Background and Problem Statement: Preventable harm events such as central line blood stream infections (CLABSI) and hospital acquired pressure injuries (HAPI) are avoidable complications of hospitalization. Both increase morbidity, mortality, length of stay, and cost. Adherence to prevention bundles has been proven to effectively decrease rates of preventable harm. Yet, critically ill patients are at increased risk for harm and may require additional and focused prevention efforts. In 2020, the Heart Institute (HI) including both the Cardiac Intensive Care Unit (CICU and Cardiac Progressive Care Unit (CPCU) at Children’s Hospital Colorado experienced an acute increase in CLABSI and HAPI rates, 39% and 49% respectively. This occurred in the setting of stably high prevention bundle compliance rates.

AIMS:
PRIMARY: Reduction in preventable harm rates in the Heart Institute, specifically, a 10% reduction in CLABSI rate and 25% reduction in HAPI rate by the end of 2021. 
SECONDARY: Establishment of a high-risk rounding (HRR) process for CLABSI and HAPI with in the Heart Institute by end of 2020.

Key Drivers and Interventions: First the formation of multidisciplinary taskforces for CLABSI and HAPI for the development of unit and harm specific High-Risk Rounding (HRR) format. With HRR defined as: a multidisciplinary proactive coaching session targeted at patients determined to be high-risk for developing CLABSI or HAPI with in HI. Teams include content experts, unit leaders, and frontline clinicians who assess barriers to prevention bundle compliance and assist in real time mitigation strategies. The HRR teams provide “just in time” coaching and hands on assistance by role-modeling correct prevention strategies such as central line sterile dressing changes or application of a skin barrier. The pilot HRR Program launched in late 2020 in the CICU. With expansion to the CPCU at the beginning of 2021. 

Results: The primary aims of a 10% of 25% reduction were achieved. With a 20% decrease for CLABSI in the CICU and a 100% decrease on the acute care floor. For HAPI a 75% reduction seen in the ICU and 76% change seen on the acute care floor. Process measure goals were also achieved. Twelve months after the implementation of HRR, the CICU CLABSI and HAPI rates have decreased and CPCU CLABSI rate have decreased. The combined cost of preventable harm has decreased from about $920,000 to $570,00 this is a total savings of $350,000.

Challenges and Barriers: Heart Institute census and acuity, in 2021 we saw a 400% increase in patient volumes in the CICU and CPCU. Limited availability of beside team members to have non-direct time to devote to QI work. Lack of night team member availability to complete HRR on night shift. 

Lessons Learned: The time devoted to in the moment high-risk rounding saves time, is low-cost, and most importantly improves patient outcomes. HRR has been integrated well into the unit culture, with nurses expressing appreciation with a conversation on prevention strategies versus an audit (critique) on their practice. 

Next steps: Secondary data analysis to evaluate patient selection criteria. Focus on sustainability, and expansion to additional types of preventable harm such as SSI and medication safety.