![[Visit Client Website]](images/banner.gif)
Immunocompromised children are at high risk for primary blood stream infections (BSI) and the associated morbidity and mortality. Prevention of BSIs depends on highly reliable care. The purpose of our study was to rapidly mitigate the impact of system stress on the rate of BSIs in a high risk population.
Methods, Intervention, & Analysis
After a dramatic increase in patient volume and acuity coupled with an increase in new and float nurse staff at a large, quaternary children’s medical center, BSI rates more than doubled. A failure-mode analysis of key processes identified poor adherence to daily hygiene guidelines, high rates of nurses requiring assistance to complete high BSI-risk procedures, and an unreliable system to escalate concerns from the bedside to unit leadership. Iteratively implemented mitigation strategies included a standard process to improve daily hygiene adherence, increased awareness of high BSI-risk patients, assistance for nurses performing high BSI-risk procedures, and improved allocation of resources to deescalate system stress.
Findings & Interpretation
Since the mitigation strategies were fully implemented there have been no further BSIs in >100 days (6000 line days). Key processes have become more reliable: 100% of dressing changes are completed with the new, 2 person standard; daily hygiene adherence has increased from 25% to 70%; 100% of bedside nurses are approached daily by nurse unit leaders to identify and plan for patients at risk for a BSI.
Discussion & Implications
Stress to a complex care delivery system for high-risk patients can degrade BSI rates. Rapidly identifying failures in key processes and improving their reliably can quickly stabilize outcomes.