October 16-22, 2011

Supporting Partners:Australian IC AssociationCert. Bd of IC & Epid.CHICA-CanadaIFICInf. Prevention SocietyInter. Sci. Forum-Home Hyg / HthNational Resource for ICRoyal College of NursingSHEA

Et al….

Efficacy of Performance Improvement Collaborative: Case study involving CLABSI*Prevention Bundle...Is a Checklist Sufficient?Parallel Symposium, APIC, 11th Congress of IFIC. Russell N. Olmsted, MPH, CIC2011 President, APIC, 13 October, 2011

* Central line-associated bloodstream infection

IFIC, Grazie Mille!, for this Opportunity to Present This

Symposium Acknowledgement & Thanks to my co-faculty:

Katrina Crist

Nizam Damani

Milestones in Prevention of Health care-associated Infections (HAIs), U.S.

“ Public interest in HAIs reached an important tipping point in 2005-2006 with the publication of two studies about prevention of CLABSIs… PRHI and the other Johns Hopkins and the Michigan Hospital Association. Both brought together staff who collaborated to reduce CLABSIs. The results of the studies were striking and consistent. In each,CLABSIs were reduced by roughly 65%.”

Dixon RE. Control of Health-Care--Associated Infections, 1961—2011. MMWR 2011;60(4): 58-63.

2003 2010

Power of the Consumer: Growth in State-based

Legislation on HAI Reporting Mandates

Reporting of CLABSI in ICUs, 2011 and Colon surg + Abd. Hyst, 2012

2011

Trends in Incidence of CLABSI, U.S.2001-2009

•58% reduction in No. of cases in ICU [pooled mean, NHSN 3.64 (2001) vs 1.65 (2009)

•27,000 lives saved

•CLABSI cost avoidance = $1.8 Billion

05,000

10,00015,00020,00025,00030,00035,00040,00045,000

2001 2009

ICUNon ICUDialysis

Pathogenesis IV Associated Infection

More Common Mechanisms

• Pathogen migration along external surface: More common < 7 days• Pathogen migration from point of access: More common >10 days

Staff education on CLABSI Prevention Strategies

o Update policies

Improving system performance: standardization

o CVC equipment cart

Checklist to ensure adherence with Central Line (CL) insertion practices

o RN assist/observe total procedureo Complete the check list form

Providing feedback to staff on process and outcome data

Promote a culture of safety

Keystone Project

Implemented at SJMH: 2004

• Michigan Keystone Project• Overall rate of CLABSI in 103 ICUs in Michigan

reduced by 66%

Pronovost et al. NEJM 2006;355:2725-32.

CLABSI Prevention Bundle

Basic Interventions:

– Hand hygiene– Full barrier precautions during CL insertion– Skin cleansing with chlorhexidine– Use of insertion checklist– Avoiding femoral site– Removing unnecessary catheters

Hand Hygiene

WHO 5 Moments

Standardize

Maximal Barrier Precautions

Maximal sterile barrier precautionsUse maximal sterile barrier precautions, including the use of a cap,

mask, sterile gown, sterile gloves, and a sterile full-body drape for insertion of CVCs, PICCs, or guidewire exchange. Category IB.

CDC/HICPAC CRBSI Prevention Guideline, 2010

CDC/HICPAC CRBSI Prevention Guideline, 2010

Skin Preparation– Prepare clean skin with a > 0.5% alcohol-based

chlorhexidine preparation before central venous catheter insertion and during dressing changes. If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives. Category IA

1. Today’s Date:___________________________________ Start Time:_____________________

2. Location: �CICU MICU SICU CCU-Liv Interv. Radiol Other Unit:_________________

3. Procedure: � New Line � Guidewire exchange ; # of Lumens ________ Type of Line:� Pulm. Art. (Swan) � PICC ; � Tunneled � Non-tunneled ; � Intended for Dialysis?

4. Is the procedure: Elective Emergent (during an arrest)

5. Line Location: � Subclavian � Jugular � Femoral � Right Side � Left SideRationale for Femoral Site ______________________________

Central Line Insertion Checklist

TIME OUT— Complete Universal Protocol Procedure and Form

•If there is an observed violation of infection control practices, line placement should stop immediately and the violation should be corrected. If a correction is required, mark yes to question #9.• If there are any concerns, the nurse at the bedside or assistants should contact appropriate supervisor.

