central line associated bloodstream infections

Vanderbilt Infection Control & Prevention

Central Line Associated Bloodstream Infections

Tennessee Center for Patient Safety

Vicki Brinsko RN, CIC

Goal: Preventing CLABSI

Using the Central Line Bundle 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


Engage

Partner with Infection Control, ID experts

Increase awareness about morbidity and mortality associated with CLABSI

Make harm visible Tell stories Post # infections

Estimates of opportunity to improve


Thank You Notes to NICU Staff

Thank You From Thank You From Baby Boy JonesBaby Boy Jones

I have gone 136 days without a bloodstream infection. Keep up the

good work! My Mom left some “kisses” for you! XOXOX


Form the Dream Team

Heterogeneous in make up; homogeneous in mind set

All stakeholders must be included All RN teams fail because

MDs insert lines

Find a high profile champion

Get a process owner


TEAM FORMATION

ICU Director ICU Nurse Manager

Infection Control Practitioners

Chief Hospital Epidemiologist

Attendings & Residents

Nursing Staff (ICU)

QA/Quality Staff QI experts

Frontline Staff

Infectious Disease experts

Leaders


National Quality Scholars

Educate

Educate staff and senior leaders about CDC guidelines 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


http://www.mc.vanderbilt.edu/root/vumc.php?site=micututorial

Evaluate

Outcome measure: CLABSI rate Rate, # infections, weeks/months since last

infection

Process measures % checklists completed % violations noted # lines removed

Celebrate success


Share the Data

CLA-BSI in Trauma

0

1

2

3

4

5

6

7

8

9

2005 2006 2007

Infs

per

100

dev

ice

days

TraumaCDC Benchmark


BSI Bundle

The Check List

Adapt to your own institution

Must be filled out for each line insertion

Include 5 BSI bundle elements Simpler is better Can always add

elements as you become better at capturing data

LF

Time end (catheter secured):

MR #:

Check if:

Femoral

Internal Jugular

/ / Date:

Type of catheter:

Triple lumen Introducer Swan-Ganz

Insertion Site:

Subclavian

Other (specify):

Pt/Family teaching done Consent obtained

Pre-insertion skin prep (check any used): Alcohol Betadine (povidone-iodine) Chlorhexidine Other (specify):

Describe the circumstances under which this line was placed: Non-emergent Emergent (life-threatening or code situation)

Please file page 2 in patients chart and return top form to the designated location in the ICU.

List all sites where insertion was attempted. Other (specify):

: Time start (1st needle stick): :

How many different needle sticks did the patient receive (number of skin breaks)?

1 Unknown

The provider inserting this line:

* If “No”, was this procedure supervised by someone with least five (5) central lines experience? Yes No Didn’t ask

Yes No

Please use military time (i.e. 1:00 pm is 13:00)

a. Handed-off his/her pager before the procedure? Yes No b. Washed hands immediately prior to procedure? Yes No *

Didn’t ask Didn’t ask Didn’t ask c. Has previously placed at least five (5) central lines?

Describe the level of training of the person who actually inserted the line? Medical Student Intern (PGY-1) Resident (PGY-2+) Fellow Attending

Barrier precautions (check any used): Sterile gloves Sterile gown Mask Sterile towels Full body drape

Side: Right Left

2 3 4 5 6+

Follow-up CXR: Ordered Not ordered (specify reason):

CXR findings (check all that apply): No pneumothorax Pneumothorax (describe action taken): Catheter in good position Catheter position adjusted (describe):

Type of dressing: Bio-occlusive Gauze Other (specify):

Patient tolerated the procedure well? Yes No

Was the sterile field maintained throughout the entire procedure? Yes No

Complications? None Other (describe):

Dressing applied by: Nurse Proceduralist Other (specify):

Nursing Checklist: Central Venous Catheter Insertion

Vanderbilt University Medical Center

RIJ LIJ RSC LSC RF

Guidewire exchange

Placement unsuccessful

MC 2705 (Rev. 06/04)

NOTE: Please use either black or blue ink to complete this form.

Comments:

Vascath

Signature: ______________________________________________ Date: _________________

Indications for use: Pressors Hemodynamic monit. Fluids/blood products Frequent lab draws

Pre-existing infection

Nurse Practitioner

Double lumen

atVanderbilt

Monroe Carell Jr. OR

CCU MICU SICU BICU PCCU NICU

NSICU TICU Other


Execute

Hand Hygiene Remove Unnecessary Lines Use of Maximal Barrier Precautions Chlorhexidine for Skin Antisepsis Avoid femoral lines


Hand Hygiene

Empower nursing to enforce use of a central line checklist to be 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.


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.


Insertion Kits or CL Carts

Keep equipment stocked in 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 possibleMay Need to Order CHG and/or Kits

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.

Central Line Site Selection

Whenever possible, and not contraindicated, the subclavian line site should be preferred over the jugular and femoral sites for non-tunneled catheters in adult patients.


http://content.nejm.org/cgi/video/357/24/e26/

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.


Create Redundancy

Develop strategy to ask daily if lines can be removed Daily Goals Nursing/physician sign outs on Rounds

Implement checklist to be completed at time of insertion Nurses present during line insertion Support for speaking up Modify checklist for local use


Getting Started

Do Your Homework First!!

Interdisciplinary team Gain consensus on

plans Create timeline for

deliverables


Start Small

Select the team and the venue. It is often best to start in one 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.


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.


One ICU…then the Rest

Once the bundle has been applied 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

…So Use Data


http://groups.myspace.com/index.cfm?fuseaction=groups.groupImages&groupID=105318318&groupName=Obsessive%20Hugh%20Laurie%20Fanatics&Mytoken=80DC34C8-3D31-4D56-8E152C79A14CB6FC48628794

CLABSI per 1000 Line Days

CLABSI X 1000CL 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


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


Questions?


central line associated bloodstream infections

Education

bloodstream infection

central line placement

central line checklist

line insertioninclude

hand sanitation equipment

clabsi raterate

senior leaders

procedurescdc guidelines