How To Spread Successful CLABSI
Prevention Practices Hospital-Wide
Panelists:
Richard Brilli MD (moderator)
Charles Huskins MD MSc
Ethan Leonard MD
Kimberly Souder APN FNP –BC
Tuesday, October 9, 2012, 10:15 am – 11:15 am
Children’s Hospital Association
Annual Leadership Conference
Version 10.1.2012
Advocate Hope Children’s Hospital
Organizational Structure
• Located on the South Side of Chicago in suburban Oak Lawn, Illinois
• Children’s hospital within a hospital system
• 25 ICU beds
– 9 Pediatric CVICU beds
– 15 Pediatric ICU beds
• 45 Neonatal ICU beds (located in main hospital building)
• 45 General pediatric telemetry-capable floor beds
– 23 General Pediatrics/Cardiology
– 22 General Pediatrics/Oncology
•
•
•
•
•
Designated as a Pediatric Critical Care Center
Designated Magnet Hospital
ECMO Center of Excellence
Level III Perinatal Center
Level I Trauma Center
Why Spread Initiative Hospital-Wide?
• Multiple departments throughout the hospital
impact the care of our patients with central
lines
– OR, IR, VAD, ECMO, Cath Lab, Outpatient Cancer
Center, Outpatient Clinic
• Insertion
• Maintenance
• Standardization of care throughout pediatrics
• Culture of safety
Barriers to Overcome
• Acceptance by physician/nursing staff
– “Buying-in” by team to change practices
• Time to hardwire practices
• Communication to all disciplines
– Not only primary teams but also OR teams and
anesthesiologists etc.
• Children’s hospital within a hospital system
– Combined hospital initiative 2010
– 2 separate policies evolved
– Some departments care for adult and pediatric
patients
Key Drivers of Spread / Dissemination
• Executive Leadership
• Regulatory Leadership
• Physician Leaders/Nursing Leaders in ICU’s
*** Persistent team effort and collaboration
– Leadership
– Education
– Feedback at all levels
•
•
•
At bedside
At unit-based meetings
At monthly hospital-wide meetings
– Empowerment for culture of safety
Spread / Dissemination Efforts
• In 2010, our hospital made Pediatric CLA-BSI a hospital-wide
Key Result Area (KRA)
So what did that do for our initiative?
•
•
•
•
•
Brought ALL departments together who may care for a patient with a central
line
1-2 “Champions” from each unit/department chosen to attend monthly CLABSI task force meetings in addition to Leadership Team
Increased knowledge, education of protocols, and improved communication
followed
Environment for learning and shared resources evolved
Every unit or department began auditing some aspect of the protocol which is
reported monthly at the CLA-BSI meeting
We wanted every person that could potential touch the life of
a pediatric patient with a central line be part of the task force
and be active in CLA-BSI prevention!
5
Spread / Dissemination Efforts
What made it work???
• Established as a Key Result Area (KRA) in 2011
• Initiative fully supported by Administration and Department Heads
• Getting multiple departments involved outside pediatric critical
care arena
• Making it personable
• Case study presentation for all CLA-BSIs in individual Unit Task
Force Group meetings and at hospital-wide KRA monthly meetings
• Being transparent with results
• CLA-BSIs reported for each unit / department
• Audits reported for all departments
• Action plans put in place if <80% compliant on audits
• Sharing wins with all departments involved
6
Spread / Dissemination Efforts
• 2011 KRA
What made it work???
• Each department involved in KRA had to complete monthly audits (goal 15
per month) on one area of maintenance bundle or entire insertion bundle.
• Results and action plans discussed at monthly meeting.
• Posted on hospital “shared drive” to promote transparency.
• Various departments did presentations at monthly meetings on “How this
KRA has impacted your department”.
• 2012 KRA
• Audits expanded. Units/departments were assigned between 1-3
components of maintenance bundle.
• Results presented at monthly meeting.
• Departments with audits below <80% - actively discuss action plan.
• Results continue to be posted on “shared drive”.
• “Back to the Basics” review
7
Unit
2 HCH
2 HCH
2 HCH
4 HCH
4 HCH
4 HCH
NICU
NICU
NICU
Keyser Clinic
Keyser Clinic
PED
Interventional Rad.
Interventional Rad.
