Transcript Creating a Culture of Safety - The Healthcare Association
Prevention of Central Line Associated Bloodstream Infections (CLABs)
Quality and Patient Safety Effectiveness and Outcomes Beth Israel Medical Center Petrie and Kings Highway Divisions
CLABs Myths
Our infection rates are below national benchmarks - which is good enough.
CLABs are inevitable. It is the price we pay for sophisticated, complex care of severely ill patients.
CLABs are benign and readily treated with antibiotics.
CLABs are a common accompaniment of complex care and covered by outlier payments.
Lessons Learned
We can come surprisingly close to eliminating infections with hospital acquired determination opposed to resources as Our data must not only be reportable but actionable
Save lives Reduce costs Reduce error and waste
How We Did It
Make data actionable Observe variations in work practices Real time problem solving of origins of CLABs Implement and test practice changes
Make Data Actionable
Start small Use and monitoring of evidence based patient care practices or “bundles” with reporting back of data to end users Counter measures generated by the people who do the work Process that generates sustainable fixes Avoid “workarounds” that are constantly repeated Set a time to achieve goal Plan-Do-Study Act (PDSA) methodology
Beth Israel Medical Center
Petrie Division Kings Highway Division 94 ICU beds 3,000 discharges 824 non-ICU beds 43,000 discharges 1,200 central lines placed annually 40% of patients in ICU with central line Average length of stay for patients with central line = 5 days Average length of stay for patients with CLAB = 10 days CLABs rate of 9 per 1,000 device days or 3.8% in 2004
Beth Israel Medical Center CLABs Prevention
June 2005 ICU MICU, SICU August 2005 CCU and CSICU December 2005 Emergency Departments January 2006 General Medical Surgical Units April 2006 Operating Room August 2006 NICU and PICU
Multi-disciplinary CLABs Team Members
Physicians Chief Medical Officer Associate Chairman, Department of Medicine Director ICU, MICU, SICU Emergency Room Medical and Emergency Department Residency Programs Intensivist Critical Care Fellow Infection Control Hospital Epidemiologist Manager Practitioner Patient Care Services Vice President Director Nurse Manager ICU, MICU, SICU Emergency Room Nurse Education Manager Other Director Materials Management Housekeeping Respiratory Therapy Quality Improvement Pharmacist Dietician
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.
Multi-disciplinary CLABs Team Principles
CLABs can be eliminated by determination as opposed to additional resources.
Strict adherence to evidence based patient care practices, called “bundles” that will improve patient safety and reduce adverse patient outcomes is required.
Multi-disciplinary CLABs Team Principles
Patient hospital length of stay, morbidity and mortality can be reduced through prevention of CLABs.
We can reduce the Medical Center’s costs incurred for the care of patients with CLABs.
CLABs
BIMC Patients in ICU with Central Line CLABs Rate 40% 3.8% Increase LOS 5 d USA 48% 4% 14 d Mortality = 18% ICU risk 8x >non-ICU Additional $40,000 to hospital costs Hospitals absorb the costs!
Nationally: 80,000 CLABs in ICUs per year 14,500 CLABs deaths
Costs Incurred For 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
Multi-disciplinary CLABs Team Aims and Goals
Process that generates sustainable fixes Avoid “workarounds” that are constantly repeated Collaborative process Knowledge gained from this process is shared with all Our data must not only be reportable but actionable
Beth Israel Medical Center CLABs Prevention
Physician and Nurse reeducation and recertification on central line insertion technique and maintenance practices
Standardization of practices to ensure
Maximal barrier protection utilized Skin prep with chlorhexidine Preference for subclavian medically contraindicated site unless
Beth Israel Medical Center CLABs Prevention
Nursing practices
empowerment to monitor
Nursing permitted to ask and stop other persons who do not follow appropriate practices Hand hygiene compliance
Beth Israel Medical Center CLABs Prevention
Daily review of line necessity
Root cause analysis performed in real time for every CLAB
Development of a central line insertion kit
Barrier precaution components Insertion components Maintenance components
Beth Israel Medical Center CLABs Prevention Education and Recertification Standardization of Practices and Documentation but also: Hospital Specific Department Specific Unit Specific
2005 Infection Control Policy for Prevention of Intravascular Infection BETH ISRAEL MEDICAL CENTER INFECTION CONTROL POLICY SUBJECT: MANUAL CODE: Guidelines for Prevention of Intravascular Infection EFFECTIVE: DISTRIBUTION: February 2005 Nursing Units, Nursing Administration/Education Clinical Department Reviewed Revised I.
8/05 Handwashing A.
