On the CUSP: STOP BSI Toward Eliminating Central Line Associated Blood Stream Infections

1. On the CUSP: STOP BSIToward Eliminating Central Line Associated Blood Stream Infections

2. Immersion Call Overview • Project overview • Science of Improving Patient Safety • Eliminating CLABSI • The Comprehensive Unit-Based Safety Program (CUSP) • Building a Team • Physician Engagement

3. Learning Objectives • To understand the model for translating evidence into practice • To explore how to implement evidence-based behaviors to prevent CLABSI • To understand strategies to engage, educate, execute and evaluate

5. Safety Score Card: Keystone ICU * CUSP is intervention to improve these Pronovost PJ, Holzmueller CG, Needham DM. CCM 2006 Pronovost PJ, Berenholtz SM, Needham DM. JAMA 2007

6. Translating Evidenceinto Practice Pronovost, Berenholtz, Needham. BMJ 2008

7. Evidence-based Behaviorsto Prevent CLABSI • Remove Unnecessary Lines • Wash Hands Prior to Procedure • Use Maximal Barrier Precautions • Clean Skin with Chlorhexidine • Avoid Femoral Lines Marschall et al. Infect Control Hosp Epidemiol 2008 CDC.gov

8. Evidence-based Behaviorsto Prevent CLABSI • Remove Unnecessary Lines • Wash Hands Prior to Procedure • Use Maximal Barrier Precautions • Clean Skin with Chlorhexidine • Avoid Femoral Lines

9. Identify Barriers • Ask staff • about knowledge of prevention recommendations • what is difficult about doing these behaviors • Walk the process of staff placing a central line • Observe staff placing central line Gurses, Murphy, Martinez. Jt Comm J Qual Patient Saf 2009

10. CLABSI definition • For determining CLABSI rate • Numerator: number of CLABSIs • Denominator: number of central line-days • Expressed as a rate of X CLABSI/1,000 central line days • #CLABSI/# central line days X 1000 National Healthcare Safety Network (NHSN): Device-Associated (DA) Module www.cdc.gov/nhsn/psc_da.html

11. What is a Central Line? Pacemakers Implanted cardiac defibrillators Radial, dorsalis pedis, brachialis, ulnar arterial lines • Non-tunneled central lines • Tunneled central lines • Introducers • Implanted ports • Hemodialysis catheters • Peripherally inserted central catheters (PICCs) • Femoral artery catheter The following are examples of central lines, as long as they terminate at or close to the heart or in one of the great vessels NOTE: This list is not all-inclusive The following are examples of devices that are not central lines NOTE: This list is not all-inclusive

12. Ensure Patients ReliablyReceive Evidence

13. Partnership • To help with 4Es, partner with: • Infection control staff • Hospital quality and safety leaders • Nurse educators • Physician leaders ICU staff must assume responsibility for reducing CLABSI

14. Engage • Share about a patient who was infected • Share stories about when nurses ensured patients received the evidence • Post baseline rates of infections • Estimate number of deaths and dollars from current infection rates (see opportunity calculator on website) • Remind staff that most CLABSI are preventable

15. Educate • Conduct in-service regarding CLABSI prevention • Create forum to jointly educate physicians and nurses • Add CLABSI prevention to unit orientation • Give staff fact sheet, articles and slides of evidence

16. Execute • Standardize: Create line cart or kit that includes necessary supplies for line insertion • Create independent checks • Create line insertion checklist • Empower nurses to ensure that physicians comply with checklist • Nurses can stop takeoff for non-emergent insertions • Learn from mistakes • Review every infection using learning from defect tool

17. Daily Goals • What needs to be done for the patient to be discharged? • What is the patients greatest safety risk? • What can we do to reduce the risk? • Can any tubes, lines, or drains be removed? Pronovost, Berenholtz, Dorman. J Crit Care 2003

18. Evaluate • Post in the unit rates of infections per quarter • Post number of weeks or months without an infection

19. Action Items • Meet with unit based CUSP/CLABSI team, infection control staff, quality and safety leaders, nurse educators, and physician champions • Understand barriers to eliminating CLABSI • Walk the process and talk to providers • Assess what you have for placing central lines; do you have all recommended pieces of the bundle? • Work with supply to order anything you don’t have for recommended line insertion kit or cart

20. Action Items • Use 4E grid to develop strategies to engage, educate, execute and evaluate • Identify local stories to engage stakeholders • Post CLABSI rate in your unit • Post estimated number of deaths and dollars based on CLABSI rate in your unit • Develop and implement strategy to educate stakeholders • Look at the CLABSI checklist sample and begin to modify for your use • Who will nurses call if providers do not comply with recommendations after being reminded? Who is going to back-up nursing?

22. References • CDC. Guidelines for the Prevention of Intravascular Catheter-Related Infections; August 2002. www.cdc.gov • Gawande A. The checklist. The New Yorker 2007 Dec. Annals of Medicine section. • Goeschel CA, Pronovost PJ. Harnessing the potential of healthcare collaboratives: Lessons from the Keystone ICU project. AHRQ Advances in Patient Safety: New Directions and Alternative Approaches, in press. • Gurses, Murphy, Martinez. A practical tool to identify and eliminate barriers to comlpiance with evidence-based guidelines. Jt Comm J Qual Patient Saf 2009;35(10):526-32.

23. References • Lubomski LH, Marsteller JA, Hsu YJ, Goeschel CA, Holzmueller CG, Pronovost PJ. The team checkup tool: Evaluating QI team activities and giving feedback to senior leaders. Jt Comm J Qual and Pat Saf 2008 34(10):619-23. • Marschall et al. Strategies to Prevent Central Line–Associated Bloodstream Infections in Acute Care Hospitals. Infect Control Hosp Epidemiol 2008;29(S1):S22-S30. • Pronovost PJ, Berenholtz SM, Dorman T. Improving communication in the ICU using daily goals. J Crit Care 2003; 18(2):71-75. • Pronovost PJ, Needham D, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. New Eng J Med 2006 355(26):2725-32. • Pronovost PJ, Holzmueller CG, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual and Saf 2006 32(2):102-8.

24. References • Pronovost P, Holzmueller CG, Needham DM, Sexton JB, Miller M, Berenholtz S, Wu AW, Perl TM, Davis R, Baker D, Winner L, Morlock L. How will we know patients are safer? An Organization-wide Approach to Measuring and Improving Safety. Crit Car Med 2006;34(7):1988-1995. • Pronovost PJ, Berenholtz SM, Needham DM. A Framework for Healthcare Organizations to Develop and Evaluate a Safety Scorecard. JAMA 2007;298(17):2063-2065. • Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ 2008 337:963-965. • Pronovost PJ, Berenholtz SM, et al. Improving patient safety in intensive care units in Michigan. J Crit Care 2008 23(2):207-21.