Central Line Associated Central Line Associated Bloodstream Infection Bloodstream Infection

Prevention is Primary!Prevention is Primary!

Tennessee CollaborativeTennessee CollaborativeReducing Healthcare Associated Reducing Healthcare Associated

Infections Infections

Erlanger Health System Erlanger Health System ImplementationImplementation

Erlanger Health SystemErlanger Health System

Level 1 Trauma Level 1 Trauma CenterCenter

4 Inpatient 4 Inpatient Campuses Campuses

564 Inpatient Beds - 564 Inpatient Beds - Adult and PediatricsAdult and Pediatrics– 77 Adult ICUs with Adult ICUs with 6666

beds beds – 5050 bed Neonatal ICU bed Neonatal ICU – 88 bed Pediatric ICU – bed Pediatric ICU –

expanding to 12 bedsexpanding to 12 beds

CLA-BSI Prevention CLA-BSI Prevention “Erlanger Timeline”“Erlanger Timeline”

19991999 Implemented CHG skin prep for CVL insertions Implemented CHG skin prep for CVL insertions and site care and use of antimicrobial impregnated CVL and site care and use of antimicrobial impregnated CVL in TICUin TICU

2000- 20012000- 2001 Implemented use of CHG skin prep and Implemented use of CHG skin prep and antimicrobial impregnated CVL in other ICUsantimicrobial impregnated CVL in other ICUs

20022002 Standardized central line dressing change kit and Standardized central line dressing change kit and site care site care

20032003 Implemented new central line insertion kits to Implemented new central line insertion kits to include all items for the procedure including;include all items for the procedure including;

Full Sheet drape Full Sheet drape Chloraprep™Chloraprep™ Safety devicesSafety devices

CLA-BSI PreventionCLA-BSI Prevention“Erlanger Timeline”“Erlanger Timeline”

20062006 Central Line Central Line checklist implemented checklist implemented

2007 2007 Development of Development of poster to show the poster to show the major points related to major points related to CVL insertion and CVL insertion and placed on all patient placed on all patient care unitscare units

2008-092008-09 Participation Participation in the statewide in the statewide initiative to reduce initiative to reduce healthcare associated healthcare associated infectionsinfections

““Bundle Components”Bundle Components” Hand HygieneHand Hygiene Maximal sterile barriersMaximal sterile barriers CHG skin antisepsis- Chloraprep®CHG skin antisepsis- Chloraprep® Optimal site selection- avoid femoral Optimal site selection- avoid femoral

lineline Daily review of line necessityDaily review of line necessity Line maintenance- dressing changes, Line maintenance- dressing changes,

disinfection of access ports, limit disinfection of access ports, limit number of times it is accessed!number of times it is accessed!

Elements of Elements of Implementation Implementation

#1 Education#1 EducationMultidisciplinary TeamMultidisciplinary Team formed with members from; formed with members from;

ICIC

Executive Management, leaders from Critical Care,Executive Management, leaders from Critical Care,

Med/Surg, Anesthesia, Children’s, and frontline staff.Med/Surg, Anesthesia, Children’s, and frontline staff.

EducationEducation; ;

BarrierBarrier: : Large facilityLarge facility SolutionSolution: :

• Developed a computerized comprehensive education Developed a computerized comprehensive education program/s which is required by all who manage CVLsprogram/s which is required by all who manage CVLs

• Visual education- picture is worth a thousand words!Visual education- picture is worth a thousand words!

ICU Nurse’s Hands Pre-hand hygiene

Normal skin flora carried by the healthcare provider puts susceptible patients at risk

Clave Cultures

Before Alcohol Swab

After alcohol Swab (10 reps)

Swab it every time. Make it safe for your patient.

Elements of Elements of Implementation Implementation

#2 Standardize#2 Standardize BarrierBarrier: :

– Bundle Checklist: Initially taped on top of Bundle Checklist: Initially taped on top of each CVL kit- Misplaced, torn off, missingeach CVL kit- Misplaced, torn off, missing

SolutionSolution::– Developed custom kit that included Developed custom kit that included

checklist placed inside the kit and placed checklist placed inside the kit and placed checklist on intranetchecklist on intranet

– IV team responsible for dressing changes IV team responsible for dressing changes for all CVLsfor all CVLs

Elements of Elements of Implementation Implementation

#2 Standardize#2 Standardize BarrierBarrier: :

Issue’s with Daily Maintenance – Different Issue’s with Daily Maintenance – Different dressing change protocolsdressing change protocols

SolutionsSolutions::IV team responsible for dressing IV team responsible for dressing

changes for all patients with CVLschanges for all patients with CVLs

Elements of Elements of Implementation Implementation

#2 Standardize#2 Standardize

BarrierBarrier: “Daily Review of Line : “Daily Review of Line Necessity”Necessity”

SolutionsSolutions::• Added an area for documentation of “daily Added an area for documentation of “daily

review of line necessity” to the nursing flow-review of line necessity” to the nursing flow-sheetsheet

• Developed an electronic report of all patients Developed an electronic report of all patients with CVLs -automatically forwarded to the with CVLs -automatically forwarded to the nurse managersnurse managers

Elements of Elements of Implementation Implementation #3 Feedback of Data#3 Feedback of Data

• Unit specific infection data is forwarded Unit specific infection data is forwarded monthly to nurse managers and physician monthly to nurse managers and physician leaders. Information is shared with frontline leaders. Information is shared with frontline staffstaff

• Monthly compliance data is placed on each Monthly compliance data is placed on each area’s “report card” and posted in the area area’s “report card” and posted in the area

• This data is shared with frontline staff at staff This data is shared with frontline staff at staff meetings and monthly credentialing classes meetings and monthly credentialing classes

• Celebrate success! Celebrate success!

Outcome Measure: BSIs per 1,000 Line Days

0

1

2

3

4

5

6Ja

n-07

Feb-

07M

ar-0

7Ap

r-07

May

-07

Jun-

07Ju

l-07

Aug-

07Se

p-07

Oct

-07

Nov-

07De

c-07

Jan-

08Fe

b-08

Mar

-08

Apr-0

8M

ay-0

8Ju

n-08

Jul-0

8Au

g-08

Sep-

08O

ct-0

8No

v-08

Dec-

08Ja

n-09

Feb-

09M

ar-0

9Ap

r-09

May

-09

Jun-

09

Cent

ral L

ine

Asso

ciat

ed B

SIs

0

300

600

900

1200

1500

1800

Cent

ral L

ine

Days

Primary CLA-BSI (per CDC) CL Days

0

1

2

3

4

5

6

Jan-Mar 08

Apr-Jun

Jul-Sept

Oct-D

ec

Jan-Mar 09

Apr-Jun 09

Cen

tral

Lin

e In

fect

ion

s

50

100

150

200

250

300

350

400

450Infections Total Central Line Days

Success StoriesSuccess StoriesCSICU & NNICUCSICU & NNICU

0

1

2

3

4

5

6

Jan-Mar 08

Apr-Jun

Jul-Sept

Oct-D

ec

Jan-Mar 09

Apr-June

09

Cen

tral

Lin

e In

fect

ion

s

0

50

100

150

200

250

300

350

400

450Infections Total Central Line Days