CREATING AN
INTEGRATED CLABSI
PREVENTION PROGRAM
Presented by:
Tracy Shamburger, RN, MSN and Karen Bailey, RN
OBJECTIVES





Identify The Joint Commission (TJC) National
Patient Safety Goal 07.04.01 Elements of
Performance
Cite the Mike Denton Infection Reporting Act (2009)
Define CLABSI and Central Lines per CDC
Guidelines
Identify National Healthcare Safety Network
(NHSN): ADPH HAI Reporting Requirements
Understand that the Comprehensive Unit-based
Safety Program (CUSP) is a process for creating a
culture of patient safety
The Joint Commission
NPSG.07.04.01
Institute for Healthcare
Improvement (IHI)
Monitoring;
Evidence Into
Practice
CLABSI
Prevention
Comprehensive
Unit-based
Safety Program
(CUSP)
Patient
Safety
Evaluation
& PI
Standards;
Regulatory
Compliance;
& Reporting
National Healthcare
Safety Network
(NHSN);
CMS; ADPH
EVALUATING COMPLIANCE WITH
TJC NPSG.07.04.01

Conduct periodic hospital-wide risk assessments
for CLABSI; monitor compliance with evidencebased practices; and evaluate the effectiveness of
prevention efforts.

After conducting your risk assessment, do you have
gaps in compliance or process improvement
opportunities? If so, what are the gaps; are you
conducting process reviews; and are your developing
action plans to achieve compliance?
MONITORING AND REPORTING
COMPLIANCE RATES


Compliance with evidence-based practices should
be measured weekly or monthly and
reported/charted to show progress towards goal of
100% compliance.
Compliance rate must be calculated with the
whole bundle, not just parts.
CALCULATING COMPLIANCE RATES
# of pts with CVC during monitoring period who received all 5
elements of bundle (with documentation)
# of pts with CVC audited during the monitoring period
X 100 = Compliance Rate (%)
•
Do you have a process for evaluating and reporting compliance
rates with documentation? CLABSI rates?
SAMPLE COMPLIANCE RATES AND CLABSI REPORTING
SCORECARD
July
Aug
Sept
Oct
0.11/1000
0.09/1000
0.09/1000
0.08/1000
Compliance Rate? Goal: 90% or
43%
82%
82%
88%
Are we improving based on data
monitoring?
Yes
Yes
Yes
Yes
Where are we failing based on data
monitoring? Non-compliance Rate:
57%
18%
18%
12%
a. Non-compliance with insertion
documentation: Nurses
24%
b. Non-compliance with barrier
precautions: Physicians
19%
c. System implementation issues:
14%
How often did we harm (CLABSI)?
Goal: <1CLABSI/1000 CL DAYS
greater
**Processes exist for ER and OR staff to document data;
however, the data is not flowing between modules for M/S and
ICU
10%
9%
9%
3 nurses did not
document CVC
insertion; Infusa Ports
not consistently
documented in the
insertion screen as POA
3 nurses did not
document CVC
insertion; Infusa
Ports not consistently
documented in the
insertion screen as
POA
2 M/S and 1 ICU
nurse did not
document insertion
screens; M/S staff
are not consistently
documenting the
insertion screen for
Infusa Ports POA
8%
9%
3%
3 MD failed to
wear full barrier
precautions
3 MD failed to
wear full barrier
precautions
1 MD failed to
use full barrier
precautions
**0%
**0%
**0%
COMMUNICATE AND REPORT
COMPLIANCE AND INFECTION RATES


TJC requires that you report CLABSI rate data
and prevention outcome measures to key
stakeholders, including leaders, nursing staff,
and other clinicians
Regulatory guidelines require reporting CLABSI
rates to the National Healthcare Safety Network
(NHSN)
The Joint Commission
NPSG.07.04.01
Institute for Healthcare
Improvement (IHI)
Monitoring;
Evidence Into
Practice
CLABSI
Prevention
Comprehensive
Unit-based
Safety Program
(CUSP)
Patient
Safety
Evaluation
& PI
Standards;
Regulatory
Compliance;
& Reporting
National Healthcare
Safety Network
(NHSN);
CMS; ADPH
CDC’S NATIONAL HEALTHCARE SAFETY
NETWORK (NHSN): CENTRAL LINE
DEFINITION

An intravascular catheter that terminates at or close to the
heart or in one of the great vessels which is used for infusion,
withdrawal of blood, or hemodynamic monitoring.
-The Great Vessels Include the following:
Aorta
Superior Vena Cava
Pulmonary Artery
Brachiocephalic Veins
Internal Jugular Veins
Subclavian Veins
Inferior Vena Cava
External Iliac Veins
Common Femoral Veins
Umbilical Artery in neonates
INFUSION DEFINED

