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Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Central Line Infections
Avoidable? Preventable?
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
• What is a CLC-RBSI?
• Can we avoid them?
• The IHI tools
• The UHW experience
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
What is a CLC-RBSI?(Central Line Catheter–Related Blood Stream Infection)
Agree a definition
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
HELICS(Hospital in Europe Link for Infection Control through
Surveillance)
• CLC-RBSI– The patient has a positive blood culture with
a recognised pathogenOr
– 2 positive blood cultures drawn within 48 hours for a common skin contaminant
And– Clinical evidence of infection (fever/
hypotension)And
– A culture positive line tip
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
HELICS(Hospital in Europe Link for Infection Control through
Surveillance)
• CLC infection
– Clinical signs of infection (fever/ hypotension)
– A positive line tip culture
– Symptoms resolve within 48 hours of line removal
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
What can cause the infection?
• Poor insertion hygiene• Poor insertion technique• Lack of appropriate skills• Poor line maintenance• Lines remaining in place for an
inappropriate length of time• Use of 3 way taps.......
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
What is the cost to the patient?
• CLC-RBSI’s are a major cause of morbidity
• A 2006 prevalence survey found that 42.3% of bloodstream infections in England are central line-related
• National Audit Office (2000) estimated the additional cost of a bloodstream infection to be £6,209 per patient
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
How to avoid/prevent Line Infections
• Standardise practicePractice variation is the enemy of quality
• Measure our practice and outcomesKnow the extent of the problem in order to show
improvement over time
• Develop a checklist model...... Care BundleIt makes the right thing to do the easy thing to do
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Care bundles explained• A global standard of care management
• A group of interventions related to a disease process that when implemented together result in better outcomes than when implemented individually
• Bundle components can easily be measured as completed or not completed: ‘all-or-none’ compliance
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Bundle Aim
• To eliminate the piecemeal application of
evidence-based guidelines that characterises
the majority of clinical environments today
• To make it easier for clinicians to bring
guidelines into practice
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
What else is a bundle?
• Methodology to spread the use of generally accepted science
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
What else is a bundle?
• Methodology to spread the use of generally accepted science
• Provide a “pressure” for teamwork
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
What else is a bundle?
• Methodology to spread the use of generally accepted science
• Provide a “pressure” for teamwork• Simple, memorable checklist
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
What else is a bundle?
• Methodology to spread the use of generally accepted science
• Provide a “pressure” for teamwork• Simple, memorable checklist• Audit tool
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
What else is a bundle?
• Methodology to spread the use of generally accepted science
• Provide a “pressure” for teamwork• Simple, memorable checklist• Audit tool• All aspects should be done to get the
maximum benefit
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Bundles bridge the “Guideline Gap”
Evidence Guidelines Practice
Bundle
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
What makes a bundle so special?
• The power of a bundle
– science behind it
– method of execution: with complete consistency
• The changes in a bundle are not new; they’re well established best practices, but they’re often not performed uniformly, making treatment unreliable
• A bundle ties the changes together into a package of interventions that people know must be followed for:
– every patient
– every single time
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Types of Care Bundles
• Ventilator Care Bundle
• Sepsis Care Bundle
• Central Line Care Bundle
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
CLC Bundle.....insertion• Hand hygiene
– Decontaminate hands before and after each patient contact– Use correct hand hygiene procedure
• Maximal barrier precautions– PPE
• Single use gloves• Eye/face protection
– Aseptic technique• Sterile gown, gloves and full body drape
• Chlorhexidine skin antisepsis (2% Chlorhexidine Gluconate in 70% Isopropyl Alchohol)
• Catheter– Optimal catheter site selection, with subclavian vein as the
preferred site for non-tunnelled catheters– Single lumen unless indicated otherwise– Consider antimicrobial impregnated catheter if duration of 1-
3 weeks and risk of CLC-RBSI high
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
CLC Bundle....maintenance• Hand hygiene
– Decontaminate hands before and after each patient contact– Use correct hand hygiene procedure
