Transcript Reducing Central Line Infections

Reducing Central Line Infections
(CLI)
National Call
September 5, 2007
Purpose
• By the end of this call, participants will have:
– Updated information on the SHN Campaign,
Getting Started Kits and reporting worksheets
– Heard successes and learnings from
Improvement Teams
– Answers to your team’s questions about
intervention-specific changes and measurement
– An understanding of benefits and expectations of
enrolling in the Canadian ICU Collaborative
September 5, 2007
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Campaign Support
SHN National Steering Committee
Secretariat - CPSI
CIHI
Clinical Support
CCHSA
Campaign Structure
Operations
Teams
Western
Node
Quebec
Campaign
Patients
Canadian
ICU
Collaborative
Peer
Support
Network
Ontario
Node
CAPHC
Measurement
Working Group & CMT
Atlantic
Node
Other
Canadian
Faculty
ISMP
Canada
Education & Resource
Working Group
September 5, 2007
IHI
Partner
Network
Communication
Working Group
3
Teams Continue to Enroll
Safer Healthcare Now! Overview Total # Enrolled Teams
September 2005 to August 2007
800
669
700
Updated August 21, 2007
600
546
557
579
602
695
718
734
628
491
500
443
403
400
296
300
200
118
100
0
Total # of Enrolled Teams
Sep-05
Nov-05
Mar-06
Jun-06
Aug-06
Nov-06
Dec-06
Jan-07
September 5, 2007
Feb-07
Mar-07
May-07
Jun-07
Jul-07
Aug-07
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Safer Healthcare Now!
Enrollment by Intervention
Intervention
Number of Teams
Deploy Rapid Response Teams
52
Improve Care for Acute Myocardial Infarction
111
Prevent Adverse Drug Events through Medication
Reconciliation
282
Prevent Central Line-Associated Bloodstream Infection
66
Prevent Surgical Site Infection
129
Prevent Ventilator-Associated Pneumonia
94
Total
734
As at August 21, 2007
September 5, 2007
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Safer Healthcare Now!
Enrollment by Province & Territory
Province/Territory
Number of Teams
New Brunswick
24
Newfoundland & Labrador
16
Nova Scotia
56
Prince Edward Island
11
Quebec
22
Ontario
278
Alberta
63
British Columbia
118
Manitoba
55
Northwest Territories
1
Saskatchewan
22
Yukon
1
Total
669
September 5, 2007
As at May, 2007
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Enrollment Update
West
Ontario
Atlantic
Quebec
Total
53
115
25
17
210*
Healthcare
Delivery
Organizations
[includes
hospitals,
agencies, services
and regions (with
one or more
hospitals
participating)]
*Total at August 21, 2007
September 5, 2007
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Bloodstream Infection Rate per 1000 days
CLI Rate
INTERVENTION - CLI MEASURE: 1.0 Central Line-Associated Primary Bloodstream Infection (BSI)
Rate per 1000 Central Line-Days
10
9
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6
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Month
Local Team
National
September 5, 2007
Goal
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Percent Compliance
Insertion Bundle Compliance
INTERVENTION - CLI MEASURE: 2.0 Central Line Insertion Bundle Compliance
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Local Team Month
National
September 5, 2007
Goal
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Percent Compliance
Maintenance Bundle Compliance
INTERVENTION - CLI MEASURE: 3.0 Central Line Maintenance Bundle Compliance
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Local Team Month
National
September 5, 2007
Goal
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Updates to GSK
• Essentially unchanged since previous
edition
• Suggestions for implementation:
– Begin with insertion bundle
– Standardize policies, equipment and cleaning
agents
• Suggestions for measurement:
– Deviation from bundle components will assist
with strategizing for improvement
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Updates to Measurement
Worksheets
• Three worksheets for each measure: chart,
data entry and submitted by
• Compliance to individual bundle
components
• Instructions for new section
September 5, 2007
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Resources
• CLI Getting Started Kit & Worksheets
http://www.saferhealthcarenow.ca/Default.aspx?fold
erId=82&contentId=180
• Communities of Practice
http://www.saferhealthcarenow.ca/Default.aspx?fold
erId=124
• Canadian ICU Collaborative Improvement Guide
Available when enrolled in the Collaborative
September 5, 2007
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Questions
Success Stories
• Pediatric ICU’s
• Centre Hospitalier Régional de Lanaudière
September 5, 2007
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Reduction of Catheter Related
Blood Stream Infections
A Canadian National
PICU Collaborative Experience
October 2004 to October 2005
T. Northway, RN, MSN, & A. Robin, RN, BScN, BC Children’s Hospital;
E. Folz, RN, BScN, Alberta Children’s Hospital;
M. Golberg, RN, BScN, NP, Stollery Children’s Hospital;
J. Plouffe, RN, BScN, NP, Winnipeg Children’s Hospital
Incidence of CRBSI
• Comparatively high rate of CRBSI in PICU (NNIS
6.6/1000 CVC line days)
• CDC reports 5.3/1000 CVC line days adult ICU
• Attributable cost approximately $34,500-$56,000
US
• Increased LOS (3 weeks)
• Estimated mortality rate 13% - 19% (child) & 12% 25% (adult)
oElward, A et al. (2005). Pediatrics 115(4), 868-872.
