reduce piv complications and costs using the five rights ......reduce piv complications and costs...
TRANSCRIPT
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Reduce PIV Complications and Costs Using the Five Rights Approach
MAVAN Conference, June 5th, 2019
By Lee Steere, RN, CRNI, VA-BA – Unit Leader, IV Therapy Services
Hartford Hospital, Connecticut
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Lee Steere Bio
6/3/2019Confidential. Internal Use Only.
2
RN / 23 years
Hartford Hospital, Unit Leader IV Therapy Services /14 years
▪ Member of the hospital’s HAI committee since 2007 / Chair, 2 years
▪ Co-chair of the hospital’s Clinical Quality Value Analysis committee
▪ Member of the hospital’s Purposeful Hourly Rounding Committee
▪ Local and national Speaker for INS and AVA meetings on LEAN IV
Therapy, CLABSI prevention, and CVAD occlusion management
▪ Prior experience in Critical Care, hyperbaric medicine
▪ Two prior Nurse manager positions - inpatient Medical Units
Recent Peer Review Publications:
1. Lean Six Sigma for Intravenous Therapy Optimization: A Hospital Use of
Lean Thinking to Improve Occlusion Management/ March 2017 JAVA
2. Reducing False Positive Blood Cultures: Using a Blood Diversion
Device/February 2019 Connecticut Medicine
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Financial Disclosures
1. Disclosure of Relevant Financial RelationshipsI have the following financial relationships to disclose:
Consultant for: Nexus Medical, BBraun
Past consultant for: Teleflex
Speaker’s Bureau for: Nexus Medical, Entrotech life sciences
Past Speaker for: Ivera Medical
Honoraria from: Nexus Medical , Entrotech LifeScience
Employee of: Hartford Hospital
2. Disclosure of Off-Label and/or investigative UsesI will not discuss off label use and/or investigational use in my presentation.
6/3/2019Confidential. Internal Use Only. 3
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Learning Objectives
✓ Verbalize, after literature review, the reasons why PIV failure is over 50% in the USA with a focus on infiltrations and occlusions
✓ Describe the peripheral bundle with the 5 RIGHTS that were utilized for this randomized controlled study to achieve successful outcomes
✓ Demonstrate how the results of this study can be utilized to establish a business model for the value of the IV team
6/3/2019Confidential. Internal Use Only. 4
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AcknowledgmentsHartford Hospital IV and Leadership Team
6/3/2019Confidential. Internal Use Only. 6
Cheryl Ficara, RN, MS, NEA-BCVP, Patient Care Services
Michael Davis, RN, MBADirector of Nursing: Medicine, Oncology, IV Therapy
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Hartford Hospital, Hartford CT
➢ Built in 1854 – only level 1 trauma center in CT
➢ 867 licensed beds
➢ 6 ICU’s comprising total of 94 beds
➢ Over 7025 employee’s
➢ Air Ambulance Service - Lifestar
➢ ED visits : 104,698
➢ Transitions from Inpatient Care: 43,831
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Integrity We Do the Right Thing
Caring We Do the Kind
Thing
Excellence We Do the Best Thing
Safety We Do
the Safe Thing
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Patient Centric Improvement Initiatives
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Opening Questions
▪ Does anyone truly know their annual cost per bed for IV Therapy?
6/3/2019Confidential. Internal Use Only. 10
$7968 annual cost per bed
Hartford Hospital
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The Journey to Clinically Indicated…
6/3/2019Confidential. Internal Use Only. 11
▪ Are nurses assessing peripheral IV sites well enough to leave in until clinically necessary?
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The Journey to Clinically Indicated…
6/3/2019Confidential. Internal Use Only. 12
▪ Are nurses assessing peripheral IV sites well enough to leave in until clinically necessary?
▪ They were not at
Hartford Hospital Evidenced Based?
Best Practice?