• Catheter site inspection– Regular observation for signs of infection ie. leakage, inflammation etc – AT
LEAST DAILY
• Dressing– A sterile, transparent, semi-permeable dressing should be in place– Ensure dressing is intact and dry
• Catheter access– Aseptic technique swabbing ports/hubs with 2% Chlorhexedine prior to access
• Administration set replacement– Following administration of blood/blood products – immediately– Following TPN – after 24 hours or 72 hours if no lipids– All other fluid sets – after 72 hours
• TPN should be infused via dedicated lumen
Daily review of line necessity with prompt removal of unnecessary lines
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
How to measure
1. Hand hygiene Yes No � �
(hands washed & alcohol gel used)
2. Maximal barrier precautions on insertion Yes No � �
(user: cap, mask, sterile gown, sterile gloves
patient: covered with large sterile drape)
3. Chlorhexidine skin antisepsis Yes No � �
4. Optimal catheter site selection Yes No � �
(document site in notes & reason for site selection)
5. Daily review & documentation of line necessity Yes No � �
(To be documented in patients notes)
6. Ultra sound used for insertion Yes No � �
Cen
tral
Lin
e C
are
Bun
dle
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Results
• Structure in place• Process in place........... will result in the desired
outcome
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Structure
• Staff• Equipment• Documentation
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Process MeasureCompliance with all elements of the
CLC Care Bundle (insertion and maintenance)
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Outcome Measure
Avoid / reduce Central Line Catheter-Related Blood Stream Infections
(CLC-RBSI)
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
S + P = O
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
How do we achieve reliable improvements to our systems?• Implementing evidence-based
changes to improve patient outcomes
• Set time frames......how much, by when?
• Getting the data to show what impact the changes are having
• Spread
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
The Three Fundamental Questions for Improvement
• What are we trying to accomplish?
• How will we know that a change is an improvement?
• What changes can we make that will result in improvement?
Source, API The Improvement Guide, p. 10
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make that will result in improvement?
The Model for Improvement
Act Plan
Study Do
When you combine
the 3 questions with the…
PDSA cycle, you
get…
…the Model for
Improvement.
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
The PDSA Cycle for Learning and Improvement
Act
• What changes are to be made?
• Next cycle?
Plan• Objective• Questions & predications (why)• Plan to carry out the cycle (who, what, where, when)• Plan for data collection
Study• Complete the analysis of the data
•Compare data to predictions
•Summarize what was learned
Do• Carry out the plan• Document problems and unexpected observations• Begin analysis of the data
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Use the PDSA Cycle for :
• Testing or adapting an improvement change
• Implementing the change
• Spreading the change to the rest of your system
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Repeated Use of the PDSA Cycle
Hunches, theories,
best practices
Changes That Result in
Improvement
A P
S D
APS
D
A P
S D
D SP A
DATA
Very Small Scale Test
Follow-up Tests
Wide-Scale Tests of Change
Implementation of Change
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for Improvement
Sequential building of knowledge under a
wide range of conditions
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Use a PDSA form to organize, standardize and document your tests!
Worksheet for Testing Change – Critical Care
Aim: Primary: To reduce mortality and adverse effects Secondary:
Every goal will require multiple smaller tests of change
Describe your first (or next) test of change Person Responsible
When to be done
Where to be done
Plan List the tasks needed to set up this test of change Person
Responsible When to be done
Where to be done
Predict what will happen when the test is carried out Measures to determine if prediction succeeds
Do Describe what actually happened when you ran the test
Study Describe the measured results and how they compared to the predictions
Act Describe what modifications to the plan will be made for the next cycle from what you learned
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Plan
• Clear objective• State predictions• Who, what, where, when?• Describe data collection plan
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Do
• Attempt to carry out plan• Document any problems or
unexpected events• Collect planned data• Capture feedback or observations
from those conducting the plan• Suggestions to improve in the DO
phase of the PDSA
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Study
• Complete the analysis of the data• Analyse feedback or observations• Compare data/feedback to
predictions & summarise what was learned
• Suggestions
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Act
• What will happen in the next PDSA cycle?