o(2007) http://www.edwards.com/Products/CentralVenous/VantexInservice.htm?
wbc_purpose=Basic&WBCMODE=PresentationUnpublished
oSlonim, A et. Al (2001). Pediatric Critical Care Medicine 2, 170-174.
oYogaraj, J. et al. (2002). Pediatrics 110(3), 481-485.
September 5, 2007
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Aim and Goals/Objectives
Aim:
• To reduce the incidence of catheter related
blood stream infections (CRBSI) within
Canadian PICUs
Goals/Objectives:
• To reduce the incidence of CRBSIs by 20%
to 50% within 12 months (October 2005)
September 5, 2007
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Teams
September 5, 2007
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CRBSI Improvement Bundles
Insertion Bundle
• Hand Hygiene
• Maximum Barrier
Precautions (Inserter &
Patient)
• Chlorhexidine for Skin
Prep
• Site selection
Maintenance Bundle
• Hand Hygiene
• Standardized Hub
Antisepsis
• Standardized
Accessing of Line
– Line set-up
– Accessing hubs
– Dressing & tubing
changes
• Daily Reviewing of Line
Necessity
September 5, 2007
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Changes Tested
Creating controversy through transparency!
Adoption of insertion
& maintenance bundles
Moving to a culture
of safety
Celebrating successes!
Developing staff clinical
champions
Adoption of CDC definition
Handwashing campaign
Establish current reality
Awareness of current reality
Increased understanding of
ICU Collaborative & process
Awareness of importance
Of CVC infections
Baseline
Stream
Education
Stream
September 5, 2007
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Changes Tested
Let’s make it easy to do the right thing & difficult to do the wrong thing!
CVC maintenance OSCE
station at annual RN
competency validation days
Culture shift: RNs halting insertion
if insertion bundle violated
CVC Maintenance Bundle:
•Hand hygiene
•Line set-up (closed system)
•Dressing & tubing changes
• Standardized cleansing solution
Creation of insertion bundle
•Hand hygiene
•Full barrier precautions
•Site selection
•Cleansing solution change
Standardize equipment:
Creation of line insertion cart
Standardized data collection
Create line insertion checklist
Standardize equipment:
Creation of vascular access tray
Insertion
Stream
Daily Goal Sheet to review
line necessity
Maintenance
Stream
September 5, 2007
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Collaborative Results
PICU Monthly CRBSI Incidence
(June to Dec 2005)
PICU Line Counts (June to Dec 2005)
5000
4000
15
Total line days
9030
3000
Total CRBSI
29
10
2000
5
1000
0
0
Hosp A
Hosp B
Hosp C
Hosp D
Hosp E
Hosp F
Hosp A
Hosp B
Hosp C
Hosp D
Hosp E
Hosp F
Cumulative CRBSI per 1000 line days
(June to Dec 2005)
5.0
4.0
3.0
Group 3.2
CRBSI/1000 line
days
2.0
1.0
0.0
Hosp A
Hosp B
Hosp C
Hosp D
September 5, 2007
Hosp E
Hosp F
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Collaborative Results
NNIS Benchmark
6.6 per 1000 Line Days
Initial Learning
Session (LS)
for CRBSI
Collaborative
June to Dec 2005:
Period with existing
6 teams contributing
data
September 5, 2007
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Preventing central line infections
at the CSSSNL
Jean Levasseur MD
CSSSNL
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Large regional, community hospital
275 acute care beds
12 beds 8 ICU and 4 CCU beds
Closed Unit
Working on Collaborative projects since
2003
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Aims and objectives
• Eliminating C.L. infections
• Implementing the insertion bundle
• Initiate the maintenance bundle
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Results
• 9 months of surveillance (insertion bundle)
–
–
–
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Hand washing
Strict sterile technique
Chlorhéxidine
Insertion site
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Results
• Data collection sheets
– Insertion technique
– Insertion protocol
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Results
• Insertion
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Results
• Technique
