CLABSI Prevention
THE PLAN
1.
Review base line data and
look for trends
Units of occurrence
Frequency of occurrence (per month, per year)
Type of line associated with the infection
Time from insertion to infection (per SIA review)
If infection occurred in <7 days, be sure to consider insertion as a possible factor. If > 7 days insertion
unlikely a factor.
Compare outcomes to facility expectations, published literature and possibly other local like HC facilities
 Make sure comparisons are ones that team members support. If the source is not respected, the
conclusions from the comparisons won’t be respected.
2.
Review best practice
guidelines
Document1
Joint Commission - see specifically section 07.04.01
http://www.jointcommission.org/assets/1/6/HAP_NPSG_Chapter_2014.pdf CDC (Centers for Disease Control) (category 1A and 1B citable by JC)
http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf
John’s Hopkins -Peter Provonost and Michigan Keystone – includes checklist examples
http://www.hopkinsmedicine.org/innovation_quality_patient_care/areas_expertise/infections_
complications/BSI.html
http://www.onthecuspstophai.org/on-the-cuspstop-bsi/
IHI – Institute for Healthcare Improvement –
http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventCentralLineAssociatedBloodstr
eamInfection.aspx
SHEA (The Society for Healthcare Epidemiology of America)
http://www.shea-online.org/Assets/files/position_papers/hicpac_catheter.pdf
SHEA (The Society for Healthcare Epidemiology of America)
http://www.jstor.org/stable/10.1086/676533 (2014 update)
National Kidney Foundation (for management of temporary dialysis catheters)
http://www.kidney.org/professionals/kdoqi/guidelines_updates/doqiupva_i.html#doqiupva6
Kagan, Richard. A Performance Improvement Initiative to Determine the Impact of Increasing
the Time Interval Between Changing Centrally Placed Intravascular Catheters. Journal of Burn
Page 1 of 13
THE PLAN
3.
Review current
organizational practices
4.
Review onboarding
5.
Assemble Team(s)
Document1
Care and Research 2014; 35:143-147
Infusion Nursing Standards of Practice. Journal of Infusion Nursing 2011, Vol 34.
International Society for Burn Patients
Infection Control in Burn Patients http://www.worldburn.org/documents/infectioncontrol.pdf
Timsit, JF. Dressing disruption is a major risk factor for catheter-related infections. Crit Care
Med 2012; 40:1707-1714
 How does staff know about the expectations? Is it in a policy, or is it something that is
taught with variety or assumed to be known when arriving?
 Have key medical Team Leaders seek out subspecialty best practices (ex Medical Director
lead to work with renal experts). This may help find other specialty best practices to
consider.
 How are nursing staff trained to organizational expectations (lecture, return demo, etc)
 How are staff MD’s trained to organizational expectations
 How are residents and students trained to organizational expectations
Based on findings from baseline data, best practice, and current organizational practice,
determines who needs to be on the improvement team.
 Consider who in the organization stands to be affected by the changes, and where
opportunity lays in standardization of practices across the institution -even in areas that may
not currently appear to have issues.
 Participants respond to executive leadership participation. Medical directors and unit
managers level of participation changed when the CEO met with the group and clearly
outlined his expectations of the workgroup.
 Select Project Team Leaders:
o ICU Director
o Operating Room Director
o Infection Prevention Director
o SICU Medical Director
o MICU Medical Director
 Consider service lines and area of influence.
 Do not rely on the director of one service line to have influence over another service line. If
the team is too large for one group, divide teams up and determine the subgroup goals,
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THE PLAN
6.
7.
8.
actions, and levels of authority.
