Transcript PowerPoint presentation

On the CUSP: STOP BSI
Toward Eliminating Central Line Associated
Blood Stream Infections
Immersion Call Overview
1. Project overview
2. Science of Improving Patient Safety
3. Eliminating CLABSI
4. The Comprehensive Unit-Based Safety Program
(CUSP)
5. Building a Team
6. Physician Engagement
© 2009
Learning Objectives
• To understand the model for translating evidence
into practice
• To explore how to implement evidence-based
behaviors to prevent CLABSI
• To understand strategies to engage, educate,
execute and evaluate
© 2009
Safety Score Card: Keystone ICU
2004
2006
How often did we harm (BSI) (median)
2.8/1000
0
How often do we do what we should
66%
95%
How often did we learn from mistakes*
100s
100s
Have we created a safe culture
What areas need improvement (%)
Safety climate*
Teamwork climate*
84%
82%
43%
42%
* CUSP is intervention to improve these
Pronovost PJ, Holzmueller CG, Needham DM. CCM 2006
Pronovost PJ, Berenholtz SM, Needham DM. JAMA 2007
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Translating Evidence
into Practice
Pronovost, Berenholtz, Needham. BMJ 2008
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Evidence-based Behaviors
to Prevent CLABSI
1. Remove Unnecessary Lines
2. Wash Hands Prior to Procedure
3. Use Maximal Barrier Precautions
4. Clean Skin with Chlorhexidine
5. Avoid Femoral Lines
Marschall et al. Infect Control Hosp Epidemiol 2008
CDC.gov
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Evidence-based Behaviors
to Prevent CLABSI
1. Remove Unnecessary Lines
2. Wash Hands Prior to Procedure
3. Use Maximal Barrier Precautions
4. Clean Skin with Chlorhexidine
5. Avoid Femoral Lines
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Identify Barriers
• Ask staff
– about knowledge of prevention recommendations
– what is difficult about doing these behaviors
• Walk the process of staff placing a central line
• Observe staff placing central line
Gurses, Murphy, Martinez. Jt Comm J Qual Patient Saf 2009
© 2009
CLABSI definition
• For determining CLABSI rate
– Numerator: number of CLABSIs
– Denominator: number of central line-days
– Expressed as a rate of X CLABSI/1,000 central line days
• #CLABSI/# central line days X 1000
National Healthcare Safety Network (NHSN):
Device-Associated (DA) Module
www.cdc.gov/nhsn/psc_da.html
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What is a Central Line?
The following are examples of
central lines, as long as they
terminate at or close to the heart
or in one of the great vessels
NOTE: This list is not all-inclusive
The following are examples of
devices that are not central lines
NOTE: This list is not all-inclusive
Non-tunneled central lines
Tunneled central lines
Introducers
Implanted ports
Hemodialysis catheters
Peripherally inserted
central catheters (PICCs)
• Femoral artery catheter
• Pacemakers
• Implanted cardiac
defibrillators
• Radial, dorsalis pedis,
brachialis, ulnar arterial
lines
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Ensure Patients Reliably
Receive Evidence
Senior
leaders
Team
leaders
Staff
Engage
How does this make the world a better place?
Educate
What do we need to do?
Execute
What keeps me from doing it?
How can we do it with my resources and
culture?
Evaluate
How do we know we improved safety?
© 2009
Partnership
• To help with 4Es, partner with:
− Infection control staff
− Hospital quality and safety leaders
− Nurse educators
− Physician leaders
ICU staff must assume responsibility for reducing CLABSI
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Engage
• Share about a patient who was infected
• Share stories about when nurses ensured patients
received the evidence
• Post baseline rates of infections
• Estimate number of deaths and dollars from current
infection rates (see opportunity calculator on website)
• Remind staff that most CLABSI are preventable
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Educate
• Conduct in-service regarding CLABSI prevention
• Create forum to jointly educate physicians and nurses
• Add CLABSI prevention to unit orientation
• Give staff fact sheet, articles and slides of evidence
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Execute
• Standardize: Create line cart or kit that includes
necessary supplies for line insertion
• Create independent checks
• Create line insertion checklist
• Empower nurses to ensure that physicians comply with
checklist
– Nurses can stop takeoff for non-emergent insertions
• Learn from mistakes
• Review every infection using learning from defect
tool
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Daily Goals
• What needs to be done for
the patient to be
discharged?
