clabsi reduction – on the road to zero! · • clabsi can be prevented through proper insertion...
TRANSCRIPT
CLABSI Reduction – On the Road to Zero!
Sharon Tylka MSN, RN, NE-BC Fatima Bah MSN, RN
Teresa Kostelec MSN, RN, CEN Mary Linthicum BSN, RN
Terri Palazzo MS, RN, FACHE
Interprofessional Team • Fatima Bah MSN, RN • Deborah Brown RN • Heidi Chroszielewski MSN,
RN-BC, PCCN • Melissa Eberhard BSN, RN,
CCRN • Tanja Gross BSN, RN, PCCN • Julia Irwin BSN, RN • Tracy Kostelec MSN, RN, CEN • Rekeya Leslie MSN, RN,
CMSRN
• Mary Linthicum BSN, RN • Terri Palazzo MS, RN, FACHE • Leah Richards MSN, RN,
CCRN • April Saathoff DNP, RN,
CPHIMS • James Tsonis BS • Sharon Tylka MSN, RN, NE-
BC • Nikasha Uqdah BSN, RN • Janine Zoch MSN, RN
Insert CLABSI team photo
Team Members Not Pictured
• Deborah Brown RN • Heidi Chroszielewski MSN, RN-BC, PCCN • Melissa Eberhard BSN, RN, CCRN • Julia Irwin BSN, RN • Rekeya Leslie MSN, RN, CMSRN • Nikasha Uqdah BSN, RN • Janine Zoch MSN, RN
Objectives
1. Reduce the organizational CLABSI rate with a strategic goal of zero CLABSI
2. Implement a multi-modal approach to teaching nurses best practice in the care of central venous access devices (CVAD)
Mercy Medical Center
• 264 Bed Hospital – Founded 1874 • Magnet Designated since 2012 • Ranked #3 Hospital (tied) in Maryland by U.S.
News & World Report 2017-2018 • Women’s Choice Award
Nursing Strategic Plan
Goal 1 – Nurses provide high quality patient and family centered care
Goal 2 – Nurses are recognized as leaders in quality and safety
Goal 3 – Nurses collaborate interprofessionally to provide efficient, effective, and coordinated patient care
• Central line-associated BSI (CLABSI): A laboratory-confirmed
bloodstream infection (LCBI) where central line (CL) or umbilical catheter (UC) was in place for >2 calendar days on the date of event
• These infections are usually serious infections typically causing a • Prolongation of hospital stay • Increased cost • Risk of mortality
• CLABSI can be prevented through proper insertion techniques and management of the central line
CDC Surveillance for Central Line-associated Bloodstream Infections (CLABSI) Protocol , January 2017
The Details Matter
+ + +
+ +
+ = Zero CLABSI
The CLABSI Journey Begins
• Slight rise in CLABSI • Maintenance • Organizational effort • Interprofessional team
Eradication of CLABSI requires Organizational Effort
Assess the data
Consult the
experts
Create the plan
Eradication of CLABSI requires Organizational Effort
• Assess data • Examine best practices • Consult the experts • All hands on deck • Form team • Create the plan • Implement education and plan • Measure progress • Maintain positive progress
AIIMM
Assess Improve
Implement Measure & Maintain
A Bundled Approach
• Needleless system • Daily CVAD rounds with peer coaching • Healthcare personnel education
– Hand hygiene – Scrub the hub – Tubing/Dressing changes – Blood culture collection – Email blasts
A Bundled Approach
• Formal focused case reviews • Development of port access kits • Blood culture drill-down • Disinfecting caps • Documentation improvements • CHG bathing trial
Nov-15
Needleless System
Housewide
Formal Focused Case Reviews Initiation of
Port Access Kit Task Force
IPM CLABSI Presentation To CLABSI Team
Blood Culture Drill Down
Dec-15
Jan-16 Feb-16 Jul-16 Oct-16
MedSurg Disinfecting Caps
Trial
Healthcare Personnel Education
CLABSI PREVENTION PROGRAM Timeline
Housewide Implementation of Disinfecting Caps
CHG MedSurg Trial
Daily CVAD Rounds with Peer
Coaching
Initial Meeting of CLABSI
Multidisciplinary Group
Implementation of Mandatory Education
Nov-16
Housewide Implementation of Port Access Kits
= Start of New Phase
Implementation of Needleless System
• November 2015
• Organizational wide implementation
• Official CLABSI team formation
CVAD rounds and peer coaching
• CVAD assessment with real time feedback – Daily review of necessity – Site – Dressing – IV tubing – Needleless connector – Disinfecting cap
• Above 90 % compliance in all measures since January 2, 2017
Paving the Way to Zero
• Administer pre-test
• Identify knowledge gaps
• Create meaningful and engaging instruction
iCARE Rounds
• Brief in-services to all nursing units • Focused on IV tubing changes, cap care, scrub
the hub, use sterile red end caps • Change central line dressings every 72 hours
and prn. Document ALL central line care • Review the need for central line daily • Educate patients, family and staff on central
line care
iCARE Rounds
CLABSI Focused Review
• IPM performs in-depth case review and meets with unit manager
• Dissemination of findings shared with nursing personnel
• Case reviews discussed at monthly CLABSI team meetings
Post CLABSI Review
CVC Documentation Audit Date Shift CVC doc Drsg date BIOPATCH IV Tubing ∆ Cap ∆ Bld Rtn
Proximal Bld Rtn Middle
Bld Ret Distal
Bld Return L (Port Only)
7A
4/19/16 7P √ No date * N/A √ * Port accessed in ED 4/20/16 7A N/A
7P √ No date * N/A √ √ * 2nd assessment 4/21/16 7A √ 4/19/16 N/A √ documented
