CLABSI Prevention

CLABSI Prevention

THE PLAN
Review base line data and look for trends / Units of occurrence
Frequency of occurrence (per month, per year)
Type of line associated with the infection
Time from insertion to infection (per SIA review)
If infection occurred in <7 days, be sure to consider insertion as a possible factor. If > 7 days insertion unlikely a factor.
Compare outcomes to facility expectations, published literature and possibly other local like HC facilities

Make sure comparisons are ones that team members support. If the source is not respected, the conclusions from the comparisons won’t be respected.

Review best practice guidelines / Joint Commission - see specifically section 07.04.01
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CDC (Centers for Disease Control) (category 1A and 1B citable by JC)

John’s Hopkins-Peter Provonost and Michigan Keystone – includes checklist examples

IHI – Institute for Healthcare Improvement –

SHEA (The Society for Healthcare Epidemiology of America)

SHEA (The Society for Healthcare Epidemiology of America)
(2014 update)
National Kidney Foundation (for management of temporary dialysis catheters)

Kagan, Richard. A Performance Improvement Initiative to Determine the Impact of Increasing the Time Interval Between Changing Centrally Placed Intravascular Catheters. Journal of Burn Care and Research 2014; 35:143-147
Infusion Nursing Standards of Practice. Journal of Infusion Nursing 2011, Vol 34.
International Society for Burn Patients
Infection Control in Burn Patients
Timsit, JF. Dressing disruption is a major risk factor for catheter-related infections. Crit Care Med 2012; 40:1707-1714
Review current organizational practices /

How does staff know about the expectations? Is it in a policy, or is it something that is taught with variety or assumed to be known when arriving?
Have key medical Team Leaders seek out subspecialty best practices (ex Medical Director lead to work with renal experts). This may help find other specialty best practices to consider.

Review onboarding /

How are nursing staff trained to organizational expectations (lecture, return demo, etc)
How are staff MD’s trained to organizational expectations
How are residents and students trained to organizational expectations

Assemble Team(s) / Based on findings from baseline data, best practice, and current organizational practice, determines who needs to be on the improvement team.

Consider who in the organization stands to be affected by the changes, and where opportunity lays in standardization of practices across the institution -even in areas that may not currently appear to have issues.
Participants respond to executive leadership participation. Medical directors and unit managers level of participation changed when the CEO met with the group and clearly outlined his expectations of the workgroup.
Select Project Team Leaders:
ICU Director
Operating Room Director
Infection Prevention Director
SICU Medical Director
MICU Medical Director
Consider service lines and area of influence.
Do not rely on the director of one service line to have influence over another service line. If the team is too large for one group, divide teams up and determine the subgroup goals, actions, and levels of authority.
Steering Committee Team Members:
Infection Prevention and Infectious Disease Physician
MICU Nurse Manager
SICU Nurse Manager
Peds Nurse Manager and Peds Medical Director
Burn Nurse Manager and Burn Medical Director
ED Nurse Manager and ED Lead Physician
Anesthesia – MDA and CRNA
Interventional Radiologist
Dialysis Physician
Nursing IV Team Lead
Office of the Medical Director
Quality Staff – Medical and LEAN
Electronic Health Record developers and report writers
We didn’t have these, but in retrospect may have benefited from:
Residents (the ones who are actually putting in the line)
Supply Chain

Determine early on what practice care areas have “exceptions” / Are the exceptions the preference of staff, or are the exceptions supported by literature and scientific evidence.
Determine what is considered a success / Targets and goal options: state, federal , institutional, etc
Example: Minnesota State Action Plan to Prevent Healthcare-Associated Infections
National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination
Determine what will be measurable /

Consider important process measures as a means of sustaining change and maintenance of best practices.
Determine which outcomes measures should be used.
Define standard work for who does the measuring and how to make the measuring most effective
Develop a process to measure practices and/or outcomes that may be required by external agencies.
Set reporting frequency