• What is the patients
greatest safety risk?
• What can we do to reduce
the risk?
• Can any tubes, lines, or
drains be removed?
Pronovost, Berenholtz, Dorman. J Crit Care 2003
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Evaluate
• Post in the unit rates of infections per quarter
• Post number of weeks or months without an infection
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Action Items
• Meet with unit based CUSP/CLABSI team, infection
control staff, quality and safety leaders, nurse educators,
and physician champions
• Understand barriers to eliminating CLABSI
• Walk the process and talk to providers
• Assess what you have for placing central lines; do
you have all recommended pieces of the bundle?
• Work with supply to order anything you don’t have
for recommended line insertion kit or cart
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Action Items
• Use 4E grid to develop strategies to engage,
educate, execute and evaluate
– Identify local stories to engage stakeholders
– Post CLABSI rate in your unit
– Post estimated number of deaths and dollars based on
CLABSI rate in your unit
– Develop and implement strategy to educate
stakeholders
– Look at the CLABSI checklist sample and begin to modify
for your use
– Who will nurses call if providers do not comply with
recommendations after being reminded? Who is going
to back-up nursing?
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References
•
CDC. Guidelines for the Prevention of Intravascular Catheter-Related
Infections; August 2002. www.cdc.gov
•
Gawande A. The checklist. The New Yorker 2007 Dec. Annals of
Medicine section.
•
Goeschel CA, Pronovost PJ. Harnessing the potential of healthcare
collaboratives: Lessons from the Keystone ICU project. AHRQ
Advances in Patient Safety: New Directions and Alternative
Approaches, in press.
•
Gurses, Murphy, Martinez. A practical tool to identify and eliminate
barriers to comlpiance with evidence-based guidelines. Jt Comm J
Qual Patient Saf 2009;35(10):526-32.
© 2009
References
•
Lubomski LH, Marsteller JA, Hsu YJ, Goeschel CA, Holzmueller CG,
Pronovost PJ. The team checkup tool: Evaluating QI team activities
and giving feedback to senior leaders. Jt Comm J Qual and Pat Saf
2008 34(10):619-23.
•
Marschall et al. Strategies to Prevent Central Line–Associated
Bloodstream Infections in Acute Care Hospitals. Infect Control Hosp
Epidemiol 2008;29(S1):S22-S30.
•
Pronovost PJ, Berenholtz SM, Dorman T. Improving communication in
the ICU using daily goals. J Crit Care 2003; 18(2):71-75.
•
Pronovost PJ, Needham D, et al. An intervention to decrease
catheter-related bloodstream infections in the ICU. New Eng J Med
2006 355(26):2725-32.
•
Pronovost PJ, Holzmueller CG, et al. A practical tool to learn from
defects in patient care. Jt Comm J Qual and Saf 2006 32(2):102-8.
© 2009
References
•
Pronovost P, Holzmueller CG, Needham DM, Sexton JB, Miller M,
Berenholtz S, Wu AW, Perl TM, Davis R, Baker D, Winner L, Morlock L.
How will we know patients are safer? An Organization-wide
Approach to Measuring and Improving Safety. Crit Car Med
2006;34(7):1988-1995.
•
Pronovost PJ, Berenholtz SM, Needham DM. A Framework for
Healthcare Organizations to Develop and Evaluate a Safety
Scorecard. JAMA 2007;298(17):2063-2065.
•
Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into
practice: a model for large scale knowledge translation. BMJ 2008
337:963-965.
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Pronovost PJ, Berenholtz SM, et al. Improving patient safety in
intensive care units in Michigan. J Crit Care 2008 23(2):207-21.
© 2009