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The Journey to Clinically Indicated
▪ We are now using a Vascular Access Team and a Best Practice Bundled Approach with all PIVC insertions
▪ Safety We Do the Safe Thing
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The Journey to Clinically Indicated
▪ We are now using a Vascular Access Team and a Best Practice Bundled Approach with all PIVC insertions
▪ Safety We Do the Safe Thing
6/3/2019Confidential. Internal Use Only. 14
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The One Invasive Procedure Common to Most Hospitalized Patients
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The One Invasive Procedure Common to Most Hospitalized Patients
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The One Invasive Procedure Common to Most Hospitalized Patients
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The United States
2018 Population = 327M 2018 PIV Catheters Sold = 350M
*GHX Data
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53% Chance you Make it Home?
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PIV Catheter Failures
6/3/2019Confidential. Internal Use Only. 21
The known causes of IV failures are avoidable
if PIVC’s are inserted using…
Evidenced Based, Best Practice
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Past, Current and Future State
A3 to define past, current and future state of PIVC insertions
Past State
▪ All RN’s hired where PIVC’s inserted, validated by IV educator
Current State
▪ All RN’s hired where PIVC’s inserted, validated by IV RN
Future State
▪ Centralize all IV insertions by a trained IV expert using a Best Practice Bundle
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CM A ID
PIVC Insertions using Best Practice Bundle: Study Protocol Designed to Deliver Better Patient Care, Better Patient Outcome and Long Term Economic Results
Define Measure Analyze ControlImprove
Lean Healthcare
6/3/2019Confidential. Internal Use Only. 23
1 PIVC
per Stay
past published studies13 years of direct IV placement voice of our patient LOS datahours spent training new hiresCLABSI ratesavg wait time for IV
Publications and data collected
IRB approval &data collection by research RN with CITI Training using an app with pictures taken of each assessment performed
Study completed in 15 monthsPresentation to CNO →results of presentation Study tools locked each day – downloaded daily
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Aim
6/3/2019Confidential. Internal Use Only. 24
2 0 1 6 I N S S t a n d a r d s o f P r a c t i c e - L e a v e P I V C ’s i n u n t i l c l i n i c a l l y i n d i c a t e d
- A i m o f o u r s t u d y- 1 P I V C p e r a d m i t t e d p a t i e n t
L e a n S i x S i g m a D M A I C a p p r o a c h - c r e a t e d a b e s t p r a c t i c e b u n d l e a n d m a d e i t s t a n d a r d w o r k a m o n g s t o u r t e a m .
T h e r e s u l t s exc e e d e d o u r g o a l a n d d e f i n e d o b j e c t i v e s
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Outcome Variables
Primary Outcome(s)
▪ PIVC Dwell Time
▪ PIVC Success Rate (from insertion to discharge
without complications)
Secondary Outcome
▪ Complications (Phlebitis, Occlusion, Infiltration, Infection, Dislodgement)
▪ Patient Satisfaction
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Design, Setting, Recruitment
▪ IRB approved → prospective, multi-modal
comparator study
▪ November 2016 → February 2018
▪ Setting → 47 Bed Medical Unit
▪ Recruitment →
▪ All new admits placed in an empty bed
▪ Able and willing to consent or have a LAR who could consent for the patient
▪ Exclusion criteria → patient has a central line or patients transferred
in from another unit or patients transferred off the unit
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Assigned to One of Two GroupsStandard Care (Control) vs. VAST Using Bundled Approach (Experimental)
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Control
Standard Care
Experimental
Best Practice Bundle
Inserter RN, ER/EMT RN, IV Proficient
USG/Vein Viewer No Yes
Site Location Hand/Wrist/AC Forearm
Catheter Type 20g/1” 22g/1.75”
Needleless
Connector
Neutral connector Anti-Reflux connector
Dressing and
Securement
Standard dressing + Tape CHX antimicrobial bordered securement + Chevron, Change as
needed or e. 7d
Kit Used No Yes
Assessment No 1-2x/day (5 minutes)
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Data Collection Tool
Daily Assessment and data collection
▪ Cloud Based iPad app (COMMAND APP) ▪ Amazon Warehouse Server (HIPAA
compliant)▪ Min. of 54 data inputs per PIVC insertion –
Took less than 10 minutes to complete▪ +21 data inputs for every assessment
thereafter – Took less than 5 minutes to complete
