VASCULAR ACCESS
SPECIALIST TEAM
Ownership of the
Bundle
April VanDerSlik BSN RN CIC
Infection Prevention Manager
November, 2013
1
2
Bronson Healthcare System
•
Regional, not-forprofit health system
•
Recognized for
workplace excellence
•
National leader in
healthcare quality
•
3
Keystone, including
CUSP
Bronson Methodist Hospital
•
434 bed tertiary teaching hospital
•
11 VAST nurses (7 full-time, 2 part-time,
2 on-call)
•
642 Acute CVCs / year
•
Approximately 1,000 PICCs / year
•
4
~ 50% PICCs are placed in critical care units
Commitment to Excellence
5
The Bronson Story
6
History
•
Team Beginnings: Hyperal Initiation
•
•
•
•
Formed 1978
Dr. James Heersink, General Surgeon
Hyperalimention Team (doctors, nurses,
pharmacist, and dieticians)
Duties
•
•
•
•
•
7
Assisted with CVC inserts
Education of staff and patients
Improved patient outcomes
Decreased infection rate
Team name change in 2009 (VAST)
VAST: Team Responsibilities
1. Education
a.
b.
c.
d.
e.
Develop policies and procedures according to INS
standards, CDC & Joint Commission guidelines
Teach IV & Infusion Management class
Patient, family and staff education
Manage Champion program
Clinical resource to community
2. Placement
a.
b.
Assist providers with CVC insertions
Insertion of PICCs at bedside
3. Post Placement
a.
b.
8
PICC daily surveillance
PICC dressing changes
Central Line Associated Blood
Stream Infections (CLABSIs)
Adult Population Only
12
10
8
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
1994
1988
0
1993
2
1991
4
9
%
All TPN Dressing
6
Low CLABSI National Recognition
•
Healthgrades, 2013
•
•
Consumer Reports, Jun 2011
•
•
•
reported zero
received highest score
Commonwealth Fund, Dec 2011
•
10
Better than average
reported zero
Bronson’s Implementation Plan
Reduce CLABSI
11
Methodology
Guidance
•
•
•
CDC & Joint Commission guidelines
Keystone: CVC bundle
PICC bundle (Bronson specific protocol)
Practice
•
•
•
•
•
•
•
•
12
Daily PICC and TPN surveillance
Dressing change protocols
Hand hygiene program with auditors
Ultrasound guided CVAD placement
Blood sampling protocols
Education
Scrub the hub
Chlorhexidine disc
Actual Practice Example
13
Keystone CVC Bundle
Before procedure
•
Hand hygiene, chlorhexidine prep
During Procedure
•
•
•
•
•
•
Full Barrier Pre-cautions: Hat, mask, sterile gown, sterile
gloves
Assist physicians and residents with insertion – avoid
femoral site
Monitor sterility
Empowered to stop procedure
Monitor traffic pattern
Use of checklist
After procedure
•
•
14
Sterile dressing applied
Removing unnecessary catheters
•
•
Bronson PICC Bundle
at the Bedside
Hand hygiene
Max barrier precautions
•
•
•
•
•
•
•
15
pre-packaged insertion kit
Chlorhexidine prep
Ultrasound guided PICC
insertion
Neutral connector system
Connector disinfection
Flushing protocol
Daily monitoring of all PICCs by VAST
Scrub the Hub1
1. Wash hands or use hand
sanitizer
2. Wear gloves
3. Scrub the hub for 30
seconds each and every
time with chlorhexidine
1Centers
for Disease Control, Guidelines for the
Prevention of Intravascular Catheter-Related Infections,
2011
16
Patient Ownership
Goal: Patient Empowerment of their VAD
•
Inpatient
•
•
•
Discharge
•
•
•
17
Permission to say “no” to care being
given (i.e. change your gloves, wash
your hands, scrub for 30 seconds)
Basic care & maintenance education
Care & maintenance instructions
Emergency contact information
All CVAD types
Checklist and Nurse Empowerment
Goal: Assist providers with CVC insertion
 Checklist to delineate, guide and document
completion of each step
 Source of data collection to verify adherence
to protocol
 Taught to speak up and “stop the line”
 Patient safety strong backing by RN, MD and
management
18
Vascular Access Infusion Training
(Who do we educate?)
