creating an integrated clabsi prevention program

1. creating an integrated clabsi prevention program Presented by: Tracy Shamburger, RN, MSN and Karen Bailey, RN

2. objectives • Identify The Joint Commission (TJC) National Patient Safety Goal 07.04.01 Elements of Performance • Cite the Mike Denton Infection Reporting Act (2009) • Define CLABSI and Central Lines per CDC Guidelines • Identify National Healthcare Safety Network (NHSN): ADPH HAI Reporting Requirements • Understand that the Comprehensive Unit-based Safety Program (CUSP) is a process for creating a culture of patient safety

3. The Joint Commission NPSG.07.04.01 Institute for Healthcare Improvement (IHI) Monitoring; Evidence Into Practice Standards; Regulatory Compliance; & Reporting CLABSI Prevention Comprehensive Unit-based Safety Program (CUSP) Patient Safety Evaluation & PI National Healthcare Safety Network (NHSN); CMS; ADPH

5. EVALUATING COMPLIANCE WITH TJC NPSG.07.04.01 • Conduct periodic hospital-wide risk assessments for CLABSI; monitor compliance with evidence-based practices; and evaluate the effectiveness of prevention efforts. • After conducting your risk assessment, do you have gaps in compliance or process improvement opportunities? If so, what are the gaps; are you conducting process reviews; and are your developing action plans to achieve compliance?

6. MONITORING AND REPORTING COMPLIANCE RATES • Compliance with evidence-based practices should be measured weekly or monthly and reported/charted to show progress towards goal of 100% compliance. • Compliance rate must be calculated with the whole bundle, not just parts.

7. CALCULATING COMPLIANCE RATES # of pts with CVC during monitoring period who received all 5 elements of bundle (with documentation) # of pts with CVC audited during the monitoring period X 100 = Compliance Rate (%) • Do you have a process for evaluating and reporting compliance rates with documentation? CLABSI rates?

8. SAMPLE COMPLIANCE RATES AND CLABSI REPORTING SCORECARD

9. COMMUNICATE AND REPORT COMPLIANCE AND INFECTION RATES • TJC requires that you report CLABSI rate data and prevention outcome measures to key stakeholders, including leaders, nursing staff, and other clinicians • Regulatory guidelines require reporting CLABSI rates to the National Healthcare Safety Network (NHSN)

10. The Joint Commission NPSG.07.04.01 Institute for Healthcare Improvement (IHI) Monitoring; Evidence Into Practice Standards; Regulatory Compliance; & Reporting CLABSI Prevention Comprehensive Unit-based Safety Program (CUSP) Patient Safety Evaluation & PI National Healthcare Safety Network (NHSN); CMS; ADPH

11. CDC’s National Healthcare Safety Network (NHSN): CENTRAL LINE definition • An intravascular catheter that terminates at or close to the heart or in one of the great vessels which is used for infusion, withdrawal of blood, or hemodynamic monitoring. -The Great Vessels Include the following: Aorta Superior Vena Cava Pulmonary Artery Brachiocephalic Veins Internal Jugular Veins Subclavian Veins Inferior Vena Cava External Iliac Veins Common Femoral Veins Umbilical Artery in neonates

12. Infusion Defined • Introduction of a solution through a blood vessel via a catheter lumen. Includes: Continuous Infusions such as nutritional fluids, medications, or Intermittent infusions such as flushes or IV antimicrobial administration, or Administration of blood or blood products in the case of transfusion or hemodialysis.

13. CDC’s National Healthcare Safety Network (NHSN): Central Line Blood Stream Infection • A Central Line Blood Stream(CLABSI) is a primary bloodstream infection (BSI) in a patient that had a Central line within the 48 hour period before the development of the BSI.

15. CDC’s National Healthcare Safety Network (NHSN): AL HAI Reporting • Mike Denton Infection Reporting Act (2009; Rules and Regulations Released-August 2010) -Requires Critical Access hospitals in Alabama to begin reporting certain HAIs using CDC’s NHSN.

16. ALABAMA CENTRAL LINE/CLABSI DATA ENTRY REQUIREMENTS • NHSN monthly reporting: • Report central line device days • Report CLABSI events **You must have a monitoring plan for each month that you plan to report. • Reporting Deadline for Alabama -All data must be entered into NHSN no later than the last day of the subsequent month. Ex. January data is due by 28February).

17. National Healthcare Safety Network (NHSN): CMS HAI Reporting • CMS Final Rule Passed (July 2010) -Requireshospitals accepting Medicaid across the Nation to begin reporting certain HAIs using CDC’s NHSN January, 2011

19. Extended to 28 Feb 2011

20. Considerations: • Have you evaluated all the different central lines utilized in your facility that fit the definition of a central line? • Do you have a Device Days Report? • Do you consistently collect device day information at the • same time each day? • If the patient is in CC/ICU, how do you capture positive blood • cultures that return after the patient is transferred to a • regular floor? • Have you updated your NHSN monthly monitoring plan to include • both CMS, and Alabama Central line/CLABSI reporting mandates? • Are your Locations Correctly Mapped? • Are staff informed of their role in reporting HAIs?

21. ALABAMA HAI REPORTING AWARENESS CAMPAIGN • Resources: http://www.adph.org/hai/

22. Surveillance tipS Periodically check the accuracy of line day data by visiting units and comparing reported catheter days with actual number of patient lines. Remember…. –Internal validation of central line data is critical!! -when counting central line days, only count one central line day for patients with multiple central lines. -Under reporting line days will artificially increase CLABSI rates.

