The 5 Million Lives Campaign: “Preventing Central Line Infections”

1. The 5 Million Lives Campaign: “Preventing Central Line Infections” Institute for Healthcare Improvement

2. The Central Line Bundle

3. Do Central Lines Cause Blood Stream Infections? • Central venous catheters (CVCs) disrupt the integrity of the skin, making infection with bacteria and/or fungi possible. • Infection may spread to the blood stream (bacteremia) and hemodynamic changes and organ dysfunction (sepsis) may ensue. • Approximately 90% of the catheter-related blood stream infections (BSIs) occur with CVCs. Maki DG. Infections due to infusion therapy. In: Hospital Infections, Third Edition, Bennett JV, Brachman PS (eds), Little, Brown, Boston 1992.

4. Incidence & Risk: • 48% of ICU patients have central venous catheters, accounting for 15 million central venous catheter-days per year in ICUs. • The case fatality rate for catheter-related blood stream infections approaches 20%. • Attributable mortality ranges from 12-25% but was 3% in one meta-analysis. Mermel LA. Ann Int Med 2000;132: 391-402 Soufir L et al. Infect Control Hosp Epidemiol 1999 Jun;20(6):396-401.

5. Incidence & Risk: • Studies that control for underlying illness severity give lower estimates of attributable mortality. • These data suggest that attributable mortality is between 4 and 20%. • Thus, between 500-4000 U.S. patients die annually due to blood stream infections. Pittet D, Tarara D, Wenzel RP. Jama. May 25 1994;271(20):1598-1601 Soufir L et al. Infect Control Hosp Epidemiol 1999 Jun;20(6):396-401.

6. BSI is Costly & Prolongs Care • Attributable cost per blood stream infection is estimated to be $3,700 to $29,000. • Nosocomial blood stream infections prolong hospitalization by a mean of 7 days. Pittet D, Tarara D, Wenzel RP. Jama. May 25 1994;271(20):1598-1601 Soufir L et al. Infect Control Hosp Epidemiol 1999 Jun;20(6):396-401.

7. BSI Risk Factors Risk Factors with Percutaneous or Tunneled Catheters: • Site of insertion: Subclavian vein less risky than internal jugular or femoral vein. • Multiple ports/hubs: More manipulation and contamination. • Parenteral feeding: TPN and/or lipids • Infection elsewhere: Remote, e.g. UTI or wound. Mermel LA, Am J Med. Sep 16 1991;91(3B):197S-205S McCarthy MC, J Parenter Enteral Nutr 1987; 11:259.

8. BSI Risk Factors Risk Factors with a Central Venous Access Device (C-VAD): • Lower infection rates: 0.1 to 0.2 per 100 catheter days. • Subcutaneous ports: 10-12 fold lower rate of infection compared with tunneled catheters. • Some risks remain: • Colonization of catheter with organisms • IV catheterization longer than 72 hours • Inexperience of personnel inserting the C-VAD Groeger JS, et al. Ann Intern Med 1993; 119:1168.

9. CDC Guidelines Major areas of emphasis: • Education and training of providers who insert lines • Maximal sterile barrier precautions • Use of 2% chlorhexidine for skin antisepsis • Avoiding routine replacement • Consider antiseptic/antibiotic impregnated catheters if rate of infection remains high O’Grady NP. MMWR Aug 9, 2002; 51: RR10, 1-29

10. AHRQ-Sponsored Evidence Summary • Attributable mortality 4-20% • Analyses of costs very variable • Routine replacement does not reduce risk • Maximum barrier precautions reduce risk • CVCs coated with antiseptics or antibiotics might reduce risk but are expensive • Use of chlorhexidine skin prep reduces risk more than povidone-iodine Saint S. http://www.ahrq.gov/clinic/evrptfiles.htm#ptsafety

11. Opportunity Knocks • What if a series of interventions could markedly reduce the risk of BSI? • What if those interventions were already readily available in hospitals? • What if all of those interventions were done all of the time on each patient?

12. Benefits of Reducing BSI • Better patient outcomes • Reduced mortality • Improved satisfaction • Nursing • Physician • Patients and families • Financial benefits

13. The Central Line Bundle …is a group of interventions related to patients with intravascular central catheters that, when implemented together, result in better outcomes than when implemented individually.

14. What is a Bundle? • A grouping of best practices with respect to a disease process that individually improve care, but when applied together result in substantially greater improvement. • The science behind the bundle is so well established that it should be considered standard of care. • Bundle elements are dichotomous and compliance can be measured: yes/no answers. • Bundles eschew the piecemeal application of proven therapies in favor of an “all or none” approach.

15. Central Line Bundle Elements • Hand hygiene • Maximal barrier precautions • Chlorhexidine skin antisepsis • Appropriate catheter site and administration system • Avoidance of routine replacement

16. But, Does it Work? ICUs that have implemented multifaceted interventions similar to the central-line bundle have nearly eliminated CR-BSIs. Berenholtz SM, Pronovost PJ, Lipset PA, et al. Eliminating catheter related bloodstream infection in the intensive care unit. Critical Care Medicine. 2004; 32:2014-2020.