 Steering Committee Team Members:
o Infection Prevention and Infectious Disease Physician
o MICU Nurse Manager
o SICU Nurse Manager
o Peds Nurse Manager and Peds Medical Director
o Burn Nurse Manager and Burn Medical Director
o ED Nurse Manager and ED Lead Physician
o Anesthesia – MDA and CRNA
o Interventional Radiologist
o Dialysis Physician
o Nursing IV Team Lead
o Office of the Medical Director
o Quality Staff – Medical and LEAN
o Electronic Health Record developers and report writers
 We didn’t have these, but in retrospect may have benefited from:
o Residents (the ones who are actually putting in the line)
o Supply Chain
Determine early on
Are the exceptions the preference of staff, or are the exceptions supported by literature and
what practice care areas scientific evidence.
have “exceptions”
Determine what is
Targets and goal options: state, federal , institutional, etc
considered a success
Example: Minnesota State Action Plan to Prevent Healthcare-Associated Infections
National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination
Determine what will be
 Consider important process measures as a means of sustaining change and maintenance of
measurable
best practices.
 Determine which outcomes measures should be used.
 Define standard work for who does the measuring and how to make the measuring most effective
 Develop a process to measure practices and/or outcomes that may be required by external
agencies.
 Set reporting frequency
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THE PLAN
9.
Determine Timeline
10.
Determine who keeps
record of plan and
activities
11.
Consider other literature
that will help providers
champion the best
practice
TOOLS:
1.
2.
3.
4.
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Frequency of meetings, how decisions are to be made, who gets to make the decisions, how
is this communicated, what is the final goal; keep people aware of the scope of the project,
set ground rules
 Determine who and how to keep executive leadership up to date and when to reach out if
roadblocks occur
Select a person who is knowledgeable in the subject matter:
 keep notes
 write minutes
 update timeline
 set agendas
Do spend time discussing with the providers what their current practice is, but at the same time discuss
with them what it would take to get them to the best practices. It will confound issues if time is spent
discussing what is thought to be best practice.
Examples:
 JAMA 2009. Pittet. CLABSI Prevention beyond the Checklist
 NEJM 2006 Provonost. CLABSI Prevention
 Int J Nurs Stud. 2007 Nov;44(8):1324-33. Tsuchida T, The effectiveness of a nurse-initiated
intervention to reduce catheter-associated bloodstream infections in an urban acute hospital: an
intervention study with before and after comparison.
 Crit Care Med. 2004 Oct;32(10):2014-20. Berenholtz SM. Eliminating catheter-related
bloodstream infections in the intensive care unit.
Call To Action Burning platform summary
Meeting agenda template
Action plan template
Best practice summary templates
Best practices/Policy (DO)
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Best practices/Policy (DO)
1.
Burn unit exceptions
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2.
NICU specifics
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3.
Dialysis practices
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4.
Orders
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Document1
Insertion and duration of CVC in burn patients. Limited data is available at this time for the
management of burn patients. HCMC practice, based loosely on Shriner’s practice: Place central line,
change over a guide wire @day 5; change site at day 10. (INFECTION CONTROL IN BURN PATIENTS
Author: Joan Weber, RN, BSN, CIC Infection Control Coordinator, Shriners Burns Hospital, Boston,
Massachusetts)
Depending on location of line and patient burn surfaces, established and preferred dressing change
intervals may not be feasible. Develop a plan for managing the maintenance of these lines. Ensure
that staff is familiar with separate process.
Review unique requirements for NICU related to UVC and UAC lines, PICC placement location best
practices, alternatives to CHG use, prepping the port.
Contracted with Davita for dialysis services and found that Davita practice did not mirror HCMC policy.
o Davita policy was to change dressings at every dialysis run and frequently using gauze dressing.
Worked with Davita leadership to align dressing change frequency and methods to that of HCMC and
established best practices.
o Discovered that larger Biopatch was not onsite for dialysis lines. Made the larger size a storeroom item
for dialysis catheters
Discovered HCMC practices were not standard to the KDOQI guidelines.
o Unauthorized access. Multiple reports of unauthorized dialysis catheter access. KDOQI guidelines limit
access outside of dialysis for emergent use only or with a Renal order for use. Added this to the policy
and training.
o Needless connectors were not in use for dialysis lines, only end caps only were being used between
runs. Explored opportunities and found that Tego connectors (a dialysis line needleless connector)
were standard in the dialysis community. Worked with MICU staff and Davita staff to bring in
connectors and train staff for use. Needed to take into consideration MICU and other staff performing
CRRT at HCMC.