▪ Picture records for every patient when the IV was placed and during assessments (1-2x/day)
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Data Collection Tool – Calibrated scales for Consistency
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Data Collection Tool – Site Selection Verification
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Data Collection Tool – Drug Library
6/3/2019Confidential. Internal Use Only. 31
4 Reference Screens:▪ Continuous▪ Intermittent▪ Bolus▪ Maintenance
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Data Collection Tool – Bar Scan & Survey Capabilities
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Statistics & Analysis
▪ The study was powered for 210 sites (included 5%
anticipated loss rate for post enrollment exclusions)
▪ A priori alpha level of 0.05 (p<0.05)
▪ 85% power
▪ Students t-test or Mann-Whitney U (M-W-U) test for comparison and Spearman non-parametric test for correlation to success rates
▪ SPSS v. 21 utilized for Statistical Analysis
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Evidence Based Solution: PIV 5-Rights
To get the right results, you need the right approach!
Description Reference(s) Research
Right Proficiency
USG Trained; Site Assessment Decision Making; Demonstrates 1st Stick Success
10 publicationsCarr,
Cochrane Review, INS
Right Insertion Use of USG or Vein Viewer for 100%
success53 Publications
Gregg, Constantino
Right Vein & Catheter
Forearm, Distance from Valve, V:C Ratio (diameter & length)
22 PublicationsMoureau, Piper, INS
Right Supplies & Technology
1. Procedural kit for compliance 2. 22g / 1.75” catheter (forearm)3. Anti-reflux needleless connector (7d)4. Alcoholic chlorhexidine skin preparation5. Antimicrobial bordered securement dressing (7d)
44 PublicationsMarsh, Hull,
INS
Right Review & Assessment
Alcohol cap for hub disinfection, Flushing, and
Assessment for dressing change13 Publications
Hadaway, INS
P
IV
5
R
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P = Right ProficiencyI = Right InsertionV = Right Vein & Catheter
Bulls Eye
Medial, upper arm,
basilic and
brachial veins avoided
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P = Right ProficiencyI = Right InsertionV = Right Vein & Catheter
▪ Avoid placement in a point of flexion
▪ One of the major contributors to
IV related complication
▪ Target Zone – cephalic vein, 20-40 mL/min
▪ Vein depth 0.5-0.75 cm → avoid greater
then 1 inch deep
- Longer catheter → Introcan 1.75 inch
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Step by Step
“Aseptic USG IV”
Step 1: Disinfect Probe
Step 2: Wash Hands
Step 3: Don Non-Sterile Gloves
Step 4: Open IV Kit
Step 5: Open catheter
Step 6: Apply non-latex tourniquet
Step 7: Prep skin (ChloraPrep)
Step 8: Apply pea size drop of Non-Sterile
Ultrasound gel to probe
Step 9: Assess vein
Step 10: Hold probe in place, guide needle into
vein
Step 11: Check for Blood return
4 6
7
8 9
5
10
11
1 2
3
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Step by Step “Aseptic
USG IV”Step 12: Thread Catheter
Step 13: Open new ChloraPrep
Step 14: Clean area and let dry
Step 15: Remove CHX Dressing
Release Liner
Step 16: Apply Dressing around IV
Step 17: Remove Dressing Liner
Step 18: Remove Needle from
Catheter
Step 19: Attach Anti-Reflux Tube Set
Step 20: Check for blood return
15 16
17 18 19
12 13-14
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Step by Step “Aseptic
USG IV”
Step 21: Flush Site
Step 22: Clamp Tube Set
Step 23: Add Tape Strip
below Hub
Step 24: Tent Tape Strip
above Hub
Step 25: Loop the IV Set
and Tape It
Step 26: Add additional
strip over hub and
Looped IV Set 23 24
25 26
20-21 22
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Right Supplies and Technology:
Pure Chlorhexidine (CHX) impregnated bordered IV securement dressing
Effective against gram
positive and gram
negative bacteria and
yeasts commonly found at
catheter sites
Rapid Onset of
Action
Consistently
maintains high
efficacy levels from
day 1 through day 70
1
2
3
4
5
6
7
8
Log
10
Reduction
Day 1 Day 3 Day 7
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Right Supplies – CHX Dressing Protecting the Site From Bacterial Invasion
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Right Supplies – Preventing Blood Reflux 24/7
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5 = Right Supplies & Technology → Complimented the
Proficiency of the Insertor- Anti-Reflux Needleless Connector
Goal: protect the Tunica Intima
- Trauma
- mechanical (pistoning)
- “blowing the clot” out of the tip of the catheter
Anti-Reflux Needleless Connectors → Keeps blood out of the catheter 24/7
- Success with tPA reduction by greater then 50%
- Not People Dependent – No Clamping Sequence!
