Post on 10-Feb-2022
Select team, educate and collect feedback▪ hospital ‘buy in’ sought and approved▪ CLAB team identified▪ instigate weekly/fortnightly meetings
Gather information▪ using resources from national groups to lower costs of implementation and save ‘re-inventing the wheel’▪ ghant chart developed▪ drapes/CVL pack
Evaluate current practice▪ identified CVL care of practice and blood culture collection▪ look at use of insertion and maintenance bundles▪ blood culture guidelines
Developed forms for WDHB▪ review national and regional pathways▪ review forms
Staff education▪ one to one▪ use of CVL pack▪ CLAB site on intranet▪ posters to identify key practice▪ flow charts for data collection▪ handover ‘hubs’▪ ward meetings▪ peer review
Commence use▪ bundles▪ pathways▪ insertion packs
Audit process reviewed▪ mini PDSA cycle▪ ongoing communication▪ daily rounding
Analyse▪ data collection▪ insertion and maintenance bundles perfect in CCU, OT and PACU first▪ wait to roll out to wards
Review▪ bundles and packs▪ blood cultures▪ data collection▪ education and communication▪ leads from other DHBs
Improve and implement▪ CLAB focus board for staff▪ CLAB free days sign▪ bundles formatted▪ surveillance and blood culture process▪ packs finalised
Support and commitment▪ keep momentum▪ indentify champions▪ involve ward CNC and educators▪ prepare for 2013 roll out▪ education▪ communication
PLAN
DO
STUDY
ACT
CLAB WDHB WhanganuiDistrict Health Board
What?Part of a national collaborative to provide baseline measuring of the extent of Central Line Associated Bacteraemia (CLAB) in NewZealand and provide a tool for measuring improvement
Central Line Associated Bacteraemia
Why? Zero incidence of CLAB will lower mortality, lessen associated costs and improve patient outcomes.
Hospital and Community
‘Barry’s’ storyConcern
How?
LessonsLearnt
POSITIVES▪ being a part of this new ‘national collaborative’▪ sharing ideas through the network▪ strengthening of relationships between ICU’s, particularly in our region▪ insertions were initially anaesthetist - quick acceptance. Now: physician, surgeon, Emergency Department SMO, PICC registered nurses▪ empowering our patients▪ utilising our own resources - packs and insertion kits▪ change of practice - the spin off is improved hand hygiene, blood culture collection and care of IV lines
FinalProduct
BUNDLES DATA COLLECTION DETECTION AND REPORTING
TheWDHBTeam
CCU CLAB Detection & reporting FLOWCHART
Central Line Inserted
Signs of Sepsis
Blood culture Taken
Microbiology contact CCU
MDT confirm CCU CLAB reportable event*
CCU review central line insertion
checklist & access simultaneous feedback data
CCU completes tally tool to
capture line days
Infection Control notify IHI of CLAB (Numerator*) &
tally data (denominator*)
CCU notify infection control
of tally data
IHI data feedback process
TheFuture
▪ Standardised bundles ▪ Involvement in other collaboratives ▪ Roll out to wards▪ Standardised practice ▪ Implement the hand hygiene ‘naked unit’ Clinical Lead
Dr Marco MeijerAnaesthetist
Project LeadJoanne VigenserCNC - CCU/ED
Patient Safety & QualityDeclan RogersCNS - Infection Prevention & Control
Public HealthBronwynne AndersonIV Advisor, HITH Coordinator
TheatreDiane McClellandCNS
PACULyndel WilsonCNS
WDHB CCU CLAB data collection process
No
Insertion basket collected for CL
insertion
Insertion checklist included in the
insertion basket
Insertion checklist form completed at the
time of insertion. Form stays in patient
notes
Maintenance checklist form is used for every
line day thereafter until discharge
Completed forms copied and placed in
CLAB box
Daily checklists showing compliance
for insertion and maintenance
CNC checks non-compliant forms for
errors
Highlighted to staff; corrected if verified
Data input every Monday for the
previous week if able
Weekly/monthly chart printed and displayed
on CLAB board
No
Yes
▪ Barry Arthur is a 52 year old married male with Burketts Lymphoma.▪ Portacath insertion in 2008.▪ Monthly infusions of Intragram-P.▪ November 2010 developed a CLAB whilst in hospital and nearly died.▪ Portacath was removed.▪ After his miraculous recovery, Barry and Amelia went on a three day cruise to celebrate.▪ Venous access was discussed again as Barry required monthly infusions over the next 14 months.▪ Barry made his decision to have a new port inserted based on research and discussion with different staff.▪ New portacath inserted January 2012. ▪ Major education for Barry to not allow staff to use port access, unless hands had been washed and they had “scrubbed the hub” for 15 seconds. Barry realises that this is his “lifeline” and comments that many staff had not always done this with his previous portacath access.
