So, I wanted to talk about some of the educational aspects of implementing something like this. And I want to talk about the physicians who we focused on because, at first, we were looking at our infection rate, our CLABSI rates, being because of a poorly placed central line. And so, there was a lot that we needed to do and we hadn't focused on maintenance who were nurses or technicians maintaining the line as well. So, this is what we did for physicians. You had to be very clear. You're talking with a very educated audience and we want to have an open discussion. So, we view this as optimally assertive communication, you're talking about the evidence. And when I say assertive, I mean we're using assertive behavior because we're putting everything out there, but people that are assertive view the person they're having the discussion with as a peer and somebody that's at their level, versus somebody who's aggressive and just says, "You will do it." That's no kind of conversation. You're never going to win. The adaptive component would say we need to look at all of these things. But we wanted them to know from an organizational standard that our goal for CLABSI was going to be zero. And keep in mind, some of these had been directors for several ICUs for years. And some of them were so used to a rate of 10 per 1,000 days that they really just thought that that was expected. They go, "When I was educated, they said, you're always going to have infections whether it's a surgical site infection or whether it's sepsis from a central line or whatever, it's going to happen." But we had the evidence from some of our pilot sites that we looked at to show that not only was that really not true, that we could prevent the infections, that we talked to them about how we were going to get there and we talked about what we wanted from them to participate. So, as I said, it was an interdisciplinary or even transdisciplinary intervention. Then, we were calling it interdisciplinary. Now, it's transdisciplinary because we want opinions across all the providers and some outsiders like organizational psychology to explain why people do the things that they do. And we wanted them to know that this was kind of team building. So, for the first time, nurses said, "It's the first time the attending really talked to me when we were putting in the central line about some of the things that I really felt like we connected." So, it was very important. This wasn't something that we were doing to physicians. This was something we were doing for the benefit of our patients and both physicians and nurses were going to be participating and they had to in order to suffer any type of success. And we really wanted to be in the lower percentile from the NSH data. And again, our goal set by the organization, the president of the hospital, was the zero CLABSIs. We also developed the fact sheet because we wanted them to know exactly what they were going to do. So, we reviewed the checklist with them eventually after we developed it. We reviewed the step by step process of the evidence-based practice. We talked about the chlorhexidine, the maximal barrier precautions, and not to substitute a different barrier. All things which are very important. We showed them the carts that we were going to use. And I think the most important thing is that we started the work in two really high acuity units and we had success where they too felt that infections were inevitable. And I think seeing that data from within your own organization, that was both positive, was very important for them to see. And as a physician, we told different stories, we talked differently. So, there was a study sponsored by Daimler-Benz probably 10 years ago now and it say that physicians and nurses would communicate better if, A, physicians listened more like nurses, and nurses talked more like doctors. So instead of the nurse telling a story, she would be much more succinct like a physician, but a physician should be listening as intently as the nurse does when they're getting guidance on what needs to be done. So, we had to make sure everything was at their level. In some cases, we even made a physician orientation pack so that they thought we had done something specific for them which I think was really important in some units that really did not include a lot of input from frontline staff. Remember, the adaptive work, and I'm going to show you our results in just a bit, really changed over time so some of the frontline staff, some of the house officers, never really felt that they were listened to. And what they really needed to know was that we had a method to implement CLABSI with the comprehensive unit safety program which is what we used to address some of our adaptive challenges that we had with this improvement because the CUSP program was and is one of the few programs that has actually been shown to change culture over time. And I think that that was really important, too, because we were asking them to participate not only in evidence-based practice but we were asking for their opinion and for their participation in a quality improvement group which was through the CUSP program. The other thing that I think was really important was what our goals were. The CDC guidelines were, to the CDC, very clear. But when we talked to physician providers, there were things that were subject to interpretation. So, using clear terminology to make sure that we were using the surveillance definition of the CDC guidelines and not the laboratory definition, and that's what we would be monitoring, I think was really important because it took several weeks before we were all on the same page using the surveillance definition. So they had to know what we were doing and why we were doing it and we thought if we're going to break out to other hospitals in Johns Hopkins that don't have the same laboratory setup that we have, we would prefer to use the surveillance definition and I think that was important for them to know, and that went kind of site-wide. And again, I'm saying assertive non-aggressive because if you are assertive, you value input, you respect the person you're having a discussion with. If you're aggressive, your goal is to command and you really don't care what anybody thinks. So, again, it was an open forum of discussion between the physicians and the implementation team and all of their questions were answered. We were available to them 24/7 had they had any additional questions. And then gradually, we began to show them their data. So, the next thing that we address after education is, how do we engage them? And these were some of the questions that I asked. So, how do I get their attention? How can I ask the physician to change something he's been doing to meet a protocol, because they had a protocol before but now we're seeing the protocol is outdated? And what do I do if they say no? And again this is all adaptive work. This is taking culture into