- Clear, Straight Fluid Pathway
- 360 Degree Compressible seal
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Results – Participants, Insertion Technique, Vein Utilized
• Control Group = 94 sites
• 51 male (54%)
• 43 female (46%)
• 91% between ages 41-100
• 100% placed by EMS, ED RN, Floor RN without u/s
• 61% → 20G, 1.25 inch
• 15% → 22G, 1 inch
• 37% cephalic
• 32% forearm
• Various dressings, needleless connectors
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• Experimental Group = 113
• 56 male (50%)
• 57 female (50%)
• 90% between ages 41-100
• 87% placed by IV RN using u/s
• 90% → 22G, 1.75 inch
• 89% cephalic
• 91% forearm
• Same supplies
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Results - Catheter RemovalControl
N=94
Experimental
N=113
Total
N=207
P value
Success
- End of Treatment/Patient Discharge 14 (15%) 101 (89%) 115 (56%) <0.001
Lost Catheters (primary complication)
- Per policy (Location/other) 27 (29%) 0 27 (13%) <0.001
- Per policy – deviation from standard of
care15 (16%) 0 15 (7%) <0.001
- Per policy (Primary Complication) 38 (40%) 12 (11%) 50 (24%) <0.001
Breakdown of Primary Complication
- Inadvertent Removal 1 (1%) 1 (1%) 2 (1%) NS
- Catheter Occlusion 8 (9%) 0 8 (4%) 0.002
- Infiltration 7 (8%) 4 (4%) 11 (5%) 0.212
- Phlebitis 13 (14%) 5 (5%) 18 (9%) 0.017
- Pain 9 (10%) 2 (2%) 11 (5%) 0.013
- CLABSI 0 0 0 NS
- Other/Unknown 0 0 0 NS
Values in red are statistically significant at p<0.05; NS=not significant/too few cases to evaluate
6/3/2019Confidential. Internal Use Only. 45
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Main Objective of Study Demonstrated
▪ Mean dwell time (± SD)
▪ Experimental Arm (n=113)
▪71.4 ± 58.8 hours (333.21 hours)
▪ Control Arm (n=94)
▪29.6 ± 18.0 hours (110.98 hours)
6/3/2019Confidential. Internal Use Only. 46
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Main Objective of Study Demonstrated
▪ Mean dwell time (± SD)
▪ Experimental Arm (n=113)
▪71.4 ± 58.8 hours (333.21 hours)
▪ Control Arm (n=94)
▪29.6 ± 18.0 hours (110.98 hours)
6/3/2019Confidential. Internal Use Only. 47
2.5 Fold Improvement in Dwell Times
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Study Outcomes
▪ Primary Objective:
▪ Control Arm: 15% lasted till end of therapy
▪ Experimental Arm: 89% lasted till end of therapy
▪ Secondary Objectives:
▪ Control Arm: 40% complication rate
▪ Experimental Arm: 11% (p<0.001).