September 5, 2007
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Results
Hand washing
90
60
30
0
3 months
6 months
September 5, 2007
9 months
34
Results
Face mask
95
63
32
0
3 months
6 months
September 5, 2007
9 months
35
Results
Sterile gown
95
63
32
0
3 months
6 months
September 5, 2007
9 months
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Results
Large sterile drape
95
63
32
0
3 months
6 months
September 5, 2007
9 months
37
Results
Clorhexidine
100
67
33
0
3 months
6 months
September 5, 2007
9 months
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Results
Cap
55
37
18
0
3 months
6 months
September 5, 2007
9 months
39
Results
Site SSC
Site FEM
75
50
25
0
3 months
6 months
September 5, 2007
9 months
40
Results
• During the last year :
• NO line infections for lines inserted on the
unit
• BUT, 4 line infections during the 24 months
of provincial surveillance for lines cared for
on the unit.
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Results
• Common points to infected lines :
• Site
• “Emergent” insertions
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Results
Dx
LOS
Germ
Site
(days)
Outcome
1
2005
VC Paralysis
67
Staph C-
Fem. (2)
Survived
2
2005
MVR
12
Candida
Fem. (8)
Died
3
2006
AAA
22
Staph C-
IJ (6)
Survived
4
2006
Urosepsis
16
Staph C-
Fem. (3)
Survived
September 5, 2007
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Changes tested
Dedicated cart
September 5, 2007
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Changes tested
Withdrawal of other
products
September 5, 2007
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Reminders...
• Technique
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Patient Perspective
Results are posted
September 5, 2007
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Lessons Learned
• Small changes can bring big results
• The maintenance bundle has to be
implemented as soon as possible…
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Remerciements
• Thanks to the fantastic and hard working
CSSSNL ICU quality team.
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About the Canadian ICU Collaborative
Benefits of Participating
• Faster learning and quicker gains
September 5, 2007
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Benefits of Participating (continued)
•
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Face-to-face Learning Sessions
Evidence-based changes, ready to test and implement
Coaching from experienced Faculty on application of changes
Education and training on tools for improvement and
measurement
Advice on targeted strategies to overcome resistance and
address barriers
Monthly feedback on progress from the Collaborative Faculty
Monthly conference calls specific to challenges your team is
facing
A List-Serve that provides real-time sharing of information,
direct to your email Inbox
A website for storing and sharing your documents with others
A comprehensive Improvement Guide with examples,
checklists, tools
No cost to join!
September 5, 2007
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Expectations for
Participating Teams
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Commitment of a team sponsor
Full participation of a multidisciplinary team
Development of measures
Regular reporting of progress to the Faculty
Willingness and commitment to implement
rapid and widespread changes
• Desire to innovate
• Regular access to email and Internet
September 5, 2007
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Collaborative Resources
• To Enroll
http://www.saferhealthcarenow.ca/Default.aspx?fold
erId=104&contentId=420
• About the ICU Collaborative
http://www.improvementassociates.com/dnn/Default
.aspx?tabid=190
• About Breakthrough Series Collaboratives (general)
http://www.ihi.org/IHI/Results/WhitePapers/TheBrea
kthroughSeriesIHIsCollaborativeModelforAchieving
%20BreakthroughImprovement.htm
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Questions
Contacts
• Bruce Harries, Collaborative Director
[email protected]
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