The Doctor’s Advocate | Third Quarter 2014
An Ounce of Prevention

A Team Approach to Reducing Risk

Paul Bauer, MD, Children’s Mercy Hospital, Assistant Professor of Pediatrics, University of Missouri- Kansas City School of Medicine, and Tara Benton, MD, MSCI, Children’s Mercy Hospital, Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine

Physicians can and should routinely engage in quality and safety work to reduce risk and the possibility of harm to patients. Over the past decade, The Doctors Company has promoted many safety and quality initiatives by organizations such as the Institute for Healthcare Improvement and the Agency for Healthcare Research and Quality.

These projects include reducing prescribing errors through medication reconciliation, improving asthma maintenance care, reducing surgical site infections, deploying rapid response teams for clinical deterioration, and reducing catheter-associated bloodstream infections (CA-BSIs). Improvements in these areas can be invaluable for patients and for hospitals and larger health networks.

This kind of commitment to risk prevention goes beyond clinical work; it requires engaging with multiple aspects of the healthcare system. Reducing risk in CA-BSIs, for example, required physician involvement beyond placing the line and ordering/delivering medications. In our pediatric ICU (PICU) over the last year, our team at Children’s Mercy Hospital has worked to decrease central line entries and reduce CA-BSIs by implementing a rounding checklist as part of a multi-institutional collaborative effort by the Children’s Hospital Association.1

A systems engineering approach has been invaluable in planning new quality improvement initiatives.

As described by the Systems Engineering Initiative for Patient Safety,2 the five components of a system include (1) people who accomplish (2) tasks using (3) tools and technologies within (4) an environment supported by (5) a larger organizational structure. To understand CA-BSIs in this context, aiming to reduce risk by reducing line entries means that we consider these elements within our own system.

We formed a multidisciplinary team to design and implement an intervention that would reduce central line entries.

Systems Components Our Microsystem—The Pediatric ICU
People Nurse, physician, pharmacist, residents, care assistants
Tasks Rounding review and decision making, daily record of line entries, daily checklist collection and review, day-night nurse handoffs, infection control
Tools/Technologies Paper checklist, checklist utilization database, electronic line utilization report
Environment Patient room, rounding checklist storage, records storage
Organization Quality physician and nurse leaders within the PICU and hospital-wide, pharmacy leaders, infection control

In addition to focusing on the systems engineering concepts described above, we used a variety of quality improvement tools and methodologies to guide our project. We created a diagram to illustrate the factors that influence the decision to enter a central line. We also created a charter to structure the strategic aim of the project, and we outlined the outcome, process, and balancing measures that we would use to monitor our progress.

Working with our information systems colleagues, we leveraged the electronic medical record to gather baseline central line entry data to collect comparative information before and after our intervention. We engaged key stakeholders, including hospital administration and PICU leadership, for further project support.

Using the above methods, we developed a daily checklist that is completed by nursing and discussed by the rounding team. This checklist focuses on the reasons why a line was entered, the number of days it has been present, and any factors putting the patient at greater risk for infection, such as mechanical obstruction and subsequent tissue plasminogen activator (TPA) administration. The rounding teams were instructed to discuss the necessity of the line daily and whether any reductions in line entries could be made.

Planning has been vital to the project’s success. In addition to surveying the landscape of work using the methods described above, we also anticipated educating a large multispecialty PICU. Education occurred on multiple levels and in different formats. Through several unit-wide nursing update meetings, we demonstrated the process and articulated our goals. We hosted several announcements for the physicians during staff meetings. We held personal meetings with pharmacists and nurse managers. Although the rollout phase of the education has finished, we continue to provide nursing and physician staff with monthly updates by e-mail and in person. Checklist compliance has seen a steady rise over the last two months.

So far, the work has prompted a new level of engagement with colleagues in nursing, pharmacy, and infection control. It has taken longer than we anticipated and has uncovered assumptions we never knew we made about each other’s work within our own unit. It has engaged a new level of teamwork within the PICU and the hospital, changed expectations about what is possible, and engaged front-line nursing and physician staff in the details of a process not routinely evaluated.

The clinical team has been encouraged by back-to-back decreases in the CA-BSI rate over the last two years. Although specific data cannot be shared because of our agreements with other research collaboratives, the average CA-BSI rate has been cut in half since the rounding checklist was implemented.

Catheter-associated bloodstream infections affect the patient, the clinicians who treat the patient, and the healthcare system. Accomplishing a successful and sustainable improvement in any patient outcome requires routine work. It is an effort that benefits from the energetic involvement of physicians and a clinical team willing to assess and eliminate the identified risk. The results, both measurable and intangible, have been tremendously beneficial for our patients and immensely rewarding for everyone on our team.


  1. Carayon P, Schoofs Hundt A, Karsh BT, et al. Work system design for patient safety: the SEIPS model. Qual Saf Health Care. 2006 Dec;15 Suppl 1:i50-8.
  2. Miller MR, Niedner MF, Huskins WC, et al. Reducing PICU central line–associated bloodstream infections: 3-year results. Pediatrics. 2011 Nov;128(5):e1077-83.

The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.

The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.

The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

The Doctor’s Advocate is published quarterly by Corporate Communications, The Doctors Company. Letters and articles, to be edited and published at the editor’s discretion, are welcome. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of The Doctors Company. Please sign your letters, and address them to the editor.

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