From kamishibai card to key card: a family-targeted quality improvement initiative to reduce paediatric central line-associated bloodstream infections

Abstract

<jats:sec><jats:title>Background</jats:title><jats:p>Central line-associated bloodstream infections (CLABSIs) are major contributors to preventable harm in the inpatient paediatric setting. Despite multiple guidelines to reduce CLABSI, sustaining reliable central line maintenance bundle compliance remains elusive. We identified frontline and family engagement as key drivers for this initiative. The baseline CLABSI rate for all our paediatric inpatient units (January 2016–January 2017) was 1.71/1000 central line days with maintenance bundle compliance at 87.9% (monthly range 44%–100%).</jats:p></jats:sec><jats:sec><jats:title>Objective</jats:title><jats:p>To reduce CLABSI by increasing central line maintenance bundle compliance to greater than 90% using kamishibai card (K-card) audits and family ‘key card’ education.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>We transitioned our central line maintenance bundle audits from checklists to directly observed K-card audits. K-cards list the central line maintenance bundle elements to be reviewed with frontline staff. Key cards are cue cards developed using a plain-language summary of CLABSI K-cards and used by frontline staff to educate families. Key cards were distributed to families of children with central lines to simultaneously engage patients, families and frontline staff after a successful implementation of the K-card audit process. A survey was used to obtain feedback from families.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>In the postintervention period (February 2017–December 2019), our CLABSI rate was 0.63/1000 central line days, and maintenance bundle compliance improved to 97.1% (monthly range 86%–100%, p&lt;0.001). Of the 45 family surveys distributed, 20 (44%) were returned. Nineteen respondents (95%) reported being extremely satisfied with the key card programme and provided positive comments.</jats:p></jats:sec><jats:sec><jats:title>Conclusion</jats:title><jats:p>Combining the key card programme with K-card audits was associated with improved maintenance bundle compliance and a reduction in CLABSI. This programme has the potential for use in multiple healthcare improvement initiatives.</jats:p></jats:sec>

Sustaining quality improvement efforts: emerging principles and practice

“…A recent study showed that involving a Patient and Family Advisory Board led to a completely different shape of random audits and involving families more actively in central line maintenance by helping them understand the safety practices aimed at preventing harm, resulted in sustained CLABSI reductions and a 97% compliance rate even 2 years following the intervention. 25 The table shows Patients with implanted cardiac devices (such as pacemakers) requested a 'one stop shop' for MRIs where devices could be reprogrammed and scans acquired at a single location and visit. This led to a complete service redesign that increased throughput to 20 times the national average in England, a wait time reduction from 60 to 15 days, and results that were sustained for 2 years.…”

“…Patients and caregivers then served as 'extended memory' that shared responsibility for ongoing central line maintenance and felt empowered to speak up. 25 (education & audits)…”

“…Methods to improve sustainability of common QI interventions, illustrated by published case examples The results were displayed on the unit-based kamishibai board in green or red, visible for staff and families in a central location, with failed bundle elements used as coaching opportunities in real-time. Families were also more actively involved to improve compliance (see below), leading to sustained CLABSI reductions and a 97% compliance rate even 2 years following the intervention 25. …”

We’re all in this together: how COVID-19 revealed the co-construction of mindful organising and organisational reliability

“…Patient personal support (eg, family, friends, personal caregiver) Unique insight into when a patient is "not right" or "a little off" in ways clinicians may miss and be signs of medical errors (eg, adverse drug events) or unexpected deterioration (eg, unresponsiveness to treatment) Leaders solicit and share family perspectives 21 Establish family-centred rounding and routines 13 Bedside coordinators to amplify patient voice 23 Localise PFACs to units and/or conditions 24 Boundary-spanning professionals (eg, chaplains, social workers) Elevate the social determinants and patient/ family voice regarding factors that could threaten patient safety Providing emotional and psychological support for the patient, family and team delivering care Leaders (publicly) recognise the value of chaplains and social workers to care quality and safety 20 Embed these professionals in routines (rounding) and roles (bedside coordinator, PFAC leader) that bridge patient and those delivering care [23][24][25] Create forums where they support direct care providers emotional and psychological needs (eg, processing trauma) 20 Created by the authors. PFAC, patient and family advisory committee.…”

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“…As an example, as part of an improvement initiative to reduce paediatric central line-associated bloodstream infections (CLABSI), families were given cards explaining the elements of the intervention bundle and what can be done to prevent CLABSI in their child. 5 Given their direct involvement in the project, patients and families were appropriately acknowledged as contributors to the study. 4.…”