B.
starting the procedure. Wash hands with soap and water or use alcohol based hand rub solution prior to Verify the patient’s identity by name and birth, explain the procedure and obtain informed consent. II. Surveillance for Catheter-Related Infection A.
B.
Palpate the catheter insertion site for tenderness daily through the intact dressing. Visually inspect the catheter site if the patient develops tenderness at the insertion site, fever without obvious source, or symptoms of local or blood stream infection. III.
Barrier Precautions During Catheter Insertion & Care IV.
A.
Wear clean gloves when inserting a peripheral venous catheter and during catheter dressing site changes required by the Occupational Safety and Health Administration (OSHA). Bloodborn Pathogens standard. Sterile Gloves are not required. B.
Use sterile technique, including the use of a sterile gown and gloves, a mask, cap, and a large sterile drape (i.e., maximal barrier precautions) for the insertion of central venous lines including PICCs and guidewire exchanges. Use these precautions, even if the catheter is inserted in the operating room. C.
During central line catheter dressing site care, use a mask and sterile gloves. Selection of Catheter Insertion Site
DISTRIBUTION
All Manual Holders
PURPOSE
To provide the Registered Nurse with the guidelines for dressing and cap change on a central venous access device (includes single/double lumen catheters, implanted venous access ports, triple lumen catheters and PICC lines.)
POLICY
This procedure may be performed by a Registered Nurse whose competence has been demonstrated.
Central Venous Access Device dressings are changed at least every 7 days or if they become damp, soiled, loose or if inspection of the site or catheter change is necessary. In addition, dressings on implanted ports must be changed when the non-coring needle is changed once every five days. Caps must be changed whenever the integrity of the cap has been compromised but not less than once a week on Mondays.
EQUIPMENT
A Dressing Change Tray (sterile) containing: powder-free vinyl gloves (one pair) dressing ChloraPrep
Biopatch®
One-Step chlorhexidine foam pad towel tape mask (optional) cotton tip applicator (optional) clean gloves (one pair) 1.
PROCEDURE
Verify the patient’s identity by name and date of birth. 2. Wash hands and don clean gloves.
KEY PONTS
3. Carefully remove the old dressing completely and discard. Touch only the outer layer of the dressing to avoid contamination 4. Inspect the insertion site for color, tenderness, swelling or any discharge. 5. Remove gloves and wash hands 6. Open the Dressing Change Tray and don the sterile gloves 7. Prep the skin with ChloraPrep One Step a. Pinch the wings on the applicator to break the ampule and release the antiseptic Look for leakage, swelling. bruising, tenderness, redness and general skin condition. Notify physician of any changes. Strict aseptic technique is essential when carrying out any procedure involving central venous access catheter Do not touch the sponge
Beth Israel Medical Center CLABs Prevention Education and Recertification Indications Anatomy Procedure “Time Out” Universal Protocol Patient Position Skin Preparation Maximal Barrier Precautions Anesthesia Approach Dressing Additional Expectations Clean up Monitor for complications
Procedure Competency Form
Procedure Competency Form: Central Line /Transvenous Pacemaker
Patient Addressograph
Resident: ____________________ Observing Faculty: _______________________ Date: _______________________ Procedure: Line Site:
Central Line
Transvenous Pacemaker IJ Subclavian Femoral
R L R L R L if femoral, reason for choice
_____________________
Indication: ____________________________ Time Out @ ___________AM/PM
Verified Correct (all must be verified): Position Patient
# or Attempts
Supplies _________ Procedure Site/Side Equipment _________________________ RN/MD ________________________RN/MD
Consent Signed and In Chart
Sterile Technique & Order of Procedure Operator / Sup Check 1. All equipment at bedside __________/______
2. Wash hands (before procedure) __________/______
3. Prep with Chlo-prep x 3 4. Gown 5. Gloves 6. Cap __________/______
__________/______
__________/______
__________/______
7. Drape 8. Time-out 9. Procedure with sterile technique 10. Place Bio-patch 11. Dressing with date 12. Dispose sharps 13. Wash hands (after procedure) __________/______
