Post on 31-Dec-2015
CREATING AN INTEGRATED CLABSI PREVENTION PROGRAMPresented by:
Tracy Shamburger, RN, MSN and Karen Bailey, RN
OBJECTIVES Identify The Joint Commission (TJC) National Patient
Safety Goal 07.04.01 Elements of Performance
Cite the Mike Denton Infection Reporting Act (2009)
Define CLABSI and Central Lines per CDC Guidelines
Identify National Healthcare Safety Network (NHSN): ADPH HAI Reporting Requirements
Understand that the Comprehensive Unit-based Safety Program (CUSP) is a process for creating a culture of patient safety
Standards; Regulatory Compliance; & Reporting
Monitoring; Evidence Into Practice
Patient Safety
Evaluation& PI
CLABSIPrevention
The Joint CommissionNPSG.07.04.01
Institute for Healthcare Improvement (IHI)
National HealthcareSafety Network
(NHSN);CMS; ADPH
Comprehensive Unit-based Safety Program (CUSP)
EVALUATING COMPLIANCE WITH TJC NPSG.07.04.01
Conduct periodic hospital-wide risk assessments for CLABSI; monitor compliance with evidence-based practices; and evaluate the effectiveness of prevention efforts.
After conducting your risk assessment, do you have gaps in compliance or process improvement opportunities? If so, what are the gaps; are you conducting process reviews; and are your developing action plans to achieve compliance?
MONITORING AND REPORTING COMPLIANCE RATES
Compliance with evidence-based practices should be measured weekly or monthly and reported/charted to show progress towards goal of 100% compliance.
Compliance rate must be calculated with the whole bundle, not just parts.
CALCULATING COMPLIANCE RATES
# of pts with CVC during monitoring period who received all 5 elements of bundle (with documentation)
# of pts with CVC audited during the monitoring period
X 100 = Compliance Rate (%)
• Do you have a process for evaluating and reporting compliance rates with documentation? CLABSI rates?
SAMPLE COMPLIANCE RATES AND CLABSI REPORTING SCORECARD
JulyJuly AugAug SeptSept OctOct
How often did we harm How often did we harm (CLABSI)? (CLABSI)? Goal: Goal: <1CLABSI/1000 CL DAYS<1CLABSI/1000 CL DAYS
0.11/1000.11/10000
0.09/10000.09/1000 0.09/1000.09/10000
0.08/1000.08/10000
Compliance Rate? Compliance Rate? Goal: 90% or Goal: 90% or greatergreater
43%43% 82%82% 82%82% 88%88%
Are we improving based on Are we improving based on data monitoring? data monitoring?
YesYes YesYes YesYes YesYes
Where are we failing based on Where are we failing based on data monitoring? Non-data monitoring? Non-compliance Rate:compliance Rate:
57%57% 18%18% 18%18% 12%12%
a. Non-compliance with a. Non-compliance with insertion documentation: insertion documentation: NursesNurses
24%24% 10%10%3 nurses did not 3 nurses did not document CVC document CVC
insertion; Infusa insertion; Infusa Ports not Ports not
consistently consistently documented in the documented in the insertion screen as insertion screen as
POAPOA
9%9%3 nurses did not 3 nurses did not document CVC document CVC
insertion; Infusa insertion; Infusa Ports not Ports not
consistently consistently documented in the documented in the insertion screen as insertion screen as
POAPOA
9%9%2 M/S and 1 ICU 2 M/S and 1 ICU
nurse did not nurse did not document document
insertion screens; insertion screens; M/S staff are not M/S staff are not
consistently consistently documenting the documenting the insertion screen insertion screen for Infusa Ports for Infusa Ports
POAPOA
b. Non-compliance with barrier b. Non-compliance with barrier precautions: precautions: PhysiciansPhysicians
19%19% 8%8%3 MD failed to 3 MD failed to
wear full wear full barrier barrier
precautionsprecautions
9%9%3 MD failed to 3 MD failed to
wear full wear full barrier barrier
precautionsprecautions
3%3%1 MD failed to 1 MD failed to
use full use full barrier barrier
precautionsprecautions
c. System implementation c. System implementation issues:issues:**Processes exist for ER and OR staff to document data; **Processes exist for ER and OR staff to document data; however, the data is not flowing between modules for however, the data is not flowing between modules for M/S and ICUM/S and ICU
14%14% **0%**0% **0%**0% **0%**0%
COMMUNICATE AND REPORT COMPLIANCE AND INFECTION RATES
TJC requires that you report CLABSI rate data and prevention outcome measures to key stakeholders, including leaders, nursing staff, and other clinicians
Regulatory guidelines require reporting CLABSI rates to the National Healthcare Safety Network (NHSN)
Standards; Regulatory Compliance; & Reporting
Monitoring; Evidence Into Practice
Patient Safety
Evaluation& PI
CLABSIPrevention
The Joint CommissionNPSG.07.04.01
Institute for Healthcare Improvement (IHI)
National HealthcareSafety Network
(NHSN);CMS; ADPH
Comprehensive Unit-based Safety Program (CUSP)
CDC’S NATIONAL HEALTHCARE SAFETY NETWORK (NHSN): CENTRAL LINE
DEFINITION An intravascular catheter that terminates at or close to
the heart or in one of the great vessels which is used for infusion, withdrawal of blood, or hemodynamic monitoring.
