Details of the PDSA cycles in the study
| PDSA cycle | Change idea tested | PLAN | DO | STUDY | ACT |
| PDSA cycle 1 in phase II for 3 days | Improving the knowledge of NICU staff regarding CLABSI bundles of NICU staff using a handout in local language which is easily readable | QI team decided to develop and test the ease of use of the CLABSI bundle handout translated in local language (Hindi) | The CLABSI bundle was translated into Hindi (online supplemental figure 3). The QI team members deliberated on the readability and content of the handout in Hindi. Feedback was obtained | Translation in Hindi and obtaining feedback from NICU staff was feasible. However, all of them gave a feedback that Hindi handout was difficult to read and understand as compared with the English handout. September 2018 Mean compliance to insertion bundle: 100% Maintenance bundle: 0% LONS rate: 8.3/1000 patient-days | Hindi handout was discarded and the NICU staff decided to continue using the English handouts. FINAL ACTION: ABANDONED |
| PDSA cycle 2 in phase II for 7 days | To organise focused group discussions for enhancing the knowledge regarding CLABSI bundles among NICU staff | QI team members decided to conduct focused group discussions on CLABSI Bundle and central line care with NICU staff in morning and evening shifts for 7 days (14 sessions) | Handouts of the CLABSI bundle in English were given to all the staff nurses in morning and evening shifts and focused group discussions (FGDs) were conducted by a designated QI team member. | Organising FGDs was partially feasible and difficult to conduct in all morning and evening shifts. Only 3 sessions out of 14 planned were held. The average session length was 20 min. 15/25 staff nurses attended the FGDs. The staff nurses found it difficult to attend the FGDs due to heavy workload in the NICU and difficulty in assembling at one place for a duration of 20 min in each shift | This change idea was adapted to PDSA 3 with an aim to improve the staff attendance and increase the frequency of FGDs. FINAL ACTION: ADAPTED |
| PDSA cycle 3 in phase II for 11 days | Formation of a mobile phone application–based group to increase the number of FGDs conducted to sensitise staff to CLABSI bundle and improve the staff participation | Creation of a WhatsApp group of the QI team and nurses of NICU. This was started by the QI team leader and it was planned to create awareness regarding CLABSI bundle on this group | After creating the group, study material relevant to the topic were shared in the group as per the plan. During the 11 days, 7 virtual FGDs were held on the CLABSI bundles and prevention of LONS and CLABSIs | To study the effectiveness of WhatsApp group–based FGDs, a subject-based questionnaire using SurveyMonkey application was sent to the NICU team on mobile phone before starting FGDs and 7 days after formation of the group. There was an increase in the proportion of correct responses from a baseline of 49% to 90% (online supplemental figure 4a,b) October 2018 Compliance to insertion bundle: 67% Maintenance bundle: 0% LONS rate: 6.5/1000 patient-days | The change idea was adopted as it was feasible, improved participation (all 25 NICU staff participated and 24 took part in the assessments) and led to an objective increase in knowledge of NICU staff to CLABSI bundles. Virtual FGDs were now conducted regularly on a weekly basis. FINAL ACTION: ADOPTED |
| PDSA cycle 4 in phase II for 6 days | To introduce novelty in the discussions and sustain participation of the NICU staff on the WhatsApp group to maintain and sustain interest in staff regarding the concepts of central line care by use of an educational video game | The team leader used a video game on the prevention of hospital-acquired infections with the help of a link from Institute of Healthcare Improvement website (www.ihi.org). This game was disseminated to staff nurses on the WhatsApp group for 6 days. The group members were requested to participate in all the modules of the game and provide feedback. It was felt that introduction of this video game would improve participation and create novelty in the contents of the FGDs | Conducted as per plan | A feedback using the SurveyMonkey application was obtained regarding the feasibility and usefulness of the game. Only 5 out of 25 (20%) nurses were able to complete the game. The major reasons for non-completion were poor internet connectivity and length of the game | The QI team discussed that the video game would need to be adapted by editing its length (reducing number of modules) and re-testing the participation rates and its applicability by the NICU staff. FINAL ACTION: ADAPTED |
