Strategies to Sustain Quality Interventions: Case Examples of Chlorhexidine Gluconate Bathing

Field: Health Professions (Health Sciences)

Sustaining improvements achieved through clinical inquiry projects is challenging. Often improvements are observed early after a change; however, over time, clinical staff will frequently revert to their previous practices, even if efforts to “hardwire” the practice change were initially put into place. One key reason why improvements are not sustained is that long-term monitoring of processes is not sustained. Identifying a few, simple metrics that can be easily measured over time to gauge how (or if) the processes are still in place is warranted.1 In clinical practice, these process metrics are often measured through tasks such as auditing nurse’s documentation compliance with specific interventions. Only when process and outcome metrics are tracked can clinical staff see signals that the evidence-based change is not being sustained. By identifying these signals early, clinicians can quickly work to identify barriers and improve processes, outcomes, and ultimately, patient care. When learning skills for conducting and completing evidence-based practice (EBP) and quality improvement (QI) initiatives, it is imperative for nurses to also understand the importance of sustainability and how to maintain gains made over time.The purpose of this column is to describe strategies and provide practical examples to overcoming unique barriers that plague individual patient populations or clinical units in achieving sustainable improvements following adoption of guideline-based care. Secondly, we hope to describe the value of combining a set or series of unit-based initiatives across a hospital or health system to generate additive results through systematically supporting nurses across a system.If EBP changes are not sustained over time, patients will not consistently receive high-quality care and the initial QI efforts (including the time, money, and effort) may go to waste. As such, health care and implementation science researchers have sought to identify components that impact implementation success. The National Institutes of Health Fogarty Center describes 3 implementation science frameworks in detail, including the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance), PRISM (Performance of Routine Information System Management), and CFIR (Consolidated Framework for Implementation Research).2 Each framework provides guidance on how to successfully implement EBP at the bedside. The concept of sustainability is prevalent across all frameworks, as it is an essential element to any clinical inquiry project. The scope and conceptual design of these frameworks vary, however, each depicts initial implementation as only one piece of the puzzle; indeed, the most challenging piece is that of sustainability. Choosing a sustainability strategy that fits your clinical problem is a critical decision point, as the work involved requires effort from everyone on the team; this is true not only in the early planning phase and throughout a clinical inquiry project but long after the initial project has ended.To monitor and measure sustainability effectively, various strategies or approaches can be used and should be selected on the basis of unit-specific needs and gaps.1 Even if an evidence-based change is made at a health-system level, different units may struggle with different aspects of the change. For example, the intensive care unit may have needs and challenges in sustaining a practice that are different than those of a pediatric medical/surgical unit. As such, sustainability efforts should be focused on unit-specific barriers and gaps.For a practical example, we share the experiences, strategies, and results of a sustainability program that was developed following an original implementation science study in which chlorhexidine gluconate (CHG) bathing was implemented to achieve a reduction in central line–associated bloodstream infection (CLABSI) rates.3,4 The positive results and clinical impact were suggestive of a high-value, low-cost initiative that was worth sustaining.Unit-specific issues have the greatest impact on the success or failure of system-wide sustainability plans. As such, these unit-based issues are central considerations in developing a strong plan. Below we report on the activities and barriers experienced by 4 unique clinical practice units that implemented sustainability plans for CHG bathing treatments. Each of the examples represents a real-world case implemented for a 12-month period in a large university-based health system in the southeastern United States.On a general medical unit in the university hospital, compliance with documentation of daily CHG bathing treatments was lower than the health system’s goal of 95%. On the electronic health record, a worklist task fired twice a day, as a reminder for staff to complete the daily bath. Worklist tasks were set to alert the nurse at 8 am and 8 pm. After the nurse would document the CHG bath treatment, the task would be removed from the nurse’s worklist, and they would receive a green check mark for completion. One barrier identified by a clinical nurse upon discussion with her colleagues was that nurses would often document something such as “not due this shift” within this flowsheet row at the beginning of their shift simply to remove it from their task list early in their shift. Nurses would then forget to complete the CHG bath treatment, leading to poor compliance with this EBP. To improve nurses’ compliance, the