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Evidence-Based Approaches to Elimination of Neonatal CLABSI

Evidence-Based Approaches to Elimination of Neonatal CLABSI. Janet Pettit DNP, NNP-BC, VA-BC. Disclosures . Argon Medical California Childrens Services NICU HAI Collaborative PDI. Objectives. At the conclusion of the presentation, the participant will be able to:

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Evidence-Based Approaches to Elimination of Neonatal CLABSI

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  1. Evidence-Based Approaches to Elimination of Neonatal CLABSI Janet Pettit DNP, NNP-BC, VA-BC

  2. Disclosures • Argon Medical • California Childrens Services NICU HAI Collaborative • PDI

  3. Objectives At the conclusion of the presentation, the participant will be able to: • Identify common components of insertion bundles used for central lines in neonates • Identify three controversial components of maintenance bundles used for central lines in neonates • List three care processes with proven efficacy in decreasing CLABSI • Distinguish two avenues beyond the insertion and maintenance bundles that have proven success in reducing and sustaining CLABSI reduction efforts

  4. California: If You’ve Seen 1 NICU, You’ve Seen 1 NICU!

  5. xxx _ ____ _ _________ _ __ _ ___

  6. Getting To Zero CLABSI! … A Believable Goal?

  7. The Results

  8. The California Journey

  9. yyy

  10. Building a Better Bundle: Sources of Evidence NICU Teams CPQCC HAI Toolkit

  11. yy

  12. x

  13. z

  14. Beyond the Basic Bundle: CCS CLABSI Prevention Bundle Elements • Insertion • Maintenance • Leadership • Diagnosis • Go to website for information about bundle http://www.dhcs.ca.gov/ProvGovPart/initiatives/nqi/Pages/default.aspx

  15. CCS CLABSI Prevention Bundle:Insertion • Maximum sterile barrier precautions • Disinfect skin withchlorhexidine or povidone iodine • Dedicated team for placement & care • All supplies for procedure at bedside • Hand hygiene performed • Insertion checklist used • Staff empowered to stop non emergent procedure if sterility breached

  16. Adopting Evidence-Based Use of CHG/Alcohol in the NICU • Barriers • Previous product labeling restricted use if < 2 months of age. • Updated product labeling January 2012: Use with care in premature infants or infants under 2 months of age. These products may cause irritation or chemical burns. • Skin reactions • Absorption • Fear of the unknown • Facilitators • Emerging evidence • Improved CLABSI reduction • Minimal reactions • Adjusting use based on gestation & chronologic age • No toxicity associated with the minimal absorption • Realization that all skin antiseptics problematic • More than half of NICUs in US are using

  17. CCS CLABSI Prevention Bundle: Maintenance Should practice extend to all lines? • Daily assessment of catheter need • Review dressing integrity & cleanliness • Use closed system for infusion, blood sampling & medication administration • Assemble & connect infusion tubing using aseptic or sterile technique. • Use consistent tubing configuration

  18. CCS CLABSI Prevention Bundle : Maintenance • Disinfect injection port with alcohol or chlorhexidine/alcohol for 15 seconds & allow to dry. • Use of alcohol port protectors • Hand hygiene performed & clean gloves worn for catheter entry • Use prefilled, flush containing syringes • Staff empowered to stop the line in non-emergent procedure if sterility breached

  19. Every day ask the question… Can the catheter be removed? • Daily assessment & documentation of catheter need – Joint Commission NPSG.07.04.01 & CA requirement • Plan for removal • Key times for removal to lessen risk

  20. Review Dressing Integrity & Site Cleanliness • PRN change recommended • Routine change intervals • Remove blood & drainage • Not intact • Use sterile technique • Dressing type • Transparent vs. gauze • Transparent: allows direct visualization and requires fewer changes, but no other demonstrated clinical advantage.

  21. Closed Systems for All Vascular Access Devices • Definition of “closed” • Infusion, blood withdrawal, med administration • Close all or only central catheters

  22. Closed Medication System • Entry point to catheter kept out of bed • Needleless connector capped with syringe at all times • System changed along with other infusion tubing Part of Aly, 2005 bundle & adopted by many NICUs

  23. Aseptic vs. Sterile Technique for Tubing Assembly • Bundle component • Aly 2005 & others • Lack of standardization • Sterile vs aseptic technique • Resource availability • 1-2 personnel • Set-up carts/stations • Consistent tubing configurations • Procedural checklist • Frequency of change

  24. Biofilm & Bacteria on External Surface of Needleless Connector Ryder et al. Microscopic Evaluation of Microbial Colonization on Needleless Connectors. 2009. APIC Poster Presentation