consideration. And these were some of the things that we came up with. So, at first, this was an Interdisciplinary Patient Centered Intervention. And research had shown since the 1990s that collaborating among medical personnel improved patient outcomes and role clarity. And we found articles as far back as the 80s but most of them were in the 90s talking about when physicians and nurses worked together, that we had better communication and we had better outcomes. So that this wasn't something again being done to them, this was something being done for the patient. And we looked at the need for physician leaders to stake up and take charge. So what we were looking for, is somebody that volunteered to be the physician champion for that unit. And that was really helpful because we wanted somebody that was well respected and somebody that people would listen to. Because his skill set was high, he was valued as an intellectual very scientific person, and people just felt really good about the information that he gave them. And then finally, Patient Centered Care, was what it was really all about, and getting their input. And for years we would close the patient's room after the- if we were doing rounds. We didn't keep them informed at all. But we wanted this to be an opportunity for them to educate the patient and family as to why we were doing some of the things like removing a central line even though it meant your family member might have to be stuck for blood, and those kind of things. So, we covered every element of the implementation bundle. We walked the process with them. As I said, we picked the physician champion to walk the process and to see what changes they would make. And then we asked them to make the chain like where the central line is placed. So that was pretty significant, showing them the evidence and I can't tell you how many physicians were so comfortable with the femoral line. And, you know, it was going to be big. We had ultrasound machines that were sitting in the unit that weren't being used, when clearly they would have helped and later the CDC would go on to say that an ultrasound machine actually reduces your risk of infection. So, the fact sheet turned out to be important but not enough. So, for them, what evidence or what site was best? And this was a randomized controlled trial. We are a teaching hospital. People are taking care of patients on randomized controlled trials all the time or observational studies. And, this is what finally got the buy in. So, when we showed them the original articles and we included, we weren't just saying that the subclavian was better, we were saying that the higher rate of infection was definitely in a femoral line versus the subclavian, a higher rate of thrombotic complications also. What we couldn't answer and this was because there was no study, and there was never a study done large enough that looked at the difference between subclavian and IJs or IJs and femoral which is why for this position, they didn't have time for the additional training with ultrasound and subclavian lines. We allowed them to do the IJ and we said, "Avoid the femoral line." And then when they did have time, we happily invited them to additional training so that they were comfortable placing the subclavian line. So, this was pretty significant information for them and very important to the nurses as well. And as I said, it meant more over time because getting them to admit that there were places for line that were better, and then saying that even the IJ wasn't perfect if it was a male patient, they were going to have a percutaneous line for several days and the beard growth would loosen the dressing. That would mean that the dressing had to be reapplied, and you would need clippers not a razor to reduce the risk of infection. So, showing them all the evidence and we provided all the articles and we highlighted in PowerPoint for them what we needed to do. These are the kits that we provided for them. And I want to say that this is just your average cart. And we set it up, and we set the standards. So there you see somebody in maximal bear precautions in the gown with the cart. And we said you have an option to make sure that you have all the supplies with you. You can either bundle it in a kit or have the central line cart. And it really depended on storage. If they kept the cart, then we made sure that they were updated twice a day and all the supplies were replaced. And we made sure that we had bundles in the units that preferred bundles, that there were always at least three on hand. And central stores kept them to meet their needs. And I think that that was really important. The other thing that I think so happens when you put in a central line you say, "Oh I can't find this, I cant find that," was we set up and at the top of every cart, we had an inventory of what was in every one of the drawers. So, where's the central line? Where are dressing supply kits? Where are culture bottles if we were sending a culture? And any other supplies like the sterile gloves and the kits themselves. So that physicians within a very short time became very accustomed to the cart and were able to pull things out. It didn't take the nurses time because they weren't helping to try and find the supplies that the physician had ignored, the cart got rolled to the room, they put out what they need, they put the line in, got their X-ray. They put the cart back. Somebody refilled it, restocked it and it went on to the next patient. And we stocked it with enough equipment to place three lines at any given time. We put one in the front of the unit, one and in the back of the unit, so that they always had this. And this made a huge difference. Our compliance skyrocketed to 95 percent that they had done every one of the steps which I think is important. So, the checklist was also something. If you were a systems engineer or human factors engineer and you really took to heart that we are fallible, we do need reminders. So, this is what we developed and the checklist was in the news for quite a while by Dr. Pronovost. The importance of the checklist as a reminder, just like a white board in an O.R to let you know what you're doing. So, in a stepwise progression, you can look at each one of those steps to see what you've done. And while you're doing your work, your nurse is checking off that it's done. If you haven't done it, it's either the nurse has done it with redirection or when reminded. And this was not only imperative to the success of the program, but it allowed us to audit compliant so that we could say we were at 98 percent compliance or 100 percent compliance with the reduction of central lines after they were placed. And it was incredibly important because when we still had central lines, we knew that it wasn't from their placement. Again, it was because of maintenance which was something that we addressed later, a different version for both adults and children.