-The Great Vessels Include the following: Aorta Superior Vena Cava Pulmonary Artery Brachiocephalic Veins Internal Jugular Veins Subclavian Veins Inferior Vena Cava External Iliac Veins Common Femoral Veins Umbilical Artery in neonates
INFUSION DEFINED Introduction of a solution through a blood vessel via a catheter
lumen. Includes: Continuous Infusions such as nutritional fluids,
medications, or Intermittent infusions such as flushes or IV antimicrobial administration, or
Administration of blood or blood products in the case of transfusion or hemodialysis.
CDC’S NATIONAL HEALTHCARE SAFETY NETWORK (NHSN): CENTRAL LINE BLOOD STREAM INFECTION
A Central Line Blood Stream(CLABSI) is a primary bloodstream infection (BSI) in a patient that had a Central line within the 48 hour period before the development of the BSI.
CDC’S NATIONAL HEALTHCARE SAFETY NETWORK (NHSN): AL HAI REPORTING Mike Denton Infection Reporting Act (2009; Rules
and Regulations Released-August 2010) -Requires Critical Access hospitals in Alabama to begin
reporting
certain HAIs using CDC’s NHSN.HAI Reporting Requirement
Denominator Requirement
Locations
CLABSIs Central Line Days Medical CCUsSurgical CCUs
Medical Surgical CCUsPediatric CCUs
CAUTIs Catheter Days Medical WardsSurgical Wards
Medical Surgical Wards
SSIs for Colon Surgeries and Abdominal Hysterectomies
(inpatient)
All inpatient procedures for Colon Surgeries and
Abdominal Hysterectomies
Any
ALABAMA CENTRAL LINE/CLABSI DATA ENTRY REQUIREMENTS
NHSN monthly reporting: Report central line device days Report CLABSI events
**You must have a monitoring plan for each month that you plan to report.
o Reporting Deadline for Alabama -All data must be entered into NHSN no later
than the last day of the subsequent month. Ex. January data is due by 28February).
NATIONAL HEALTHCARE SAFETY NETWORK (NHSN): CMS HAI
REPORTING
HAI Reporting Requirement
Denominator Requirement
Locations
CLABSIs Central Line Days All CCU locations
SSIs (2012) ?
oCMS Final Rule Passed (July 2010)
-Requires hospitals accepting Medicaid across the Nation to begin reporting certain HAIs using CDC’s NHSN January, 2011
Extended to 28 Feb 2011
CONSIDERATIONS: Have you evaluated all the different central lines utilized in
your facility that fit the definition of a central line?
oDo you have a Device Days Report?
oDo you consistently collect device day information at the same time each day?
oIf the patient is in CC/ICU, how do you capture positive blood cultures that return after the patient is transferred to a regular floor?
oHave you updated your NHSN monthly monitoring plan to include both CMS, and Alabama Central line/CLABSI reporting mandates? oAre your Locations Correctly Mapped?
oAre staff informed of their role in reporting HAIs?
Resources: http://www.adph.org/hai/
ALABAMA HAI REPORTING AWARENESS CAMPAIGN
SURVEILLANCE TIPSPeriodically check the accuracy of line day data
by visiting units and comparing reported catheter days with actual number of patient lines.
Remember….–Internal validation of central line data is critical!!
-when counting central line days, only count one central line day for patients with multiple central lines.
-Under reporting line days will artificially increase CLABSI rates.
Standards; Regulatory Compliance; & Reporting
Monitoring; Evidence Into Practice
Patient Safety
Evaluation& PI
CLABSIPrevention
The Joint CommissionNPSG.07.04.01
Institute for Healthcare Improvement (IHI)
National HealthcareSafety Network
(NHSN);CMS; ADPH
Comprehensive Unit-based Safety Program (CUSP)
COMPREHENSIVE UNIT-BASED SAFETY PROGRAM (CUSP)
NHSN and CUSP Participation
The main focus of the two year “On the CUSP: Stop BSI” project is to improve our culture of safety, thereby decreasing CLABSIs. Furthermore, participation in the project facilitates standards compliance, measurement, and reporting of CLABSI, along with other HAI data, to the CDC/NHSN
HOW DOES CUSP WORK?
