Transcript Central Line Associated Bloodstream Infections

Central Line Associated
Bloodstream Infections
Tennessee Center for Patient Safety
Vicki Brinsko RN, CIC
Vanderbilt Infection Control & Prevention
Goal: Preventing CLABSI
 Using the Central Line Bundle
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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
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Engage
 Partner with Infection
Control, ID experts
 Increase awareness
about morbidity and
mortality associated
with CLABSI
 Make harm visible
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Tell stories
Post # infections
 Estimates of opportunity
to improve
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Thank You Notes to NICU Staff
Thank You From
Baby Boy Jones
I have gone 136 days without a
bloodstream infection. Keep up the
good work! My Mom left some
“kisses” for you! XOXOX
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Form the Dream Team
 Heterogeneous in make
up; homogeneous in mind
set
 All stakeholders must be
included
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All RN teams fail because
MDs insert lines
 Find a high profile
champion
 Get a process owner
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TEAM FORMATION
ICU Nurse Manager
Leaders
ICU Director
Infection Control
Practitioners
Infectious Disease experts
Chief Hospital
Epidemiologist
Nursing Staff (ICU)
Frontline Staff
Attendings & Residents
QA/Quality Staff
National Quality Scholars
QI experts
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Educate
 Educate staff and senior leaders about CDC
guidelines
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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
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Rate, # infections, weeks/months since last
infection
 Process measures
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% checklists completed
% violations noted
# lines removed
 Celebrate success
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Share the Data
Infs per 100 device days
CLA-BSI in Trauma
9
8
7
6
5
4
3
2
1
0
BSI Bundle
Trauma
CDC Benchmark
2005
2006
2007
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The Check List
MC 2705 (Rev. 06/04)
Vanderbilt University Medical Center
 Adapt to your own
Monroe Carell Jr.
OR
atVanderbilt
Nursing Checklist:
Central Venous Catheter Insertion
NOTE: Please use either black or blue ink to complete this form.
CCU
BICU
MR #:
/
Date:
Type of catheter:
Double lumen
Triple lumen
Introducer
Swan-Ganz
Vascath
Time start
(1st needle stick):
Insertion Site:
Internal Jugular
Subclavian
Femoral
Other (specify):
List all sites where insertion was attempted.
RIJ
LIJ
RSC
LSC
MICU
PCCU
Side:
Right
Left
RF
:
LF
Mask
NSICU
Other
Time end
(catheter secured):
Other (specify):
Yes
No
Didn’t ask
Yes
No
Didn’t ask
Yes
No *
Didn’t ask
(5) central lines experience?
Sterile towels
Full body drape
Attending
Nurse Practitioner
How many different needle sticks did the patient receive (number of skin breaks)?
1
2
3
4
5
6+
Unknown
Was the sterile field maintained throughout the entire procedure?
Yes
Pre-insertion skin prep (check any used):
Alcohol
Betadine (povidone-iodine)
Other (specify):
Describe the circumstances under which this line was placed:
Non-emergent
Emergent (life-threatening or code situation)
Follow-up CXR:
Ordered
CXR findings (check all that apply):
No pneumothorax
Catheter in good position
Dressing applied by:
Nurse
None
Pre-existing infection
Pneumothorax (describe action taken):
Catheter position adjusted (describe):
Bio-occlusive
Complications?
No
Not ordered (specify reason):
Type of dressing:
Patient tolerated the procedure well?
:
Check if:
Consent obtained
Pt/Family teaching done
Guidewire exchange
Describe the level of training of the person who actually inserted the line?
Medical Student
Intern (PGY-1)
Resident (PGY-2+)
Fellow
Chlorhexidine
SICU
Please use military time
(i.e. 1:00 pm is 13:00)
/
Indications for use:
Pressors
Hemodynamic monit.
Fluids/blood products
Frequent lab draws
The provider inserting this line:
a. Handed-off his/her pager before the procedure?
b. Washed hands immediately prior to procedure?
c. Has previously placed at least five (5) central lines?
* If “No”, was this procedure supervised by someone with least five
Yes
No
Didn’t ask
Barrier precautions (check any used):
Sterile gloves
Sterile gown
TICU
NICU
Gauze
Placement unsuccessful
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Simpler is better
Can always add
elements as you become
better at capturing data
Other (specify):
Proceduralist
Yes
institution
 Must be filled out for each
line insertion
 Include 5 BSI bundle
elements
Other (specify):
No
Comments:
Other (describe):
Please file page 2 in patients chart and return top form to the designated location in the ICU.
Signature: ______________________________________________
Date: _________________
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Execute
 Hand Hygiene
 Remove Unnecessary Lines
 Use of Maximal Barrier Precautions
 Chlorhexidine for Skin Antisepsis
 Avoid femoral lines
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Hand Hygiene
 Empower nursing to enforce use of a central line checklist to be
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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.
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Insertion Kits or CL Carts
 Keep equipment stocked in
May Need to Order CHG and/or Kits
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 possible
CHG Skin Asepsis
 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.
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Central Line Site Selection
 Whenever possible, and
not contraindicated, the
subclavian line site
should be preferred
over the jugular and
femoral sites for nontunneled catheters in
adult patients.
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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
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Daily Goals
Nursing/physician sign outs on Rounds
 Implement checklist to be completed at time
of insertion
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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
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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
…So Use Data
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
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CLABSI per 1000 Line Days
 CLABSI X 1000
CL 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?
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