us, it felt like we were spinning our wheels. Because we were coming up with interventions that didn't seem to be having the effect that we were hoping for and that we were not reducing our CLABSI rate.

00;05;07;07 - 00;05;14;16
Dr. Nishant Prasad
So we took the tack of, and I'm sure this has been done before, is we copied the airline industry.

00;05;14;18 - 00;05;15;00
Marie Cleary-Fishman
Okay.

00;05;15;02 - 00;05;46;22
Dr. Nishant Prasad
We called in our experts. So we put together a very diverse team to focus and address the problem, of course, led by infection control and infectious diseases, because we know we're the sort of the stewards of infection control and health care associated infections at any hospital. And then we added to that everybody that takes part in the lifecycle of a central line.

00;05;46;24 - 00;06;20;20
Dr. Nishant Prasad
So interventional radiology, the intravenous access team, right? The nurses on the floor to maintain the catheters, supply is right acquisition for a purchasing right What kind of supply should we purchasing for these catheters and their maintenance, right? The interns in the intensive care unit - all of these people were brought to the table and we had a committee formed and it was a sizable committee at the time and we discussed how to approach the problem.

00;06;20;23 - 00;06;55;14
Dr. Nishant Prasad
And one of the things I remember, one of the one of the attendings speaking at that time is: we need to centralize our expertise. So one of the issues that we identified was that when we were doing the sort of the old teaching of having an RCA with the people who were caring for the patient, where the event occurred; you were asking the people who had the event what they think went wrong, where they're not necessarily subject matter experts in that occurrence.

00;06;55;17 - 00;07;15;00
Dr. Nishant Prasad
So what we needed to do is reverse that. We needed to do our own evaluation before the root cause analysis. And that's what we started doing. So I felt infectious diseases, infection control and the other teams that were involved with those would do an incredibly detailed analysis of every single event.

00;07;15;03 - 00;07;16;01
Marie Cleary-Fishman
Okay. Interesting.

00;07;16;08 - 00;07;41;07
Dr. Nishant Prasad
So just like the airline industry does when there's a catastrophe on a plane, right? They will investigate with experts to figure out what happened. And sometimes they can even focus their investigation to the point where they can identify a single component, right? You've heard about those results of those investigations. We tried to get that level of granularity with our investigations and then we would have the RCA.

00;07;41;09 - 00;07;49;21
Marie Cleary-Fishman
So you would actually look at the data and do that analysis prior to sitting down in the room with those at the frontline. Correct. Interesting.

00;07;49;21 - 00;08;15;10
Dr. Nishant Prasad
And sometimes, the other thing we did is we greatly accelerated the initiation of that review process. As we would be monitoring - for example - when it comes to CLABSIs, we would be monitoring blood culture, positivity, these daily. And as soon as a blood culture turned up positive and it had the potential to be called a CLABSI we would start that review process to see, okay, is it truly a CLABSI?

00;08;15;10 - 00;08;36;05
Dr. Nishant Prasad
If it is, what can we do and look at to see why was this a CLABSI? And once you do that deep investigation, sometimes even I would go and see the patient myself after talking to the primary team and say, Hey, listen, this might be a CLABSI, Do you mind if I see your patient and take a look and see what's going on and talk with the staff they've been caring for them?

00;08;36;05 - 00;08;58;04
Dr. Nishant Prasad
They're always happy to accept our help in those regards. And when we go to the RCA, we're just adding to that incredibly detailed investigation because most of the time we actually had a pretty good idea of why the CLABSI had already occurred, and we're just adding more pieces to that puzzle with that RCA.

00;08;58;06 - 00;09;22;13
Marie Cleary-Fishman
That's great. I really appreciate that and I think that's new, thinking or just kind of reordering things and really thinking about what's the best way to get at this. One thing in your case study, I just wanted to ask about, you mentioned including the palliative care team and and so that's not always a member of the team that we think about for central line infections.

00;09;22;13 - 00;09;28;21
Marie Cleary-Fishman
Can you just briefly describe what palliative care was doing there and why you brought them in?

00;09;28;24 - 00;09;59;05
Dr. Nishant Prasad
Yeah. So in that initial group of participating services that we put together to address this issue, we did not include palliative care in the beginning, but as a result of those incredibly detailed analysis, it turned out we identified cases where their input would have been very appropriate earlier on in the lifecycle of the central line. And so we chose to incorporate them into that group.

00;09;59;05 - 00;10;27;10
Dr. Nishant Prasad
And as part of those, our RCA results, we decided that they would be an integral part and they were very helpful in addressing urgent palliative care issues, right? I know even right now, palliative care physicians and consultants are being employed as early as even the emergency room. It's great. You know, that was the new thing, right? So back then, getting them involved earlier was the recommendation.