Determine Timeline /

Frequency of meetings, how decisions are to be made, who gets to make the decisions, how is this communicated, what is the final goal; keep people aware of the scope of the project, set ground rules
Determine who and how to keep executive leadership up to date and when to reach out if roadblocks occur

Determine who keeps record of plan and activities / Select a person who is knowledgeable in the subject matter:

keep notes
write minutes
update timeline
set agendas

Consider other literature that will help providers champion the best practice / Do spend time discussing with the providers what their current practice is, but at the same time discuss with them what it would take to get them to the best practices. It will confound issues if time is spent discussing what is thought to be best practice.
Examples:

JAMA 2009. Pittet. CLABSI Prevention beyond the Checklist
NEJM 2006 Provonost. CLABSI Prevention
Int J Nurs Stud. 2007 Nov;44(8):1324-33. Tsuchida T, The effectiveness of a nurse-initiated intervention to reduce catheter-associated bloodstream infections in an urban acute hospital: an intervention study with before and after comparison.
Crit Care Med. 2004 Oct;32(10):2014-20. Berenholtz SM. Eliminating catheter-related bloodstream infections in the intensive care unit.

TOOLS:

Call To Action Burning platform summary
Meeting agenda template
Action plan template
Best practice summary templates

Best practices/Policy (DO)
Burn unit exceptions /

Insertion and duration of CVC in burn patients. Limited data is available at this time for the management of burn patients. HCMC practice, based loosely on Shriner’s practice: Place central line, change over a guide wire @day 5; change site at day 10. (INFECTION CONTROL IN BURN PATIENTS Author: Joan Weber, RN, BSN, CIC Infection Control Coordinator, Shriners Burns Hospital, Boston, Massachusetts)
Depending on location of line and patient burn surfaces, established and preferred dressing change intervals may not be feasible. Develop a plan for managing the maintenance of these lines. Ensure that staff is familiar with separate process.

NICU specifics /

Review unique requirements for NICU related to UVC and UAC lines, PICC placement location best practices, alternatives to CHG use, prepping the port.

Dialysis practices /

Contracted with Davita for dialysis services and found that Davita practice did not mirror HCMC policy.
Davita policy was to change dressings at every dialysis run and frequently using gauze dressing. Worked with Davita leadership to align dressing change frequency and methods to that of HCMC and established best practices.
Discovered that larger Biopatch was not onsite for dialysis lines. Made the larger size a storeroom item for dialysis catheters

Discovered HCMC practices were not standard to the KDOQI guidelines.
Unauthorized access. Multiple reports of unauthorized dialysis catheter access. KDOQI guidelines limit access outside of dialysis for emergent use only or with a Renal order for use. Added this to the policy and training.
Needless connectors were not in use for dialysis lines, only end caps only were being used between runs. Explored opportunities and found that Tego connectors (a dialysis line needleless connector) were standard in the dialysis community. Worked with MICU staff and Davita staff to bring in connectors and train staff for use. Needed to take into consideration MICU and other staff performing CRRT at HCMC.
Discovered Surgical Services did not have all of the best practice supplies for dialysis catheters. Did not have Tego connectors and did not have larger Biopatch. Nursing staff in surgical services needed training on accessing dialysis lines.

Orders /

Need order for use for nursing practice. How do the orders address cares? Should incorporate other activities directly surrounding placement such as radiology for verification of placement.
Plan what orders are needed if patient comes in with an existing line.
Determine if Renal approves use of dialysis lines for routine blood draws and other fluid administration in nonemergent situations.
Need to consider how orders flow throughout the organization. How do central lines orders differ for nontunnel vs tunneled catheters placed in the OR.

