The Saving Lives and 100,000 Lives programmes: Good news for critical care nurses
Article Outline
The subject of healthcare associated infections continues to grab the headlines, costing the National Health Service (NHS) in the United Kingdom approximately £1
billion each year, an amount equivalent to the annual running costs of eight hospitals (Department of Health, 2005). In response to this growing problem, we have recently seen the launch of two ambitious programmes to reduce healthcare associated infections, one in the United States of America (USA) and one in the United Kingdom (UK). The UK programme is called Saving Lives (Department of Health, 2005) and the USA programme is known as 100,000 Lives. Both programmes are of particular relevance and interest to intensive care nurses as two of the main elements common to both programmes are the reduction of ventilator associated pneumonias and catheter related blood stream infections from central venous catheters. These are two of the most common infections affecting patients on ICU, leading to increased mortality, morbidity, length of stay and costs (Warren et al., 2003). What will also be of interest to critical care nurses is that both Saving Lives and 100,000 Lives use a care bundles approach. The care bundles approach is one that is already familiar to many UK nurses working in ICU, where the ventilator care bundle, and the more recent sepsis care bundles are being used to improve patient care (Crunden et al., 2005, Fulbrook and Mooney, 2003, Robson, 2004).
100,000 Lives Campaign
The 100,000 Lives Campaign is lead by the Institute for Health Improvement (IHI) (2004) in the USA, and aims to prevent 100,000 avoidable deaths in American hospitals by promoting the adoption of six evidence-based interventions. The six interventions are as follows:
The campaign was launched in December 2004 and is set to end on June 14, 2006.
The IHI website has comprehensive ‘How-to Guides’ for each of the interventions, available for download from their website. The ‘how to guide’ for preventing central line infections promotes a central line bundle with five elements, and encourages hospitals to empower nurses to enforce the bundle through the use of a central line checklist, which is completed at every insertion. This idea is based on the results of a study by Berenholtz et al. (2004) which found that the use of an insertion checklist to monitor adherence to evidence-based guidelines, and empowering nurses to stop the catheter insertion if the guidelines were not followed, nearly eliminated catheter related blood stream infections from a surgical ICU. It is questionable if this approach of empowering nurses to stop central line insertions would receive full support in the UK, as medicine still appears to be the dominant group within the ICU team (Coombs, 2003), and many nurses may feel uncomfortable stopping a line insertion if doctors did not adhere to the guidelines. Some may argue that it might be seen as aggressive and confrontational, and may result in doctors feeling nurses are trying to ‘catch them out’. However, such an approach is certainly in keeping with the current mood in the UK, which encourages nurses to regain control of cleanliness and asepsis, challenging colleagues from all disciplines who do not wash their hands. I think the insertion checklist could be very effective, but must be employed and enforced sensitively, using a proactive approach of offering caps, masks, large drapes and 2% chlorhexidine, rather than waiting to see if the doctor is going to ask for them. The IHI has already done much to influence nursing care in the UK by promoting the use of the ventilator care bundle, and the more recent sepsis bundles as a part of the surviving sepsis campaign. A central line bundle that uses some form of the insertion checklist could be equally as effective.
Saving Lives
The Saving Lives programme is very similar in some respects to the earlier USA 100,000 Lives programme. It is a delivery programme which aims to reduce healthcare associated infections, including MRSA. The programme concentrates on five clinical interventions that could make the biggest impact on reducing infections. The five interventions, which are called high impact interventions, are as follows:
High impact intervention 1 centres on good hand washing and underpins all the other interventions. It is good to see urinary catheters included, as these are responsible for the largest group of healthcare associated infections, but may not always be as readily associated with ICU patients as infections from ventilators or central venous catheters. Marklew (2004) argues that the importance of urinary catheter care is sometimes overlooked in ICU.
The Saving Lives Campaign also promotes the care bundle approach, but unlike the 100,000 Lives Campaign, it does not set specific aims for the reduction of infections. For example, the care of ventilated patient intervention merely states the aim as being “To reduce the incidence of ventilator associated infection”, it does not say by how much or in what time frame. Before hospitals in the UK can set more time-specific and measurable targets for the reduction of these infections, maybe we need to first start to routinely record how many ventilator associated pneumonias and catheter related blood stream infections from central venous lines we actually get, and we need to do this in a standard form such as per 1000 catheter days as recommended by the Centres for Disease Control (CDC) in the USA.
It is staggering that many hospitals in the UK appear not to collect this data routinely already. With increased patient choice in the future, data on such infection rates may be the kind of information that patients will want to know before they choose a hospital for elective surgery that may carry a risk of needing ICU care.
Putting it into practice and making it work
The Saving Lives programme does not appear to be too prescriptive about how compliance with the various bundles will be audited, and there is no reason why some elements of the 100,000 Lives Campaign bundles should not be adapted and combined with Saving Lives.
For example, one simple element from 100,000 Lives central line bundle, that could be added to Saving Lives, is asking if the central line can be removed on a daily basis. This daily review of line necessity was part of the intervention package used in the Berenholtz et al. (2004) study that almost eliminated infections from a surgical ICU. This reminder approach has also been successfully used with urinary catheters. In a USA study (Saint et al., 2005), nurses attached reminders for doctors, to patients’ charts who had a urinary catheter in place for more than 48h. This reminded the doctor to consider if the catheter could be removed. The average time patients remained catheterised fell by 7.6% where reminders were issued. Such approaches, like check lists and care bundles may be seen by some as too prescriptive, taking away individual decision making. However, even where we have evidence-based guidelines available, not everyone will apply them, and considerable variation in clinical practice can exist (Morris, 2001). For example, evidence exists that nursing patients in a semi recumbent position 30–45° reduces the incidence of ventilator associated pneumonia (Drakulovic et al., 1999), but despite such research being available, nurses and doctors do not always act upon it with average head of bed angles reported as 22.9°, or 19.2° in studies carried out before the widespread adoption of a ventilator care bundle (Grap et al., 1999, Grap et al., 2003). Vincent (2005) argues that checklists are used widely outside of hospitals, and that the highly technical and rapidly changing environment of the ICU can be compared to the aviation cockpit, a place where checklists are accepted as a routine part of ensuring safety.
Both the Saving Lives and 100,000 Lives programmes are good news for patients, helping to reduce their chances of acquiring a healthcare associated infection. They are also good for critical care nurses, endorsing and promoting work that many of us had already begun with the use of the ventilator care bundle. However, we will need appropriate resources to successfully implement them. Who will audit compliance with the bundles of care for each high impact intervention? Nurses working clinically on the shop floor are often already too busy delivering direct care to audit compliance. Saving Lives must be fully supported with clerical and audit staff to measure and report compliance. We should all read and publicise both campaigns and embrace them as a chance to make a real difference to the vulnerable patients we care for.
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PII: S0964-3397(05)00128-X
doi:10.1016/j.iccn.2005.09.006
© 2005 Elsevier Ltd. All rights reserved.