▪ Barry is an advocate for patients being proactive in preventing CLAB, he is a great example to all.
Final Version following further Regional Consultation 23rd July 2012 48hr rule added 11.10.12.
Temp >38ºC
Signs of sepsis: ↑HR, ↓SBP, Rigors
Suspicion of sepsis
Or Or
Collect 2 blood culture sets (4 bottles): 10mls of blood per bottle
Take one set at a time (Paediatric volumes will be different)
Take blood from: Preferred: 2 separate peripheral sites or NEW CV line
Difficult access: 1 peripheral line and 1 existing line
No peripheral access 2 samples from any existing line, only to be used in extreme circumstances – least preferred
The two blood sets should be taken within 48hrs of each other.
o Perform hand hygiene o After removing blood culture bottle lids, swab with alcohol, allow 20 seconds to dry o Disinfect skin, allow 60 seconds to dry o Take cultures before taking other blood samples (no discard required) o Fill Aerobic bottle first, then Anaerobic,repeat for second set. o 10 ml blood per bottle (adults) o Clearly label each culture bottle and form with site of origin o Repeat at next site
How
Where
When
What
Blood Culture Guidelines
We have preventedCentral Line Associated Bacteraemia
in all of our patients
for
310days
WhanganuiDistrict Health Board
SOLUTIONS
▪ identifying champions ▪ communication ▪ slowly but surely▪ education packages and ongoing support ▪ look at data collection improvement
BARRIERS▪ time constraints - part of own workload▪ keeping the momentum▪ staff apathy to process changes and more paperwork▪ focus on packs and drapes▪ roll out to wards: fear of losing control, an increase in paper work and compliance (all on the ‘to-do’ list)▪ no electronic data collection in DHB▪ staff unable to visualise ‘the big picture’
STAT No: ?? Date form created: 12/02/2013 Catalogue No: ???? Review Date: 12/02/2015
MA
INTE
NA
NC
E B
UN
DLE
CLA
B
Patient Label Surname: NHI: First Names: Ward: Address: DOB: ACC No: GP: Consultant:
Please photocopy form and place in CLAB box when complete.
Ward/Unit: Line Day: Yes No Today’s Date: Yes No Time removed: Was Central Line reviewed
for necessity today? Was Central line removed today?
Is IVN/TPN being infused? If Yes, is dedicated port being used for IVN/TPN?
Did you check the site today for inflammation?
If any signs of infection present review the catheter promptly
High Risk Patient – Is there a prevention measure in place? e.g. Chlorhexidine Impregnated Dressing
Not a high risk patient
AM Shift 8hr Before accessing injection ports did you clean with 2% CHG in 70% alcohol each time?
Not accessed
PM Shift 8hr Before accessing injection ports did you clean with 2% CHG in 70% alcohol each time?
Not accessed
Night Shift
8hr Before accessing injection ports did you clean with 2% CHG in 70% alcohol each time?
Not accessed
Comments: Date/time transfer to another department:
Ward/Unit: Line Day: Yes No Today’s Date: Yes No Time removed: Was Central Line reviewed
for necessity today? Was Central line removed today?
Is IVN/TPN being infused? If Yes, is dedicated port being used for IVN/TPN?
Did you check the site today for inflammation?
If any signs of infection present review the catheter promptly
High Risk Patient – Is there a prevention measure in place? e.g. Chlorhexidine Impregnated Dressing
Not a high risk patient
AM Shift 8hr Before accessing injection ports did you clean with 2% CHG in 70% alcohol each time?