Purpose: To work as a team to decrease patient harm from CLABSIsWhen:During all central venous or central arterial line insertions or guidewire exchangeBy whom: Bedside nurse or other assistant

CLABSI Outcome Data, SJMHS, Ann Arbor, MI, U.S. 2004-2010

Nov-10Mar-10Jul-09Nov-08Mar-08Jul-07Nov-06Mar-06Jul-05Nov-04Mar-04

12

8

4

0

Month/year

Indi

vidu

al V

alue

_X=1.39

UCL=4.61

LCL=-1.83

Mar-04Jul-04Mar-04Jul-04Mar-04Jul-04

Nov-10Mar-10Jul-09Nov-08Mar-08Jul-07Nov-06Mar-06Jul-05Nov-04Mar-04

6

4

2

0

Month/year

Mov

ing

Ran

ge

__MR=1.211

UCL=3.956

LCL=0

Mar-04Jul-04Mar-04Jul-04Mar-04Jul-04

6666666666666666

1

8

8

6

1

5

111

11

11

I-MR Chart of BSI rate by Month/year

Project: BSI CONTROL CHART.MPJ; Worksheet: Worksheet 1; 01/28/2011

Rate

No.Cases

Can CLABSI Prevention Be Sustained?

Pronovost PJ, et al. Sustaining reductions in catheter related bloodstreaminfections in Michigan intensive care units: observational study. BMJ 2010;340:c309

Mean & median CLABSI rate at 36 months after ICU collaboration = 1.1 & 0.0

0

10

20

30

40

50

60

70

80

90

100%

of r

espo

nden

ts w

ithin

an IC

U re

porti

ng g

ood

team

work

clim

ate

Teamwork Climate Across Michigan ICUs

No BSI 21%No BSI 21% No BSI 44%No BSI 44%No BSI 31% No BSI 31%

No BSI = 6 months or more w/ zeroNo BSI = 6 months or more w/ zero

The strongest predictor of clinical excellence:caregivers feel comfortable speaking up if they

perceive a problem with patient care

Is a Checklist Sufficient?

• “Culture is local. It occurs in the cracks and corners of hospitals and is unique to each and every unit…

• Doctors and nurses need more than a checklist…you can give clinicians a checklist, but if it’s not used properly, if nurses do not question problems with care delivery, if culture does not improve, the infection rates won’t go down…”– Pronovost P, Vohr E. Safe Patients, Smart Hospitals,

2010.

Non-ICU CLABSIs:

Pathogen & Line-Type Details

Non-ICU Central Line Types FY11 (Jul10 - Jun11)

Piccs53%

Perm Caths41%

TLC femoral0%

TLC IJ0% Port

6%

Non-ICU CLABSI Pathogens FY11 (Jul10 - Jun11)

Staph aureus23%CONS

12%Diphtheroids6%

Klebsiella pneu6%

Micrococcus0%

Serratia6%

Candida23%

Pseudomonas6%

Enterobacter6%

Enterococcus12%

No. Non-ICU CLABSIs

2010 = 22

2011 = 13 YTD (Aug ’11)

23

Limitations of the Checklist

• Use of CLs in ICUs is high however the number of these in use outside the ICU is increasing

• Culture in non-ICU is different from ICU

Clin Infect Dis 2010

24

Limitations of the Checklist

Clin Infect Dis 2010

Checklist is present but are personnel incorporating infection prevention into theirdaily care? Survey of 250 NHSN facilities: 38% reported complete use of all elements

Need > 95% adherence before a correlation was seen with lower CLABSI rates

AHRQ Safety Assessment Tool

http://www.ahrq.gov/qual/patientsafetyculture/hospsurvindex.htm

Conceptual ModelFor ImplementationScience

Saint S, et al ICHE 2010

Summary Points• Prevention strategies depend on a strong foundation of

scientific evidence• A very high proportion of CLABSIs can be prevented

when prevention strategies are part of routine care.• A checklist alone will not necessarily eliminate CLABSIs• Culture beats strategy in most units and all culture is

local.• Assess culture of safety• Use a conceptual model to promote patient safety

practicesThank You.