Preventing Harm: Eliminating Central Line

Associated Blood Stream Infections Project Overview & Background

KPNC Panel Discussion

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Definitions

CRBSI- Is a clinical definition that requires specific laboratory testing that thoroughly identifies the catheter as the source of BSI. Not routinely used for surveillance purposes.

CLABSI- Is the term used by NHSN, is a primary BSI in a person that had a central line within the 48hr period before the development of the BSI and is not related to an infection at another site. Therefore it may overestimate the true incidence of CRBSI.

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Let’s start with some numbers

Risk of infection per 1000 intravascular device day

(IVD) Pulmonary Arterial catheters- 3.7 BSI/1000 IVD days

HD Catheters- 2.8

Standard non tunneled non cuffed- 2.3

PICC- 2.1

Cuffed tunneled CVC- 1.2

Midline catheters- 0.8

SQ Ports- 0.2

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U.S. CLABSI Data

“80,000 CRBSI occur in ICUs each year”

• CRBSI are bloodstream infections introduced through the large intravenous catheters that deliver medication, nutrition, and fluids to patients in intensive care.

• 15 million central venous catheter (CVC) days in our ICUs every year.

• 250,000 CRBSI every year in US hospital wide

• Estimated cost = $28,000 each ICU CLABSI

CDC (2011) Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011.tT

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Routes to Infection

Intraluminal

migration

Extraluminal Migration (most

common in short term

catheters)

From Cath Tip during

insertion

Hematogenous

Seeding

Scales K (2011) Reducing infection associated with central venous access

devices. Nursing Standard. 25, 36, 49-56.

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Variation

A national study compared central-line infection

data for intensive-care units at 926 hospitals in 43

states finding wide variation within same cities

and even within same health care systems.

Consumer Reports, March 2010, “Deadly infections: Hospitals can lower the risk, but many fail to act”

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2010 CLABSI SPIKE

2010 ICU CVA Manteca Modesto

ICU Rooms 6 12

Ave CL Days 56 190

Utilization Rate 37% 66%

CLABSI 0 6

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CLABSI SPIKE 2010

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CLABSI SPIKE 2010

Team Established to Investigate Root Cause and

Recommend Interventions:

Clinical Education

Infection Control

Patient Care Services

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Discovery Modesto 2010

CLIP workgroup formed to monitor practices in the ICU as well as in the Medical-Surgical units

• Type of line – Central Venous or PICC

• Anatomical site

• Date of insertion

• Name of inserter

• Location of insertion – ED, ICU, OR, IR

• CLIP bundle completed?

• Dressings – dated and timed, changed per policy, documentation of change

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Immediate Implementation

“Minimize contamination risk by scrubbing the access port with an appropriate antiseptic…… Category IA” CDC Guideline, 2011

• Implemented Luer Access Valve Disinfectant Cap – One time use orange cap impregnated with 70% isopropyl alcohol

• Every Sunday central line dressing change

• Weekly hospital wide central line audits with visual inspections

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PICC Line

Dressing must be changed 24 hours post insertion

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PICC Line

PICC line dressings must be changed anytime it is

soiled; it also must have a chlorhexidine sponge

dressing

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Central Venous Line

“Use a chlorhexidine-impregnated sponge dressing for

temporary short-term catheters …..” CDC Guideline

However,

It needs to be

placed correctly

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Flushing

How much - 10ml or 20ml

How frequent – once a shift 8hr or 12 hr

How is it done – push/pause, pulsatile

Documentation of flushing

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What is wrong with this picture?

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Implementation Elements

Initiate Central Line Infection Prevention

(CLIP)committee

Implement a defined day of the week for weekly dressing

changes.

Complete facility assessment to establish baseline and

to identify gaps / areas of opportunity.

Implement Standardized Central Line Policies

Implement standard insertion kits.

Implement standard dressing change kits.

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Implementation Elements

Complete annual competency of central line

maintenance for all impacted RNs, with return

demonstration.

Implement standard patient/family education

materials.

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Implementation Elements

Establish workflows to ensure daily oversight of

central lines, to include daily dressing

observations, line necessity, and documentation.

Establish notification process to senior leaders

when an infection occurs.

Establish a process to monitor and/or confirm

daily oversight workflow

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Best Practices – Line insertion

• All providers, in all areas, insert lines following the central line bundle: Hand hygiene

Site preparation

Full barrier precautions

Optimal site selection

Daily review of line necessity reviewed and discussed

• PICC nurses insert PICC lines act as central line champions and expert resources for nurses in the unit.