Introduction of a solution through a blood vessel via a catheter lumen.
Includes:
Continuous Infusions such as nutritional fluids,
medications, or
Intermittent infusions such as flushes or IV
antimicrobial administration, or
Administration of blood or blood products in the
case of transfusion or hemodialysis.
CDC’S NATIONAL HEALTHCARE SAFETY
NETWORK (NHSN): CENTRAL LINE BLOOD
STREAM INFECTION

A Central Line Blood Stream(CLABSI) is a
primary bloodstream infection (BSI) in a patient
that had a Central line within the 48 hour period
before the development of the BSI.
CDC’S NATIONAL HEALTHCARE SAFETY
NETWORK (NHSN): AL HAI REPORTING

Mike Denton Infection Reporting Act (2009; Rules and
Regulations Released-August 2010)
-Requires Critical Access hospitals in Alabama to begin reporting
certain HAIs using CDC’s NHSN.
HAI Reporting
Requirement
Denominator
Requirement
Locations
CLABSIs
Central Line Days
Medical CCUs
Surgical CCUs
Medical Surgical CCUs
Pediatric CCUs
CAUTIs
Catheter Days
Medical Wards
Surgical Wards
Medical Surgical Wards
SSIs for Colon Surgeries
All inpatient procedures
and Abdominal
for Colon Surgeries and
Hysterectomies (inpatient) Abdominal Hysterectomies
Any
ALABAMA CENTRAL LINE/CLABSI
DATA ENTRY REQUIREMENTS

NHSN monthly reporting:
Report central line device days
 Report CLABSI events

**You must have a monitoring plan for each month that
you plan to report.
o
Reporting Deadline for Alabama
-All data must be entered into NHSN no later than
the last day of the subsequent month. Ex. January
data is due by 28February).
NATIONAL HEALTHCARE SAFETY
NETWORK (NHSN): CMS HAI
REPORTING
oCMS Final Rule Passed (July 2010)
-Requires hospitals accepting Medicaid across the Nation to
begin reporting certain HAIs using CDC’s NHSN January, 2011
HAI Reporting
Requirement
Denominator
Requirement
Locations
CLABSIs
Central Line Days
All CCU locations
SSIs (2012)
?
Extended to
28 Feb 2011
CONSIDERATIONS:

Have you evaluated all the different central lines utilized in your
facility that fit the definition of a central line?
oDo you have a Device Days Report?
oDo you consistently collect device day information at the
same time each day?
oIf the patient is in CC/ICU, how do you capture positive blood
cultures that return after the patient is transferred to a
regular floor?
oHave you updated your NHSN monthly monitoring plan to include
both CMS, and Alabama Central line/CLABSI reporting mandates?
oAre your Locations Correctly Mapped?
oAre staff informed of their role in reporting HAIs?
ALABAMA HAI REPORTING AWARENESS CAMPAIGN

Resources: http://www.adph.org/hai/
SURVEILLANCE TIPS
Periodically check the accuracy of line day data
by visiting units and comparing reported
catheter days with actual number of patient
lines.
Remember….
–Internal validation of central line data is critical!!
-when counting central line days, only count one
central line day for patients with multiple central
lines.
-Under reporting line days will artificially increase
CLABSI rates.
The Joint Commission
NPSG.07.04.01
Institute for Healthcare
Improvement (IHI)
Monitoring;
Evidence Into
Practice
CLABSI
Prevention
Comprehensive
Unit-based
Safety Program
(CUSP)
Patient
Safety
Evaluation
& PI
Standards;
Regulatory
Compliance;
& Reporting
National Healthcare
Safety Network
(NHSN);
CMS; ADPH
COMPREHENSIVE UNIT-BASED
SAFETY PROGRAM (CUSP)

NHSN and CUSP Participation

The main focus of the two year “On the CUSP: Stop
BSI” project is to improve our culture of safety,
thereby decreasing CLABSIs. Furthermore,
participation in the project facilitates standards
compliance, measurement, and reporting of CLABSI,
along with other HAI data, to the CDC/NHSN
HOW DOES CUSP WORK?
“CUSP IS A PROCESS”

CUSP comprises five fundamental steps and is a
continuous process.

CUSP guides you on a journey of education and
communication; implementation and evaluation;
review and transparency.

