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
Med Center
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Committee
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?