VAD team
VAD team
Cath lab
CV Surgery OR team
CV Surgery OR team
Peds General Surgery team
Area Audited
Line entry
Dressing change
Cap change
Line entry
Dressing assessment
Port access
Daily goals
Dressing change
Tubing change
Line Entry
Dressing change
Port Access
Line Entry
Insertion Bundle
Line Entry
Dressing Change
Line entry
Insertion bundle
Line entry
Line entry
ECMO team
ECMO team
Line entry
Circuit set-up/change
PACU
Day surgery
MRI
CT
Imaging Center
Radiation Oncology
Radiation Oncology
Line entry
Line entry
Line entry
Line entry
Line entry
Port access
Dressing assessment
Audit numbers
% audits that followed bundle
House-Wide
Monthly Audit
Results
Maintenance of Success
• Nursing and Physician Leaders act as ongoing
resources and advocates for initiative
• Continuous guidance/feedback
• Provide each department with products and
tools necessary to be efficient
– Frequent monitoring made to assure usage
• Reward and recognition
Pediatric Critical Care Data
Annual CLA-BSI Rates for Pediatric Critical Care Units (2007-2012).
Year
PICU
PSHU
2007
5.3
5.3
2008
4.0
4.97
2009
5.47
4.49
2010
3.59
5.23
2011
1.65
2.94
2012
0.84
0
Current Days BSI-Free > 230 days
> 390 days
Data reported as CLA-BSI rates measured per 1,000 catheter days.
General Pediatric Floor Data
Annual CLA-BSI Rates for General Pediatric Care Units (2011-2012).
Year
2011
2012
Current Days BSI-Free
2 Hope Pediatrics
0.0
2.10 (1 CLA-BSI)
> 90 days
4 Hope Pediatrics
0.0
0.75 (1 CLA-BSI)
> 89 days
Data reported as CLA-BSI rates measured per 1,000 catheter days
NICU Data
Annual CLA-BSI Rates for Neonatal Intensive Care Unit (2007-2012).
Weight
Group
2008
2009
2010
2011
2012
> 750g
0.0
0.0
0.7 (1)
0.0
0.0
750g-1000g
0.0
0.0
0.5 (1)
0.0
0.0
1001g-1500g 0.0
0.0
0.0
0.76 (1)
0.0
1501g-2500g 0.0
0.0
0.6 (1)
0.0
0.99
> 2500g
0.0
0.0
0.52
0.0
(1)
2.0
(1)
(2)
Data reported as CLA-BSI rates measured per 1,000 catheter days
Celebration of Wins
CVICU 1 Year CLA-BSI-Free!!!
How To Spread Successful CLABSI
Prevention Practices Hospital-Wide
Mayo Clinic Children's Center
W. Charles Huskins, MD, MSc
Chair, Quality and Safety
Dept. of Pediatric and Adolescent Medicine
Children’s Hospital Association
2012 Annual Leadership Conference
October 9, 2012
Washington, DC
©2011 MFMER | slide-1
Disclosures
• No commercial conflicts
• Faculty member CHA Quality Transformation
Network PICU CLABSI Collaborative
Off-label use
• None
©2011 MFMER | slide-2
Mayo Clinic Children’s Center
• Mayo Eugenio Litta Children's Hospital
• Comprehensive pediatric medical
•
& surgical inpatient services
95-beds
• 14 PICU (including HSCT & SOT)
• 10 CVICU (including ECMO)
• 28 NICU (Level III)
• 43 general care (including oncology)
• T. Denny Sanford Pediatric
Center
• Comprehensive pediatric medical
& surgical subspecialty clinic
& services
Mayo Clinic Children’s Center
©2011 MFMER | slide-3
Strategy for Spread
• Utilize PICU as “laboratory” for testing changes
• Evidence-base for effective prevention practices
• Learning through CHA QTN PICU Collaborative
• Leverage institutional structures to spread
improvements hospital (institution)-wide
• Quality Subcommittee of Clinical Practice Committee
• Nursing Clinical Practice Committee
• Quality Academy – QI training & projects in specific units
Mayo Clinic Children’s Center
©2011 MFMER | slide-4
Key Elements to Spread – I
• Insertion bundle
• Cart & training video – 2006
• Insertion guideline – 2008
• Training & certification in
Simulation Center – 2008
• Cap disinfection
• 15 second alcohol
•
“Scrub-the-Hub” – 2007
Passive cap protection/
disinfection device – 2011
Mayo Clinic Children’s Center
©2011 MFMER | slide-5
Key Elements to Spread – II
• Reducing central line entries
• Data collection form – 2008-12 PICU, 2011 other units
• Unit specific interventions
• PICU – IV to po conversion
prompted by pharmacist;
bolus to continuous infusion
for sedation & analgesia
• CVICU – bolus to continuous
infusion for sedation & analgesia
• NICU – IV to po conversion; bolus to continuous infusion for
sedation & analgesia; reduce unnecessary lab tests
• General ward – consolidate lab tests
Mayo Clinic Children’s Center
©2011 MFMER | slide-6
Adaptations Into Unit Culture
NICU ACCESS Initiative
• Advancement of calorie
and/or volume?
