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Transcript of Vanderbilt Infection Control & Prevention Central Line Associated Bloodstream Infections Tennessee...
Vanderbilt Infection Control & Prevention
Central Line Associated Bloodstream Infections
Tennessee Center for Patient Safety
Vicki Brinsko RN, CIC
Goal: Preventing CLABSI
Using the Central Line Bundle Hand Hygiene Remove Unnecessary Lines Use of Maximal Barrier Precautions Chlorhexidine for Skin Antisepsis Avoid femoral lines
Report CLABSI rates to the units Celebrate success
Vanderbilt Infection Control & Prevention
Engage
Partner with Infection Control, ID experts
Increase awareness about morbidity and mortality associated with CLABSI
Make harm visible Tell stories Post # infections
Estimates of opportunity to improve
Vanderbilt Infection Control & Prevention
Thank You Notes to NICU Staff
Thank You From Baby Thank You From Baby Boy JonesBoy Jones
I have gone 136 days without a bloodstream infection. Keep up
the good work! My Mom left some “kisses” for you! XOXOX
Vanderbilt Infection Control & Prevention
Form the Dream Team
Heterogeneous in make up; homogeneous in mind set
All stakeholders must be included All RN teams fail because
MDs insert lines Find a high profile
champion Get a process owner
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TEAM FORMATION
ICU Director ICU Nurse Manager
Infection Control
Practitioners
Chief Hospital
Epidemiologist
Attendings & Residents
Nursing Staff (ICU)
QA/Quality StaffQI experts
Frontline Staff
Infectious Disease experts
Leaders
Vanderbilt Infection Control & Prevention
National Quality Scholars
Educate
Educate staff and senior leaders about CDC guidelines Develop a resource notebook Develop policies and procedures CDC guidelines and Fact Sheet Power point slides for In-services
Consider a quiz to evaluate provider knowledge
Can use on-line training
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http://www.mc.vanderbilt.edu/root/vumc.php?site=micututorial
Evaluate
Outcome measure: CLABSI rate Rate, # infections, weeks/months since last
infection Process measures
% checklists completed % violations noted # lines removed
Celebrate success
Vanderbilt Infection Control & Prevention
Share the Data
CLA-BSI in Trauma
0
1
2
3
4
5
6
7
8
9
2005 2006 2007
Infs
per
100
dev
ice
days
TraumaCDC Benchmark
Vanderbilt Infection Control & Prevention
BSI Bundle
The Check List
Adapt to your own institution
Must be filled out for each line insertion
Include 5 BSI bundle elements Simpler is better Can always add
elements as you become better at capturing data
LF
Time end (catheter secured):
MR #:
Check if:
Femoral
Internal Jugular
/ / Date:
Type of catheter:
Triple lumen Introducer Swan-Ganz
Insertion Site:
Subclavian
Other (specify):
Pt/Family teaching done Consent obtained
Pre-insertion skin prep (check any used): Alcohol Betadine (povidone-iodine) Chlorhexidine Other (specify):
Describe the circumstances under which this line was placed: Non-emergent Emergent (life-threatening or code situation)
Please file page 2 in patients chart and return top form to the designated location in the ICU.
List all sites where insertion was attempted. Other (specify):
: Time start (1st needle stick): :
How many different needle sticks did the patient receive (number of skin breaks)? 1 Unknown
The provider inserting this line:
* If “No”, was this procedure supervised by someone with least five (5) central lines experience? Yes No Didn’t ask
Yes No
Please use military time (i.e. 1:00 pm is 13:00)
a. Handed-off his/her pager before the procedure? Yes No b. Washed hands immediately prior to procedure? Yes No *
Didn’t ask Didn’t ask Didn’t ask c. Has previously placed at least five (5) central lines?
Describe the level of training of the person who actually inserted the line? Medical Student Intern (PGY-1) Resident (PGY-2+) Fellow Attending
Barrier precautions (check any used): Sterile gloves Sterile gown Mask Sterile towels Full body drape
Side: Right Left
2 3 4 5 6+
Follow-up CXR: Ordered Not ordered (specify reason):
CXR findings (check all that apply): No pneumothorax Pneumothorax (describe action taken): Catheter in good position Catheter position adjusted (describe):
Type of dressing: Bio-occlusive Gauze Other (specify):
Patient tolerated the procedure well? Yes No
Was the sterile field maintained throughout the entire procedure? Yes No
Complications? None Other (describe):
Dressing applied by: Nurse Proceduralist Other (specify):
Nursing Checklist: Central Venous Catheter Insertion
Vanderbilt University Medical Center
RIJ LIJ RSC LSC RF
Guidewire exchange
Placement unsuccessful
MC 2705 (Rev. 06/04)
NOTE: Please use either black or blue ink to complete this form.