• Line insertion is documented in health connect – includes all required elements in the Central Line Insertion Practice (CLIP) bundle

• Standard insertion kits are available in all areas needed in the facility

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Best Practices – Line Maintenance

• Standardized Line maintenance includes: Accessing the port or the injection cap, changing the cap, replacement of IV tubing

• Line Dressing: (post insertion bundle elements include) Daily inspection of area surrounding insertion site (looking for signs of

infection)

Dressing – dry and intact, dated and changed per policy

Daily assessment of line necessity

Proper application of the biopatch

• Documentation in KPHC - Line insertion, Dressing Change & Site Care

• Staff are trained and competent to assist with CL insertions, and in accessing (“Scrub the Hub”) and maintaining central lines (dressing changes) SuppliesDressing change kits are available with all required components

(e.g. includes bio-patch)

Pre-filled spring-loaded/pulsitile syringes (e.g. PosiFlushTM) are available

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Best Practices- Managers Role

• Standard Policies cover all units where central lines are inserted or cared for by staff.

• Managers know who has central lines on their units

• Managers know that “line necessity” is discussed daily Managers conduct observational audits of dressings Dry/intact

Dated and timed

Changed per policy

Standard appearance (bio-patch correctly positioned, not soaked)

• Managers periodically observe nurses accessing and flushing central lines (“scrub the hub” and pulsing flush)

• Managers know that staff have complete kits for insertion and line maintenance.

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Central Valley Service Area

Kaiser Permanente Manteca

Formerly known as St. Dominic’s Hospital (CHW)

Became Kaiser Permanente in 2004

San Joaquin County

Building opened Sept. 1990

ICU 12 hour shifts

ICU 6 bed

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Central Valley Service Area

Kaiser Permanente Modesto

Stanislaus County

Hospital opened Oct 2008

ICU 8-hr shifts

ICU 20 beds

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Contributing factors to discrepancy

• Cohesiveness of the nursing staff working

together

• Size of the unit

• Difference in length of shifts

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Set-up

-Target population

-Successful sites

-Key groups that will

make adoption decision

-Initial strategy to reach

all sites

Successful

Sites

Infrastructure:

A Framework for Spread

Social System -Key messengers -Communities

-Transition issues

-Technical support

Knowledge Management

Measurement and Feedback

Leadership -Topic is a key strategic initiative

-Goals and incentives aligned

-Executive sponsor assigned

-Day-to-day managers identified

Better Ideas -Develop the case -Describe the ideas

Source: Institute for Healthcare Improvement

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Determine Organizational readiness

to spread

• Start with the end in mind

• Determine how improvement links to strategic

objectives

• Assess practice readiness to spread

• Assess site readiness to receive

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Ownership Uniformity Reliability Sustainability

Heat

Harm Heart

(Cycles of Scrutiny

and Collaboration)

4WD

Compelling Need to Move

Destination

What Gets Us There:

Designing for Spread

Standardization / Systemization Leadership alignment Data that drives Project Management

OURS

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Align in Design & Implementation

Regional Hospital Leadership Hospital Leadership

Regional Faculty

Summits and Collaborative

Med Center

Steering

Committee

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Leadership Alignment

Physician,

Nursing and

Quality Peer

Groups

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Infrastructure & Systems

support spread

• Senior Leadership supports initiative as an

organizational priority

• Clearly define goal – What will success look like?

• Measurement strategy – how we know that medical

centers are implementing key elements to achieve

goal? How will you measuring spread?

• What infrastructure supports the work?

(collaborative calls, regular data to monitor

progress, site visits to understand practice,

successes and challenges.

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Scorecard on Patient Safety

Senior Leadership viewed data

Adult ICU

BSI

Adult Non-ICU

BSIC-Diff* ICU Mortality

Stage 3+

Reportable

HAPU

Falls Resulting in

Permanent Loss

of Function or

Death**

Safety

Climate

Verification

Injuries OR/ASU

& Cataract

Retained Foreign

Objects

OR/ASU

Study Period Q2'10 - Q1'11 Q3'10 - Q2'11 Q3'10 - Q2'11 Nov '10 Q3'10 - Q2'11 Q3'10 - Q2'11

2011 Target 0 0 4.2 12.0% 0.07 0 70% 0 0

Antioch 0 - 0 - 0 - 4 1 - 1 - 1 - 1 3.5 11.0% 0.03 0 - 1 - 0 - 0 65% 0 - 0 - 0 - 0 0 - 0 - 0 - 0

Fremont 1 - 1 - 0 - 0 0 - 0 - 0 - 0 3.0 10.8% 0.00 0 - 0 - 0 - 0 76% 0 - 0 - 0 - 0 0 - 0 - 0 - 0

Fresno 0 - 0 - 0 - 0 0 - 0 - 0 - 0 4.9 16.1% 0.06 0 - 3 - 0 - 1 51% 0 - 0 - 0 - 0 0 - 0 - 1 - 0

