Four “C’s” to Conquer CLI:

1. Four “C’s” to Conquer CLI: An Integrated Approach to Performance Enhancement Elaine C. Killough, RN, MSN, CCRN, CS Sturdy Memorial Hospital Attleboro, MA

2. www.cdc.gov/nicdod/dhqp/images/Fig_CLABSI_ICU accessed 05/31/08

3. Sturdy Memorial Hospital • 128-bed community hospital • 14 bed medical-surgical ICU • Open unit with primary intensivist coverage • Admits ~700 patients/year • Mean LOS 4.8 days

4. Central Lines (2007) • 265 lines managed • 74.9% Multi-lumen catheters • 14.3% Dialysis catheters • 10.9% SwanGanz catheters • 73.6% placed in the ICU • 93.3% placed by intensivist • Site Selection • 46.7% IJ • 45.0% SC • 8.3% Femoral

5. Frequency: Line Placement 2004 - 2007

6. ICU Line Days 2004 - 2007

7. CLI: SMH ICU 2002 - 2007

8. Sturdy Excellence Program • Integrated quality and service improvement goals • Validity supported by evidence • Measurable outcomes • Unit/department-based • Regular reporting to Quality and Service Enhancement Committee • Review and feedback from administrative and multidisciplinary resources • High emphasis on progress and accountability

9. An Integrated Approach Sturdy Excellence Program Senior and Risk Management/ Quality Improvement Unit Management Prevent CLI Infection Control Physicians ICU Nursing

10. SMH ICU: CLI Prevention Practices: 2004 • Developed a formalized program of daily surveillance • Established system for auditing related documentation and dressing changes per existing protocol (record review) • Provided parameters for identification of suspect lines and clarified expectations for physician response • Worked on development of comprehensive program for 2005

11. SMH ICU CLI Prevention Program: 2005 - 2007 • Adopted evidence-based interventions as standard of care • Developed total management program: Comprehensive Collaborative Current • Partnering with QSEC to review and evaluate program effectiveness • Goal: To remain at or below the CDC median occurrence rate

12. A Comprehensive Approach • Prior to placement: Conservative decision-making as to appropriateness of intervention. • Inclusive documentation tool: • Identifies accountable personnel. • Validates implementation of evidence-based standards at insertion. • Describes line maintenance per hospital standard, including description of insertion site, documentation of dressing changes. • Documents problems identified and resolution. • Documents analysis and review if line is suspect.

13. A Comprehensive Approach • Line maintenance documented each shift in the electronic record. • Daily assessment/data collection by CNS or unit leadership staff: • Insertion site • Intactness/quality of the dressing • All program elements are reviewed and reinforced in orientation for all new staff including temporary personnel.

14. A Collaborative Approach • Proactive, facilitative approach with MDs not familiar with standards • Problem-solving related to difficult sites or persistent patient problems • Regular review of documentation tools by IC RN • CNS/IC RN analysis of occurrences • Dissemination of findings to staff • Collaborative problem-solving

15. A Collaborative Approach • Nursing education involvement in all changes in program/protocol • QSEC review of documented performance progress and goal achievement; dialogue to provide feedback, identify problems, and suggest solutions.

16. Keeping Things Current • Problems identified are addressed immediately. • Bi-weekly reporting to management on all process elements. • Monthly reporting of process compliance and outcomes in staff meetings and through e-mail. • Reports to QSEC available on unit; feedback shared as it is received. • Annual review of program.

17. CLI: SMH ICU 2002 - 2007

18. CLI: SMH ICU Cases of CLI in 20 Months! (Since September, 2006)

19. SMH ICU: CLI Prevention Practices: 2008 Incorporated a “Zero Tolerance” Approach into Our 2008 CLI Prevention Sturdy Excellence Goal

20. The Fourth “C”…….. • Continued excellent performance. • Consistent goal-achievement. • Commitment to improving patient outcomes.