• Develop change further?• Test?• Implement?
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
PDSA example: CLC Care Bundle
CLC Bundle
Routine use of CLC Bundle
A P
S D
APS
D
A PS D
D SP A
DATA
Cycle 1: 1 Doctor/1 Nurse / 1 patient/1 day use of Chlorhexedine 2%
Cycle 2: Repeat using 2 patients and 2 doctors/nursesfor 2 days
Cycle 3: Repeat using 2 patients, doctors/nurses for 1 week
Cycle 4: Repeat using 6 patients
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Multiple PDSA Cycles Running on Parallel Ramps with Multiple Aims
Testin
g and
adap
tatio
n
A P
S D
A PS D
A P
S D
D S
P A
A P
S D
A PS D
A P
S D
D S
P A
A P
S D
A PS D
A P
S D
D S
P A
A P
S D
A PS D
A P
S D
D S
P A
Alcohol gel each bed area
Coloured aprons
Use of Chlorhexedine
2%
Stricter visiting times
Change Concepts
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
AIM
Change Concepts, Theories, Ideas
Concept B
Concept C
Concept A
Concept D
Multiple PDSA Cycles Directed Toward a Single Aim
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Whatcan you accomplish
by Tuesday?It all depends on the size and scope of the planned change!
1 patient, 1 nurse, 1 doctor, 1 day
Start small
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
References on Measurement and Improvement• Brook, R. et. al. “Health System Reform and Quality.” Journal of the
American Medical Association 276, no. 6 (1996): 476-480.
• Carey, R. and Lloyd, R. Measuring Quality Improvement in healthcare: A Guide to Statistical Process Control Applications. ASQ Press, Milwaukee, WI, 2001.
• Langley, G. et. al. The Improvement Guide. Jossey-Bass Publishers, San Francisco, 1996.
• Lloyd, R. Quality Health Care: A Guide to Developing and Using Indicators. Jones and Bartlett Publishers, Sudbury, MA, 2004.
• Nelson, E. et al, “Report Cards or Instrument Panels: Who Needs What? Journal of Quality Improvement, Volume 21, Number 4, April, 1995.
• Solberg. L. et. al. “The Three Faces of Performance Improvement: Improvement, Accountability and Research.” Journal of Quality Improvement 23, no.3 (1997): 135-147.\
• Associate in Process Improvement. The Improvement Handbook: Models, Methods and Tools for Improvement, Austin, TX, January 2005.
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
UHW experience
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Structure and Process
Compliance with CLC Bundle
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
1 doctor non-compliant
Dressing packs
introduced
Lines Trolleys
introduced
Start small
Compliance tick-box stickers
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Outcome
Zero CLC infections
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
No agreed
definition
HELICS agreed
National surveillance
in Wales
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
A fundamental tenet of improvement in any industry is that if you want to
improve you must develop a system to evaluate performance
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
Future challenges
Spread
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro
References on Measurement and Improvement• Brook, R. et. al. “Health System Reform and Quality.” Journal of the
American Medical Association 276, no. 6 (1996): 476-480.
• Carey, R. and Lloyd, R. Measuring Quality Improvement in healthcare: A Guide to Statistical Process Control Applications. ASQ Press, Milwaukee, WI, 2001.
• Langley, G. et. al. The Improvement Guide. Jossey-Bass Publishers, San Francisco, 1996.
• Lloyd, R. Quality Health Care: A Guide to Developing and Using Indicators. Jones and Bartlett Publishers, Sudbury, MA, 2004.
• Nelson, E. et al, “Report Cards or Instrument Panels: Who Needs What? Journal of Quality Improvement, Volume 21, Number 4, April, 1995.
• Solberg. L. et. al. “The Three Faces of Performance Improvement: Improvement, Accountability and Research.” Journal of Quality Improvement 23, no.3 (1997): 135-147.\
• Associate in Process Improvement. The Improvement Handbook: Models, Methods and Tools for Improvement, Austin, TX, January 2005.
Cardiff and Vale NHS TrustYmddiriedolaeth GIG Caerdydd a’r Fro