| PDSA cycle 5 in phase II for 5 days | To make the educational video game simple to play, easy to load on their phones and easy to use by reducing the length of the video game | The game was shortened by the QI team to 2 modules. The QI team felt that reduction in number of modules would make it easier to load on their phones even with low bandwidth internet connectivity. This would facilitate more staff to participate in the game and remain a part of the virtual FGD sessions | The game was recreated with 2 modules as planned. It was posted on the WhatsApp group for next 5 days. The participants were encouraged to enrol and complete the video game. Feedback was obtained from the staff nurses regarding the ease of use and participation | Feedback regarding the shortened video game was obtained regarding ease of use and participation by SurveyMonkey application. Responses increased from 5/25 (20%) to 18/25 staff nurses (72%). All respondents felt that the video game was easier to use, improved their awareness regarding healthcare infections, created empathy to needs of NICU patients and made them strive for patient safety | The improvement in response and participation as well as the behaviour change noted enabled this idea to be adopted. It was decided by the QI team that this modified video game will now be routinely shared with all the newly posted staff nurses and residents in the NICU. FINAL ACTION: ADOPTED |
| PDSA cycle 6 in phase II for 14 days | It was noted that although insertion bundle compliance was above 80% in the study until now, the maintenance bundle compliance was consistently low (between 30% and 40%). In order to reinforce the components of maintenance bundle in an effective manner to the NICU staff, preparing and showing a video on maintaining asepsis during intravenous fluid/medication administration through central line was considered | It was planned by the QI team to shoot a short 3 min video on maintaining asepsis during intravenous fluid administration through central lines and show it to all the NICU staff. It was felt that the video would address components of the CLABSI maintenance bundle | With the help of residents and staff nurses from QI team, a 3 min video was shot by team leader on administration of medications and intravenous fluids in an aseptic manner through the central lines. It was shown in 3 different group viewing sessions over 2 weeks consisting of 6 staff nurses in each session Feedback was obtained from the 18 staff who attended the viewing session regarding the usefulness of the video and its accuracy in showing the correct procedure | Feedback was obtained in FGDs on the WhatsApp group. Some minor errors and lack of contextual specificity in the video were noted by the QI team in feedback from NICU staff who viewed the video November 2018 Insertion bundle compliance: 100% Maintenance bundle compliance: 20% LONS rate: 5.8/1000 patient-days | As per the feedback obtained, the video was planned to be reshot to address the concerns raised in the feedback. FINAL ACTION: ADAPTED |
| PDSA cycle 7 in phase II for 15 days | To reshoot and create an educational video of 3 min duration incorporating the suggestions from the NICU staff as per the observations during PDSA 6 | The QI team discussed the method to re-shoot and create an educational video of 3 min considering the suggestions by the NICU staff who had viewed the video in PDSA 6 | The suggestions as obtained in PDSA 6 were enlisted and incorporated into a video which was re shot by the team. 3 group viewing sessions for the NICU staff were organised. The video was also posted in the WhatsApp group | A positive feedback was obtained in the FGD. The team observed that the reshot video was accurate and contextually valid. They felt this could serve as a powerful educational aid | It was decided by the QI team to organise need-based group viewing sessions periodically for NICU staff and newly posted nurses and doctors. FINAL ACTION: ADOPTED |