__________/______
__________/______
__________/______
__________/______
__________/______
__________/______
________________________________________________________________
Continued on Reverse Side Assessment of Procedure
______ Informs patient of procedure including risks and benefits and obtains consent (if appropriate for circumstances) ______ Observes universal precautions ______ Positions patient properly ______ Maintains proper sterile technique ______ Uses ultrasound appropriately to identify vessel/patency ______ Central line flushed if appropriate ______ Skin prep appropriate for procedure ______ Appropriate local anesthesia ______ Needle aimed at proper angle and direction ______ Resident able to analyze and correct potential reasons for unsuccessful procedure ______ Venous blood obtained ______ Wire introduced and syringe removed ______ Skin cut made prior to inserting catheter dilator ______ Wire withdrawn as catheter advanced ______ Confirmation of port function ______ Catheter secured in place ______ Patient cleaned up and proper dressing applied ( Bio-Patch placed ) ______ Sharps disposed of in appropriate container ______ Confirmatory x-ray ordered and reviewed as necessary
Assessment: Unsatisfactory Proficient Mastered
Comments: Faculty Signature:________________________ Resident Signature: _______________________ Date: __________________ Date: ____ ______________
Beth Israel Medical Center CLABs Prevention Education and Recertification Generated By:
Beth Israel GME & Residency Manager Procedure Report: Summary
05/03/06 05:40
Medical Resident KM Procedure Central Venous Line Placement - Femoral Line Insertion Central Venous Line Placement - Internal Jugular Insertion
Central Venous Line Placement - Subclavian Insertion
Review Status Medicine Logged Acc. Rej. Pend. No Rev. Req. Exp. Compliance 2 0 0 0 2 5 NC (40%) 1
6
0
6
0
0
0
0
1
6
5
5
NC (20%)
C (100%+)
Beth Israel Medical Center CLABs Prevention Standardization of Practices Enforcement of Policy and Procedure Procedure Note Insertion Kit Nursing Empowerment
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:_______
Central Line Insertion Kit
Compliance - Central Line Bundle
Rate (%) 100 90 80 70 60 50 40 30 20 10 0 Aug Oct Dec Feb Time Apr Jun Aug
Results Data from PDSA Cycles
2004 2005 2006 2007 Number of CLABS 46 18 7 2 Costs of CLABS $1,510,000 $705,000 $392,000 $112,000 Incremental cost per episode of CLAB ranges from $25,000 to $56,000 (CDC data: Burke 2003)
Results Data from PDSA Cycles
2004 2005 2006 2007 Number of CLABS 46 Attributable Morbidity and Mortality 9 18 7 2 4 2 0 Attributable morbidity and mortality: 12 – 25% (Wenzel 2001)
Results Data from PDSA Cycles
Significant reduction in CLABs 95% reduction for institution Achievement of zero CLABs on a variety of units Reduction in morbidity and mortality Daily review of need for line necessity 20% decrease in central line days Reduction in costs incurred in caring for patients with CLABs $1,500,000 costs avoided 90% reduction in costs from 2004 Costs to implement Additional $15 per line inserted Total additional costs $30,000
Beth Israel Medical Center CLABs Prevention
CCU ICU ED SICU PICU non-ICU MICU CSICU Unit Longest Duration of Days Without CLAB 644 601 547 483 396 345 344 300
Beth Israel Medical Center CLABs Prevention ICUs
2 1 0 5 4 3 2004 2005 Rate per 1,000 Line Days 2006 2007 Rate per 100 Patients
BETH ISRAEL MEDICAL CENTER CLABs Prevention CCU
10 8 6 4 2 0 Q4 2005 Q1 2006 Q2 2006 CCU Q3 2006 Q4 2006 YEAR NHSN Q1 2007 Q2 2007 Q3 2007 NYS
Beth Israel Medical Center CLABs Prevention Root Cause Analyses Within 24 hours of a CLAB All involved patient care staff 4 – 12 persons ED, ICU, non-ICU 20 – 45 minutes Collaborative, non-punitive process
Beth Israel Medical Center CLABs Prevention Root Cause Analyses Process that generates sustainable fixes Avoid repeated “workarounds” that are constantly Knowledge gained from this process is shared with all
Beth Israel Medical Center CLABs Prevention Root Cause Analysis – August 2005 84 year old female with a history of hypertension, CHF, cardiac arrhythmia with pacer, insulin dependent diabetes Admitted to ICU with CHF exacerbation, pleural effusion Developed acute renal failure requiring dialysis Nephrologist places Shiley catheter Groin site chosen Difficult procedure requiring multiple attempts Maximal barrier precautions not fully utilized Nursing staff attempt to assist Call intensivist to place line Blood cultures positive for
C. albicans
48 hours later