6/3/2019Confidential. Internal Use Only. 48
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Control Group
• Wide variance• 40% of patients had a complication • 15% success rate with 1 PIVC/patient
6/3/2019Confidential. Internal Use Only. 49
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Current State: Waste, Variability, Defects
6/3/2019Confidential. Internal Use Only. 50
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Experimental Group
6/3/2019Confidential. Internal Use Only. 51
• Consistent approach• 11% of patients had a complication • 89% success rate with 1 PIVC/patient
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Future State: Standard Work (PIV5R’s), EVB-Best Practice, Bandwidth
6/3/2019Confidential. Internal Use Only. 52
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Benchmark Data
Meta Analysis on
PIVC
Complications.
Helm, et al. JINS.
2015
Published Data on PIVC
Complications
Rickard et al. BMC Medicine, 2010.
Current Standard of Practice
New Data
Steere, L et al.
P value vs.
Rickard
Clinically
Indicated
Prospective
Randomized
Controlled Studies,
1990-2014(Mean Complication Rates)
Rickard: Routine
Replacement
Change Group
(n=177)
Rickard: Clinically
Indicated Change
Group (n=185)
Steere: ER
Control Group
(N=94)
Steere: Five
Rights
Experimental
Group (n=113)
Primary:
IVD complications per patient, n (%) 46% 36% 41% 40% 11% <0.001
IVD complications per 1000 days* n/a 66.0 67.8 330.7 35.7 <0.001
Secondary:
Phlebitis, n (%) 15.4% 7% 10% 23% 4% 0.072
Infiltration, n (%) 23.9% 30% 33% 13% 4% <0.001
Occlusion, n (%) 18.8% 3% 2% 12% 2% 0.815
Accidental removal, n (%) 6.9% 6% 9% 1% <1% 0.004
IVD-related BSI, n (%) 0.2% 0 0 0 0 ---
The control group findings were comparable to nationally published failure rates. The experimental group demonstrated a 2-10x improvement across all categories of IV complications.
1. Helm RE, Klausner JD, Klemperer JD, Flint LM, Huang E. Accepted but Unacceptable: Peripheral IV Catheter Failure. Journal of Infusion Nursing. 2015;38(3):189-203.
2. Rickard C, McCann D, McGrail M. Routine resite of peripheral intravenous devices every 3 days did not reduce complications compared with clinically indicated resite: a randomised controlled trial. BMC Medicine. 2010;8:53.
*Calculation: The rate of catheter complications per 1,000 catheter days was calculated as follows: the total number of complication events divided by the total number of device days multiplied by 1,000 (Moureau, N. et al.
Central Venous Catheters. SIR. 2002. Total Device Days (969, 1121, 114.9, and 330)
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6/3/2019 54
PATIENT CASE STUDIES
Confidential. Internal Use Only.
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69 year old FEMALE admitted to the ER
diagnosis: pneumonia
drugs: Vanco, cefepime, solumedrol
total IV duration: 14.07 DAYS
Control PIVC: 0.95 days
- PIVC removed for pain per policy
Experimental PIVC: 13.12 days
- Lasted until therapy complete; no complications
6/3/2019 55
Case Study 1: Patient 27
Confidential. Internal Use Only.
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6/3/2019 56
No. 027
13d: “Therapy complete“ 1x dressing change
No. 027-1
<1d: “Per policy / pain with palpation” "Pain“ "Pain with touch"
Confidential. Internal Use Only.
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70 year old MALE admitted to the ER
diagnosis: Endophthalmitis of left eye
drugs: Cefepime, hydrazaline, Zyvox
total IV duration: 6.22 DAYS
Control PIVC: 0.39 days
- PIVC removed for non-sterile coveringand blood in hub
Experimental PIVC: 5.83 days
- Lasted until needed; no complications
6/3/2019
Case Study 2: Patient 12
Confidential. Internal Use Only. 5757
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No. 012
No. 012-1
0.39d “Patient came out of ED with IV site only covered with paper tape" “Blood in Cath Hub”
6/3/201958
5.83d “No longer needed”
Confidential. Internal Use Only.