Line selection /

When to move to tunneled line? Literature suggests 3 weeks. How to make this happen?
What type of line is best practice – PICC vs PIV, vs tunneled, etc. To become the policy supporting document

Insertion /

Ensure there is an insertion checklist
Created an insertion checklist after review of existing checklists from institutions that were successful thenmodified with Steering Team agreement
Start with paper and trial in one area before expanding or modifying. This may take several revisions to determine final product
Determine who can be the insertion observer
Determine where the blank checklists are to be kept
Determine what happens with completed checklists
Determine criteria for site selection
Work with best practice and needs of a medical teaching facility for recommendations.
CVC kits
Evaluate current supplies to ensure that staff can perform to best practices
Don’t just ask, but pull several kits and have users demonstrate how the kit is used and if it meets needs and best practices. Asking elicited one answer, demonstration of use provided very different responses
Use supply chain orders for volume use and type of lines used, but also consider direct order options. Go unit to unit and look for kits. Products can make their way into the institution without using supply chain.
Worked with providers to come to an agreement on a limited number of CL kits to reduce variability and push toward best practice
Line cart – a JC NPSG
Determine where carts should be located
Determine contents are standard for all carts
Create standard work for maintaining supplies in cart
Management of non sterily placed lines
Determine what is considered a nonsterily placed line
Create a process to communicate this
HCMC determined indicator would be a sticker placed on the line to change in 48 hours
Consider other areas that may use CVC’s and the supplies needed. Ex: OR supplies – biopatch, tego, dressing; IR, etc

Maintenance /

Ensure dressing change kits have adequate supplies to meet best practice
Determined to use a standard dressing change kit to allow staff best practice for line maintenance

Use supply chain orders for volume use and locations of product used
Interview nursing staff who perform dressing changes
Observe dressing change practices by a variety of practice groups (ICU, floor, IV team)
As a result of this process, HCMC found dressing kit did not have all the best tools, nor was there standard work for dressing changes and line maintenance
Because of limitations by supplier to reconfigure dressing change kits to meet best practice, switched dressing from Sorbaview to Tegaderm after brief unit trial. Realized cost savings as in incidental effect in the dressing change

Scrub the hub
Determine what product to use to prep the port prior to access – alcohol or CHG
Determine expectations for adequate hub prep.
Contacted manufacturer of products and reviewed literature to determine length of time to scrub the hub. Best practice guidelines do not provide a time. Manufacturers only provide times to prep site for insertion and surgical procedures. Asked for manufacturer recommendations in writing and cited journal articles to determine HCMC would use a 10 second scrub and a 20 second dry time for hub prep.
Dressing disruption
Observations by medical staff and nursing indicated not all CVC dressings were remaining intact, nor were the dressings being changed routinely when not in optimal condition.
Reviewed literature and found recent evidence linking risk of infection related to number of unintended dressing disruptions.
Incorporated into policy and EPIC documentation the practice to change CVC when 2 or more unintended disruptions occurred
Dressing options for patients without intact skin (eg Burn)
Still to explore options. Not yet complete

Daily assessment for need /

Come to an agreement of what is a daily assessment for need
How is this communicated to nursing staff
How is this documented
What are the downstream effects of the assessment – eg: order for removal, monitor, etc

Removal /

Agree to the timing of removal once the line is no longer medically necessary
What is the documentation
Interviews revealed delays in removal related to time of day, availability IV team etc.
Misperceptions of how to remove PICC’s and who was able to remove
Need to set expectations on unit and in policy of who can remove a central line and what type of central line
How to manage documentation of patients discharged with central lines

Policy / Develop a hospital policy related to the best practices and unique practices and issues specific to facility. Ensure the support and agreement of the Steering Committee to promulgate the policy to peers.
When to revisit/how to avoid the pendulum effect / Need to balance best practice and emphasize care of patient come first. Focus on prevention from leaders can push providers to avoiding the use of central lines and possible inappropriate use of peripheral lines.
Daily CHG bathing / Daily CHG bathing already established in the ICU’s. Need to find a way to expand this to the floors so that non-ICU patients with CVC’s get a daily bath with CHG. Need to make sure processes align with other initiatives (ex surgery pre-op, etc).

