Four Seasons Project: Continuous Training and Lessons Learned in a Brazilian Hospital

FOUR SEASONS PROJECT –

CONTINUOUS TRAINING AND LESSONS LEARNED IN A BRAZILIAN HOSPITAL

Cláudia Cândido da Luz. RN Nurse. Coordinator of the Infusional Therapy Team (TTI) Hospital Israelita Albert Einstein. Jorge Luis Saraiva dos Santos. RN Nurse. Member of the Infusional Therapy Team (TTI) Hospital Israelita Albert Einstein. Claudia Regina Laselva. RN Nurse. MsC. Director of Hospital Israelita Albert Einstein. Alexandra do Rosario Toniolo. RN Nurse. MsC. Specialist in hospital infection control of Hospital Israelita Albert Einstein. Ellen Cristina Bergamasco. RN Nurse. MSC. PhD. Professor in Faculdade Israelita de Ciências da Saúde Albert Einstein.

One of the biggest challenges for the prevention of infections related to health care is keeping the multidisciplinary care team continuously trained. Many studies have reported difficulties in keeping staff engaged in infection control measures, including measures to prevent Central LineAssociated Bloodstream Infection (CLABSI). The U.S. Centers for Disease Control and Prevention (CDC) suggests that instituted training programs should be continuous and systematic; although the guidance is clear, it is increasingly difficult to put it into practice.

In hospital services, training is related to new protocols, new products, admission training for new employees, training related to adverse events, or periodic training; in general they are led by a specific area that works with the development of professionals. Hospitals with large number of beds and, consequently healthcare professionals, have specific sectors for development of employees and typically organize training by teams, making it difficult to look at the specific care with central catheter and CLABSI-prevention measures.

At the Hospital Israelita Albert Einstein, located in the city of São Paulo (Brazil), 682 beds are available. The training is organized by a corporate team that inserts into its annual timeline activities related to the prevention of bloodstream infection. The historical rate of Central Line-Associated Bloodstream Infection (CLABSI) was approximately 1.4 percent per month until 2011. Team (TTI). It consists of nurses, who are responsible for the insertion and maintenance of peripherally inserted central catheters. The nurses also responsible for improving the success rates in peripheral punctures, reducing the incidence of chemical phlebitis, reducing pain related to peripheral puncture, ensuring early removal central venous catheters, and acting to reduce bloodstream infection rates related to intravascular devices.

In addition to the professional development of the TTI members, the institution proposed the creation of care protocols and monitoring of patients with implanted catheters. During their activities, TTI realized the need for specific training on the care of implanted catheters, which would happen continuously and systematically. TTI found that training should be extended to the entire multidisciplinary team assisting patients, which included approximately 4,000 professionals, including: physicians, nurses, physiotherapists, and psychologists and, among others. This is how the 4 Seasons Project was created.

The construction of the 4 Seasons Project was based on the premise that continuous training can improve patient safety by providing quality care andreducing CLABSI. The project was named 4 Seasons because the training occurred quarterly with the seasons (Spring, Summer, Fall and Winter).

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The training programs invariably use playful strategies. Some of the training occurred in the inpatient and patient care units, where healthcare professionals are most frequently stationed. But the training also occurred in unusual settings like the cafeteria, auditorium, hallways, elevator hall, and other locations around the hospital.

The main objectives of the 4 Seasons Project are to promote discussion of infection prevention initiatives and to reinforce hand hygiene in the maintenance of the venous catheter. A goal was to initiate changes in attitudes and behaviors of healthcare professionals regarding the care provided. Although the central focus is the multiprofessional team, the actions seek to involve patients, caregivers, and family members as it is believed that self-care should be encouraged to aid in prevent infection.

In the eight years of the project, many strategies have already been used, such as a “card game championship,” “button soccer game,” “sticker album,” “memory game,” “trial-simulated jury,” among others (Figure 1); all strategies, with no exception, replace the rules and guidelines of the original activities with information related to hand hygiene and infection prevention.

The strategies last for three months, and they choose a specific theme, for example “Everyone in action, zero infection.” At the end of each season, all healthcare professionals of the institution are invited to a celebration of the results obtained and the completion of another stage of the training. In addition to playful strategies, the 4 Seasons Project seeks to certify professionals in good practices in handling catheters. Hand hygiene, disinfection of connectors, and flushing with swirling, and positive pressure are important pillars within this certification. Certified professionals receive the Golden Seal to be attached to their identification badge (Figure 2). Annually, 98 percent of nursing professionals are validated (approximately 2,300 people). In order to encourage nursing staff to continue adherence to good practices, professionals with the best care performance are identified in each area. These individuals then participate in a high-fidelity clinical simulation scenario with a case related to the topics discussed during the year. After participation, the winners are recognized prominently in the institution’s digital media and are awarded trophies and prize vouchers.

The training results showed an 81.8 percent reduction in the historical rate of CLABSI, in which we have an average in 2019 of 0.24 per 1,000 central line-days and at times reaching 0 per 1,000 central line-days. It was observed that the reduction in CLABSI directly impacted the reduction of hospital bed turnover time because it was noticed that patients with catheters implanted and monitored by TTI are discharged early since they do not have infections.

In addition to reducing the infection rate and turning the bed, it was realized that the 4 Seasons Project is sustainable and ensures the continuity of training, which results in a change of behavior and improves the provision of patient care.

In 2020, despite all the adaptations and impacts caused by the pandemic, TTI remained active and performed the insertion and monitoring of patients with implanted catheters, in addition to the training of Project 4 Seasons.

Corresponding Author: Ellen Cristina Bergamasco. RN Nurse. PhD. Professor in Faculdade Israelita de Ciências da Saúde Albert Einstein. Address: Rua Antonio Júlio dos Santos, 201, bloco 5 apto 11. Fazenda Morumbi. São Paulo – São Paulo. Brazil. E-mail: ellen.bergamasco@einstein.br E-mail: ellenbergamasco@gmail.com Fone: +5511982492219 All authors should have made substantial contributions to all of the following: (1) The conception and design of the study, or acquisition of data, or analysis and interpretation of data - Claudia Cândido Luz and Jorge Luis Saraiva dos Santos (2) Drafting the article or revising it critically for important intellectual content - Claudia Cândido Luz, Jorge Luis Saraiva dos Santos, Claudia Regina Laselva, Alexandra do Rosario Toniolo and Ellen Cristina Bergamasco