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62 year old FEMALE admitted to the ER
diagnosis: alcohol withdrawal
drugs: Maintenance IVF’s
total IV duration: 3.91 DAYS
Control PIVC: 0.86 days
- PIVC removed for infiltration, occlusion, phlebitis,
dressing soiled
Experimental PIVC: 3.05 days
- Lasted until therapy complete; no complications
6/3/2019
Case Study 3: Patient 84
Confidential. Internal Use Only. 5959
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No. 084
>3d: "Pt discharge home"
No. 084-1
6/3/201960
<1d: "Blood in Cath Hub", "Inability to Flush / Occluded", "Infiltration", "Pain", "Swelling"
Confidential. Internal Use Only.
Non Anti-
Reflux NC
Anti-Reflux
NC
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68 year old MALE admitted to the ER via ambulance
diagnosis: pneumonia
drugs: heparin, vanco, cefepime
total IV duration: 12.22 DAYS
Control PIVC: 1.32 days
- PIVC removed for phlebitis, blood in cath hub, pain
Experimental PIVC: 10.90 days
- Lasted until therapy complete; no complications
6/3/2019
Case Study 6: Patient 22
Confidential. Internal Use Only. 6161
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No. 022
10d: "Therapy complete“
No. 022-1
1d: “Blood in Cath Hub“ “Occlusion” “Pain” “Loose Dressing”
6/3/201962Confidential. Internal Use Only.
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Getting the Team Back
Making the business case for centralizing and increasing the role of IV Therapy at Hartford Hospital
6/3/2019Confidential. Internal Use Only. 63
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Our CEO’s Vision of One
Elliot Joseph, CEO of Hartford Healthcare
One Admission, One Registration, One Bill
6/3/2019Confidential. Internal Use Only. 64
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Our CEO’s Vision of One
Elliot Joseph, CEO of Hartford Healthcare
One Admission, One Registration, One Bill
I would add…
One PIVC per hospitalization inserted on the first attempt 92% of the time
6/3/2019Confidential. Internal Use Only. 65
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How much money are we actually saving
Hartford Hospital? Can we put a dollar
figure to this initiative?
I pose the question - How could 1 catheter
per patient visit impact LOS? Patient
Satisfaction? Costs?
Direct Cost
- Fewer restarts = cost savings
- No more time training bedside RNs
Indirect Cost
- CLABSI Prevention
- Treating fewer IV adverse related events
- Patient Satisfaction Scores
- Needlesticks #6 Top Fears of Patients Being Hospitalized
- LOS impact – less delays in treatment interruptions
I think this
equates to
MILLIONS
OF
DOLLARS!!
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HH PIVC Yearly Stats: ALL CATHETERS
1. Hartford Hospital 2018 Annual Report and Internal Data Sources, including GPO data report.
2. Definitive Health Care Data. 2017
3. Rickard, et al. Reported data on time to successfully place a PIVC including all steps.
4. Glassdoor.com (Hartford, CT; Avg RN) + HH Benefits
Catheters
Purchased1
ADMITS
FY18
247,000 44,648
Patient Communication
Gather Supplies
Assesses Site
Vein Selection
Catheter Selection
Prep the Site
Insert the Catheter
Clean the Site
Secure & Dress the
Site
Label & Document
IV Time3 HH Nurse
Minutes
HH Nurse Hours HH Nurse FTE
equivalent
20 Minutes 4,940,000 82,300 402080h/yr. per FTE
Labor Cost4 Supplies Cost1 Cost per
Placement
Total Cost(pre drug admin)
$16.17RN @ $48.50/hr.
