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 toward a goal
of 100% compliance.
Compliance rate must be calculated with the
whole bundle, not just parts.
EXAMPLE OF STANDARDIZED
DOCUMENTATION
DEVICE DAYS REPORT
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
Jan
Feb
1 MTD OR
0 MTD or
4.2 CLABSI /
1000 CL Days
2 CLABSI/1000
CL Days YTD
69%
82%
Are we improving based on data
monitoring?
NO
YES
Where are we failing based on data
monitoring? Non-compliance Rate:
31%
18%
a. Non-compliance with insertion
documentation: Nurses
4 ICU
nurses; 1 ER
nurse; 1 3
M/S nurse
failed to
document
insertion
screens
1 ER nurse; 1
OR nurse; 1
ICU nurse; and
3 Third floor
M/S nurses
failed to
document
insertion
screens
b. Non-compliance with barrier
precautions: Physicians
2 MDs had 4
infractions
2 MDs failed to
use
appropriate
barrier
precautions
c. Miscellaneous Obstacles:
Need to CVC
Insertion
screen to
populate
process
intervention
board –done
3/1/11 note
screen
documentation
will be
imbedded in
shift
assessment –
done
How often did we harm (CLABSI)? Goal:
≤1/1000 central line days
Compliance Rate (documentation & use of
barrier precautions?
Goal: 90% or greater
Mar
Apr
May
Jun
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 and
Abdominal Hysterectomies
(inpatient)
All inpatient procedures for
Colon Surgeries and 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).
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 interrelated, 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?