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Four “C’s” to Conquer CLI:
An Integrated Approach to Performance Enhancement
Elaine C. Killough, RN, MSN, CCRN, CSSturdy Memorial HospitalAttleboro, MA
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www.cdc.gov/nicdod/dhqp/images/Fig_CLABSI_ICU accessed 05/31/08
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Sturdy Memorial Hospital
128-bed community hospital
14 bed medical-surgical ICU
Open unit with primary intensivist coverage
Admits ~700 patients/year
Mean LOS 4.8 days
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Central Lines (2007)
265 lines managed 74.9% Multi-lumen catheters 14.3% Dialysis catheters 10.9% SwanGanz catheters
73.6% placed in the ICU 93.3% placed by intensivist
Site Selection 46.7% IJ 45.0% SC 8.3% Femoral
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Frequency: Line Placement 2004 - 2007
Year
Patients with
Lines
(# of Lines)
Total ICU
Admissions
Pts with Lines/ Total ICU Pts
(%)
2004 264
(294)
708 37.3
2005 245
(278)
710 34.5
2006 225
(247)
686 32.8
2007 232
(255)
812 28.5
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ICU Line Days 2004 - 2007
Year # of Lines Total Line Days
Line Days/
Line
(mean)
2004 294 4777 16.2
2005 278 3904 14.0
2006 247 2114 8.6
2007 255 2225 8.7
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CLI: SMH ICU 2002 - 2007
ICU Primary Central Line BSI 2002-2007
0 0 0 0 0
2.5
0
3.5
3.42.1
0.8
1.41.2
2.5
1.81.3
0
5.1
0 0 0
1.5 1.7
0.2
0
1
2
3
4
5
6
J an-Mar02
Apr-J un02
J ul-Sept02
Oct-Dec02
J an-Mar03
Apr-J un03
J ul-Sept03
Oct-Dec03
J an-Mar04
Apr-J un04
J ul-Sept04
Oct-Dec04
J an-Mar05
Apr-J une05
J ul-Sept05
Oct-Dec05
J an -Mar06
Apr-J une
06
J uly-Sept06
Oct -Dec06
J an-Mar07
Apr-J un07
J ul-Sept07
Oct-Dec07
Quarter/Year
Rat
e/10
00 L
ine
Day
s
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Sturdy Excellence Program
Integrated quality and service improvement goals Validity supported by evidence Measurable outcomes
Unit/department-based Regular reporting to Quality and Service
Enhancement Committee Review and feedback from administrative
and multidisciplinary resources High emphasis on progress and
accountability
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An Integrated Approach
Senior and Risk Management/
Quality Improvement
Unit Management
ICUNursing
InfectionControlPhysicians
PreventCLI
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SMH ICU: CLI Prevention Practices: 2004
Developed a formalized program of daily surveillance
Established system for auditing related documentation and dressing changes per existing protocol (record review)
Provided parameters for identification of suspect lines and clarified expectations for physician response
Worked on development of comprehensive program for 2005
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SMH ICU CLI Prevention Program: 2005 - 2007
Adopted evidence-based interventions as standard of care
Developed total management program:
ComprehensiveCollaborative
Current Partnering with QSEC to review and
evaluate program effectiveness Goal: To remain at or below the CDC
median occurrence rate
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A Comprehensive Approach Prior to placement: Conservative decision-
making as to appropriateness of intervention. Inclusive documentation tool:
Identifies accountable personnel. Validates implementation of evidence-based
standards at insertion. Describes line maintenance per hospital standard,
including description of insertion site, documentation of dressing changes.
Documents problems identified and resolution. Documents analysis and review if line is suspect.
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A Comprehensive Approach Line maintenance documented each
shift in the electronic record. Daily assessment/data collection by
CNS or unit leadership staff: Insertion site Intactness/quality of the dressing
All program elements are reviewed and reinforced in orientation for all new staff including temporary personnel.
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A Collaborative Approach
Proactive, facilitative approach with MDs not familiar with standards
Problem-solving related to difficult sites or persistent patient problems
Regular review of documentation tools by IC RN
CNS/IC RN analysis of occurrences Dissemination of findings to staff Collaborative problem-solving
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A Collaborative Approach
Nursing education involvement in all changes in program/protocol
QSEC review of documented performance progress and goal achievement; dialogue to provide feedback, identify problems, and suggest solutions.
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Keeping Things Current Problems identified are addressed
immediately. Bi-weekly reporting to management on all
process elements. Monthly reporting of process compliance
and outcomes in staff meetings and through e-mail.
Reports to QSEC available on unit; feedback shared as it is received.
Annual review of program.
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CLI: SMH ICU 2002 - 2007
ICU Primary Central Line BSI 2002-2007
0 0 0 0 0
2.5
0
3.5
3.42.1
0.8
1.41.2
2.5
1.81.3
0
5.1
0 0 0
1.5 1.7
0.2
0
1
2
3
4
5
6
J an-Mar02
Apr-J un02
J ul-Sept02
Oct-Dec02
J an-Mar03
Apr-J un03
J ul-Sept03
Oct-Dec03
J an-Mar04
Apr-J un04
J ul-Sept04
Oct-Dec04
J an-Mar05
Apr-J une05
J ul-Sept05
Oct-Dec05
J an -Mar06
Apr-J une
06
J uly-Sept06
Oct -Dec06
J an-Mar07
Apr-J un07
J ul-Sept07
Oct-Dec07
Quarter/Year
Rat
e/10
00 L
ine
Day
s
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CLI: SMH ICU
Cases of CLI in 20 Months!(Since September, 2006)
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SMH ICU: CLI Prevention Practices: 2008
Incorporated a“Zero Tolerance”Approach into Our
2008 CLI Prevention
Sturdy Excellence
Goal
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The Fourth “C”……..
Continued excellent performance.
Consistent goal-achievement.
Commitment to improving patient outcomes.