00;10;27;10 - 00;10;43;08
Dr. Nishant Prasad
But we as the committee could make that official recommendation to the department and the administration saying, hey, we need to get palliative care involved earlier on these patients, because quite frankly, a lot of patients that have central lines may benefit from earlier interventions from palliative care.

00;10;43;15 - 00;11;12;07
Marie Cleary-Fishman
Right. That's great. I love that. It's including all of those across the care continuum. So it sounds like you've really built a lot of trust, a lot of credibility within your organization on that infection control prevention resources, the folks that you have in your organization. And if you were going to summarize the lessons learned, what are those things that in your experience that you've really learned?

00;11;12;07 - 00;11;21;20
Marie Cleary-Fishman
I think you've identified a few things, but if you can also talk about those things that have really reinforced that trust and credibility of the team as lessons learned.

00;11;21;22 - 00;11;56;05
Dr. Nishant Prasad
Thank you for that, because that's a perfect question. The real emphasis on our process is centralizing your expertise. And that's where you have to have people who understand infections and central lines, part of the analysis of every single CLABSI. See, because once you've got experts with that level of understanding, evaluating those events, they can really drill down to the why.

00;11;56;07 - 00;12;30;01
Dr. Nishant Prasad
Why did that CLABSUI occur? And once they've identified that, then identifying effective interventions becomes much more easy and then you can implement your plan, do study, act cycles, because deciding what to do is incredibly time consuming and expensive, right? Some of these things do cost, you know, $0. You know, switching from one type of catheter to another type of catheter is a substantial cost, especially when the when the when the new catheter costs more money than the old catheter.

00;12;30;04 - 00;12;42;29
Dr. Nishant Prasad
But having a good reason for why you're doing that is predicated on understanding that that switch, that intervention is very likely to have the desired effect.

00;12;43;01 - 00;12;59;17
Marie Cleary-Fishman
And then also, as you mentioned, that I would imagine the role of leadership in your C-suite and maybe even the board plays a role in that trust and credibility from the front line all the way through. Can you just talk a little bit about the leadership support that you've had for this?

00;12;59;19 - 00;13;28;11
Dr. Nishant Prasad
Oh, yeah. The support was incredible from our leadership in that once we were able to really tell them and define the problem, right, and then say, you know what, this we think is an intervention that's going to be helpful. They were incredibly supportive and I think they were more willing to support us because we had such detailed analysis.

00;13;28;13 - 00;13;50;15
Dr. Nishant Prasad
It's not that we were saying, oh, it seems like or it looks like now we can actually point to individual cases and say, okay, this is what our analysis showed. This is what happened on that case. We think if we implement this process, it's going to make it better. And most of the time we had already done, you know, like a cheap you know, PDSA cycle just to see if it had a desired effect.

00;13;50;15 - 00;14;12;17
Dr. Nishant Prasad
So we had an idea that, okay, now we need to request more resources or, you know, ask for more staffing or something like that to, to get the full, you know, protocol implemented throughout the hospital. And of course, they were always involved when we had to change workflows because sometimes the intervention required that kind of a workflow change.

00;14;12;20 - 00;14;30;10
Marie Cleary-Fishman
Yeah, I think that's so important. I mean, if we go back to that fundamental and I say it over and over again, but structure, process and outcome, if you don't look at the workflow as part of that, then it's unlikely that structure alone is going to get you to the outcome you're looking at or looking for. So that's really important.

00;14;30;12 - 00;14;53;19
Marie Cleary-Fishman
The timeframe that you worked on this covered the COVID 19 pandemic and you know, that had such an impact on our workforce, our supply chain, and on our organizational priorities, where we really had to shift how we were doing things, what we were doing. How did that impact this effort? Did it help? Did some of the change come out of that or what?

00;14;53;21 - 00;14;56;07
Marie Cleary-Fishman
Can you talk a little bit about that experience?

00;14;56;10 - 00;15;12;04
Dr. Nishant Prasad
Yeah. So the kind of good news for us is that most of our effective initiatives had already been implemented prior to the pandemic, sort of coming to New York City. And as you know, you know, Queens was hit pretty hard.

00;15;12;10 - 00;15;12;29
Marie Cleary-Fishman
That's right.