Discovered Surgical Services did not have all of the best practice supplies for dialysis catheters. Did not have
Tego connectors and did not have larger Biopatch. Nursing staff in surgical services needed training on
accessing dialysis lines.
Need order for use for nursing practice. How do the orders address cares? Should incorporate other activities
directly surrounding placement such as radiology for verification of placement.
Plan what orders are needed if patient comes in with an existing line.
Determine if Renal approves use of dialysis lines for routine blood draws and other fluid administration in
nonemergent situations.
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Best practices/Policy (DO)
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5.
Line selection
6.
Insertion
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Need to consider how orders flow throughout the organization. How do central lines orders differ for
nontunnel vs tunneled catheters placed in the OR.
When to move to tunneled line? Literature suggests 3 weeks. How to make this happen?
What type of line is best practice – PICC vs PIV, vs tunneled, etc. To become the policy supporting document
Ensure there is an insertion checklist
 Created an insertion checklist after review of existing checklists from institutions that were successful
then modified with Steering Team agreement
 Start with paper and trial in one area before expanding or modifying. This may take several revisions
to determine final product
 Determine who can be the insertion observer
 Determine where the blank checklists are to be kept
 Determine what happens with completed checklists
Determine criteria for site selection
 Work with best practice and needs of a medical teaching facility for recommendations.
CVC kits
 Evaluate current supplies to ensure that staff can perform to best practices
 Don’t just ask, but pull several kits and have users demonstrate how the kit is used and if it meets
needs and best practices. Asking elicited one answer, demonstration of use provided very different
responses
 Use supply chain orders for volume use and type of lines used, but also consider direct order options.
Go unit to unit and look for kits. Products can make their way into the institution without using supply
chain.
 Worked with providers to come to an agreement on a limited number of CL kits to reduce variability
and push toward best practice
Line cart – a JC NPSG
 Determine where carts should be located
 Determine contents are standard for all carts
 Create standard work for maintaining supplies in cart
Management of non sterily placed lines
 Determine what is considered a nonsterily placed line
 Create a process to communicate this
 HCMC determined indicator would be a sticker placed on the line to change in 48 hours
Consider other areas that may use CVC’s and the supplies needed. Ex: OR supplies – biopatch, tego, dressing;
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Best practices/Policy (DO)
7.
Maintenance
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8.
Daily assessment for
need
9.
Removal
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IR, etc
Ensure dressing change kits have adequate supplies to meet best practice
 Determined to use a standard dressing change kit to allow staff best practice for line maintenance
 Use supply chain orders for volume use and locations of product used
 Interview nursing staff who perform dressing changes
 Observe dressing change practices by a variety of practice groups (ICU, floor, IV team)
 As a result of this process, HCMC found dressing kit did not have all the best tools, nor was there
standard work for dressing changes and line maintenance
 Because of limitations by supplier to reconfigure dressing change kits to meet best practice,
switched dressing from Sorbaview to Tegaderm after brief unit trial. Realized cost savings as
in incidental effect in the dressing change
Scrub the hub
 Determine what product to use to prep the port prior to access – alcohol or CHG
 Determine expectations for adequate hub prep.
 Contacted manufacturer of products and reviewed literature to determine length of time to
scrub the hub. Best practice guidelines do not provide a time. Manufacturers only provide
times to prep site for insertion and surgical procedures. Asked for manufacturer
recommendations in writing and cited journal articles to determine HCMC would use a 10
second scrub and a 20 second dry time for hub prep.
Dressing disruption
 Observations by medical staff and nursing indicated not all CVC dressings were remaining intact, nor
were the dressings being changed routinely when not in optimal condition.
 Reviewed literature and found recent evidence linking risk of infection related to number of
unintended dressing disruptions.
