In this video we're going to continue to talk about our practical strategy for translating evidence into practice, and in particular, we're going to focus on the second step of this model identifying local barriers to implementation. We'll continue to use our story about preventing central line-associated bloodstream infections to give context to this practical model. To identify local barriers, our human factor experts recommend three different strategies. Number one, observe staff performing the interventions. Number two, walk the process yourself to identify the defects in each step of intervention implementation. And then third, enlist all stakeholders to share concerns and identify potential losses or gains associated with intervention implementation. In other words, talk to the frontline staff. Our frontline staff has a tremendous amount of wisdom about what happens within organizations and why it is that patients aren't receiving the evidence-based therapies they should. Our role in leading these quality improvement efforts is to understand what those local barriers of implementation are so we can better design our intervention to address some of these local barriers. In our story about preventing bloodstream infections, we identified five evidence-based practices, but one of the things that we've recognized was that providers weren't consistently providing that evidence-based care. And again, we knew that providers cared deeply and they wanted to do the best that they can, there must be a reason why they're not providing these evidence-based therapies. We summarized the evidence, we identified five key best practices from the overall CDC guidelines for the prevention of central line-associated bloodstream infections, but yet still we recognize that patients weren't receiving those evidence-based therapies so we had to dig a little bit deeper. And when we talked to frontline staff, when we walked the process, and we participated in the care of patients, particularly during this process of inserting central line, we gained additional important insights. One of the things that we recognized that it was the providers had to go to eight different places to get all the equipment and supplies that they needed to comply with insertion practice guidelines. Essentially, we were making it difficult for providers to do the right thing. So, we needed to address these issues by making it easier for providers to do the right thing, and the way that we did that was we created a central line cart. We brought all the equipment together in one place essentially making it easier for providers to do the right thing. In addition, we needed to create independent checks based upon our discussions with providers and walking the process at the point of care and during times of stress. Often times, providers forgot what they were supposed to be doing so we created redundancy in the system. We engaged our nursing staff by creating a central line checklist. This checklist engaged our nursing colleagues to be actively involved in the point of care and to help ensure that patients receive the therapies they should. For the evidence-based practice about making sure that we ask everyday whether those lines could come out, we didn't have a great process. Rather, we left it up to individual providers to determine whether that care was necessary or that line was an imminent and important part of care. But yet, that system is perfectly designed to achieve the results that it does and we lacked redundancy in that system. So to address this issue, we brought together a group of stakeholders. We tried to gain consensus about who exactly needed a central line. That process was exceedingly difficult and not surprisingly, we really couldn't gain consensus from providers about who needed a central line because there are no clear evidence-based guidelines to guide that decision. Instead, what we decided to do was we added to our checklist a question about whether that line could be removed every day. This daily goals checklist is used on every patient every day in the inpatient ICU setting and has been adapted to many other settings. This is perhaps one of the most versatile and important tools that we use within our intensive care unit to ensure that patients receive the therapies they should. For the prevention of central line-associated bloodstream infections, we simply asked the question, "Can any tubes, lines, or drains be removed today?" And we were committed to asking that question for every patient everyday. If someone on the care team thought that that central line was an important part of care, no problem at all. We're not going to have a debate. We're not going to have any arguments. Instead, we're going to ask again the next day, Is this line an important part of care? And we're going to continue to ask that question every day until that line could be removed to minimize the risk of that patient developing a central line-associated bloodstream infection. The next step of the TRIP Model is measuring performance and making sure that we get that feedback to frontline staff. The reality is that many of our frontline staff, though they care deeply, without a doubt they care deeply about patient care, they're not aware of current performance. Whether we don't do a good job of measuring how often we provide the evidence-based therapies they should or we don't do a great job of making sure that our frontline staff really understand how well we're performing. We'll be talking a lot more about measuring performance and giving feedback to staff in another video.