Beth Israel Medical Center CLABs Prevention Root Cause Analysis – August 2005 Nephrologist conducts RCA Credentialed Central line indicated Urgent not emergent Supplies available and easily obtainable but not fully utilized for maximal barrier precautions Need to ask for assistance sooner rather than later Corrective Actions Central line insertion kit Nursing staff empowered and more comfortable with role Reeducation and recertification of nephrologist
Beth Israel Medical Center CLABs Prevention Root Cause Analyses
2005
Central Line Care
Dressings Access
Insertion Practices
Maximal barrier precautions Supplies never an issue Certification of physicians
Results - Data from PDSA Cycles ICU CLABs
10 8 6 4 2 0 2004 Q1 2005 Q2 2005 Q3 2005 YEAR ICU NHSN Q4 2005 Q1 2006
Beth Israel Medical Center CLABs Prevention Root Cause Analyses
2006
Central Line Care
Dressings Access
Maintaining the momentum
Results - Data from PDSA Cycles ICU CLABs
10 8 6 4 2 0 20 04 Q1 2 00 5 Q2 2 00 Q3 5 2 00 5 Q4 2 00 5 Q1 2 00 Q2 6 2 00 6 Q3 2 00 6 Q4 2 00 6 Q1 2 00 7 Q2 2 00 7 Q3 2 00 7 YEAR ICU NHSN
Beth Israel Medical Center CLABs Prevention
Use and monitoring of evidence based patient care practices or “bundles” with reporting back of data to end users resulted in the rapid and sustained elimination or decreased incidence of CLABs on many units Limited additional resources were necessary for the success of this initiative Efforts were effective for all areas of the hospital where central lines are inserted As compliance of CLABs with insertion bundle improves, line maintenance has assumed a greater role in the prevention Culture change regarding goal of zero CLABs infections is applicable for all hospital acquired infections and patient safety issues
GNYHA/UHF CLABs Collaborative • • • • • • • • • • • • • • • • • • • • • • Participating Hospitals Beth Israel Medical Center Bronx-Lebanon Hospital Center Brookdale Hospital Medical Center Cabrini Medical Center Good Samaritan Hospital Medical Center Interfaith Medical Center Kingsbrook Jewish Medical Center* Kingston Hospital* Lenox Hill Hospital Long Beach Medical Center Long Island College Hospital Lutheran Medical Center Montefiore Medical Center Mount Sinai Hospital • • • • North Shore-Long Island Jewish Health System, including: – Forest Hills Hospital – – – – – – – – – Franklin Hospital Glen Cove Hospital Huntington Hospital Long Island Jewish Medical Center North Shore University Hospital Plainview Hospital Southside Hospital Staten Island University Hospital Syosset Hospital Peninsula Hospital Center Richmond University Medical Center* Sound Shore Medical Center of Westchester Mount Sinai Hospital of Queens New York Downtown Hospital New York Hospital Queens* New York Methodist Hospital New York-Presbyterian Hospital New York University Medical Center North General Hospital Our Lady of Mercy Medical Center *Hospitals that joined the CLABs Collaborative in the second round of participation (i.e., in August/September 2006).
• • • • • • • • • • • St. Catherine of Siena Medical St. Charles Hospital St. Joseph’s Medical Center, Yonkers* St. Luke’s - Roosevelt Hospital Center St. Luke's Cornwall Hospital St. Vincent’s Medical Center, Manhattan* Stamford Hospital The Parkway Hospital* Trinitas Hospital Winthrop University Hospital* Wyckoff Heights Medical Center
GNYHA-UHF CLABs Collaborative Characteristics of Participating
•
Hospitals
• 38 hospitals participating, 56 ICUs*
At inception of Collaborative, hospital practice was widely variable across participants:
Area of Focus
Daily Goals Sheet Interdisciplinary Rounds Central Line Bundle Ventilator Bundle
Consistently Use
21 45 11 16
Inconsistently Use
7 9 27 30
Do Not Use
26 2 17 10
GREAT OPPORTUNITIES FOR IMPROVEMENT !
Responses obtained from ICUs within participating hospitals.
*Note that these were responses from the original group of 38 CLABs Collaborative participating hospitals.
GNYHA-UHF CLABs Collaborative Design • Systematic model for change that would – Meet needs of hospitals within the region – Use existing staffing and financial resources
• • • • • • • • • • •
GNYHA/UHF CLABs Collaborative Design
Hospital leadership involvement and commitment Interdisciplinary teams / Physician and Nurse champions Evidence-based interventions:
Implemented “Central Line Bundle”
3 learning sessions:
Reviewed key interventions for eliminating CLAB infections, guidelines for inserting central line, materials needed, maintaining central lines, hospital best practices, and approaches to sustaining improvements.
Bi-weekly conference calls:
Shared information / tools specific to reducing CLAB infections.
