title: The evolution of knowledge exchanges enabling successful practice change in two intensive care units.
abstract: BACKGROUND
  Many hospitals are unable to consistently implement evidence-based practices. For example, implementation of the central line bundle (CLB), known to prevent catheter-related bloodstream infections (CRBSIs), is often challenging. This problem is broadly characterized as "change implementation failure."
  
  
  OBJECTIVE
  The theoretical literature on organizational change has suggested that periodic top-down communications promoting tacit knowledge exchanges across professional subgroups may be effective for enabling learning and change in health care organizations. However, gaps remain in understanding the mechanisms by which top-down communications enable practice change at the unit level. Addressing these gaps could help identify evidence-based management strategies for successful practice change at the unit level. Our study sought to address this gap.
  
  
  METHODS
  A prospective study was conducted in two intensive care units within an academic health center. Both units had low baseline adherence to CLB and higher-than-expected CRBSIs. Periodic top-down quality improvement communications were conducted over a 52-week period to promote CLB implementation in both units. Simultaneously, the study examined (a) the content and frequency of communication related to CLB through weekly "communication logs" completed by unit physicians, nurses, and managers and (b) unit outcomes, that is, CLB adherence rates through weekly chart reviews.
  
  
  RESULTS
  Both units experienced substantially improved outcomes, including increased adherence to CLB and statistically significant (sustained) declines in both CRBSIs and catheter days (i.e., central line use). Concurrently, both units indicated a statistically significant increase in "proactive" communications-that is, communications intended to reduce infection risk-between physicians and nurses over time. Further analysis revealed that, during the early phase of the study, "champions" emerged within each unit to initiate process improvements.
  
  
  CONCLUSIONS
  The study helps identify evidence-based management strategies for successful practice change at the unit level. For example, it underscores the importance of (a) screening each unit for change champions and (b) enabling champions to emerge from within the unit to foster change implementation.
authors.affiliation: Pavani Rangachari, PhD, is Associate Professor and MPH Program Director, Department of Health Management and Informatics, Georgia Regents University, Augusta. E-mail: prangachari@gru.edu. Michael Madaio, MD, is Professor of Medicine and Chair, Department of Medicine, Medical College of Georgia, Georgia Regents University, Augusta. E-mail: mmadaio@gru.edu. R. Karl Rethemeyer, PhD, is Associate Dean and Chair, Department of Public Administration and Policy, Rockefeller College of Public Affairs and Policy, University at Albany, State University of New York. E-mail: kretheme@albany.edu. Peggy Wagner, PhD, is Clinical Professor and Director, Institute for Advancement of Healthcare, School of Medicine-Greenville, University of South Carolina. E-mail: pwagner@ghs.org. Lauren Hall, MPH, is Graduate Research Assistant, Department of Health Management and Informatics, Georgia Regents University, Augusta. E-mail: lauhall@gru.edu. Siddharth Roy, MPH, is Graduate Research Assistant, Department of Health Management and Informatics, Georgia Regents University, Augusta. E-mail: s.roy5@gmail.com. Peter Rissing, MD, is Professor of Medicine and Section Chief (Infectious Diseases), Department of Medicine, Medical College of Georgia, Georgia Regents University, Augusta. E-mail: prissing@gru.edu.
authors.forename: Pavani
authors.initials: P
authors.lastname: Rangachari
authors.forename: Michael
authors.initials: M
authors.lastname: Madaio
authors.forename: R Karl
authors.initials: RK
authors.lastname: Rethemeyer
authors.forename: Peggy
authors.initials: P
authors.lastname: Wagner
authors.forename: Lauren
authors.initials: L
authors.lastname: Hall
authors.forename: Siddharth
authors.initials: S
authors.lastname: Roy
authors.forename: Peter
authors.initials: P
authors.lastname: Rissing
mesh_terms: D055499:Catheter-Related Infections / Q000517:prevention & control; D003142:Communication; D055317:Evidence-Based Practice / Q000458:organization & administration; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration*; D058436:Knowledge Management; D009936:Organizational Innovation; D011446:Prospective Studies