• Physician and residents
• Clinical staff (more than 800 FTEs)
• Management
• Patients and families
19
Post Insertion Care
Goal: Dressing Change and Line Surveillance
20
•
Daily: PICC & TPN lines –VAST Team
•
Daily: Acute CVC – Staff Nurses
•
Check bag & tubing–labeled with time/date/initials
•
Lab values
•
Fever
•
Line Necessity
Staff Engagement Activities
Traveling Story Board
Updated
according to
unit specific
educational
needs
»Transferred from unit to unit»
21
Champion Program Selection
Clinician empowerment of insertion procedure,
care & maintenance and training of staff






22
RN for two years at Bronson
VAST and management approval needed
Attends Champion class done by VAST
Specially trained in high risk central line skills
Ability to sign off other RN’s on certain procedures
Yearly peer review
Champion Program: Duties / Skills
•
Champion Duties
•
•
•
•
•
•
Champion Sign off Staff (Procedures)
•
•
•
•
23
Sign off floor staff
Removal PICC / CVC
Dressing Changes (CVC)
Catheter Clearance - Thrombolytic
Continuing Education
Hanging TPN
Blood draws
Dressing Change (CVC)
Port Access
Champion Program: Competency
Goal: Proficiency Demonstration
VAST or unit champion to sign RN off on
procedure
•
•
•
24
RN observation
RN practicum / performance
of procedure with assistance
RN demonstrated competency
without assistance
New Hire Employee: Infusion
Training
Computer Based Learning
(CBL) class
•
•
25
IV insertion and infusion
management
Practicum for hands on
demonstration in
classroom setting
New Initiative: Community Education
Goal: Initiative to decrease readmits from
community due to CLABSIs w/ outside staff
training
•
•
•
26
Local Nursing homes
Home Health Agencies
Local Hospice – policies only
27
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
0
1994
2
1993
4
All TPN Dressing
6
1991
1988
Central Line Infection Rate History
(Adult Population Only)
12
10
8
%
Obstacles to Overcome
• Hospital Administration
support of empowerment
• Finding a Physician(s)
Champion
• A hospital wide culture
change
28
Lessons Learned
•
•
•
•
•
29
Participate in infection prevention collaboratives to share
your challenges and best practices with other hospitals.
Involve physician champions and multidisciplinary teams.
Use checklists.
Employ small, specially trained teams and individuals
(including intensivists in the ICUs) to conduct and/or
oversee line insertion and maintenance throughout the
hospital.
Sustain best practices with ongoing education, monitoring,
and adjustments and provide performance data to staff to
keep them focused on outcomes.
References
•
•
•
•
•
•
•
•
30
Carroll SS (December 2011) Eliminating Central Line Infections and
Spreading Success at High-performing Hospitals Synthesis Report
December 2011 Commonwealth Fund publication 1559 Volk 21
Ending Health Care-Associated Infections Agency for Healthcare
Research and Quality (2009)
www.ahrq.gov/research/findings/factsheets/errors-safety/haicusp/index
Lowes R (2011) High Central-Line Infection Rates at Many Teaching
Hospitals New Consumer Reports Study Gives Poor Marks to 67
Institutions Medscape Medical News June 7,2011
www.medscape.com/viewarticle/744131
O’Grady NP et al (2011). CDC Guidelines for the Prevention of
Intravascular Catheter-Related Infections
Sardone F (2010) Celebrating Nursing Excellence Bronsonhealth.com
www.commonwealthfund.org
www.bronsonhealth.com/about
www.healthgrades.com/quality/top-hospitals-2013
Thank You!
bronsonhealth.com
31