  25. Agents & Methods for Disinfection of Needless Connectors 31% don’t clean! Alcohol CHG/alcohol

  26. Gloves for Catheter Entry

  27. Use of Pre-filled, Flush Containing Syringes • Increase contamination of vials & ampules when prepared in ward vs pharmacy Van Grafhorst Critical Care Med 2002. • Syringe contamination • Nurse filled vs. prefilled

  28. Empower Staff to The Line

  29. Leadership Bundle

  30. CCS CLABSI Prevention Bundle: Leadership • Administrative involvement & support for zero HAIs • Engage staff with feedback • Posting days since last CLABSI • Posting rates of CLABSI • Perform investigation of each CLABSI/BSI • Surveillance activities for critical processes • Hand hygiene • Line management and entry • Off unit procedures • Stop the line support • Trained personnel to perform specialized maintenance activities

  31. Surveillance of Care Practices: Overt & Covert • Helps to ensure quality of care • Means to monitor compliance with policy • Multidepartmental personnel monitor adherence to policy • Unit-based • Hospital-based • Correct problem behavior while its occurring • Reward proper behavior

  32. Line Insertion Checklist

  33. Tubing Change Checklist

  34. Needleless Connector Checklist

  35. Monitoring Staff Performance

  36. Line Set-Up Auditing Developed by CCS CLABSI Prevention Collaborative

  37. Catheter Entry Auditing Developed by CCS CLABSI Prevention Collaborative

  38. Investigating Failure

  39. zz

  40. Getting it Right: Diagnostic Challenges • NHSN criteria • Culturing techniques

  41. CLABSI & Beyond : Other Considerations Respiratory care practices Skin assessment & # punctures # Line entries Feeding tubes & practices

  42. Supporting Continuous Improvement and Sustainability The way in which Each individual pays attention to and performs their job PLUS The way All individuals inter-relate, interact, and communicate while working, ultimately determines the sustainability of high quality, safe health care.

  43. a What will you do next week?

  44. The End Questions: jspettit@sbcglobal.net

  45. References • Chaiyakunapruk, N., Veenstra, D. L., Lipsky, B. A., & Saint, S. (2002). Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis. Ann Intern Med, 136(11), 792-801. doi: 200206040-00007 [pii] • Curry, S., Honeycutt, M., Goins, G., & Gilliam, C. (2009). Catheter-associated bloodstream infections in the NICU: getting to zero. Neonatal network : NN, 28(3), 151-155. • MarschallJ., Mermel, L. A., Classen, D., Arias, K. M., Podgorny, K., & Yokoe, D. S. (2008). Strategies to prevent central line associated bloodstream infections in acute care hospitals. Infection Control and Hospital Epidemiology, 29, S22-30. • Mullany, L., Darmstadt, G. L., & TielschJ. M. (2006). Safety and impact of chlorhexidine antisepsis interventions for improving neonatal health in developing countries. Pediatric Infectious Disease Journal, 25, 665-675. • O'Grady, N. P., Alexander, M., Burns, L. A., Dellinger, E. P., Garland, J., Heard, S. O., . . . (HICPAC)., H. I. C. P. A. C. (2011). 2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections 1-83. Retrieved from Centers for Disease Control and Prevention website: http://www.cdc.gov/hicpac/bsi/bsi-guidelines-2011.html • Payne, N. R., Carpenter, J. H., Badger, G. J., Horbar, J. D., & Rogowski, J. (2004). Marginal increase in cost and excess length of stay associated with nosocomial bloodstream infections in surviving very low birth weight infants. Pediatrics, 114, 348-355.

  46. References • Pettit, J. & Wyckoff, M. M. (2007). Peripherally inserted central catheter: Guidelines for practice. Glenview, IL: The National Association of Neonatal Nurses. • Powers, R. J., & Wirtschafter, D. W. (2010). Decreasing central line associated bloodstream infection in neonatal intensive care. Clinics in perinatology, 37(1), 247-272. doi: 10.1016/j.clp.2010.01.014 • Suresh, G. K., & Edwards, W. H. (2012). Central line-associated bloodstream infections in neonatal intensive care: changing the mental model from inevitability to preventability. American journal of perinatology, 29(1), 57-64. doi: 10.1055/s-0031-1286182 • Wirtschafter, D. D., Pettit, J., Kurtin, P., Dalsey, M., Chance, K., Morrow, H. W., . . . Kloman, S. (2010). A statewide quality improvement collaborative to reduce neonatal central line-associated blood stream infections. [Multicenter Study]. Journal of perinatology : official journal of the California Perinatal Association, 30(3), 170-181. doi: 10.1038/jp.2009.172 • Zingg, W., Imhof, A., Maggiorini, M., Stocker, R., Keller, E., & Ruef, C. (2009). Impact of a prevention strategy targeting hand hygiene and catheter care on the incidence of catheter-related bloodstream infections. Critical care medicine, 37(7), 2167-2173; quiz 2180. doi: 10.1097/CCM.0b013e3181a02d8f

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