Not accessed
PM Shift 8hr Before accessing injection ports did you clean with 2% CHG in 70% alcohol each time?
Not accessed
Night Shift
8hr Before accessing injection ports did you clean with 2% CHG in 70% alcohol each time?
Not accessed
Comments: Date/time transfer to another department:
Ward/Unit: Line Day: Yes No Today’s Date: Yes No Time removed: Was Central Line reviewed
for necessity today? Was Central line removed today?
Is IVN/TPN being infused? If Yes, is dedicated port being used for IVN/TPN?
Did you check the site today for inflammation?
If any signs of infection present review the catheter promptly
High Risk Patient – Is there a prevention measure in place? e.g. Chlorhexidine Impregnated Dressing
Not a high risk patient
AM Shift 8hr Before accessing injection ports did you clean with 2% CHG in 70% alcohol each time?
Not accessed
PM Shift 8hr Before accessing injection ports did you clean with 2% CHG in 70% alcohol each time?
Not accessed
Night Shift
8hr Before accessing injection ports did you clean with 2% CHG in 70% alcohol each time?
Not accessed
Comments: Date/time transfer to another department:
STAT No: ## Date form created: 12/02/2013 Catalogue No: ## Review Date: 12/02/2015
INSE
RTI
ON
BU
ND
LE
Patient Label Surname: NHI: First Names: Ward: Address: DOB: ACC No: GP: Consultant:
Please photocopy form and place in CLAB box when complete.
PLEASE COMPLETE FOR ALL CENTRAL LINE INSERTIONS ON ALL PATIENTS
Where was the line inserted?
CCU
Radiology
Theatre
SCBU
Other DHB
Other: _______________
Insertion site:
Right Left
Subclavian Jugular
Basilic Cephalic
Femoral Saphenous
UAC UVC
Other: ______________
Catheter Type:
Non-Tunnelled PICC Vas Cath
Tunnelled Implanted Vascular Device
Other: _______________________________
Line Coating: Antibacterial Antiseptic None
All Catheters Placement confirmed by X-ray and SMO Inserted Catheter Length: ________________
Date Line Inserted: __________________________ Time Line Inserted: ________________ INSERTION BUNDLE: To be completed by the observer and signed by both proceduralist and observer.
1. Hand Hygiene - Did the proceduralist?
Perform hand hygiene using chlorhexidine(CHG) solution Yes No
2. Chlorhexidine Skin Antisepsis - Did the proceduralist?
Prep the procedural site using chlorhexidine 2% in 70% alcohol (In NNU CHG % is titrated for weight/age) for 30 seconds and allow solution time to dry completely
Yes No
3. Maximum Barrier Precautions - Did the proceduralist?
Wear a hat Yes No
Wear a mask Yes No
Wear a sterile gown Yes No
Wear sterile gloves Yes No
Use a large sterile drape that covered the entire patient Yes No
Maintain sterile technique during procedure and when applying the dressing Yes No
Where high-risk patients have a CVC (e.g. burns, emergency insertion, TPN, ICU stay >7 days, immunocompromised, rewired line) consider using other preventative strategies, e.g. Chlorhexidine Impregnated Dressing , Antibacterial Line Applied on insertion? Yes No
Proceduralist Name: Proceduralist Signature:
Observer Name: Observer Signature:
Ward/Unit: Insertion Day 0 Insertion Time: Yes No Comments
Is IVN/TPN being infused?
If Yes, is there a dedicated port being used for the IVN/TPN?
Before accessing injection ports did you clean with 2% CHG in 70% alcohol?
Please check which shifts the line was in place for on the day of insertion.
AM Shift PM Shift Night Shift Date/time transfer to ward: ____________
CENTRAL LINE DEFINITION ANY CATHETER WHOSE TIP TERMINATES IN A GREAT VESSEL
INSERTION AND MAINTAINANCE AUDIT
Date Bed NHI Line day
Insert. bundle
Review line
Site Chlor hex
TPN Comment
MON
TUE
WED
THU
FRI
SAT
SUN