 Incorporated into policy and EPIC documentation the practice to change CVC when 2 or more
unintended disruptions occurred
Dressing options for patients without intact skin (eg Burn)
 Still to explore options. Not yet complete
Come to an agreement of what is a daily assessment for need
How is this communicated to nursing staff
How is this documented
What are the downstream effects of the assessment – eg: order for removal, monitor, etc
Agree to the timing of removal once the line is no longer medically necessary
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Best practices/Policy (DO)
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10.
Policy
11.
When to revisit/how to
avoid the pendulum
effect
Daily CHG bathing
12.
TOOLS:
1.
2.
3.
4.
5.
What is the documentation
Interviews revealed delays in removal related to time of day, availability IV team etc.
o Misperceptions of how to remove PICC’s and who was able to remove
o Need to set expectations on unit and in policy of who can remove a central line and what type of
central line
 How to manage documentation of patients discharged with central lines
Develop a hospital policy related to the best practices and unique practices and issues specific to facility. Ensure
the support and agreement of the Steering Committee to promulgate the policy to peers.
Need to balance best practice and emphasize care of patient come first. Focus on prevention from leaders can
push providers to avoiding the use of central lines and possible inappropriate use of peripheral lines.
Daily CHG bathing already established in the ICU’s. Need to find a way to expand this to the floors so that non-ICU
patients with CVC’s get a daily bath with CHG. Need to make sure processes align with other initiatives (ex surgery
pre-op, etc).
Policy
Insertion checklist
CHG daily bathing
Rounding checklist
Line cart contents
Education (DO)
1.
Baseline audit of best practices
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2.
NICU
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3.
Patient Education
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Document1
Using Best Practice and policy perform an audit of current activities.
HCMC was able to use Biopatch reps, IP and IV staff to perform a 1 day point prevalence audit.
Used this information to help determine education targets
Reviewed NICU unit policies and discussed practices with NNP’s and physicians. Found variety
of practices that were not optimal (ex how infant was draped, using sterile water to prep the
skin instead of PI disinfectant with removal of PI after procedure, etc)
JC NPSG requires the patient and/or their family to be educated to the risk of and prevention
of CLABSI.
HCMC decided to use the insertion checklist as the place to document education.
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Education (DO)
4.
5.
Create an education plan that
involves the caregiver as the
agent of change and why the
driving need for change
What should you educate?
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6.
Determine frequency of
education
7.
Determine how to educate (big
bang/unit based/passive/active,
etc)
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Incorporated expectations into policy and topics to discuss
Once plan is in place and best practices have been accepted by leadership. Involve key
educators and staff.
HCMC education team members:
o Project Team Leaders
o IP
o ICU manager
o Floor manager
o Nursing education department
o Office of the Medical Director
o IV Team
Determine who to educate and what is unique or special for the practice group
Determine what each practice group should know and what should they know about others. Ie
what should nursing know that is the responsibility of the provider. What should the provider
know to expect from nursing.
Use baseline audits to determine where gaps are for targeted education
Why the change and why it is considered best practice. Give examples how implementing best
practice leads to success
Facility expectations
Insertion checklist
Where are supplies and what supplies should be used (ex line carts vs kits, dressing kits, etc)
Maintenance expectations and return demonstrations of competency
Assessment for removal
Documentation
Are there regulations that determine the frequency of education?
HCMC is following Joint Commission requirements for those how are involved with CVC’s
upon hire, annually thereafter and when transfer of duties include CVC s
Residents
o All residents must have successfully placed a simulated central line and
o Demonstrate competency per the Resident/Fellow Scope of Practice
Select a method of education that fosters active learning and participation.
HCMC required (as a condition of work to complete in a 1 month period of time)
o online facility made/facility specific videos to introduce concept and expectations
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Education (DO)
 nursing, residents, Staff MD’s
In addition nursing was required:
 Return demonstration and competency of dressing change
 Interactive Q and A in the form of Jeopardy! Game for use and maintenance
o The HCW person was to be removed from the work schedule until education
successful.