7P √ " N/A
date 4/19 but no bld rtn
4/22/16 7A √ " N/A √ √ √ 7P N/A
4/23/16 7A √ " N/A √ * √ √ * * 2nd assessment 7P √ " N/A √ √ cap ∆ and bld return
4/24/16 7A √ " N/A √ proximal & lateral 7P √ " N/A
4/25/16 7A √ " N/A √ 7P √ " N/A
4/26/16 7A √ 4/23/2016* N/A √ √ * Needle changed
7P √ 4/26/16 N/A √ Used IVT assessment
4/27/16 7A √ " N/A √ 7P √ " N/A
4/28/16 7A N/A 7P √ " N/A √ √ √
4/29/16 7A √ " N/A √ 7P √ " N/A ∆ ∆ cap should have
4/30/16 7A √ " N/A √ √ been changed 7P √ " N/A
5/1/16 7A N/A 7P √ No date N/A √
5/2/16 7A N/A
Right Chest Single lumen Portacath POA (inserted 7/7/15 in IR)
Date Shift CVC doc Drsg date BIOPATCH IV Tubing ∆ Cap ∆ Bld Ret P
Bld Ret M
Bld Ret D
2/24/17 7P Pt Adm @ 2226
2/25/17 7A
2/25/17 7P √ √ Cont. Tubing ∆; Lipid/TPN Tubing ∆ All Caps √ √
2/26/17 7A √ 2/26/2017 √ Cont. Tubing ∆; Lipid/TPN Tubing ∆ All Caps √ √
2/26/17 7P √ √ √ Cont. Tubing ∆; Lipid/TPN Tubing ∆ No Cap ∆ √ √
2/27/17 7A √ √ √ Cont. Tubing ∆; Lipid/TPN Tubing ∆ No Cap ∆ √
(Neg) √
(Neg) tPA Flush @ 1132
2/27/17 7P √ √ √ Intermit Tubing ∆ No Cap ∆ √ √
2/28/07 7A √ √ √ No Tubing ∆ due No Cap ∆
2/28/07 7P √ √ √ Cont. Tubing ∆ No Cap ∆ √ √
3/1/17 7A √ √ √ No Tubing ∆ due No Cap ∆ √ √
3/1/17 7P √ √ √ No Tubing ∆ due No Cap ∆ √ √
RUE DL PICC line Inserted 2/7/2017; Line Removed 3/3/2017 ; Port POA - not accessed until 3/3/17
CVC Documentation Audit
Port Access Kits
Task force convened to address standardizing the care and maintenance of ports in all areas that access ports – Plan and implement a new port access kit
– Kit recommendations by Value Analysis Committee
– Standardize port access practice
Port Access Kits
• Sample kit components reviewed and individualized
• Port access video created and included in annual competencies
• Kits implemented after education in
November 2016
Blood Culture Contamination
• Monthly report of blood culture contaminations
• Unit managers review findings with involved nurses
• Coaching to improve practice • Education on blood culture collection to
healthcare team
Disinfecting Caps
• Trial started on Oncology unit
• House wide implementation in November 2016
• Compliance consistently above 94%
Documentation Improvements
• Partnered with Nursing Informatics to improve central line documentation
• Revamped required fields • Developed posters to educate nurses on
proper catheter types, lumen names, and uses
E-mail Blasts Checking CAVD for a blood return • Be sure to check for a blood return in your patient’s central line. • If there is no blood return, reposition the patient and retry! • Advise the provider and IV team to investigate the situation further Why draw blood specimens from the distal lumen of a central line? • Distal lumen is the largest lumen and is closest to the SVC • Better blood flow and best sampling • Thanks for helping to keep our patients safe and free from CLABSI
CHG Bathing Trial
• Trial initiated on progressive care unit with
patients that have a central line • 80% reduction of CLABSI on this unit pre and
post trial
CHG Trial MedSurg Unit
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
0
1
2
3
4
5
6
Feb16-Oct16 Nov16-July17
Number of CLABSIs Rate
Housewide CLABSI Rate
0.0
0.5
1.0
1.5
2.0
2.5
CLABSI Rate Linear (CLABSI Rate)
Number of CLABSIs
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
0
2
4
6
8
10
12
14
16
18
FY16 FY17
Number of CLABSIs Rate
•Clean collaborative initiative •Wipe out video •Reviewing EBP guidelines •Team continues to meet regularly •Hand hygiene •Antibiotic stewardship •ATP testing •Collaboration with EVS •Vested in ongoing education
Ongoing Efforts
Next Steps
Meet monthly
Achieve zero CLABSI goal
Give feedback
Celebrate successes!
Acknowledgement
A special thank you and acknowledgement to the entire iCARE/CLABSI team for their contributions to this ongoing initiative.
Questions
References
• Center for Disease Control and Prevention. (2017). Bloodstream Infection Event. Retrieved from https://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf
• Center for Disease Control and Prevention (2011). CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm
• Dumont, C. and Nesselrodt, D. (2012). Preventing CLABSI. Nursing 2012, 35(1). Retrieved from www.Nursing2012.com
• Journal of Infusion Nursing (2016). Infusion Therapy: Standards of Practice. Retrieved from www.r2library.com/Resource/Title/000016612X
• Lippincott Nursing Center (2017). Clinical Resources for Practice. Retrieved from www.nursingcenter.com
• The Joint Commission. (2012). Preventing Central Line Associated Blood Stream Infections: A Global Challenge, A Global Perspective . Oak Brook, IL: Joint Commission Resources, May 2012. http://www/PreventingCLASIs.pdf
• SHEA/IDSA Practice Recommendation: Strategies to Prevent Central Line–Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update. Infection Control and Hospital Epidemiology 35(7). Retrieved from www.dhhr.wv.gov/oeps/disease/AtoZ/Documents/SHEA_IDSA CLABSI...