“CUSP IS A PROCESS”
CUSP comprises five fundamental steps and is a continuous process.
CUSP guides you on a journey of education and communication; implementation and evaluation; review and transparency.
It starts with one high risk unit but provides a scalable intervention program that can be implemented throughout your organization.
FIVE FUNDAMENTAL STEPS TO CUSP
Engage Senior Leadership Open lines of communication between frontline
staff and administration
Educate leadership about clinical issues and safety hazards
Improve providers attitudes about leadership
Enlist administration in obtaining necessary resources to improve patient safety
FIVE FUNDAMENTAL STEPS TO CUSP
Educate Staff on Science of Safety Ensure all current staff have viewed the Science
of Safety video and incorporate the video into new hire orientation (consider adding the video to annual review)
Evaluate HSOPS results; identify safety needs and develop a plan of action. Form a team to assist with these goals and monitor for improvement.
FIVE FUNDAMENTAL STEPS TO CUSP
Implement Teamwork Tools Engage staff to be active team players, not
passive players
Breakdown physician – nurse barriers
Provide tools to facilitate teamwork and communication (ex: daily goals sheet)
Incorporate morning briefings and observing rounds
FIVE FUNDAMENTAL STEPS TO CUSP
Identify Defects Use incident reports, liability claims, or sentinel
events
Survey staff and ask, “How will the next patient be harmed?”
FIVE FUNDAMENTAL STEPS TO CUSP
Learn From Defects Incorporate a practical tool to address what
happened, why it happened, what you did to reduce future risk, and how to measure for reduced risk
Use resources such as the “Learning from Defect Tool” and “Investigating a CLABSI Tool” found on the CUSP: Stop BSI website
Plan to learn from at least one defect a month
APPLYING CUSP TO CLABSI PREVENTION
Begin by reviewing your TJC NPSG 07.04.01 risk assessment:
APPLYING CUSP TO CLABSI PREVENTION
If you’ve already conducted a TJC risk assessment for NPSG.07.04.01, then you’ve already identified gaps, deficiencies, and/or process improvement opportunities
Now develop actionable plans to improve processes
Monitor compliance with evidence-based practices
Evaluate effectiveness of prevention efforts
APPLYING CUSP TO CLABSI PREVENTION
Educate staff, patients, and family about CLABSIs and prevention
Implement policies aimed at reducing the risk of central line infections
Adhere to the CLABSI Prevention Bundle: Strict and consistent hand hygiene Maximum use of barrier precautions, including full
patient drape Site prep with Chlorhexidine Optimal site selection (avoid femoral insertions when
possible) Scrub the hub before accessing ports Remove catheters when no longer necessary; assess
daily need
APPLYING CUSP TO CLABSI PREVENTION
Create a Central Line Insertion Kit or Cart
Devise and consistently use a Central Line Insertion Checklist
Empower nurses to stop the procedure if guidelines are not followed
Post the # of patients infected per month and your quarterly infection rates
Participate in monthly CUSP calls, enter data into MHA Care Counts, and complete the Monthly Team Check-up Tool
EVALUATING PROCESSES If your CLABSI rate is NOT going down,
evaluate your processes!
Determine if processes are breaking down and if so, develop a plan of action to correct the deficiencies!
Finally, CUSP is not exclusive to CLABSI prevention. It is a process to address your overall culture of patient safety. Once you understand the process, CUSP can be applied to any process improvement program i.e., other TJC National Patient Safety Goals:
Standards; Regulatory Compliance; & Reporting
Monitoring; Evidence Into Practice
Patient Safety
Evaluation& PI
SSIPrevention
The Joint CommissionNPSG.07.05.01
National HealthcareSafety Network
(NHSN);CMS; ADPH
Comprehensive Unit-based Safety Program (CUSP)
Standards; Regulatory Compliance; & Reporting
Monitoring; Evidence Into Practice
Patient Safety
Evaluation& PI
CAUTIPrevention
The Joint CommissionNPSG.07.07.01
National HealthcareSafety Network
(NHSN);CMS; ADPH
Comprehensive Unit-based Safety Program (CUSP)
CONCLUSION Creating an integrated CLABSI Prevention program is
about evaluating your TJC compliance; understanding how to define and report CLABSI to NHSN; and implementing CUSP processes that sustain a culture of patient safety!
The Alabama Department of Public Health and the Alabama Hospital Association truly wish every IP great success in this new venture! Odds are, now that you understand how all these elements are inter-related, you will probably discover that you’ve done more with the CUSP project than you thought.
The challenge, use CUSP processes to raise the bar with CLABSI prevention – take it to the next level: implement daily goal sheets; begin daily rounding with physicians; conduct AM briefings.
And remember to always ask, “How will the next patient be harmed; how can I prevent it from happening?”
QUESTIONS?QUESTIONS?