From kamishibai card to key card: a family-targeted quality improvement initiative to reduce paediatric central line-associated bloodstream infections

Reduction of Central Line-Associated Bloodstream Infections on a Transplant Unit

BACKGROUND

Central line-associated bloodstream infection (CLABSI) is a preventable complication of central venous catheters (CVC) that can result in prolonged hospitalization, increased cost, and mortality.

LOCAL PROBLEM

CLABSI rates in a solid organ transplant unit were above the National Database of Nursing Quality Indicators target.

METHODS

Evidence-based CLABSI prevention interventions were implemented using the Plan-Do-Study-Act process.

INTERVENTIONS

A stepwise approach was used to implement CVC maintenance bundle pole cards, chlorhexidine gluconate (CHG) bathing treatments, and Kamishibai card (K-card) door tag processes for all patients with CVCs.

RESULTS

The unit achieved and sustained >90% compliance with both CHG bathing treatments and K-card door tag processes. The CLABSI rate decreased from 2.15 to 0.41, an 81% reduction.

CONCLUSIONS

CLABSI reduction in a transplant unit can be achieved through the systematic implementation of evidence-based practices.

Using Kamishibai Cards to Identify Barriers and Display Adherence to the Central Line-Associated Bloodstream Infection Prevention Bundle

PURPOSE

Central line-associated bloodstream infection (CLABSI) rates have been consistently high at an academic comprehensive cancer hospital. CLABSI prevention bundles can mitigate central line infections, and many components focus on nursing practice. Identification of barriers to maintaining adherence to these elements is not always assessed or addressed. The purpose of this project was to increase adherence to CLABSI prevention nursing practices and to implement a sustainable program to elevate nurses' skills and documentation of CLABSI prevention bundle components.

DESCRIPTION

Pre-implementation/post-implementation chart reviews, post-implementation visual audits, and a survey for nurses post project were completed over a 9-week period. This project identified and addressed barriers to CLABSI prevention bundle compliance. Audits assessed nursing practice elements of the CLABSI prevention bundle. Evidence-based Kamishibai cards (K-cards) were used as a visual audit tool to display compliance of CLABSI bundle elements.

OUTCOMES

Compliant documentation of daily chlorhexidine gluconate (CHG) bathing increased to 75%. Inconsistent communication practices and knowledge gaps were frequent barriers to compliance. Seventy-five percent of nurses reported the K-card display changed their own CLABSI prevention practices.

CONCLUSION

This project increased knowledge, adherence to CLABSI prevention practices, and awareness of components most often missed.

Adapting lean management to prevent healthcare-associated infections: a low-cost strategy involving Kamishibai cards to sustain bundles' compliance

Lean healthcare visual management has been successfully integrated into infection control programs, leading to lower healthcare-associated infection (HAI) rates and greater provider compliance with evidence-based prevention practices; however, its implementation during quality improvement (QI) initiatives in limited-resource settings has not yet been well exploited. We aimed to describe a low-cost strategy involving Kamishibai cards to sustain bundles' adherence to prevent HAIs in a middle-income country. This descriptive case study evaluated the implementation of a lean healthcare visual management tool-Kamishibai board (K-board)-during a nationwide QI collaborative preventing three critical HAIs in 189 adult and pediatric/neonatal intensive care units (ICUs) from September 2021 to January 2023. Considering a limited-resource setting, our team adapted a K-board using simple, cheap, and easy-to-handle materials for routine monitoring of QI procedures, including safety bundles' compliance. After test prototypes, the final K-board version was implemented. The chart materials and assembly cost BRL 80.00 (USD 15.48). Before launching, expert working group meetings were held to shape the contents, refine technical issues, and prepare the ICU teams for implementation. After starting, plan-do-study-act cycles were conducted according to the Breakthrough Series model. Participating ICU teams, including leaders and front-line health workers, performed bedside audits following a weekly chronogram. Two indicators were calculated: the percentage of ICUs in which K-boards were being implemented and whether bundles' compliance was addressed in the K-board. Audit data were recorded in 'SimpleQI'. After 17 months of this initiative, 177 (93.7%) participating ICUs had included this visual management tool in their daily care routines. When more than 94 (>50%) ICUs posted K-board data, the mean compliance for the bundles for each HAI was sustained above 85%. A lean healthcare visual management tool can be adapted to local settings, including healthcare facilities with limited resources. K-board seems to be a feasible method for auditing evidence-based practices in medical care, including safety bundles to simultaneously prevent three types of HAIs.