00;15;12;29 - 00;15;35;20
Dr. Nishant Prasad
So the good news is, is we were able to maintain pretty much all of our best practices throughout the pandemic. We didn't really suffer for it in any real way. Because one of the things that we identified even before the pandemic was these interventions are not sort of a fad diet, to put it that way. You can't start them and do them for a little bit until the problem is solved,

00;15;35;20 - 00;15;48;08
Dr. Nishant Prasad
then stop. Yeah, sure, you have to switch and change and maintain. And so I like to say, you know, kind of the price of of good, good work is eternal vigilance in the world of infection control.

00;15;48;11 - 00;16;17;28
Marie Cleary-Fishman
I love that. And that that was exactly the last place I wanted to go in really was to talk about sustainability. Yes. So you've touched on that a little bit. But any other lessons learned or issues around sustainability? Have you made any changes? Are you still maintaining the, you know, the work on your own beforehand, looking at the data and then moving to the RCA committee or what kinds of things can you tell me about sustainability?

00;16;18;00 - 00;16;25;19
Dr. Nishant Prasad
Yeah, So in sustainability for us, you know, knock on wood, we haven't had a CLABSI seeing a little bit over a year now.

00;16;25;19 - 00;16;28;06
Marie Cleary-Fishman
It's great, which is incredible.

00;16;28;10 - 00;16;44;14
Dr. Nishant Prasad
It is still just as painstaking of a process because there are many, many potential CLABSIs and that review for each one of those is still done in exactly the same way that we did it when we were having concerns.

00;16;44;14 - 00;16;45;17
Marie Cleary-Fishman
That's really great.

00;16;45;17 - 00;16;56;08
Dr. Nishant Prasad
Yeah, you can't let off the gas. It's just not feasible to to stop doing what you know works. Quite frankly its common sense.

00;16;56;10 - 00;17;19;22
Marie Cleary-Fishman
All of that. That's great. I mean, I think this is so important as we think about this whole process and the learnings that you've had, the best practice items that have come out of this. But, you know, we really are looking at how do we reinforce and sustain that trust with our patients. And every CLABSI belongs to someone's loved one and we really want to prevent those things.

00;17;19;24 - 00;17;42;01
Marie Cleary-Fishman
Really driving to zero is what we all want right? So really love to hear that. I'd like to just ask you if there's any other ideas or suggestions that you'd like to share that I did not touch on today. Anything you would like to share, because this is a great opportunity for you to share your success and your best practices with everybody else in the field.

00;17;42;01 - 00;17;55;16
Marie Cleary-Fishman
So now we get to best sustainability to spread, and that's really what we at the AHA like to try to facilitate across our members. So any last pieces of information you'd like to share?

00;17;55;19 - 00;18;17;25
Dr. Nishant Prasad
Yeah, thank you for that. You know, I'd really like to just emphasize the couple of key points that I made. Number one, centralize your expertise, get people who know the subject materials, right? I'm not an interventional radiologist. I don't know how to place a central line. Last time I did that was when I was a resident and that was over a decade ago.

00;18;17;27 - 00;18;49;23
Dr. Nishant Prasad
Right? So you really have to get those kinds of physicians and staff members involved in the evaluation of every single event. When there is an event that occurs that's related to their division, their input must be part of that RCA. And the evaluation should be done before the RCA. So again, just to reiterate, centralize your expertise and do a very, very detailed analysis because you really have to figure out that why as close as you can get to it.

00;18;49;23 - 00;19;10;05
Dr. Nishant Prasad
You know, I know many things in medicine are many times ambiguous and you can't really, really know for sure what exactly happened that may have caused something, but you want to get as close as you possibly can, because then you'll make decisions for the interventions with much more clarity and you're more likely to have interventions that are effective.

00;19;10;07 - 00;19;20;03
Dr. Nishant Prasad
So somebody just sort of taking our interventions and applying them to their facility may not be as effective because quite frankly, their problems may be different.

00;19;20;06 - 00;19;40;23
Marie Cleary-Fishman
Very well said. Well, thank you, doctor. We really appreciate your insight, your ideas that have been innovative and really have driven to your success and really all of that sustainability and spread that we're sharing with others. So thank you so much for helping us to improve and to tell everybody about that journey.

00;19;41;00 - 00;19;42;17
Dr. Nishant Prasad
Thank you for having me.

00;19;42;20 - 00;20;15;19
Tom Haederle
This publication is part of a program of the Health Research and Educational Trust, supported by the Centers for Disease Control and Prevention - CDC - of the U.S. Department of Health and Human Services - HHS - under CDC/HHS as part of a financial assistance award totaling $75,000 with 100% funded by CDC/HHS. The contents are those of the authors and do not necessarily represent the official views of nor an endorsement by CDC, HHS, or the U.S. government.