• Convert meds to oral route?
• Continuous infusion of
sedation if intubated?
• Eliminate labs?
• Switch umbilical line to
PICC?
• Stop the central line today?
©2011 MFMER | slide-7
Monitoring Adherence
• Insertion bundle – documentation of adherence
as a part of procedure documentation
• Scrub the hub – Dept. of Nursing medication
safety audits
• Passive cap disinfection – periodic prevalence
surveys
• Bottom-line: CLABSI rates
Mayo Clinic Children’s Center
©2011 MFMER | slide-8
Facilitators of Spread
Barriers to Spread
• CLABSI rates, # days since last
CLABSI
• “Mini”-RCA of CLABSI cases
• Compelling improvement ideas
• Adaptation into unit culture
• Committed pediatric nurses &
nursing committees
• CLABSIs have become
infrequent
• Challenges with IV pumps
& tubing vendors
• Competing quality & safety
priorities
• Nursing procedures
• Collaboration between ICU &
general ward nursing leadership
• Ad hoc pediatric nursing workgroup
• Institutional nursing clinical practice
committee
• Engaged physicians
• Collaborative anesthesiologists
• Skilled PICC team
©2011 MFMER | slide-9
Mayo Clinic Children's Center
Hospital-wide Quarterly Incidence of Inpatient CLABSI
5
# of CLABSI
1000 CL days
4
3
2
1
0
Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
2008
2009
2010
2011
2012
Mayo Clinic Children’s Center
©2011 MFMER | slide-10
Mayo Clinic Children's Center
Unit-Based Quarterly Incidence of Inpatient CLABSI
PICU
NICU
9
CVICU
General care
# of CLABSI
1000 CL days
8
7
6
5
4
3
2
1
0
Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
2008
2009
2010
2011
2012
Mayo Clinic Children’s Center
©2011 MFMER | slide-11
450 beds
35 bed PICU
15 bed CTICU
Richard J. Brilli, M.D.
Chief Medical Officer
Nationwide Children’s Hospital
Co-Chair NACHRI BSI Prevention Collaborative
Spread BSI care beyond the ICU = make the case
 Increased attributable LOS for PICU BSI – about 9 days
 Increased cost for PICU BSI – about $35,000
(1)
(1)
 Possibly increased mortality
 It’s the right thing to do
(1)
Nowak et al. PCCM Sep 2010
Make the Case
CLA-BSI – Pediatric ICU Data
2004 – Aug 2012
20 months no BSI
Make
the Case
Zero PICU Infections
What Worked?
 Senior Leadership engagement
 Hospital’s journey to improve safety and high reliability
practice since 2008
 Hospital wide QI BSI Team - membership from all units,
membership from nursing and MD disciplines
 PICU experience spread – Use of evidence based bundle
from QTN - NACHRI (2)
(2)
Miller et al. Pediatrics 2010
What Worked?
 Unit specific RN – MD champions
 Unit specific rates, run charts on hospital intranet
 Measure and report bundle compliance – insertion and
maintenance (on hospital intranet)
 Unit specific dressing change teams
(Short Gut Unit)
CLA-BSI – Nationwide Children’s – Whole Hospital Data
2004 – Aug 2012
What is still problematic?
