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VASCULAR ACCESS Specialist team. Ownership of the Bundle. April VanDerSlik BSN RN CIC Infection Prevention Manager November, 2013. Bronson Healthcare System. Regional, not-for-profit health system Recognized for workplace excellence National leader in healthcare quality
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VASCULAR ACCESS Specialist team Ownership of the Bundle April VanDerSlik BSN RN CIC Infection Prevention Manager November, 2013
Bronson Healthcare System • Regional, not-for-profit health system • Recognized for workplace excellence • National leader in healthcare quality • Keystone, including CUSP
Bronson Methodist Hospital • 434 bed tertiary teaching hospital • 11 VAST nurses (7 full-time, 2 part-time, 2 on-call) • 642 Acute CVCs / year • Approximately 1,000 PICCs / year • ~ 50% PICCs are placed in critical care units
History • Team Beginnings: Hyperal Initiation • Formed 1978 • Dr. James Heersink, General Surgeon • Hyperalimention Team (doctors, nurses, pharmacist, and dieticians) • Duties • Assisted with CVC inserts • Education of staff and patients • Improved patient outcomes • Decreased infection rate • Team name change in 2009 (VAST)
VAST: Team Responsibilities • Education • Develop policies and procedures according to INS standards, CDC & Joint Commission guidelines • Teach IV & Infusion Management class • Patient, family and staff education • Manage Champion program • Clinical resource to community • Placement • Assist providers with CVC insertions • Insertion of PICCs at bedside • Post Placement • PICC daily surveillance • PICC dressing changes
Central Line Associated Blood Stream Infections (CLABSIs) Adult Population Only All TPN Dressing
Low CLABSI National Recognition • Healthgrades, 2013 • Better than average • Consumer Reports, Jun 2011 • reported zero • received highest score • Commonwealth Fund, Dec 2011 • reported zero
Bronson’s Implementation Plan Reduce CLABSI
Methodology Guidance • CDC & Joint Commission guidelines • Keystone: CVC bundle • PICC bundle (Bronson specific protocol) Practice • Daily PICC and TPN surveillance • Dressing change protocols • Hand hygiene program with auditors • Ultrasound guided CVAD placement • Blood sampling protocols • Education • Scrub the hub • Chlorhexidine disc
Keystone CVC Bundle Before procedure • Hand hygiene, chlorhexidine prep During Procedure • Full Barrier Pre-cautions: Hat, mask, sterile gown, sterile gloves • Assist physicians and residents with insertion – avoid femoral site • Monitor sterility • Empowered to stop procedure • Monitor traffic pattern • Use of checklist After procedure • Sterile dressing applied • Removing unnecessary catheters
Bronson PICC Bundleat the Bedside • Hand hygiene • Max barrier precautions • pre-packaged insertion kit • Chlorhexidine prep • Ultrasound guided PICCinsertion • Neutral connector system • Connector disinfection • Flushing protocol • Daily monitoring of all PICCs by VAST
Scrub the Hub1 • Wash hands or use hand sanitizer • Wear gloves • Scrub the hub for 30 seconds each and every time with chlorhexidine 1Centers for Disease Control, Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011
Patient Ownership Goal: Patient Empowerment of their VAD • Inpatient • Permission to say “no” to care beinggiven (i.e. change your gloves, wash your hands, scrub for 30 seconds) • Basic care & maintenance education • Discharge • Care & maintenance instructions • Emergency contact information • All CVAD types
Checklist and Nurse Empowerment Goal: Assist providers with CVC insertion • Checklist to delineate, guide and document completion of each step • Source of data collection to verify adherence to protocol • Taught to speak up and “stop the line” • Patient safety strong backing by RN, MD and management
Vascular Access Infusion Training(Who do we educate?) • Physician and residents • Clinical staff (more than 800 FTEs) • Management • Patients and families
Post Insertion Care Goal: Dressing Change and Line Surveillance • Daily: PICC & TPN lines –VAST Team • Daily: Acute CVC – Staff Nurses • Check bag & tubing–labeled with time/date/initials • Lab values • Fever • Line Necessity
Staff Engagement Activities Traveling Story Board Updated according to unit specific educational needs »Transferred from unit to unit»
Champion Program Selection Clinician empowerment of insertion procedure, care & maintenance and training of staff • RN for two years at Bronson • VAST and management approval needed • Attends Champion class done by VAST • Specially trained in high risk central line skills • Ability to sign off other RN’s on certain procedures • Yearly peer review
Champion Program: Duties / Skills • Champion Duties • Sign off floor staff • Removal PICC / CVC • Dressing Changes (CVC) • Catheter Clearance - Thrombolytic • Continuing Education • Champion Sign off Staff (Procedures) • Hanging TPN • Blood draws • Dressing Change (CVC) • Port Access
Champion Program: Competency Goal: Proficiency Demonstration VAST or unit champion to sign RN off on procedure • RN observation • RN practicum / performance of procedure with assistance • RN demonstrated competency without assistance
New Hire Employee: Infusion Training Computer Based Learning (CBL) class • IV insertion and infusion management • Practicum for hands on demonstration in classroom setting
New Initiative: Community Education Goal: Initiative to decrease readmits from community due to CLABSIs w/ outside staff training • Local Nursing homes • Home Health Agencies • Local Hospice – policies only
Central Line Infection Rate History(Adult Population Only) All TPN Dressing
Obstacles to Overcome • Hospital Administration support of empowerment • Finding a Physician(s) Champion • A hospital wide culture change
Lessons Learned • Participate in infection prevention collaboratives to share your challenges and best practices with other hospitals. • Involve physician champions and multidisciplinary teams. • Use checklists. • Employ small, specially trained teams and individuals (including intensivists in the ICUs) to conduct and/or oversee line insertion and maintenance throughout the hospital. • Sustain best practices with ongoing education, monitoring, and adjustments and provide performance data to staff to keep them focused on outcomes.
References • Carroll SS (December 2011) Eliminating Central Line Infections and Spreading Success at High-performing Hospitals Synthesis Report December 2011 Commonwealth Fund publication 1559 Volk 21 • Ending Health Care-Associated Infections Agency for Healthcare Research and Quality (2009) www.ahrq.gov/research/findings/factsheets/errors-safety/haicusp/index • Lowes R (2011) High Central-Line Infection Rates at Many Teaching Hospitals New Consumer Reports Study Gives Poor Marks to 67 Institutions Medscape Medical News June 7,2011 www.medscape.com/viewarticle/744131 • O’Grady NP et al (2011). CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections • Sardone F (2010) Celebrating Nursing Excellence Bronsonhealth.com • www.commonwealthfund.org • www.bronsonhealth.com/about • www.healthgrades.com/quality/top-hospitals-2013