Central Line Associated Bloodstream Infections

1. Central Line Associated Bloodstream Infections Tennessee Center for Patient Safety Vicki Brinsko RN, CIC

2. Goal: Preventing CLABSI • Using the Central Line Bundle • Hand Hygiene • Remove Unnecessary Lines • Use of Maximal Barrier Precautions • Chlorhexidine for Skin Antisepsis • Avoid femoral lines • Report CLABSI rates to the units • Celebrate success Vanderbilt Infection Control & Prevention

3. Engage • Partner with Infection Control, ID experts • Increase awareness about morbidity and mortality associated with CLABSI • Make harm visible • Tell stories • Post # infections • Estimates of opportunity to improve Vanderbilt Infection Control & Prevention

4. Thank You Notes to NICU Staff Thank You From Baby Boy Jones I have gone 136 days without a bloodstream infection. Keep up the good work! My Mom left some “kisses” for you! XOXOX Vanderbilt Infection Control & Prevention

5. Form the Dream Team • Heterogeneous in make up; homogeneous in mind set • All stakeholders must be included • All RN teams fail because MDs insert lines • Find a high profile champion • Get a process owner Vanderbilt Infection Control & Prevention

6. TEAM FORMATION ICU Director ICU Nurse Manager Leaders Chief Hospital Epidemiologist Infection Control Practitioners Infectious Disease experts Attendings & Residents Nursing Staff (ICU) Frontline Staff National Quality Scholars QA/Quality Staff QI experts Vanderbilt Infection Control & Prevention

7. Educate • Educate staff and senior leaders about CDC guidelines • Develop a resource notebook • Develop policies and procedures • CDC guidelines and Fact Sheet • Power point slides for In-services • Consider a quiz to evaluate provider knowledge • Can use on-line training Vanderbilt Infection Control & Prevention

8. http://www.mc.vanderbilt.edu/root/vumc.php?site=micututorial

9. Evaluate • Outcome measure: CLABSI rate • Rate, # infections, weeks/months since last infection • Process measures • % checklists completed • % violations noted • # lines removed • Celebrate success Vanderbilt Infection Control & Prevention

10. Share the Data BSI Bundle Vanderbilt Infection Control & Prevention

11. The Check List • Adapt to your own institution • Must be filled out for each line insertion • Include 5 BSI bundle elements • Simpler is better • Can always add elements as you become better at capturing data Vanderbilt Infection Control & Prevention

12. Execute • Hand Hygiene • Remove Unnecessary Lines • Use of Maximal Barrier Precautions • Chlorhexidine for Skin Antisepsis • Avoid femoral lines Vanderbilt Infection Control & Prevention

13. Hand Hygiene • Empower nursing to enforce use of a central line checklist to be sure all processes related to central line placement, including hand hygiene, are executed for each line placement. • Include hand hygiene as part of your checklist for central line placement. • Keep soap/alcohol-based hand hygiene dispensers prominently placed and make universal precautions equipment, such as gloves, only available near hand sanitation equipment. • Post signs at the entry and exits to the patient room as reminders. • Initiate a campaign using posters including photos of celebrated hospital doctors/employees recommending hand hygiene. • Create an environment where reminding each other about hand hygiene is encouraged. Vanderbilt Infection Control & Prevention

14. Posters of Prominent MDs WASH Clean Hands Clean Heart

15. Maximum Barriers • Empower nursing to enforce use of a central line checklist to be sure all processes related to central line placement are executed for each line placement. • Include maximal barrier precautions as part of your checklist for central line placement. Vanderbilt Infection Control & Prevention

16. Insertion Kits or CL Carts • Keep equipment stocked in a cart for central line placement to avoid the difficulty of finding necessary equipment to institute maximal barrier precautions. • Some companies offer CL insertion kits with maximum barriers included • Value in keeping as many parts together as possible May Need to Order CHG and/or Kits

17. CHG Skin Asepsis • Empower nursing to enforce use of a central line checklist to be sure all processes related to central line placement are executed for each line placement. • Include chlorhexidine antisepsis as part of your checklist for central line placement. • Include chorhexidine antisepsis kits in carts or grab bags storing central line equipment. Many prepared central line kits include povodine-iodine kits and these must be avoided. • Ensure that solution dries completely before attempting to insert the central line. Vanderbilt Infection Control & Prevention

18. Central Line Site Selection • Whenever possible, and not contraindicated, the subclavian line site should be preferred over the jugular and femoral sites for non-tunneled catheters in adult patients. Vanderbilt Infection Control & Prevention

19. Daily Review of CL Necessity • Include daily review of line necessity as part of your multidisciplinary rounds. • Include assessment for removal of central lines as part of your daily goal sheets. • Record time and date of line placement for record keeping purposes and evaluation by staff to aid in decision making. Vanderbilt Infection Control & Prevention

20. Create Redundancy • Develop strategy to ask daily if lines can be removed • Daily Goals • Nursing/physician sign outs on Rounds • Implement checklist to be completed at time of insertion • Nurses present during line insertion • Support for speaking up • Modify checklist for local use Vanderbilt Infection Control & Prevention

21. Getting Started • Do Your Homework First!! • Interdisciplinary team • Gain consensus on plans • Create timeline for deliverables Vanderbilt Infection Control & Prevention

22. Start Small • Select the team and the venue. It is often best to start in one ICU. Many hospitals will have only one ICU, making the choice easier. • Assess where you stand presently. What precautions are taken presently when placing lines? Is there a process in place? If so, work with staff to begin preparing for changes. • Contact your Infection Control Department. Learn about your catheter-related bloodstream infection rate and how frequently the hospital reports it to regulatory agencies. • Organize an educational program. Teaching the core principles to the ICU staff will open many people’s minds to the process of change. • Introduce the central line bundle to the staff. Vanderbilt Infection Control & Prevention

23. First Test of Change • Begin using the bundle with one patient from the time of catheter placement. • Work with each nurse who cares for the patient to be sure they are able to follow the bundle and implement the checklist and daily goals sheet. • Make sure that the approach can be carried over from shift to shift to eliminate gaps in teaching and utilization. • Process feedback and incorporate suggestions for improvement. Vanderbilt Infection Control & Prevention

24. One ICU…then the Rest • Once the bundle has been applied to one patient and subsequent shifts, increase utilization to the remainder of the ICU. • Engage in additional PDSA cycles to refine the process and make it more reliable. • After achieving reduction in CR-BSI in the pilot ICU, spread the changes to other ICUs, and eventually to other places in the hospital where central lines are inserted …So Use Data Vanderbilt Infection Control & Prevention

25. CLABSI per 1000 Line Days • CLABSI X 1000 CL Days • How do I get the central line days? • Get ICU staff involved • Unit secretary counts # lines each day at 12MN • Charge nurse counts each day at change of shift • See if IT can give you the numbers electronically Vanderbilt Infection Control & Prevention

26. Potential Barriers • Fear of change • Use knowledge • Use optimism • Communication breakdown • Involve all stakeholders on the front end • MD and staff partial “buy-in” • Supply continuous data to all groups • Changes in rates convert the non-believers Vanderbilt Infection Control & Prevention

27. Questions? Vanderbilt Infection Control & Prevention