clinical nurse partnered with infection prevention and informatics to change the timing of the CHG bath worklist task to 6 am and 6 pm, thereby moving it to the end of the nurse’s shift. This time change allowed for the task to remain on the worklist for the entire shift, serving as a reminder for nurses to complete it. After implementation of this change in August 2021, the unit saw an 8.3% increase in their CHG bathing treatment compliance, from 88.3% to 96.5%, meeting the health system’s target.At a community hospital that was a part of the health system, a general surgical unit also saw reduced compliance with CHG bathing documentation. One identified barrier was that there was a knowledge deficit, with staff and patients not understanding the importance of CHG bath treatments. Literature evidence supports the claim that appropriate education, as well as staff assisting patients in completing the CHG bath treatment, can improve compliance. Through conversations with patients, it was discovered that noncompliance was the result of lack of staff education, which led to patients not receiving proper education on the importance of CHG treatment. Evidence shows that compliance rates increase when patients are educated and assisted by staff to complete CHG treatment. The purpose of this QI project was to reinforce targeted education to staff members on a general surgery unit to increase CHG treatment compliance. A survey was developed and disseminated to staff to assess their baseline knowledge of CHG bathing treatments. Results showed that staff knowledge was a barrier. On the basis of the results of the survey, various educational materials were developed to address the specific barriers and educate staff and patients with central venous catheters on the significance of completing and complying with daily CHG bathing treatments. Staff were educated via oral reminders during shift changes, a CHG bath treatment video and online module, email reminders, and flyers that were posted in frequently visited areas such as the medication cabinet, the nurse station, the bathroom, and the bulletin board. Prior to intervention, CHG bathing compliance was 83% (n = 59). Following education, CHG bathing treatment documentation compliance was 78% (n = 136). Although CHG bathing compliance decreased postintervention, the unit completed more CHG bathing audits. It was noted during CHG bathing audits that documentation was more accurate after the intervention, and “patient refusal” was documented less. It was observed that CHG treatments were completed and documented, which show an increase in implementation and patient compliance. A postintervention survey was also administered, which showed an increase in staff knowledge toward CHG bath treatments. This project helped improve the accuracy of CHG bathing documentation, increased staff knowledge of CHG bathing, and increased patient compliance with CHG treatment through educating staff and patients.Within 2 general medical-surgical units at a community hospital within the health care system, a QI project focusing on accuracy of documentation of CHG bathing treatments was undertaken. A 6-month baseline CHG bathing documentation audit showed that nurses frequently documented the option “Not Due This Shift” for several shifts in a row, leading to the patient not receiving their daily CHG bath. A collaborative clinical team proposed that including the last completed CHG treatment date and time would improve compliance. It was expected to prompt nurses to complete the CHG bath at the appropriate time. The initiative was piloted in 2 units with the lowest daily CHG treatment compliance. Enhanced documentation was discussed with nursing staff through huddle boards, shift hand-off reports, and in-person education. Chlorhexidine gluconate bathing compliance rates in the pilot units showed mixed results; one unit observed 30% improvement whereas another observed no change. Variability between units may be explained by differences in patient population, average length of stay, average central venous catheter days, and number of audits performed. Data will continue to be collected to determine sustainability of the practice and the impact on CLABSI rates. Additional implementation considerations include recognizing unit-specific adaptations for sustaining practice change.In a cardiac ICU (CICU) at the university hospital, CLABSI rates were high, despite compliance with CHG bathing treatments. As such, a variation in the approach to CHG bathing treatments was undertaken to assist with reducing the unit’s CLABSI rates. The purpose of the pilot project was to increase the frequency of cleaning the central venous catheter dressing and 6 inches of tubing from once a day with the CHG bath to every shift. The pilot began in July 2021. The CICU nursing staff were educated regarding the pilot project and the significance of cleaning the central venous catheter dressing and tubing every shift. Unit CLABSI champions facilitated this implementation via an education brochure, badge buddy, annual skill revalidation, and unit orientation. Staff meetings and shift team huddles were also used to disseminate the information and to raise awareness. A Qualtrics survey was sent to staff in August 2021 to assess staff’s awareness and compliance with the practice change, along with barriers and facilitators of the project. A total of 31 nurses responded to the survey, with the majority being from day shift (n = 21). Most staff were moderately or extremely aware of the pilot (n = 20), with 13 responding that they have implemented