Why Maintenance is so
High Maintenance: How
to Achieve Success
Tamara Johnson RN
Director Clinical Integration
Ivera Medical Corporation
OBJECTIVES
 Understand why CABSI and CLABSI are important
 Top 10 Reasons Maintenance is High Maintenance
 Understand the dynamics associated with Port Protection and
compliance and their role in the “maintenance bundle”
 Overcoming Port Protection challenges (Process Changes)
2
CLABSI TIMELINE
2001 – Beginning of the term “Never Events”
 2008 – CMS releases reimbursement guidelines which
include Vascular Catheter Related BSIs (no CL modifier)
 2011 – National Healthcare Safety Network begins
monitoring mandatory surveillance reporting on
CLABSI
2012 – Updated CLABSI Definitions from CDC
2013 – Updated CLABSI Definitions from CDC
2014 – Updated CLABSI Definitions from CDC
3
FROM OUR FRIENDS AT THE CDC…
 Central Line Associate Blood Stream Infection
(CLABSI) - a laboratory –confirmed bloodstream
infection (LCBI) where the central line (CL) or umbilical
catheter (UC) was in place for >2 calendar days on the date
of the event, with day of device placement being Day1, and a
CL or UC was in place on the date of event or the day before. If a CL
or UC was in place for >2 calendar days and then removed, the LCBI
criteria must be fully met on the day of discontinuation or the next day.
If the patient is admitted or transferred into a facility with a central line
in place (e.g., tunneled or implanted central line), day of first access is
considered Day 1.1
1. ) http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf
4
A CENTRAL LINE INCLUDES:
 Central Venous Catheter (CVC)
 Peripherally Inserted Central Catheter (PICC)
 Dialysis Catheter
 Umbilical Catheter
 Hickman Catheter
 Broviac Catheter
 Groshong Catheter
6
IMPACT OF CLABSI
$34, 500 - $56, 000 per episode2
$54,000 - $75,000 in adult Surgical ICU3
80,000 ICU BSI’s a year – leading cause of ICU
nosocomial infections4
250,000 CLABSI’s a year2
30,665 deaths a year from CLABSI5
2.) Moreau N. Nursing 2009;34:14-15
3.) Hollenbeak CS. J Infus Nurs. 2011:3309-3313
4.) O’Grady NP, et al. American Journal Infection Control
2011;39(4suppl 1):51-34
5.) Klevens RM, et al. Public Health Rep. 2007;122-160-166
7
MECHANISMS LEADING TO CLABSI6
 Pathogen migration along external surface – typically
within first 7 days
 Hub contamination leading to intraluminal colonization
 Needleless connector contamination leading to
intraluminal colonization
 Established from a different source
 Contaminated infusions
6.) The Joint Commission. Preventing Central Line–Associated
Bloodstream Infections: A Global Challenge, a Global Perspective. Oak
Brook, IL: Joint Commission Resources, May 2012.
http://www.PreventingCLABSIs.pdf.
8
PROTECTING OUR PATIENTS…
Implementation of “Bundles”
 Bundle7 - a structured way of improving the processes of care and
patient outcomes: a small, straightforward set of evidence-based
practices — generally three to five — that, when performed
collectively and reliably, have been proven to improve patient
outcomes.
CDC Guidelines for CLABSI Bundles
7.) http://www.ihi.org/explore/bundles/Pages/default.aspx
9
CLABSI BUNDLES
Central Line Insertion Practices (CLIP)8
 Hand Hygiene
 All 5 Maximal Barrier Precautions
 Sterile Gloves
 Sterile Gown
 Cap
 Mask Worn
 Sterile drape covering entire patient
 Chlorhexidene gluconate (CHG)
 Insertion Site
 Daily assessment to determine need
8.)
http://www.cdc.gov/nhsn/PDFs/pscManual/5p
sc_CLIPcurrent.pdf
10
CLIP VS MAINTENANCE
 Extraluminal vs
Intraluminal
 CLIP = happens
one time on a
patient
 Maintenance =
happens all day
long by a lot of
different people
(#1)
1 vs ???
“Bloodstream infections related to long-term CVC use
are almost always a result of intraluminal biofilm
development.”