Who can access implanted lines
Who can remove central lines
Who is trained to access dialysis lines
Blood draws from dialysis lines for OR and ICU staff or those approved to draw blood
o
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Consider specialty education
TOOLS:
1.
2.
3.
4.
5.
6.
7.
Biopatch point prevalence audit
MD video
Nursing video
LMS nursing PPT
ReNew material
What to educate the patient
JC NPSG
Measurement (Study)
1.
Insertion
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2.
Maintenance
Document1
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Checklist observation tool – how to measure this use? How do you know if every non-tunneled,
nonemergent line had 2 person insertion?
What to do with insertions that don’t go well? Early on had some staff feel the checklist was
unnecessary. The CMO was contacted and informed the staff member they would be suspended if they
didn’t follow the policy and checklist.
Modify EPIC Dashboard. Added specific process measure data elements for nurse manager to monitor
o How many days has the line been in place
o When dressing change is due (so manager can go a do staff competency assessments)
o Nonsterily placed line indication (to monitor for timely removal)
o CHG bathing occuring
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Measurement (Study)
3.
Removal
4.
Electronic Health
Record (EHR)
Davita
5.
6.
7.
TOOLS:
1.
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4.
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6.
Barriers to success
Denominator data
o Biopatch present
o Daily assessment for need
o Number of unintended dressing disruptions (to move to recommendation for new line)
 Time from order to removal?
 Device utilization?
 Why the line was removed – successful completion, complication……
 As measurements are being determined, include EHR staff to build the proper documentation structures
for orders, insertion, and maintenance such that audits are easy for the front line managers and directors
Put HCMC performance standards into contract and have unit report out compliance they monitor and
report on a monthly basis: Hand hygiene compliance, biopatch presence, and intact transparent dressings
Survey staff for possible knowledge deficits or barriers to success
Validate the numerator and denominator data
IP Outcome reports
Screen shot of EPIC Radar
Screen shot of denominators
Screen shot of MD Note Writer
Davita contract language for auditing requirements and expectation to HCMC policies
Reporting requirement document
Communication (ACT)
1.
Outcomes
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Education Programs
Meeting minutes
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Monthly report emailed to leadership (Nursing managers, Medical Directors, CEO, CNO, senior nursing
staff, quality, OMD, etc) Include rates and “Days Free” to post on each unit.
Case reviews of all CLABSI occur within a week of determining the CLABSI. Include the inserting team if
occurs within 7 days of insertion. Include residents attending.
Rates posted on all unit visual management boards
Present outcomes to Manager meetings, executive board
Related where we are at, the goals and each person’s responsibility in the prevention
Report staff compliance with attending education events to managers, CEO and OMD
Steering committee and work group minutes emailed to all team members weekly
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Communication (ACT)
Process measures
Hospital priorities
TOOLS:
1.
2.
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4.
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Audit information given to all nursing and medical staff. Drilled to unit level.
Hennepin Health System has 3 main priorities for 2014 (approved by Executive Leadership and County
Board of Directors) One of the 3 main priorities included 3 Infection Prevention initiatives: CLABSI, CAUTI
and SSI
Nursing Huddle message examples
Manager huddle presentations
Monthly report example
Board presentations
Sustain (ACT)
1.
Followup with areas as differences come to
light
Ex Tegos in the OR? Or supplies?
2.
How to know if a person is competent to
insert a line
Continue competency
How do you know a resident is competent to insert?
3.
4.
5.
6.
Measurement frequency of process
measures and outcomes
Eliminate barriers to success
Develop standard work for CLABSI Case
Review
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Per JC Staff will periodically be assessed for knowledge of adherence to
insertion and maintenance best practices.
 Determine what should staff be held accountable to
 Who performs the competency assessment
 What will be remediation tools
Determine who sees these process measures and outcomes. Who has influence to
reinforce and accountable for holding staff to performing audits, etc
 Case reviews of infections to determine if best practices are still in place and/or
what prevented practicing best practices. See #1 in sustain
 Else?
What elements should be reviewed each time and who should be present
7.
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