$11.80Catheter, Tubing,
Connectors/Caps, Kit
$27.97 $6,908,590247k*27.97
$7,968 /Bedper year ($6.9M/867 beds)
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HH PIVC Yearly Stats: ADMIT CATHETERS ONLY
1. Hartford Hospital 2018 Annual Report and Internal Data Sources, including GPO data report.
2. Definitive Health Care Data. 2017
3. Rickard, et al. Reported data on time to successfully place a PIVC including all steps.
4. Glassdoor.com (Hartford, CT; Avg RN) + HH Benefits
Catheters Adj for
ADMITS only1
ADMITS Adj.
IV only FY18
CATHETERS PER PT
VISIT
148,200Admits represent 60% of 247,00
catheters purchased
33,48675% of admits get catheter
Includes: ER admits, PACU, Ortho, Womens, Adult ICU; Excludes IOL,
Newborn, Direct
4.4148,200 ÷ 33,486
Patient Communication
Gather Supplies
Assesses Site
Vein Selection
Catheter Selection
Prep the Site
Insert the Catheter
Clean the Site
Secure & Dress the
Site
Label & Document
IV Time3 HH Nurse
Minutes
HH Nurse Hours HH Nurse FTE
equivalent
20 Minutes 2,964,000 49,400 23.752080h/yr. per FTE
Labor Cost4 Supplies Cost1 Cost per
Placement
Total Cost(pre drug admin)
$16.17RN @ $48.50/hr.
$11.80Catheter, Tubing,
Connectors/Caps, Kit
$27.97 $4,145,154148,200k*27.97
$4781 /Bedper year ($4.1M/867 beds)
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PIV5R
Labor
Cost4
PIV5R
Supplies
Cost1
PIV5R Cost
per
Placement
$18.68IV-Trained RN @
$56.03/hr
$14.40Adds better technology
$33.08
$2.9M per Year (ADMITS)
Admissions Catheters PIV5R
Time Needed
TOTAL COST
TOTAL SAVINGS
vs. Current Practice
Admissions 33,486 36,8351.1*33,486
736,70036,835*20 minutes
$1,218,50236,835 catheters*33.08
$2,926,6524,145,154 – 1,218,502
$1,405Per bed per yr
$1.2M/867 beds
$3,376Savings per bed per year
Savings do not include other added benefits such as reduced PIV-CLABSI, Patient
Satisfaction, etc which may also contribute to avoided costs, savings or reimbursement.
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Too Lean | IV Team
June 3, 2019Confidential and Proprietary Information 70
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Lean IV Team
June 3, 2019
Confidential and Proprietary Information
71
We are growing:
FY 2018 budget of 12 FTE’s
FY 2019 preliminary budget of 18 FTE’s
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All Inpatient Units7.55 FTE’s for Insertions, Assessments
Key Model Inputs:
➢ 20min Insertion; 5min assess
➢ Beds per Unit + Occupancy Rate (84% avg)
➢ New Admits/ day (17% avg)
Insertion: 20 Minutes
Patient Communication
Site Review
Check IV Pump & Tubing
Re-Dress Site per policy
Document
Assessment: 5 Minutes
IV Insertions Per Day Analysis
Tot. Time
# beds
(a.) #
admits/ day
(b.) # IV Site
Checks/ day
Hours to
complete
HH - All Hospital Units:High 12 46 5 29 4North 11 15 3 10 1Center 11 6 0 2 1Center 10 26 4 17 3North 10 26 4 16 3North 9 10 5 5 4North 9 SD 9 1 6 1North 8 27 3 15 2CB5 47 7 33 5CB4 25 5 19 3CB3 26 5 20 3
CB2 - Oncology Unit 26 4 19 3Bliss 11 SD 15 2 11 2Bliss 11E 9 2 6 1Bliss 10 SD 9 1 6 1Bliss 10E 14 2 10 1Bliss 9 SD 9 1 6 1Bliss 9E 16 3 11 1Bliss 8 42 8 28 5Bliss 7E 26 4 18 3Bliss 7SD 6 1 4 1Bliss 5 42 5 24 3
Bone and Joint Institute 29 10 18 5
Bone and Joint Institute 30 4 21 3
60
total (non-ICU, Non L&D) 536 90 355
Number of FTE's Annually 7.55
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Budget Increase Request
Category FTE Description Total FTE’s
Present State (does not include replacement)
11.2
Future State (does not include replacement)
7.55 FTE for all IV Starts1.75 FTE for DHT Insertions1.75 FTE for PICC Insertions1.25 FTE for Transfusion Room0.75 FTE for IV Insertion Training1.0 FTE for Assistant Manager