this practice change frequently or every time. Several barriers were identified, including patient refusal, time restraint, workflow/lack of reminder, and lack of documentation. Suggestions for improving the compliance with the practice change were changing documentation options in the electronic health record, reminders in worklist, patient education, and assigning a designated nursing assistant to complete this task. Ongoing evaluation of CLABSI rates and every-shift CHG treatment compliance will be completed throughout this current fiscal year.Each of these projects used the framework developed by Granger1 on the 6 steps to sustainability, including (1) Did it work? (2) Which factors contributed the most? (3) Which process factors should be monitored? (4) Is the data source reliable? (5) Is the workflow feasible? and (6) Finalizing the feedback loop (see Table). Projects focused on sustainability of efforts should use this framework to guide their process.As is evident in the cases above, a single implementation science initiative requires adaptability for sustainability across a health system to meet the needs of patients in each unique clinical area. Following the “6 simple steps to sustainability” provides a framework to plan ahead for sustainability, monitor progress over time, and make real-time adaptions to stay on track for the desired practice outcomes.1 In addition to taking these steps for an individual clinical inquiry project, a programmatic or system-wide approach is particularly useful for long-term quality monitoring and organizational priorities, such as Magnet accreditation or redesignation.Many health care systems have developed EBP workshops to teach clinical nurses the knowledge and skills to complete EBP and QI initiatives; however, these often focus more on the initial implementation of EBP and less on the sustainability of the practice. For example, O’Shea and Fischer-Cartlidge5 developed and conducted 23 interactive 90-minute workshops (n = 349 participants) to review requisite knowledge for implementing the steps of EBP. The participants improved in self-reported confidence across all measures. Similarly, Almader-Douglas and colleagues6 implemented workshops that sought to deliver video-based content remotely, from a central campus in Minnesota to nurses working at multiple Mayo Clinic sites in Arizona. These innovative workshops enlisted the local librarian to support nurses attending from each hospital, serving as an effective strategy for establishing a stronger mentoring relationship at the local level. Although these creative solutions represent innovative and effective ways to get evidence-based clinical inquiry projects off the ground, improving knowledge, conducting more efficient and effective literature appraisal, and achieving long-term sustainability require a subsequent step.Having a system-wide plan in place for sustainability is one way to develop clinical inquiry with lasting impact and high organizational value.7 Similar to the program design presented in this column, a 4-hospital system in China developed a system-wide program for improving EBP skills among nurse-participants (n = 111).8 This program also used multiple teaching strategies to improve knowledge, skills, and attitudes of nurses in conducting EBP projects. Fifteen studies were ultimately undertaken as a result of the program; however, skills for selecting a sustainability measure and the ultimate “stickiness” of the improvements made and measured over time is not addressed.8A unique component of our programmatic, system-wide sustainability plan is a 12-month EBP fellowship program, which aims to mentor staff champions through EBP implementations for sustained practice change that was achieved in a multisite, cluster-randomized implementation science study on the same topic (CHG bathing) across hospitals in a common system.3 Thus, with the health system having achieved improvements using a multisite research design, individual units subsequently designed local strategies for sustaining those improvements. The fellowship program was purposefully designed to improve staff nurses’ skills in identifying and addressing local, unit-specific nuances and barriers in care delivery. Paired with EBP implementation experts, each EBP fellow performed a gap analysis on the specific practice implementation to identify targets for improvement. As illustrated through the unit-based examples, although each unit had different practice barriers that affected adoption of CHG treatment, by working together and learning from each other, the fellows designed practice improvements and plans for sustainability that ultimately provided a stronger system-wide infrastructure for sustainable improvements.Despite the many challenges to sustaining improvements in health care practices over time, the benefit to patients and families far outweighs the investment we as nurses make in time, data collection, systems rebooting, and process redesigning. Unit-based efforts can make a real difference for patients, achieve organizational priorities for quality, and contribute to a healthy work environment for nurses through visible contribution to meaningful work. On a larger scale, by developing programs to involve new nurses in ongoing monitoring of sustainability, we stand to improve the educational imperative in the clinical setting and increase the value of sustainable improvement science to a broader national and global audience.Special thanks to the Duke University Health System and Nursing Services for support of the EBP Fellowship Program.