- James Davis, RN, CIC
Senior Infection Prevention Analyst
Pennsylvania Patient Safety Authority
11
CENTRAL LINE MAINTENANCE “GUIDELINES”
 Hand hygiene compliance ✔
 Scrub access port or hub immediately prior to
each use with appropriate antiseptic (70% IPA,
CHG, provodine iodine) ✔
 Access catheters with only sterile devices ✔
 Dressing care. Replace wet, soiled or dislodged
(using aseptic technique with clean or sterile
gloves) ✔
 Replacement of administration sets and
needleless connectors ✔
 Perform daily assessments to determine need
for CVL ✔
#2
9.) http://www.cdc.gov/hicpac/BSI/BSI-gui
2011.html
12
NEEDLELESS CONNECTOR DISINFECTION
2007 Java Vol 12, No 3, 140-142
13
Do I need to scrub when I remove CUROS®?
“SCRUB
THEhas
HUB”
NO. If CUROS
been in place for at least 3 minutes,
you do not need to scrub the port before your rst access.
15 seconds
Scrub
the
hub:
When there is visible soil on the port (blood, lipids, etc...)
Between sequential accesses per hospital protocol:
SALINE
FLUSH
MED
ADMIN
SALINE
FLUSH
NEW
CUROS
Scrub if you remove CUROSand leave the access port
exposed for a period of time before accessing.
ML-0030 Rev A | 0911
14
IS 15 SEC EVERY SINGLE TIME, EVERY SINGLE
ACCESS A PRACTICAL EXPECTATION TODAY?


Ideal web page load time 3.5 seconds
(2010 PhoCusWright/Akamai Study)
#3
15
AND THE SURVEY SAYS…
16
• Sent an electronic survey1 and asked staff nurses
to report their
compliance
involving
of
Worth
a Try: CLA-BSI
Reduction disinfection
Associated
BYU College of Nursing
With Alcohol Cap Implementation
peripheral and
central
IV access ports and IV tubing end
nursing.byu.edu
Lorraine Linford, RN, BS, CNSC; Sharon Sumner, RN, BSN, IP;
Carrie Taylor, RN, MSN, CIC; Katreena Merrill, RN, PhD
care.
CLA-BSI PICC Incidence and Interventions Over Time
Purpose
• Determine whether an alcohol cap decreases central
line associated blood stream infections (CLA-BSI).
• Determine the effect of an alcohol cap on the number of
contaminated blood culture specimens.
• Determine the financial impact of using an alcohol cap.
CLA-BSI
Pre and post alcohol cap implementation
Feedback from Nursing Staff
We scrub less than 5 seconds.
Background
• About 250,000 central line associated bloodstream
infections (CLA-BSI) occur annually.2
• CLA-BSI increases patient mortality and costs between
$25-55,000 per incident.3
• To prevent infection in patients with IV access devices
the CDC recommends disinfecting needleless
connectors.
• Current disinfection practices may be insufficient
protection against microbial contamination.
Method
• Implemented an alchohol cap in the adult inpatient
and NBICU departments of a large tertiary care trauma
center in January 2012.
• Compared retrospective rates of CLA-BSI, blood culture
contamination rates (2011/2012), compliance and
financial impact following the implementation of the
alcohol cap.
• Sent an electronic survey1 and asked staff nurses
to report their compliance involving disinfection of
peripheral and central IV access ports and IV tubing end
care.
Feedback from Nursing Staff
We scrub less than 5 seconds.
If you scrub the connector, select the
description closest to your process.
Quick swipe with alcohol
pad
If you scrub the connector, select the
description closest to your process.
• Opt
• Alco
Al
Al
Al
Al
• Imp
• Com
Result
Quick swipe with alcohol
pad
Blood Culture Contamination
• PLC
Method (Continued)
• Required education for staff nurses was distributed
electronically or in person.
Aseptic maintenance of IV tubing end
Proper blood culture technique
Use of alcohol cap
• Monitored compliance to the cap and tubing end
management on a weekly basis.
• Measured incidence of CLA-BSI and incidence of
contaminated blood cultures
• Analyzed financial impact
Short scrub motion
(less than five seconds)
Intervention
Long vigorous scrub
(15 seconds)
• Optimizing needleless connector prep prior to IV access
• Alcohol impregnated cap placed on:
All central line needleless connectors
All peripheral IV needleless connectors
All IV tubing ports
Alcohol swabs for access as needed
• Improved aseptic maintenance of IV tubing end
• Compliance reported weekly to nursing staff
Other (please specify)
Results
Long vigorous scrub
(15 seconds)
• PLCC line and overall CLA-BSI rates were significantly
decreased (p<0.05).
• Blood culture contamination rates showed a moderate
decrease (p=7.05).
Other (please specify)
• Net cost savings using alcohol cap was $683,030.
