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Zero Maintenance
On the WICU, an important infection rate hits a record low.


Yula Ponticas keeps vigilant watch over a WICU patient.

Every day there are six to eight admissions on the Weinberg Intensive Care Unit, and managing the traffic is a delicate operation. Resident staff from more than one service are in and out, fellows come and go, attendings rotate. The bedside nurses and nurse practitioners, however, are constant.

“There’s a lot of busyness,” says WICU medical director Pamela Lipsett. “Whenever you have a lot of people in the mix, there’s always opportunity to have errors.”

Yet that’s the very thing you won’t find on the 20-bed unit where 90 percent of patients have a cancer diagnosis.

In fact, the WICU has just gone 14 straight months with no central line-associated bloodstream infections—for the second time. No other unit in the hospital comes close to their record. Late last month, the staff of 75 was recognized by the Center for Innovation in Quality Patient Care for the feat.

Infection control epidemiologist Obaida Merheb credits the “steady staff and strong management” for their success. “Dr. Lipsett herself will review every [possible infection] that might come up on the radar,” she says.

Because they are inserted close to the heart, central lines are used judiciously. Still, certain medications—like chemotherapy or medications to support blood pressure—are too concentrated or dangerous to be given any other way. “Some people are dependent on them for life,” says Lipsett. Approximately three-quarters of patients who spend more than one day on the WICU will have central lines.

Infections associated with the catheters can be dangerous—they increase length of stay and can lead to sepsis. “That means an overwhelming bloodstream infection,” explains Donna Prow, nurse manager of the WICU, “so you have to put them on medication to keep their blood pressure up.” And there’s a fine line between increasing blood vessel constriction and decreasing blood flow to the extremities. “You have toes that get dusky and fingertips that get dusky,” says Prow. “Patients can be sick for several days.”

It’s critical to use sterile techniques to avoid these complications. When a central line is placed, all the supplies, such as masks, gloves and dressings remain accessible just outside the room in a portable, four-drawer line cart. “That way, no one has to leave the room to get something,” says Prow.

But perhaps most important is the 20-item central line checklist that nurses oversee. They have the power to stop a procedure if providers haven’t washed their hands or the site hasn’t been sterilized adequately, for example. The tool was developed on the WICU and is now used institution-wide. “We feel empowered by the checklist,” says WICU nurse Sharon Schromsky. “The teamwork here is phenomenal and there’s a good level of communication.”

Lipsett and Theresa Hartsell, the unit’s other medical director, anchor the team. “The nurses know they have the absolute support of the medical directors,” says Lipsett, “and that if anyone doesn’t pay attention to them, we would intervene to support them at any cost.”

When Prow gets asked how she maintains her enviable record of zero weekly harm scores, she points out that there is no magic bullet. “It’s the line cart and the checklist,” she begins. “It’s the nurses who are watching the procedure and observing for any breaks in sterility. It’s the nurse practitioners, based in the WICU, who are teaching the residents. It’s the support staff who keep the unit clean. Anybody who goes in and out of the patient’s room has something to do with zero.”         

— Mary Ellen Miller



Johns Hopkins Medicine

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