Collaborative web site for information-sharing:
http://jeny.ipro.org/clabs
“Expert on Call” clinical consultant Reinforcement of “zero tolerance” for CLAB infections Standardized Materials:
Teams developed and used standardized data collection and definitions
Root Cause Analysis (RCA)
: Real time RCAs encouraged to identify reasons for CLABs and develop solutions for prevention
Tracking Success:
Aggregate and hospital-specific results reported monthly and site visits made by Collaborative sponsors to identify areas in need of support Central Line Bundle: Hospital teams identified the “central line bundle” as a strategy to prevent infection during central line insertion. Components include: hand hygiene, use of maximal barrier precautions, chlorhexidine skin use, site of line placement, and review of line necessity. All necessary supplies should be available at the patient’s bedside when needed (creation of central line insertion kit).
CLABs Collaborative Website: http://jeny.ipro.org/clabs
Examples of Findings from Root Cause Analyses
Line Maintenance Technique not adequate Lack of Education and Staffing
Line not changed on timely basis Line in for too long Dressing not changed using aseptic techniques Not compliant with hand hygiene Line inserted w/o sterile technique IV tubing not labeled properly to change Line not manipulated appropriately Inadequate use of maximal barrier precautions Inadequate prep before insertion Femoral line subclavian Inexperienced residents and clinicians Clinicians not knowledgeable about Central Line Bundle chosen instead of Nurses do not properly know how to change dressings MD does not get someone to assist with line insertion Nurses too busy to check & change dressings
Central Line – Associated Bloodstream Infection
Barriers and Solutions
Barrier Lack of Compliance
•Maintenance •Technique
Lack of Education & Staffing Lack of Standardized Data Collection Solution Development of central line insertion & maintenance kits Creation of monitoring tools to assure compliance with bundle components Empowerment of nursing staff to stop procedure when bundle not followed Daily rounds to assess line necessity and assure appropriate maintenance Development of Department/Hospital-wide educational programs re: insertion and maintenance Reorganization of staffing to monitor and assure compliance Creation of protocols in which nursing signs off on dressing rounds Adoption of CDC’s NHSN definitions Monthly data fed back (CLAB infection rates) to participating hospitals and staff
GNYHA-UHF Collaborative 15-Month Data Results*
• • •
Bundle Implementation 1 :
88% reported full implementation; remaining 12% in process of fully implementing Mean pre-bundle implementation CLAB infection rate = 4.02 infections / 1,000 central line days Mean post-bundle implementation rate = 1.79 infections / 1,000 (p Value <0.0001) • • •
Overall Aggregate CLAB Infection Data:
Mean
baseline
rate = 4.86 infections / 1,000 central line days Mean fifteen-month
study period 2
infection rate = 2.38 infections / 1,000 51% overall decrease (p Value <0.0001) • • •
Comparison of CLAB Infection Data in 3-month Cohorts during 15 month Study Period 2 :
Mean
first three months
central line days (July through September 2005) = 3.10 infections / 1,000 Mean
last three months
(July through September 2006) = 1.76 infections / 1,000 43% decrease during the course of the study period (p Value = 0.015)
Maintaining Zero CLAB Infections during 15-month Study Period 2 :
• • 29 hospitals (81%) maintained zero for
at least 3 months
8 hospitals (22%) maintained zero
during the last 6 months
Notes: 1 Bundle implementation, reported by 34 of the 38 original participating hospitals through an
Interventions Survey
developed by Collaborative sponsors, April 2006.
2
Study Period
includes data collected by 36 of the 38 original participating hospitals from July 2005 through September 2006.
*Includes data from 36 of the 38 original participating hospitals
Monthly ICU Central Line Infection Rates for Hospitals Participating in the GNYHA/UHF CLABS Quality Improvement Collaborative Round 1 Hospitals
6.00
5.00
4.52
5.01
4.26
4.00
3.18
3.00
2.55
2.00
2.33
2.70
2.47
2.77
2.69
2.15
1.65
2.27
2.46
1.68
1.94
2.02
2.37
1.87
2.44
2.21
1.80
2.04
1.33
2.02
1.65
1.00
0.00
Baseline Jul-05 Sep-05 Nov-05 Jan-06 Mar-06 May-06 Jul-06 Sep-06 Nov-06 Jan-07 Mar-07 May-07
Monthly ICU Central Line Infection Rates for Hospitals Participating in GNYHA/UHF CLABS Quality Improvement Collaborative Round 2 Hospitals
6.00
5.13
5.00
4.75
4.00
3.31
3.00
2.62
1.88
2.00
2.45
1.73
0.88
1.00
0.68
0.81
0.00
Baseline Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07
Decreasing Incidence of MDROs!
BIMC Petrie KHD MRSA VRE MDR
Klebsiella
MDR
Acinetobacter C. difficile
65% 15% 15% 45% 10% 50% 25% 20% 50% 35% Costs avoided: $1.5 million