Short scrub motion
(less than five seconds)
Interve
Alcohol Cap Value Analysis Summary
2012 annualized projection
dec
• Bloo
dec
• Net
Conclu
• The
the
• An a
by a
Conclusions
References
1
use of an alcohol cap may be effective in reducing
Evans S,• The
Sharp
J, Linford
L, et
Risk of Symptomatic DVT Associated with P
the
rate of CLA-BSI
and contaminated
bloodal.
cultures.
3 alcohol cap may reduce the annual cost of CLA-BSI
•
An
17
Infections. 2011. CDC. gov byHollenbeak,
C The Cost of Catheter-Related Bloodstream Infections
as much as 28%
CHALLENGES WITH CLABSIs
Many Ports of Entry into the bloodstream
#4
18
CHALLENGES WITH CLABSI
Cannot See Microorganisms – blessing and curse
#5
Culture from a patient’s needleless connector.
– Wendy Kaler, MT, MPH, CIC
19
CHALLENGES WITH CLABSI
No Immediate Accountability – Patient doesn’t yell
OUCH!
#6
20
CHALLENGES WITH CLABSI
Dynamic Bedside environment – nurse gets
interrupted every two minutes
#7
21
PORT PROTECTION
What is a Port Protector?
 70% IPA in a cap
 Medical grade foam pad
 To be placed on any swab-able, luer-activated device
 To disinfect and act as a physical barrier between
accesses when not in use
22
HOW A PORT PROTECTOR WORKS
Passive Disinfection
•
•
•
•
•
•
Chemical agent – 70% Isopropyl Alcohol
Time of exposure – 3 - 5 minutes (per DFU)
Physical barrier – up to 4 - 7 days if not removed (per DFU)
No scrubbing necessary (for first access)
FDA 510(k)
Single use
23
TYPES OF PORT PROTECTORS
24
ADVANTAGES TO PORT PROTECTION
 Minimizes risk
•
Disinfected and protected vs. exposed and contaminated
 Consistent disinfection
•
No user variability #8
 Saves time*
•
Hub Scrub not necessary for first access if port protector in place for specified time
 Visible tool for managing compliance
•
Allow for complete compliance with TJC NPSG 07.04.01
 Peer Reviewed Data
Studies have demonstrated reduction in CLABSI, Contaminated Blood
Cultures, and Intraluminal contamination
• What’s next?
•
25
PORT PROTECTOR CLINICAL STUDY
 Observational before-after study in adult oncology nursing unit
(Sweet, 2012)
 Control period – manual cleaning with alcohol wipes,
retrospective CLABSI data
 1 year, 472 patients, 6851 central line days
 16 CLABSIs, 2.3 infections/1000 catheter days
 Intervention period – using port protectors on neutral
mechanical valve NC
 6 months, 282 patients, 3005 central line days
 1 CLABSI, 0.3 infections/1000 catheter days
 Reduction of contaminated blood cultures taken from catheters
26
PORT PROTECTOR CLINICAL STUDY
 Case-crossover study with PICCs indwelling for 5 or more days, 3
hospitals (Wright, 2012)
 1.5 mLs of blood drawn from PICC for culture on days 5, 6, 7
and twice weekly thereafter
 3 phases – 799 patients enrolled
 Manual scrubbing – 32/252 (12.7%) contaminated. 4 cfu/mL
median
 Use of port protector 20/364 (5.5%) contaminated, p=0.002, 1
cfu/mL median
 Return to manual scrubbing – 22/183 (12%) contaminated, 2
cfu/mL median
 Avoid 21 CLABSI, 4 fewer deaths, 13 new admissions
27
PORT PROTECTOR CLINICAL STUDY
 Observational before-after study in 2 adult ICUs (Ramirez, 2012)
 Control period – manual disinfection with alcohol pad for 15
seconds, normal surveillance data
 4 CLABSIs, 1.9 infections/1000 catheter days
 Intervention period – application of port protectors on all NCs
 1 CLABSI, 0.5 infections/1000 catheter days
28
SIX SIGMA PROJECT – TX HOSPITAL
1. Open MAR
2. Scan Medication
3. Prepare
Medication
4. Open
Alcohol Pad
= 66 sec
per injection
5. Scrub Hub
for 15 sec
6. Dry for
15 sec
7. Administer
Medication
(Avg. time spent in
12hr shifts giving
IV injections)
29
ADVANTAGES TO PORT PROTECTION
1. Open MAR
2. Scan Patient
3. Scan
Medication
4. Prepare
Medication
= 23.7 sec
per injection
5. Remove
Port Protector
6. Administer
Medication
7. Replace
with new port
protector
64 % reduction!