23. The Joint Commission NPSG.07.04.01 Institute for Healthcare Improvement (IHI) Monitoring; Evidence Into Practice Standards; Regulatory Compliance; & Reporting CLABSI Prevention Comprehensive Unit-based Safety Program (CUSP) Patient Safety Evaluation & PI National Healthcare Safety Network (NHSN); CMS; ADPH

24. COMPREHENSIVE UNIT-BASED SAFETY PROGRAM (cusp) • NHSN and CUSP Participation • The main focus of the two year “On the CUSP: Stop BSI” project is to improve our culture of safety, thereby decreasing CLABSIs. Furthermore, participation in the project facilitates standards compliance, measurement, and reporting of CLABSI, along with other HAI data, to the CDC/NHSN

25. HOW DOES CUSP WORK? “CUSP IS A PROCESS” • CUSP comprises five fundamental steps and is a continuous process. • CUSP guides you on a journey of education and communication; implementation and evaluation; review and transparency. • It starts with one high risk unit but provides a scalable intervention program that can be implemented throughout your organization.

26. FIVE FUNDAMENTAL STEPS TO CUSP • Engage Senior Leadership • Open lines of communication between frontline staff and administration • Educate leadership about clinical issues and safety hazards • Improve providers attitudes about leadership • Enlist administration in obtaining necessary resources to improve patient safety

27. FIVE FUNDAMENTAL STEPS TO CUSP • Educate Staff on Science of Safety • Ensure all current staff have viewed the Science of Safety video and incorporate the video into new hire orientation (consider adding the video to annual review) • Evaluate HSOPS results; identify safety needs and develop a plan of action. Form a team to assist with these goals and monitor for improvement.

28. FIVE FUNDAMENTAL STEPS TO CUSP • Implement Teamwork Tools • Engage staff to be active team players, not passive players • Breakdown physician – nurse barriers • Provide tools to facilitate teamwork and communication (ex: daily goals sheet) • Incorporate morning briefings and observing rounds

29. FIVE FUNDAMENTAL STEPS TO CUSP • Identify Defects • Use incident reports, liability claims, or sentinel events • Survey staff and ask, “How will the next patient be harmed?”

30. FIVE FUNDAMENTAL STEPS TO CUSP • Learn From Defects • Incorporate a practical tool to address what happened, why it happened, what you did to reduce future risk, and how to measure for reduced risk • Use resources such as the “Learning from Defect Tool” and “Investigating a CLABSI Tool” found on the CUSP: Stop BSI website • Plan to learn from at least one defect a month

31. APPLYING CUSP TO CLABSI PREVENTION • Begin by reviewing your TJC NPSG 07.04.01 risk assessment:

33. APPLYING CUSP TO CLABSI PREVENTION • If you’ve already conducted a TJC risk assessment for NPSG.07.04.01, then you’ve already identified gaps, deficiencies, and/or process improvement opportunities • Now develop actionable plans to improve processes • Monitor compliance with evidence-based practices • Evaluate effectiveness of prevention efforts

34. APPLYING CUSP TO CLABSI PREVENTION • Educate staff, patients, and family about CLABSIs and prevention • Implement policies aimed at reducing the risk of central line infections • Adhere to the CLABSI Prevention Bundle: • Strict and consistent hand hygiene • Maximum use of barrier precautions, including full patient drape • Site prep with Chlorhexidine • Optimal site selection (avoid femoral insertions when possible) • Scrub the hub before accessing ports • Remove catheters when no longer necessary; assess daily need

35. APPLYING CUSP TO CLABSI PREVENTION • Create a Central Line Insertion Kit or Cart • Devise and consistently use a Central Line Insertion Checklist • Empower nurses to stop the procedure if guidelines are not followed • Post the # of patients infected per month and your quarterly infection rates • Participate in monthly CUSP calls, enter data into MHA Care Counts, and complete the Monthly Team Check-up Tool

36. EVALUATING PROCESSES • If your CLABSI rate is NOT going down, evaluate your processes! • Determine if processes are breaking down and if so, develop a plan of action to correct the deficiencies! • Finally, CUSP is not exclusive to CLABSI prevention. It is a process to address your overall culture of patient safety. Once you understand the process, CUSP can be applied to any process improvement program i.e., other TJC National Patient Safety Goals:

37. The Joint Commission NPSG.07.05.01 Monitoring; Evidence Into Practice Standards; Regulatory Compliance; & Reporting SSI Prevention Comprehensive Unit-based Safety Program (CUSP) Patient Safety Evaluation & PI National Healthcare Safety Network (NHSN); CMS; ADPH

38. The Joint Commission NPSG.07.07.01 Monitoring; Evidence Into Practice Standards; Regulatory Compliance; & Reporting CAUTI Prevention Comprehensive Unit-based Safety Program (CUSP) Patient Safety Evaluation & PI National Healthcare Safety Network (NHSN); CMS; ADPH

39. CONCLUSION • Creating an integrated CLABSI Prevention program is about evaluating your TJC compliance; understanding how to define and report CLABSI to NHSN; and implementing CUSP processes that sustain a culture of patient safety! • The Alabama Department of Public Health and the Alabama Hospital Association truly wish every IP great success in this new venture! Odds are, now that you understand how all these elements are inter-related, you will probably discover that you’ve done more with the CUSP project than you thought. • The challenge, use CUSP processes to raise the bar with CLABSI prevention – take it to the next level: implement daily goal sheets; begin daily rounding with physicians; conduct AM briefings. • And remember to always ask, “How will the next patient be harmed; how can I prevent it from happening?”

40. QUESTIONS?