Grand rounds in methodology: four critical decision points in statistical process control evaluations of quality improvement initiatives

Quality improvement (QI) projects often employ statistical process control (SPC) charts to monitor process or outcome measures as part of ongoing feedback, to inform successive Plan-Do-Study-Act cycles and refine the intervention (formative evaluation). SPC charts can also be used to draw inferences on effectiveness and generalisability of improvement efforts (summative evaluation), but only if appropriately designed and meeting specific methodological requirements for generalisability. Inadequate design decreases the validity of results, which not only reduces the chance of publication but could also result in patient harm and wasted resources if incorrect conclusions are drawn. This paper aims to bring together much of what has been written in various tutorials, to suggest a process for using SPC in QI projects. We highlight four critical decision points that are often missed, how these are inter-related and how they affect the inferences that can be drawn regarding effectiveness of the intervention: (1) the need for a stable baseline to enable drawing inferences on effectiveness; (2) choice of outcome measures to assess effectiveness, safety and intervention fidelity; (3) design features to improve the quality of QI projects; (4) choice of SPC analysis aligned with the type of outcome, and reporting on the potential influence of other interventions or secular trends.These decision points should be explicitly reported for readers to interpret and judge the results, and can be seen as supplementing the Standards for Quality Improvement Reporting Excellence guidelines. Thinking in advance about both formative and summative evaluation will inform more deliberate choices and strengthen the evidence produced by QI projects.

Adaptation of a Lean Tool Across Surgical Units to Improve Patient Experience

BACKGROUND

High reliability organizations (HROs) sustain consistently excellent outcomes over time. Health care systems need to eliminate major quality failures to become reliable.

LOCAL PROBLEM

Practice variations, unstructured leader rounds, and unfavorable patient experience outcomes with Responsiveness of Hospital Staff prompted leaders to adopt Kamishibai cards (K-cards).

METHODS

Evidence-based practices (EBPs) such as timeliness of answering call lights, purposeful rounding, communication, and engaging patients were used to develop Responsiveness K-cards.

INTERVENTIONS

Responsiveness K-cards established standard work for staff responsiveness and audited process compliance. Findings determined what areas needed improvement, and leaders engaged frontline staff in practice changes.

RESULTS

Percentile rank for Responsiveness of Hospital Staff had a sustained increase. Four of 6 hospital units using Responsiveness K-cards achieved 80% rank or better in every patient experience domain for the entire fiscal year.

CONCLUSIONS

K-cards use HRO principles to standardize practice and improve outcomes. They encourage continuous improvement, which supports the sustainability of EBPs.

A quality improvement initiative to reduce hypothermia in a Baby-Friendly nursery - our story of algorithms, K-cards, and Key cards

BACKGROUND

Baby-Friendly hospitals encourage rooming-in newborns with mothers. In our institution, we noticed increased incidence of hypothermia following Baby-Friendly designation. We aimed to reduce the incidence of hypothermia in the mother-baby-unit to <15% and to decrease the rate of isolated hypothermia admissions to the neonatal intensive care unit (NICU) by 20% over two years.

METHODS

After a retrospective review of newborns ≥35 weeks gestation in the mother-baby-unit with hypothermia, we implemented multiple interventions such as nursing education, hypothermia algorithm, Kamishibai cards, and Key cards.

RESULTS

Hypothermia incidence in the mother-baby-unit decreased from 20.9 to 14.5% (p < 0.001) and infants requiring NICU admission decreased by 71% (p < 0.001) following all interventions. Apart from nursing education, all interventions led to significant reductions in both outcomes from baseline.

CONCLUSION

Instituting a hypothermia algorithm and utilizing K-cards and Key cards reduces the incidence of hypothermia in the mother-baby-unit and NICU admissions for isolated hypothermia.