It seemed like a simple request at the time, but Andrew Kreppel faced some resistance.
He began one of his first meetings as a pediatric infectious disease specialist at Children's Hospital University of Illinois (CHUI) in 2013 by asking the multidisciplinary pediatric care team to address each other by their first names. His thought: By stripping away the professional titles and leveling the health care hierarchy that is so critical to clinical care, everyone would assume equal ownership of preventing hospital-borne infections."I remember one of the nurses said, ‘I'm sorry, but I've been a nurse for 30 years and I respect your training. I'm going to call you Dr. Kreppel, I'm not going to call you Andrew,'" says Kreppel, M.D., M.P.H., pediatrician at CHUI in Chicago. "I could see this was going to be a change in the culture and the roles to which people were accustomed."
Collaborative effort leads to long CLABSI-free stretch
Over time, Kreppel has seen the culture shift toward one of improved "collegiality and collaboration." It is that collaborative effort, according to Kreppel, that has been the driving force behind CHUI's impressive CLABSI-free streaks:
- The general pediatrics ward hasn't had a CLABSI in more than five years.
- No pediatric intensive care unit CLABSIs in nearly three years.
- The neonatal intensive care unit has gone more than two years without a CLABSI.
"Those milestones have come through a lot of collaborative effort," Kreppel says. "The interventions were largely the benefit of improving teamwork and accountability across our units and across all our providers—not just the physicians or the nurses, but everyone working together for the safety of our patients."
Scripted rounds, mobile handwashers and plastic clappers
The spirit of team collaboration and shared responsibility for patient safety took on a variety of forms. The team used a "trial and learn" process to test a multitude of interventions. One involved mandatory participation of nursing staff in patient bedside rounds with scripted discussions around the specifics of the patient's central line, how it was being managed and if it was still necessary.
Another intervention revolved around the use of novelty plastic hand clappers. In conjunction with a hospital-wide hand hygiene campaign, Kreppel and his team tasked charge nurses as the stewards of proper hand washing. When a charge nurse witnessed someone not practicing good hand hygiene, they'd clap their plastic hands as a gentle reminder to wash up.
They also outfitted intravenous poles with alcohol dispensers to serve as makeshift mobile handwashing stations. Medical students were responsible for the dispensers and—with ordinary hierarchical norms relaxed—were empowered to ensure proper hand hygiene practices among even the most senior medical staff.
Hand hygiene campaign influences CLABSI rates
Kreppel says that although the hand hygiene campaign doesn't directly correlate to CHUI's CLABSI successes, the indirect benefits are clear. Not only does it raise the collective consciousness among staff around patient safety in general, but the effect of proper handwashing rates that now consistently run around 90 percent can't be ignored.
"I don't think we would have been successful in reducing our CLABSI rates without a concurrent push to assure people have clean hands," Kreppel says. "If you don't have clean hands, then you can't even talk about CLABSIs."
Collaboration and shared responsibility are key to improvements
Kreppel says "all organizational improvements—like politics—are local," so the processes that are working for CHUI might not succeed everywhere. But he says their CLABSI successes can be replicated anywhere if two key concepts are emphasized.
"It's really about shared responsibility and collaboration," Kreppel says. "I think if you can get those two pieces, you can really have significant improvements with respect to safety for our patients."
Those foundational concepts have helped drive important strides in patient and quality metrics at CHUI. And they ultimately got Kreppel on a first-name basis with that veteran nurse.
"I eventually got her to come around," Kreppel says. "She calls me Andrew now."