30
EVEN SIMPLE SOLUTIONS HAVE CHALLENGES
The “Silver Bullet Syndrome”
 Hand Hygiene
 Clean, Dry, Intact Dressings
 Confusing Protocol
Forced Compliance vs. Non-Forced Compliance
31
COMPLIANCE
Forced Compliance
Car keys
• Need them to drive car
Non-forced Compliance
Seat Beat
• Car drives fine without seatbelt
• Need for HARD WIRED habit
#9
32
MAIN CHALLENGE?
#10
33
Thank You!
Questions?
34
CHALLENGE ACCEPTED
 Product Location
 Easy access – grab and go
 Education – reinforce the “WHY”
 Process vs. Product
 Simple Protocols
 All Patients, All Lines, All the Time
 Eliminates confusion
 Supports Behavioral Changes
 Auditing
 Reinforcement to “hardwire” new process – 21 Days
 Management engagement
 Visibility to actual practice
35
AUDIT PROGRAM – UNIT BASED
• Real time
feedback/education
• Accountability
• Share compliance
results
• Nursing leadership
support
“If can not measure it, you
can not improve it.” – Lord Kelvin
•
•
•
•
•
Clinical ladder
Magnet story
CUSP
HEN
IP Liaisons
ADVANTAGES TO PORT PROTECTION
37
The single biggest problem with
COMMUNICATION
is the illusion that it has taken place.
- George Bernard Shaw
38
REAL TIME COMMUNICATION
Post Compliance Rates
Staff nurses, management, CLABSI
committee
Share Success Stories
Prime tubing in med room, place PP on
Celebrate Victories
Reward positive
Gain more champions
39
WEEKLY UNIT REPORTING
SICU
CUROS AUDITING FORM
Enter data by 5 pm every Monday
Patient Compliance - Blue Line
3
5
8
10
9
10
10
11
10
11
Port Compliance - Red Line
10
15
40
39
15
20
25
45
39
17
Weekly Trends
100%+
90%+
80%+
70%+
60%+
50%+
40%+
30%+
20%+
10%+
0%+
4-Mar+
11-Mar+ 18-Mar+ 25-Mar+
1-Apr+
8-Apr+
15-Apr+ 22-Apr+
29-Apr+
6-May+ 13-May+ 20-May+
40
CELEBRATE SUCCESSES
41
I DON’T HAVE TIME!
42
ORGANIZATIONS WHERE ONE BREACH
IN PROCESS CAN IMPACT LIVES…
43
MONITORING PROCESS COMPLIANCE
 High reliability organizations, i.e. military, aviation, nuclear power
 Continuous monitoring of critical processes
 # of observations
 Multidisciplinary/multidepartmental
 Process examples
 Line insertion
 Line entry
 Provide feedback - immediate and monthly
 Monitoring & Effect on CLABSI rate
 Bundle use alone not associated with lower CLABSI rate.
 Rate  when process monitored & achieved > 95%
compliance
Furuya et al; Presentation at Fifth Decennial International Conference on HAI. March 2010, Atlanta.
44
SHEA/IDSA PRACTICE RECOMMENDATIONS
INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY, VOL. 35, NO. 7 (JULY 2014) PP. 753-771
2014 Update
 Section 1: Rationale and Statements of Concern
 Section 2: Background – Strategies to Detect CLABSI
 Section 3: Background – Strategies to Prevent CLABSI
 Section 4: Recommended Strategies for CLABSI Prevention
 Basic Practices
 Special Approaches
 Section 5: Performance Measures
 Internal Reporting
 External Reporting
 Section 6: Examples of Implementation Strategies
 Engage
 Educate
 Execute
 Evaluate
45
$$$ REIMBURSEMENT
FYI 2015
 HAC Reduction Program (1%)
 Penalty enforced after VBP & Readmission adjustments
 Domain 1 – AHRQ 35%

PSI-7 CLABSI

PSI-13 Sepsis
 Domain 2 – CDC Measure 65%

CAUTI

CLABSI
 VBP (Zero Sum Bucket) (1.5% - 2% in 2017)
 Improvement (Self) – current performance vs baseline
 Achievement (Others) – how does current performance stack up to others
 Both make up your Total Performance Score
 Readmission Reduction Program (3%)
46
CONCLUSION
 CABSI and Central Line Definitions
 Challenges with BSI Prevention
 No immediate accountability
 It only takes ONE exposure to put a patient at risk
 Overcoming BSI Challenges
 Education as to WHY
 Monitoring maintenance care
 ENGAGE NURSING LEADERSHIP – Unit based programs
 Important tools to assist
 Port Protection
 Visual auditing tool
 Means to communicate compliance
47
ANY QUESTIONS?
48