17. Outcome and Cost Impact • Rate of CR-BSIs fell from 11.3 to 0 /1000 catheter days. • Prevented annually (estimated): • 43 CR-BSIs • 8 deaths • 559 ICU days • Estimated savings to hospital: $1,824,447

18. Baptist Memorial Hospital-Memphis, Memphis, TN • Reduced CR-BSI and ICU length of stay:

19. Hand Hygiene 101 • Wash hands if they are obviously soiled • Wash hands or use an alcohol based waterless hand cleaner • Before and after invasive procedures • Between patients • After removing gloves • Before eating • After using the bathroom • If contamination is suspected

20. What are Maximal Barrier Precautions? • For Provider: • Hand hygiene • Non-sterile cap and mask • All hair should be under cap • Mask should cover nose and mouth tightly • Sterile gown and gloves • For the Patient: • Cover patient’s head and body with a large sterile drape

21. Impact of Maximal Barrier Precautions (MBR) OR=odds ratio MBR= inserter washes hands and wears mask, sterile gown, sterile gloves and patient’s head & body are covered with a large, sterile drape.

22. Key Change: Central Line Checklist • Have the nurse document compliance with the insertion criteria at the time of insertion. • Create a culture of safety and prevention: • empower nurses to stop line placement if improper techniques are used • Instruct nurses in use of critical communication strategies to facilitate important exchanges. • e.g. “the sterile field has been contaminated,” rather than “Youcontaminated the catheter!”

23. Checklist Elements • Before the procedure, did they: • Wash hands? • Sterilize procedure site? • Drape entire patient in a sterile fashion? • During the procedure, did they: • Use sterile gloves, mask and sterile gown? • Maintain a sterile field? • Verify: did all personnel assisting with procedure follow the above precautions?

24. Chlorhexidine Skin Antisepsis • Prepare skin with antiseptic/detergent Chlorhexidine 2% in 70% isopropyl alcohol. • Pinch wings on the “Chloraprep” applicator to pop the ampule. Hold the applicator down to allow the solution to saturate the pad. • Press sponge against skin, apply chlorhexidine solution using a back and forth friction scrub for at least 30 seconds. Do not wipe or blot. • Allow antiseptic solution time to dry completelybefore puncturing the site ( ~ 2 minutes).

25. Baseline Compliance With Best Practice Example: At one hospital, providers were compliant with best practice during 62% of the observed Procedures Intervention: National compliance estimated to be 30%

26. Central Line Site Care • Use line carts and dressing change kits • Standardize site care procedures • Store all equipment in the same place

27. To Be Successful • Set an aim: “Reduce the incidence of central line catheter-related bloodstream infections using the central line bundle.” • Set a goal: “The rate of CR-BSI will decrease by 50% in one year using the central line bundle.” • Plan well: Adopt a change methodology that accelerates improvement such as The Model for Improvement.

28. Model for Improvement • What are we trying to accomplish? • How will we know that a change is an improvement? • What changes can we make that will result in an improvement? Act Plan Study Do

29. Me and What Army? • Form… a team • Include a diverse staff. • MDs, RNs, respiratory therapists. • Identify… a project champion • Someone who maintains visibility in the ICU. • Identify… a process owner • For concerns now and in the future.

30. Engage Stakeholders • Identify stakeholders in intensive care. • 3 groups: MDs, RNs, venous access teams. • Secure representation from each. • Facilitates physician buy-in. • Generates nursing support.

31. Role of Leadership • Committed: staff cannot improve without supportive leadership. • Set the standard: “This is how we will practice.” • Resources: make time to work on testing. • Share data: to motivate staff for change.

32. Starting the Project • Is there a method in place now? • Know your baseline performance: • Randomly select 20 patients’ records who had central lines placed. Apply the measures to them. • Be sure to check compliance with the total bundle as well, the “all or none” goal. • Educate ICU staff (using your own data).

33. Small Tests of Change • Small tests... 1 RN, 1 MD, 1 patient. • Move on to pilot test in one ICU: • Refine the process • Test on all shifts • Test on all patients with central lines • Measure your results to know if a change was an improvement.

34. Supportive Interventions • Multidisciplinary Daily Rounds: • An opportunity to assess bundle related issues. • Invite and encourage the family to join in. • Daily Goal Sheets: • Maintenance of bundle items.

35. Measure: CR-BSI per 1000 Line Days Central line-associated BSI rate per 1000 central line-days: Numerator: Number of central line-associated BSI x 1000. Denominator: Number of central line-days (total number of days of exposure to central venous catheters by all patients in the selected population during the selected time period).

36. Measure: Central Line Bundle Compliance Central line bundle elements in place: Numerator: Number of patients with central line bundle in place. Denominator: Total number of pts on central lines per day of week of prevalence sample.

37. Model for Improvement • What did we accomplish? • Was that change an improvement? • What further changes will lead to more improvement? Act Plan Study Do

38. Summary: • Central line infections are common. • Proven strategies exist to decrease CR-BSI line days. • Using the Central Line Checklist, most bundle elements are implemented. • Thousands of lives and millions of dollars saved with reliable adherence and bundle execution.