14.05
Total FTE Increase
2.85
Category Total Cost
IV Start Kits withextension set (kits we are currently using)
$99,440
New IV Start Kit with Extension Set
$296,160
Total Annual Increase for New IV Start Kit
+$196,700
Capital Investment = $92,000 (one time investment)
6/3/2019Confidential. Internal Use Only. 73
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Budget Increase Request
Category FTE Description Total FTE’s
Present State (does not include replacement)
11.2
Future State (does not include replacement)
7.55 FTE for all IV Starts1.75 FTE for DHT Insertions1.75 FTE for PICC Insertions1.25 FTE for Transfusion Room0.75 FTE for IV Insertion Training1.0 FTE for Assistant Manager
14.05
Total FTE Increase
2.85
Category Total Cost
IV Start Kits withextension set (kits we are currently using)
$99,440
New IV Start Kit with Extension Set
$296,160
Total Annual Increase for New IV Start Kit
+$196,700
Capital Investment = $92,000 (one time investment)
IS 2.85 FTE’S GOING TO BE ENOUGH?
6/3/2019Confidential. Internal Use Only. 74
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LEAN - Spaghetti Diagram
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Attempting to Institute a Plan
▪ Once CNO approval received
▪ Communication went out in many forums
▪ Nursing Council
▪ Performance Practice Council
▪ Manager/Director Meeting
▪ Kept short
▪ Expectations and timelines were presented
6/3/2019Confidential. Internal Use Only. 76
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Transition Plan (Plan A) for Centralizing IV Therapy Services
6/3/2019Confidential. Internal Use Only. 77
Phase I: Validation phase of process and cost estimates:- After standardizing all PIVC insertions using the 5-RIGHTS by a trained IV RN, we will evaluate by asking:• Did we get achieve our goal of 1 insertion per patient
visit?• Did we allocate enough resources (FTE’s) for effective
and safe implementation?• Any barriers identified?• Any successes/barriers identified by staff in the unit
huddles?• Do we need to modify any part of the plan moving
forward?
Ph I: Conklin Building – Sept → Dec 2018 (Future State)
Ph II: Bliss Building – February →March 2019
Ph III: North Building – April → May 2019
Ph IV: Center Building – June → July 2019
Ph V: Bone & Joint – August 2019
Ph VI: ?? Do we try and do something in the ED at the end of FY 2019
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I’m Not Doing It – That’s Your Job Now
6/3/2019Confidential. Internal Use Only. 79
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1. Repeat study on a larger scale, hopefully multicenter
2. Future presentations of the PIV5R approach
3. At the hospital:
* Partnering with ED during evening hours
* Partnering with Pre-op
* Discussions with CNO and Medical Director on options to support ICU’s
4. Recognition
* Publish results of study with CNO as co-author
* 2018 Finalist for Clinical Team of the Year
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Cheryl Ficara, RN, MS, NEA-BC
VP, Patient Care ServicesCo-author of PIV5R Study Manuscript
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Less Waste, Higher Satisfaction
June 3, 2019Confidential and Proprietary Information 85
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Conclusion/Key Takeaways
Hartford Hospital achieved an 89% success rate at 1 PIVC catheter per patient after implementing the Five Rights Best Practice IV Approach.
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As IV professionals, we should be taking a leadership role in improving
outcomes, reducing variability for IV Therapy