| PDSA cycle 8 in phase II for 5 days | As awareness regarding central line care increased in the unit, the team realised that there was a mismatch between the demand and the supply of consumables (sterile gowns) required for sterile central line insertion. The QI team felt that an optimised demand vs supply prediction mechanism was needed to be developed in the NICU | It was decided that one member of the QI team with the help of the nursing in charge of NICU store, would note the daily requirement of sterile gowns in the NICU over the next 2 days and ensure the availability of requisite number of gowns based on the observations thereof. The team felt that this would prevent stock-outs of sterile gowns. The observations were continued over the next 3 days as well | The QI team leader and the nursing in charge of NICU store checked the stock as planned and observed that a total of 10 gowns were required each day. Based on these observations, the nursing in charge of NICU store ensured availability of at least 10 sterile gowns each day. The PDSA was conducted as planned | The QI team met and reviewed the optimised demand vs supply mechanism and concluded that it was feasible in the current setup and was successful in preventing sterile gown stock outs in the NICU December 2018 Insertion bundle compliance: 100% Maintenance bundle compliance: 40% LONS rate: 5.5/1000 patient-days | It was noted by the team that this PDSA cycle ensured adequate supply of sterile gowns and no problems of shortage during procedures in the NICU. The team unanimously agreed to continue with this mechanism monthly and incorporate this as a unit standard operating process. FINAL ACTION: ADOPTED |
| PDSA cycle 9 in phase II for 6 days | 80 mm size central lines were in deficient supply leading to the NICU staff substituting 40 mm size central lines in their place. This led to frequent dislodgement and line handling exposing the newborns to risk of LONS and CLABSI. The QI team felt that an optimised demand vs supply prediction mechanism needed to be developed for 80/40 mm size central lines to prevent stock outs | The QI team, the resident doctors of NICU and the nursing in charge of NICU store decided to observe and note the requirement of central lines with the exact size required over next 3 days and indent the required number from the central store on a daily basis. The team felt that this would prevent stock outs of the correct size central lines (40/80 mm) | The PDSA was done as planned | It was noted over the next 3 days that every day at least 3 PICC lines of 80 mm were being used . The team decided to keep a stock of 4 PICC (80 mm) lines daily and keep the stock at all times at this level. January 2019 Insertion bundle compliance: 100% Maintenance bundle compliance: 20% LONS rate: 8.8/1000 patient-days | It was noted by the team that this PDSA cycle ensured adequate supply of 80 mm size central lines. The team unanimously agreed to continue with this mechanism with a monthly review and incorporate this as a unit standard operating process. FINAL ACTION: ADAPTED |
| PDSA cycle 10 In phase III for 6 months (at 6-weekly intervals) | The QI team noted that the compliance to central line maintenance bundles in the initial part of sustenance phase was suboptimal. It was decided to initiate weekly group discussions followed by an evaluation every 6 week regarding central line care for the NICU staff | It was planned by the QI team to use weekly group discussions with NICU staff nurses on WhatsApp as a method to reinforce the importance of the CLABSI bundle followed by an evaluation session conducted every 6 weeks (4 sessions) | Weekly group discussions, sharing of materials and reminders on the WhatsApp group was conducted by the QI team leader over the 6 months and evaluation sessions were conducted (online supplemental table 3) as planned. Compliance rates to maintenance bundle was monitored | There was an increase in average test scores from test 1 to test 4 with a 30% increment between test 4 and test 1. The compliance rate to maintenance bundle improved from mean of 23.3% in phase II to mean of 42.2% in phase III The team noted an improvement in the process and outcome indicators as mentioned below February 2019 (at the beginning of sustenance phase) Insertion bundle compliance: 100% Maintenance bundle compliance: 20% LONS rate: 7/1000 patient-days August 2019 (end of sustenance phase) Insertion bundle compliance: 100% Maintenance bundle compliance: 50% LONS rate: 6/1000 patient-days | This change idea worked successfully in reinforcing the knowledge. The idea was adopted. The QI team subsequently decided to share CLABSI bundle awareness materials and conduct tests periodically on an as-needed basis for the NICU staff especially those who were newly posted in the NICU FINAL ACTION: ADOPTED |
CLABSI, central line associated bloodstream infection; FGD, focused group discussion; LONS, late-onset neonatal sepsis; NICU, neonatal intensive care unit; PDSA, Plan-Do-Study-Act.