TOOLS:

Policy
Insertion checklist
CHG daily bathing
Rounding checklist
Line cart contents

Education (DO)
Baseline audit of best practices /

Using Best Practice and policy perform an audit of current activities.
HCMC was able to use Biopatch reps, IP and IV staff to perform a 1 day point prevalence audit. Used this information to help determine education targets

NICU /

Reviewed NICU unit policies and discussed practices with NNP’s and physicians. Found variety of practices that were not optimal (ex how infant was draped, using sterile water to prep the skin instead of PI disinfectant with removal of PI after procedure, etc)

Patient Education /

JC NPSG requires the patient and/or their family to be educated to the risk of and prevention of CLABSI.
HCMC decided to use the insertion checklist as the place to document education.
Incorporated expectations into policy and topics to discuss

Create an education plan that involves the caregiver as the agent of change and why the driving need for change /

Once plan is in place and best practices have been accepted by leadership. Involve key educators and staff.
HCMC education team members:
Project Team Leaders
IP
ICU manager
Floor manager
Nursing education department
Office of the Medical Director
IV Team

What should you educate? /

Determine who to educate and what is unique or special for the practice group

Determine what each practice group should know and what should they know about others. Ie what should nursing know that is the responsibility of the provider. What should the provider know to expect from nursing.
Use baseline audits to determine where gaps are for targeted education
Why the change and why it is considered best practice. Give examples how implementing best practice leads to success
Facility expectations
Insertion checklist
Where are supplies and what supplies should be used (ex line carts vs kits, dressing kits, etc)
Maintenance expectations and return demonstrations of competency
Assessment for removal
Documentation

Determine frequency of education /

Are there regulations that determine the frequency of education?
HCMC is following Joint Commission requirements for those how are involved with CVC’s
upon hire,annually thereafter and when transfer of duties include CVC s
Residents
All residents must have successfully placed a simulated central line and
Demonstrate competency per the Resident/Fellow Scope of Practice

Determine how to educate (big bang/unit based/passive/active, etc) /

Select a method of education that fosters active learning and participation.
HCMC required (as a condition of work to complete in a 1 month period of time)
online facility made/facility specific videos to introduce concept and expectations
nursing, residents, Staff MD’s
In addition nursing was required:
Return demonstration and competency of dressing change
Interactive Q and A in the form of Jeopardy! Game for use and maintenance
The HCW person was to be removed from the work schedule until education successful.

Consider specialty education /

Who can access implanted lines
Who can remove central lines
Who is trained to access dialysis lines
Blood draws from dialysis lines for OR and ICU staff or those approved to draw blood

TOOLS:

Biopatch point prevalence audit
MD video
Nursing video
LMS nursing PPT
ReNew material
What to educate the patient
JC NPSG

Measurement (Study)
Insertion /

Checklist observation tool – how to measure this use? How do you know if every non-tunneled, nonemergent line had 2 person insertion?
What to do with insertions that don’t go well? Early on had some staff feel the checklist was unnecessary. The CMO was contacted and informed the staff member they would be suspended if they didn’t follow the policy and checklist.

Maintenance /

Modify EPIC Dashboard. Added specific process measure data elements for nurse manager to monitor
How many days has the line been in place
When dressing change is due (so manager can go a do staff competency assessments)
Nonsterily placed line indication (to monitor for timely removal)
CHG bathing occuring
Biopatch present
Daily assessment for need
Number of unintended dressing disruptions (to move to recommendation for new line)

Removal /

Time from order to removal?
Device utilization?
Why the line was removed – successful completion, complication……

Electronic Health Record (EHR) /

As measurements are being determined, include EHR staff to build the proper documentation structures for orders, insertion, and maintenance such that audits are easy for the front line managers and directors

Davita / Put HCMC performance standards into contract and have unit report out compliance they monitor and report on a monthly basis: Hand hygiene compliance, biopatch presence, and intact transparent dressings
Barriers to success / Survey staff for possible knowledge deficits or barriers to success
Denominator data / Validate the numerator and denominator data

TOOLS: