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Quality Update - The Wisdom of the Frontline Staff

Fall 2009

The Wisdom of the Frontline Staff

Date: October 15, 2009

Two hospitals in the U.K. take the tenets of a Johns Hopkins safety program to heart.

Royal Liverpool team
A multidisciplinary team meets to discuss patient care at Royal Liverpool University Hospital, one of two in the United Kingdom to partner with the Center for Innovation on safety initiatives.

When it comes to improving patient safety, there’s a big difference between telling frontline workers how to improve care and leveraging their wisdom to devise the best way to make it happen.

So when the elderly care ward at the United Kingdom’s Royal Liverpool University Hospital looked for ways to reduce infections associated with urinary catheters, it tapped the knowledge of its caregivers rather than simply following government directives. Working with consultants from Johns Hopkins Center for Innovation in Quality Patient Care, the ward developed checklists laying out the most important steps for preventing infections, such as positioning a patient’s drainage bags below the level of the bladder.

The ward also put into place requirements that aim to prevent unnecessary catheterizations and those that stray from guidelines. Physicians now must give a reason for each catheterization procedure and a witness must verify that it is done correctly.

Within a month, all of the ward’s staff members were complying with the new guidelines. Even better, the measures helped eliminate catheter-related infections—the cause of  60 percent of hospital-associated  urinary tract infections in the United  Kingdom—on the ward for a year.

“We devised a form that didn’t require any more paperwork and also gave more authority to all staff members on the team,” says ward nurse Stephen Cooper.

It is one success story that has emerged from a partnership that began last year between the Center for Innovation and two regional hospitals in the U.K. Aintree University Hospital, also in Liverpool, has likewise adopted safety methods developed at Hopkins.

Sponsored by the Liverpool Primary Care Trust, the collaboration focused on reducing infection rates. Hopkins was hired because of its success at improving the culture of safety, and for involving doctors, nurses and other health care providers in finding solutions to infection control problems.

In the U.K., the department of health issues a wide-ranging array of directives to hospitals for making patients safer. However, there is often “little understanding and attention paid to how—or if—the frontline staff can implement them in their work,” says Stephanie Peditto, director of innovation for the center. “There may be one way to make something work best in the ICU and another in a unit of special services for the elderly. We want frontline clinical staff to work together to make best practices work for them.”

Peditto and Deborah Hobson, a Hopkins surgical intensive care nurse and patient safety clinical specialist with the center, worked with several wards that wanted to address infections.

The Hopkins team educated staff on the science of safety, assigned a hospital executive to support each ward’s safety initiatives, and helped workers identify what they considered the biggest risks to patient safety. Then Peditto and Hobson helped staff find solutions.

At Royal Liverpool’s elderly care ward, the lack of urinary catheter-related infections and a reduction in unnecessary intravenous cannulations helped to decrease patients’ length of stay from an average of 18 days to 11.4 days, according to head nurse Collette Johnston.

At Aintree’s thoracic medicine ward, head nurse Shirley Brady and physician Biz Chakrabarti, with support from executive Steve Warburton, reduced clostridium difficile bloodstream infections through such strategies as a daily auditing of isolation procedures and by using a “mystery shopper” approach to monitoring hand hygiene practices.

Before the Hopkins partnership, there were 14 C-diff cases during a five-month period but only two “unavoidable” cases over a similar period after the collaboration began. In August, when staff members gathered for a patient safety workshop, they celebrated that accomplishment as well as the absence of any incidents of MRSA bacteremia since 2008.

Infection control team leaders say such acknowledgement builds greater dedication to patient safety and inspires adherence to other initiatives, such as a project at Aintree to reduce patient falls.

“Nurses need to feel engaged and empowered,” Brady notes. “We want staff to do the right things because they have a desire to and because they understand why—rather than because they are told to.”