Hayward 0 - 0 - 0 - 0 1 - 0 - 0 - 0 3.9 10.8% 0.05 0 - 0 - 0 - 0 76% 0 - 0 - 0 - 0 0 - 0 - 0 - 0

Manteca 0 - 0 - 0 - 0 0 - 0 - 0 - 0 4.4 9.6% 0.00 0 - 0 - 0 - 0 67% 0 - 0 - 0 - 0 0 - 0 - 0 - 0

Modesto 0 - 0 - 0 - 1 0 - 0 - 0 - 1 4.2 9.6% 0.07 0 - 0 - 0 - 0 69% 0 - 0 - 0 - 1 0 - 1 - 1 - 0

Oakland 0 - 2 - 2 - 2 0 - 3 - 3 - 2 4.6 12.1% 0.05 1 - 0 - 1 - 0 48% 0 - 0 - 0 - 2 0 - 0 - 2 - 0

Richmond 2 - 0 - 0 - 0 1 - 0 - 0 - 0 8.0 12.1% 0.07 0 - 1 - 0 - 0 54% 0 - 0 - 0 - 0 0 - 0 - 0 - 0

Roseville 0 - 0 - 1 - 0 5 - 1 - 1 - 0 4.1 12.7% 0.02 0 - 0 - 0 - 1 54% 0 - 0 - 0 - 0 0 - 1 - 0 - 0

Redwood City 0 - 0 - 0 - 0 0 - 0 - 0 - 0 5.6 12.3% 0.03 1 - 0 - 0 - 0 67% 0 - 0 - 0 - 0 0 - 0 - 0 - 0

Sacramento 0 - 0 - 0 - 0 1 - 1 - 1 - 1 6.1 12.7% 0.02 0 - 0 - 0 - 1 55% 0 - 0 - 0 - 0 0 - 0 - 0 - 0

Santa Clara 2 - 0 - 0 - 0 3 - 3 - 3 - 3 6.1 8.8% 0.06 0 - 0 - 0 - 0 67% 0 - 0 - 0 - 0 0 - 0 - 1 - 0

San Francisco 1 - 3 - 3 - 2 5 - 1 - 1 - 1 4.6 7.2% 0.16 0 - 0 - 0 - 0 67% 0 - 0 - 0 - 0 1 - 0 - 0 - 1

San Rafael 0 - 0 - 0 - 0 0 - 1 - 1 - 0 4.3 11.3% 0.13 0 - 0 - 0 - 0 61% 0 - 0 - 0 - 0 1 - 0 - 0 - 0

Santa Rosa 0 - 0 - 0 - 0 0 - 0 - 0 - 1 2.7 10.7% 0.10 0 - 0 - 0 - 0 60% 0 - 1 - 0 - 0 0 - 0 - 1 - 0

S. Sacramento 0 - 0 - 0 - 0 2 - 0 - 0 - 0 4.3 12.5% 0.16 0 - 0 - 0 - 0 71% 0 - 0 - 0 - 0 0 - 0 - 0 - 0

S. San Francisco 0 - 1 - 1 - 0 0 - 0 - 0 - 0 5.4 15.2% 0.00 0 - 0 - 0 - 0 67% 0 - 0 - 3 - 0 0 - 1 - 0 - 0

San Jose 0 - 0 - 2 - 1 1 - 0 - 0 - 1 4.5 9.5% 0.06 0 - 0 - 0 - 0 69% 1 - 0 - 0 - 0 1 - 0 - 0 - 0

Vacaville 0 - 0 - 1 - 1 0 - 0 - 0 - 0 3.2 #N/A 0.00 0 - 0 - 0 - 0 89% 0 - 0 - 0 - 0 0 - 0 - 0 - 0

Vallejo 0 - 0 - 0 - 2 1 - 4 - 4 - 0 5.0 12.9% 0.03 1 - 0 - 0 - 0 52% 0 - 0 - 0 - 0 0 - 0 - 0 - 0

Walnut Creek 0 - 1 - 1 - 0 1 - 2 - 2 - 1 7.0 13.0% 0.05 1 - 0 - 0 - 1 63% 0 - 0 - 0 - 0 0 - 1 - 0 - 0

KPNC Region 6 - 8 - 11 - 13 22-17-17-12 4 - 5 - 1 - 4 1 - 1 - 3 - 3 3 - 4 - 6 - 1

KPNC Regional Total 38 68 14 8 14

% Facs Meeting Target 38% 29% 33% 50% 81% 57% 19% 76% 48%

11.5% 0.06 64%4.9

Q3'10 - Q2'11

Patient SafetyQ2 '11

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Collaboration: Sharing information

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Thank you

Questions?