It starts with one high risk unit but provides a
scalable intervention program that can be
implemented throughout your organization.
FIVE FUNDAMENTAL STEPS TO
CUSP

Engage Senior Leadership

Open lines of communication between frontline staff
and administration

Educate leadership about clinical issues and safety
hazards

Improve providers attitudes about leadership

Enlist administration in obtaining necessary
resources to improve patient safety
FIVE FUNDAMENTAL STEPS TO
CUSP

Educate Staff on Science of Safety

Ensure all current staff have viewed the Science of
Safety video and incorporate the video into new hire
orientation (consider adding the video to annual
review)

Evaluate HSOPS results; identify safety needs and
develop a plan of action. Form a team to assist with
these goals and monitor for improvement.
FIVE FUNDAMENTAL STEPS TO
CUSP

Implement Teamwork Tools

Engage staff to be active team players, not passive
players

Breakdown physician – nurse barriers

Provide tools to facilitate teamwork and
communication (ex: daily goals sheet)

Incorporate morning briefings and observing rounds
FIVE FUNDAMENTAL STEPS TO
CUSP

Identify Defects

Use incident reports, liability claims, or sentinel
events

Survey staff and ask, “How will the next patient be
harmed?”
FIVE FUNDAMENTAL STEPS TO
CUSP

Learn From Defects

Incorporate a practical tool to address what
happened, why it happened, what you did to reduce
future risk, and how to measure for reduced risk

Use resources such as the “Learning from Defect
Tool” and “Investigating a CLABSI Tool” found on
the CUSP: Stop BSI website

Plan to learn from at least one defect a month
APPLYING CUSP TO CLABSI
PREVENTION

Begin by reviewing your TJC NPSG 07.04.01 risk
assessment:
APPLYING CUSP TO CLABSI
PREVENTION




If you’ve already conducted a TJC risk
assessment for NPSG.07.04.01, then you’ve
already identified gaps, deficiencies, and/or
process improvement opportunities
Now develop actionable plans to improve
processes
Monitor compliance with evidence-based
practices
Evaluate effectiveness of prevention efforts
APPLYING CUSP TO CLABSI
PREVENTION

Educate staff, patients, and family about CLABSIs
and prevention

Implement policies aimed at reducing the risk of
central line infections

Adhere to the CLABSI Prevention Bundle:






Strict and consistent hand hygiene
Maximum use of barrier precautions, including full patient
drape
Site prep with Chlorhexidine
Optimal site selection (avoid femoral insertions when
possible)
Scrub the hub before accessing ports
Remove catheters when no longer necessary; assess daily
need
APPLYING CUSP TO CLABSI
PREVENTION

Create a Central Line Insertion Kit or Cart

Devise and consistently use a Central Line Insertion
Checklist

Empower nurses to stop the procedure if guidelines
are not followed

Post the # of patients infected per month and your
quarterly infection rates

Participate in monthly CUSP calls, enter data into
MHA Care Counts, and complete the Monthly Team
Check-up Tool
EVALUATING PROCESSES



If your CLABSI rate is NOT going down,
evaluate your processes!
Determine if processes are breaking down and if
so, develop a plan of action to correct the
deficiencies!
Finally, CUSP is not exclusive to CLABSI
prevention. It is a process to address your overall
culture of patient safety. Once you understand
the process, CUSP can be applied to any process
improvement program i.e., other TJC National
Patient Safety Goals:
The Joint Commission
NPSG.07.05.01
Monitoring;
Evidence Into
Practice
SSI
Prevention
Comprehensive
Unit-based
Safety Program
(CUSP)
Patient
Safety
Evaluation
& PI
Standards;
Regulatory
Compliance;
& Reporting
National Healthcare
Safety Network
(NHSN);
CMS; ADPH
The Joint Commission
NPSG.07.07.01
Monitoring;
Evidence Into
Practice
CAUTI
Prevention
Comprehensive
Unit-based
Safety Program
(CUSP)
Patient
Safety
Evaluation
& PI
Standards;
Regulatory
Compliance;
& Reporting
National Healthcare
Safety Network
(NHSN);
CMS; ADPH
CONCLUSION




Creating an integrated CLABSI Prevention program is about
evaluating your TJC compliance; understanding how to define
and report CLABSI to NHSN; and implementing CUSP
processes that sustain a culture of patient safety!
The Alabama Department of Public Health and the Alabama
Hospital Association truly wish every IP great success in this
new venture! Odds are, now that you understand how all
these elements are inter-related, you will probably discover
that you’ve done more with the CUSP project than you
thought.
The challenge, use CUSP processes to raise the bar with
CLABSI prevention – take it to the next level: implement
daily goal sheets; begin daily rounding with physicians;
conduct AM briefings.
And remember to always ask, “How will the next patient be
harmed; how can I prevent it from happening?”
QUESTIONS?