Comments:
Vascath
Signature: ______________________________________________ Date: _________________
Indications for use: Pressors Hemodynamic monit. Fluids/blood products Frequent lab draws
Pre-existing infection
Nurse Practitioner
Double lumen
atVanderbilt
Monroe Carell Jr. OR
CCU MICU SICU BICU PCCU NICU
NSICU TICU Other
Vanderbilt Infection Control & Prevention
Execute
Hand Hygiene Remove Unnecessary Lines Use of Maximal Barrier Precautions Chlorhexidine for Skin Antisepsis Avoid femoral lines
Vanderbilt Infection Control & Prevention
Hand Hygiene
Empower nursing to enforce use of a central line checklist to be sure all processes related to central line placement, including hand hygiene, are executed for each line placement.
Include hand hygiene as part of your checklist for central line placement.
Keep soap/alcohol-based hand hygiene dispensers prominently placed and make universal precautions equipment, such as gloves, only available near hand sanitation equipment.
Post signs at the entry and exits to the patient room as reminders.
Initiate a campaign using posters including photos of celebrated hospital doctors/employees recommending hand hygiene.
Create an environment where reminding each other about hand hygiene is encouraged.
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Posters of Prominent MDs
Maximum Barriers
Empower nursing to enforce use of a central line checklist to be sure all processes related to central line placement are executed for each line placement.
Include maximal barrier precautions as part of your checklist for central line placement.
Vanderbilt Infection Control & Prevention
Insertion Kits or CL Carts
Keep equipment stocked in a cart for central line placement to avoid the difficulty of finding necessary equipment to institute maximal barrier precautions.
Some companies offer CL insertion kits with maximum barriers included
Value in keeping as many parts together as possibleMay Need to Order CHG and/or Kits
CHG Skin Asepsis
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Empower nursing to enforce use of a central line checklist to be sure all processes related to central line placement are executed for each line placement.
Include chlorhexidine antisepsis as part of your checklist for central line placement.
Include chorhexidine antisepsis kits in carts or grab bags storing central line equipment. Many prepared central line kits include povodine-iodine kits and these must be avoided.
Ensure that solution dries completely before attempting to insert the central line.
Central Line Site Selection
Whenever possible, and not contraindicated, the subclavian line site should be preferred over the jugular and femoral sites for non-tunneled catheters in adult patients.
Vanderbilt Infection Control & Prevention
Daily Review of CL Necessity
Include daily review of line necessity as part of your multidisciplinary rounds.
Include assessment for removal of central lines as part of your daily goal sheets.
Record time and date of line placement for record keeping purposes and evaluation by staff to aid in decision making.
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Create Redundancy
Develop strategy to ask daily if lines can be removed Daily Goals Nursing/physician sign outs on Rounds
Implement checklist to be completed at time of insertion Nurses present during line insertion Support for speaking up Modify checklist for local use
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Getting Started
Do Your Homework First!!
Interdisciplinary team Gain consensus on
plans Create timeline for
deliverables
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Start Small
Select the team and the venue. It is often best to start in one ICU. Many hospitals will have only one ICU, making the choice easier.
Assess where you stand presently. What precautions are taken presently when placing lines? Is there a process in place? If so, work with staff to begin preparing for changes.
Contact your Infection Control Department. Learn about your catheter-related bloodstream infection rate and how frequently the hospital reports it to regulatory agencies.
Organize an educational program. Teaching the core principles to the ICU staff will open many people’s minds to the process of change.
Introduce the central line bundle to the staff.
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First Test of Change
Begin using the bundle with one patient from the time of catheter placement.
Work with each nurse who cares for the patient to be sure they are able to follow the bundle and implement the checklist and daily goals sheet.
Make sure that the approach can be carried over from shift to shift to eliminate gaps in teaching and utilization.
Process feedback and incorporate suggestions for improvement.
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One ICU…then the Rest
Once the bundle has been applied to one patient and subsequent shifts, increase utilization to the remainder of the ICU.
Engage in additional PDSA cycles to refine the process and make it more reliable.
After achieving reduction in CR-BSI in the pilot ICU, spread the changes to other ICUs, and eventually to other places in the hospital where central lines are inserted
…So Use Data
Vanderbilt Infection Control & Prevention
CLABSI per 1000 Line Days
CLABSI X 1000CL Days
How do I get the central line days?
Get ICU staff involved Unit secretary counts #
lines each day at 12MN Charge nurse counts each
day at change of shift See if IT can give you the
numbers electronically
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Potential Barriers
Fear of change Use knowledge Use optimism
Communication breakdown Involve all stakeholders
on the front end MD and staff partial “buy-in”
Supply continuous data to all groups
Changes in rates convert the non-believers
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Questions?
Vanderbilt Infection Control & Prevention