Getting to Zero Strategies to Reduce Central Line Associated Bloodstream Infections (CLABs) Brian S. Koll, MD, FACP Medical Director, Infection Prevention Chief, Epidemiology Beth Israel Medical Center, New York, NY

Beth Israel Medical Center 2004 • Petrie Division • Kings Highway Division • 94 ICU beds – 3,000 discharges • 824 non-ICU beds – 43,000 discharges • > 3,000 central lines placed annually Patients in ICU with Central Line CLABs Rate per 1,000 line days CLABs Rate per 100 patients Increase LOS BIMC 40% 4.5

2% 5 d USA 48% 5.3

4% 14 d

Costs Incurred Care of Patients with CLABs

Discharges Per Year CLAB Patients Incremental Cost Per CLAB Patient $40,000 94 ICU Beds 824 Non-ICU Beds 3,000 43,000 24 22 $25,000 Total Incremental CLAB Costs Annual Incremental Costs $960,000 $550,000 $1,510,000

Used BI BSI information and discharge information from 2004

Leadership • Administrative • Clinical • Physician and Nursing Champions

American Journal of Infection Control 2008;36:232-40 • • • • • Everyone has the ability, permission and responsibility to “stop the line” to prevent risk to patients (and staff) All are empowered to identify and change (or eliminate) risky processes, no matter when, where or who is involved and always without fear of retaliation There is participatory management at every level of the organization with both top-down and bottom-up communication Integrity and trust are woven into the fabric of the organizational culture Everyone is engaged prevention system, and there is reciprocal responsibility in the

Inter-disciplinary Team Members • • • • • • • • • • • Physicians Chief Executive Officer Chief Medical Officer Administrative Intern Associate Chairman, Department of Medicine Director – ICU, MICU, SICU – Emergency Room – Medical Residency Programs Intensivist Critical Care Fellow Residents and Interns Medical Student • Infection Control Hospital Epidemiologist Manager Practitioner • • • • • • Patient Care Services Vice President Director Nurse Manager – ICU, MICU, SICU Nurse Education Manager New Nurses Nursing Student • • • • • Other Director – Materials Management – Housekeeping – Respiratory Therapy – Quality Improvement Pharmacist Pharmacy Intern Radiology Transport Services

Multi-disciplinary CLABs Team Principles • It is not good enough that our infection rates are below national benchmarks.

• CLABs are preventable, they are not an inevitable consequence of sophisticated, complex care that we provide to our severely ill patients.

• CLABs can be eliminated by determination as opposed to additional resources.

Strategies to Reduce Central Line Associated Bloodstream Infections (CLABs)

BETH ISRAEL MEDICAL CENTER VASCULAR ACCESS PROCEDURE NOTE

Date: _________________ Time Out at _______ AM/PM Verified Correct (all must be verified):  Position  Supplies   Patient Equipment  Procedure  Site/Side _________________________ RN/MD ________________________RN/MD

Central vein

:

Pulmonary artery: Transvenous pacemaker

 subclavian  internal jugular  R  R  R   L  L  L femoral (if femoral, reason for choice) ________________________________________________________________

Arterial:

 R  L  radial  femoral  other_______________ Indication(s): _________________________________________________________ Consent in chart  Operator(s): _______________________________________

Central Line Check List :

1  all equipments at bedside 8  Time-out 2  Wash hands 9  Mask 3  Chlor- prep 10  procedure with sterile technique 4  Gown 11  Bio-Patch 5  Gloves 12  Dressing with date 6  Cap 13  Dispose sharps 7  Drape 14  wash hands Anesthesia: _________________________________________________________ Technique: _________________________________________________________ Comments: ________________________________________________________ Complications: ______________________________________________________ __________________________________________________________________ Signature/Title Time:_______ 8

Beth Israel Medical Center CLABs Prevention ICUs

Bundle Compliance Rate (%) 100 90 80 70 60 50 40 30 20 10 0 Aug Oct Dec Feb Time Apr Jun Aug CLABs Rates 2 1 0 5 4 3 2004 2005 Rate per 1,000 Line Days 2006 2007 Rate per 100 Patients

Unit CCU ICU ED SICU PICU non-ICU MICU CSICU Beth Israel Medical Center CLABs Prevention Longest Duration of Days Without CLAB 644 601 547 483 396 345 344 300 HAI Rates

2 1 0 8 7 4 3 6 5 Pre-Bundle CLAB VAP MRSA CDI Post-Bundle

4,5 5

CLABs Collaborative Infection Results

4,85 4,34 4 3,5 3 2,5 2 1,5 3,26 2,59 2,77 2,61 2,52 2,26 2,62 2,43 2.00

1,98 1,68 1,72 1,46 2,53 1,95 2,27 2,74 2,65 2,18 2,22 1,67 1,59 1,35 1,87 1.80

1,55 2,11 2,51 2,58 2,28 2,06 1,44 1 0,5 0

Reporting Period

11

CLABs Prevention ICUs

3 2 1 0 6 5 4 Central Line-Associated Blood Stream Infection (CLABSI) Rates by Type of Adult or Pediatric Intensive Care Unit * L *L GNYHA/UHF ICU Type *L = GNYHA /UHF rate significantly lower than rate in other hospitals Mean rate=1000 * Number of CLABSI / Number of Central Line Days 2007 NYS data, reported as of April 1, 2008

12