Central Line Associated Blood Stream Infection Prevention Project Gabrielle Hanlon, Project Manager...
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Transcript of Central Line Associated Blood Stream Infection Prevention Project Gabrielle Hanlon, Project Manager...
Central Line Associated Blood Stream Infection Prevention Project
Gabrielle Hanlon, Project ManagerTony Burrell, Chair ANZICS Steering Committee
Background• ~ 300 ICU CLABSI/yr in Australia• Costs $14,000 per case
extra $AU4.3 million
• 3,000 extra bed days• Attributable mortality 4-20%• CLABSI preventable
BackgroundCLABSI reduction projects• Pronovost (2006) & others (15yrs)• NSW CLAB ICU (2007-08) 3.0 → 1.2/1,000• WA Safety and Quality Investment for Reform
(SQuIRe) Program 2006 → 0.55/1000
This project
• ACSQHC funded ANZICS• National project• Adult & paed ICU• Public & private• Build on existing work
Objectives• Decrease rate of CLABSI in Australian ICUs to
<1/1000 line days• Accurately and consistently measure the rate
of CLABSI in ICUs throughout Australia• Timely reporting to clinicians• Benchmarking
Preparation• Review current practice (April/May 2010)
• Surveillance– Definition– Reporting method & timeframe
• ICU– CVL insertion– Knowledge of surveillance
SurveillanceAcross Australia• Majority data collected by ICPs• A few ICUs collected some data• Not all jurisdictions did CLABSI surveillance• Inconsistent definitions, reporting (method &
timing), benchmarking• Variable practises in private sector• No national reporting or benchmarking
ICU practice ICU Directors/Nurse Managers Survey• 53/100 ICUs: 24 doctors, 39 RNs (not NSW, ACT)
• Variable knowledge of surveillance processes• Some did not know CLABSI rate “but it’s low”• Variable compliance with “best practice” re
CVL insertion
ICU practiceCVL insertion – total 51 ICUs• have trolley/pack 76%• wear hats 43%• wear masks 43%• Chlorhex handwash 88%• sterile gown & gloves 100%• Chlorhex & alcohol skin prep 100%• full body draping 41%
Clinical practice
CVL insertion & maintenance• Chlorhex patch 20%• Impregnated CVC 59%• Chlorhex body-wash 25%
Schedule First • Outcome assessment & national reporting
both require– national definition – implementation/interpretation guide
Then• improve CVL insertion practises
National definition • minimise change if possible• numerator - NHSN 2008• denominator - line days • implementation guide inc “other infection”
definitions
National definition
Am J Infect Control 2008:36;309-32
National definition
• All jurisdictions adopting as able• New surveillance commencing
National reporting • No duplication at any step• Jurisdictions forward data to ANZICS if they
already collect it (hospital-level data only) • Some individual public & private hospitals
forward data to ANZICS (if above n/a)
National reporting • ANZICS generate reports
– Self vs other SA ICUs– Self vs other in same CICM level/other PICUs nationally– Self vs all in Australia
• Secure log-in• Access:
– ICU director & NUM – Inf Cont
– ? other
Monthly reportingICU CLABSI rate compared to other CICM Level I
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Time period: 2010
CL
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lin
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ays
Max-Q3
IQR
Q1-min
0-min
CLABSI rate of Identified ICU
Mean
Annual reportYearly CLABSI rate summary for <insert name of hospital & ICU ID>
2.5 1 3 2 10
0.5
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1.5
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Mean Identified ICUannual CLABSI rate
Mean CICM Level 1annual CLABSI rate
Mean <Jurisdiction>annual CLABSI rate
Mean national annualCLABSI rate
Benchmark CLABSI rate
Time period: January - December 2010
CL
AB
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rate
per
100
0 li
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Interim goals Foundations• National definition √• Implementation (interpretation) guide √• National reporting √
Now• Improve CVL insertion practises
Improving Central Line Insertion
Quality not research
However....• Based on evidence derived from research• Focus on
– sustainable practice vs short intervention– process & outcomes – ongoing measurement
Method - Clinical Practice Improvement
Too complex & time-consuming ...
MethodKeep It Simple• Measure CLABSI• Incorporate change into usual practise • Measure CLABSI• Review individual cases (ICU & IC +/- ID)• Check compliance with insertion process• Keep measuring CLABSI & review
Approach• Assumptions relevant to Australia
– multidisciplinary clinical team– ward rounds occur twice/day
• Establish multi-disciplinary project teams– ICU director & nurse manager or senior dr & ns– Infection Control/ID support– Others as appropriate
Intervention • Joint medical & nursing responsibility• Insertion & maintenance guideline based on
– NHMRC/ACSQHC Guidelines– CDC– Expert group– Core items– Optional items
Insertion Maximum barrier precautions• Hat• Mask• CHG handwash • Sterile gloves & gown• CHG & ETOH skin prep & allow to dry• Full-body drape• Maintain aseptic technique
Checklist
“Reminder”
Proceduralist acknowledges he/she would like to be reminded if he/she misses one of the steps below; eg. “ I would like you to watch me and if you see that I forget an important step in the procedure I want you to tell me”
Other suggestions• CVC (inc swan & vascath) trolley• Appropriate site• Options if rate higher than goal
– chlorhexidine patch at insertion site– impregnated CVC– daily chlorhexidine body wash
• Maintenance– Very limited re-wiring of existing lines– Replace lines with a blocked lumen– No disconnection & re-connection of lines (inc HF)
Guideline contents• Scope• Definitions• Selecting a central line• Selecting a site• Aseptic technique • Maximum barrier precautions• Stopping the procedure if asepsis breached• Daily review
– local infection– need for line
Guideline contents• Line replacement inc re-wiring• Blocked lumens• Changing fluids & administration sets• Needleless connectors• Dressings• CHG patches• Drug administration (CHG & ETOH swabs)• CHG body wash
Support Website • CVC insertion & maintenance guideline • References• Audit tools/checklist• Line day calculator• Secure discussion forum
ANZICS CLABSI Reporting Program
What now? • Establish CLABSI reporting process• Form the team - Dr, Ns, ICP, ?other• Review your protocol• Identify changes required & materials needed (eg.
trolley, big drapes, ?culture)
• Develop education strategies for all staff• Implement changes• Check compliance• Review CLABSI rate & compliance
Counting line-daysLine day counts should be done• 3 times a week, eg. Mon, Wed, Fri• At the same time • By asking the question: Does this patient have a
central line, PA catheter/swan, swan sheath, vascath (or other haemofiltration catheter), or a PICC?
This job does not require nursing/technical knowledgeThis is done by Infection Control in Vic & WA public ICUs
Counting line-daysMon Tues Wed Thurs Fri Sat Sun
Bed 1 1 0 0
Bed 2 0 1 1
Bed 3 0 1 1
Bed 4 1 1 0
Total 2 3 2
1 means the patient in that bed has at least 1 central line0 means either the bed is empty, or the patient doesn’t have a central line