Reducing Central Line Infections (CLI)

1. Reducing Central Line Infections (CLI) National Call September 5, 2007

2. Purpose • By the end of this call, participants will have: • Updated information on the SHN Campaign, Getting Started Kits and reporting worksheets • Heard successes and learnings from Improvement Teams • Answers to your team’s questions about intervention-specific changes and measurement • An understanding of benefits and expectations of enrolling in the Canadian ICU Collaborative September 5, 2007

3. Campaign Structure Campaign Support SHN National Steering Committee Secretariat - CPSI Clinical Support CIHI CCHSA Operations Quebec Campaign IHI Teams Western Node Atlantic Node Patients Canadian ICU Collaborative Ontario Node Other Canadian Faculty Peer Support Network ISMP Canada Partner Network CAPHC Measurement Working Group & CMT Communication Working Group Education & Resource Working Group September 5, 2007

4. Teams Continue to Enroll Updated August 21, 2007 September 5, 2007

5. Safer Healthcare Now! Enrollment by Intervention As at August 21, 2007 September 5, 2007

6. Safer Healthcare Now! Enrollment by Province & Territory September 5, 2007 As at May, 2007

7. Enrollment Update *Total at August 21, 2007 September 5, 2007

8. CLI Rate September 5, 2007

9. Insertion Bundle Compliance September 5, 2007

10. Maintenance Bundle Compliance September 5, 2007

11. Updates to GSK • Essentially unchanged since previous edition • Suggestions for implementation: • Begin with insertion bundle • Standardize policies, equipment and cleaning agents • Suggestions for measurement: • Deviation from bundle components will assist with strategizing for improvement September 5, 2007

12. Updates to Measurement Worksheets • Three worksheets for each measure: chart, data entry and submitted by • Compliance to individual bundle components • Instructions for new section September 5, 2007

13. Resources • CLI Getting Started Kit & Worksheets http://www.saferhealthcarenow.ca/Default.aspx?folderId=82&contentId=180 • Communities of Practice http://www.saferhealthcarenow.ca/Default.aspx?folderId=124 • Canadian ICU Collaborative Improvement Guide Available when enrolled in the Collaborative September 5, 2007

14. Questions

15. Success Stories • Pediatric ICU’s • Centre Hospitalier Régional de Lanaudière September 5, 2007

16. Reduction of Catheter Related Blood Stream Infections A Canadian National PICU Collaborative Experience October 2004 to October 2005 T. Northway, RN, MSN, & A. Robin, RN, BScN, BC Children’s Hospital; E. Folz, RN, BScN, Alberta Children’s Hospital; M. Golberg, RN, BScN, NP, Stollery Children’s Hospital; J. Plouffe, RN, BScN, NP, Winnipeg Children’s Hospital

17. Incidence of CRBSI • Elward, A et al. (2005). Pediatrics 115(4), 868-872. • (2007) http://www.edwards.com/Products/CentralVenous/VantexInservice.htm? • wbc_purpose=Basic&WBCMODE=PresentationUnpublished • Slonim, A et. Al (2001). Pediatric Critical Care Medicine 2, 170-174. • Yogaraj, J. et al. (2002). Pediatrics 110(3), 481-485. September 5, 2007 • Comparatively high rate of CRBSI in PICU (NNIS 6.6/1000 CVC line days) • CDC reports 5.3/1000 CVC line days adult ICU • Attributable cost approximately $34,500-$56,000 US • Increased LOS (3 weeks) • Estimated mortality rate 13% - 19% (child) & 12% - 25% (adult)

18. Aim and Goals/Objectives Aim: • To reduce the incidence of catheter related blood stream infections (CRBSI) within Canadian PICUs Goals/Objectives: • To reduce the incidence of CRBSIs by 20% to 50% within 12 months (October 2005) September 5, 2007

19. Teams September 5, 2007

20. Insertion Bundle Hand Hygiene Maximum Barrier Precautions (Inserter & Patient) Chlorhexidine for Skin Prep Site selection Maintenance Bundle Hand Hygiene Standardized Hub Antisepsis Standardized Accessing of Line Line set-up Accessing hubs Dressing & tubing changes Daily Reviewing of Line Necessity CRBSI Improvement Bundles September 5, 2007

21. Changes Tested P P A A D D S S S S D D A A P P A A P P S S D D P P A A D D S S Moving to a culture of safety Creating controversy through transparency! Adoption of insertion & maintenance bundles Celebrating successes! Specific TestCycles Developing staff clinical champions Adoption of CDC definition Handwashing campaign Awareness of current reality Establish current reality Increased understanding of ICU Collaborative & process Awareness of importance Of CVC infections Baseline Stream Education Stream September 5, 2007

22. P P A A D D S S S S D D A A P P A A P P S S D D P P A A D D S S Changes Tested Let’s make it easy to do the right thing & difficult to do the wrong thing! CVC maintenance OSCE station at annual RN competency validation days Culture shift: RNs halting insertion if insertion bundle violated • CVC Maintenance Bundle: • Hand hygiene • Line set-up (closed system) • Dressing & tubing changes • Standardized cleansing solution • Creation of insertion bundle • Hand hygiene • Full barrier precautions • Site selection • Cleansing solution change Specific TestCycles Standardize equipment: Creation of line insertion cart Standardized data collection Create line insertion checklist Daily Goal Sheet to review line necessity Standardize equipment: Creation of vascular access tray Insertion Stream Maintenance Stream September 5, 2007

23. Collaborative Results Total line days 9030 Total CRBSI 29 Group 3.2 CRBSI/1000 line days September 5, 2007

24. Collaborative Results NNIS Benchmark 6.6 per 1000 Line Days Initial Learning Session (LS) for CRBSI Collaborative June to Dec 2005: Period with existing 6 teams contributing data September 5, 2007

25. Preventing central line infections at the CSSSNL Jean Levasseur MD

26. CSSSNL • Large regional, community hospital • 275 acute care beds • 12 beds 8 ICU and 4 CCU beds • Closed Unit • Working on Collaborative projects since 2003 September 5, 2007

27. Aims and objectives • Eliminating C.L. infections • Implementing the insertion bundle • Initiate the maintenance bundle September 5, 2007

28. Results • 9 months of surveillance (insertion bundle) • Hand washing • Strict sterile technique • Chlorhéxidine • Insertion site September 5, 2007

29. Results • Data collection sheets • Insertion technique • Insertion protocol September 5, 2007

30. Insertion Results September 5, 2007

31. Technique Results September 5, 2007

32. September 5, 2007

33. September 5, 2007

34. Results September 5, 2007

35. Results September 5, 2007

36. Results September 5, 2007

37. Results September 5, 2007

38. Results September 5, 2007

39. Results September 5, 2007

40. Results September 5, 2007

41. Results • During the last year : • NO line infections for lines inserted on the unit • BUT, 4 line infections during the 24 months of provincial surveillance for lines cared for on the unit. September 5, 2007

42. Results • Common points to infected lines : • Site • “Emergent” insertions September 5, 2007

43. Results September 5, 2007

44. Dedicated cart Changes tested September 5, 2007

45. Withdrawal of other products Changes tested September 5, 2007

46. Technique Reminders... September 5, 2007

47. Results areposted Patient Perspective September 5, 2007

48. Lessons Learned • Small changes can bring big results • The maintenance bundle has to be implemented as soon as possible… September 5, 2007

49. Remerciements • Thanks to the fantastic and hard working CSSSNL ICU quality team. September 5, 2007

50. About the Canadian ICU Collaborative