 Operating room and compliance
 Lot’s of compliance data to collect – workload burden
 All the competing priorities for Harm reduction
 Addressing gut translocation (likely not preventable) on
Heme/Onc and short gut units
Spreading the Wealth:
Reduction in CABSI outside of
the ICU
Ethan G. Leonard, MD
Vice Chair for Quality, UH Rainbow Babies and Children’s
Hospital
1
Our PICU Journey
2
Decision to Spread
• We saw marked improvement in our rates in the
ICU and shared with ICU and non-ICU staff
• We continued to see CA-BSI related harm
outside of the ICU
• We examined our care outside of the ICU and
found significant inconsistencies
3
Inconsistencies Noted
• Practices around process and timing of
performing cap changes
• Dressing material, process and change
frequency were determined according to
individual RN or homecare agency practice
• Different practices around hub care and opening
the line
4
A Few Barriers
• As kids are transitioning out of the ICU, they
typically would only have a single IV access,
would not likely be receiving continuous
infusions without windows and are more likely to
be ambulatory/mobile: caps became necessary
and safer
• Dealing with long standing individual/team
cultural practices around line care
5
Overcoming Barriers
• The extra-ICU teams comprised of change and
content experts
– QI nurses, DIVAs
– Modified maintenance bundle to include caps
• Shared patient stories
– Parents identified variable practicesdiscomfort
– Stories of line infection impact on patients
6
Easiest Part of Spread
• Individual bundle concepts were not new
• Not a lot of added cost: although some supplies
may have been more expensive, standardizing
frequency of changes evened out cost
• Division IV advocates (DIVAs) our champions:
identified in all clinical areas: promoted, monitor,
and coach change
• Very supported senior leadership (C-suite)
7
Other Drivers of Spread
• Participation in this collaborative and Ohio
Children’s Hospitals Solution for Patient Safety
Collaborative heightened attention to all harm,
instilled safety driven culture in all staff and
brought safety to the forefront of discussion at all
levels of the organization
• Transparency of harm data to all staff
8
Achieving Spread: Maintenance
• Studied current practice
• Engaged stake holders: service-line leadership,
front-line staff, home team, family learning
center
• Developed final standard expectations
• Created easy reference for bedside providers to
follow process and order care
9
ReliabilityCollecting data for both bundles
Insertion:
Maintenance:
•
Real Time observation of
insertion
•
Real Time observation and self
evaluations of maintenance
•
PICU, NICU, PVAT (all floors)
•
R2, R3, R5, R6, PSU, ICUs
•
(not yet in OR or interventional
radiology)
•
(not yet on R7)
10
Where Are We Now?: Hopefully Early Signal
11
Next Steps
• Spread insertion bundle to the OR and IR
• Achieve maintenance reliability in every
area that provides central line care
• Continually monitor the occurrence of
infection
Appendix
RAINBOW BUNDLE
13
CENTRAL LINE INSERTION BUNDLE
1.
Hand Hygiene Immediately Prior to Procedure
2.
Chlorhexidine Scrub for Insertion Site
•
Iodine skin prep used for allergy to Chlorhexidine
3.
Prepackaged Procedural Insertion Kits
4.
Inserter Welcomes Observer to Stop the Line
•
•
•
5.
Full Sterile Barrier for Clinician
•
6.
9/25/2012
Mask, Hat, Sterile Gown, Sterile Gloves
Full Draping of the Patient and Bed
•
7.
Observer Present for Line Insertion
Completes Insertion Checklist
Empowered to Interrupt Unsafe Practice
Head to Toe
Standard Insertion Training for All Providers
University Hospitals
14
CENTAL LINE MAINTENANCE BUNDLE
1.
Daily Assessment of Continued Need for Line with Documentation in Plan of
Care
2.
Mask and Sterile Gloves for all Sterile Tasks
3.
Standard Sterile Dressing Change Kit and Procedure
4.
Cap Scrub Before Accessing the Line
5.
Cap Junction Scrub Before Removing Cap
6.
Sterile Cap Change Procedure
7.
Standard Tubing Change/Labeling Procedure
8.
Standard Mediport Needle Procedure
9.
EMR Scheduling/Communication of Care
9/25/2012
University Hospitals
15
Central Line Maintenance Bundle Easy Reference
05/2012
Bundle Elem ent
Details
Tips for Practice
Hand Hygiene
Hand Hygiene BEFORE/AFT ER Patient Care
-Hand Sanitizer Rub Golf Ball Amount
-Soap and Water Wash for 30 Seconds
•Scrub ALL Surfaces Including Betw een the Fingers
•Visibly Soiled Hands Require Soap and Water
Cap Scrub
Cap Scrub PRIOR to EVERY Line Entry
-Alcohol is the Standard for Cap Scrubs
-15 Seconds and Dry
•Alcohol, w ith Friction, for 15 Seconds and Dry
•Chlorhexidine for 30 Seconds and Dry OR
•Betadine, 3 sw abs, and Dry
Sterile Cap Changes
-Scrub Connection Junction BEFORE Rem oving
-Wear Mask and Sterile Gloves to Remove Cap
Change: -Every 96 Hours Routinely
-When Cap Cannot be Cleared of Blood
-Every 24 Hours Infusing Lipids/Blood
BEFORE Line Entry
Cap Junction Scrub
To REMOVE Cap
-Every 12 Hours Infusing Propofol
Tubing
Labeled with Initials, Date & Time
Tip Sterilely Covered (intermittent use)
Mask and Sterile Gloves
For Sterile Tasks
Dressing
Labeled with Initials, Date & Time
Dry and Intact
Mediport Needle Change
Tubing Connections Handled Sterilely
-Clean Gloves Connecting Tubing to Cap
-Sterile Gloves Direct Tubing Connection w /o Cap
Change: -Every 96 Hours Routine
-Every 24 Hours Infusing Lipids/Blood
-Every 12 Hours Infusing Propofol
-Sterile Connection Cover for Intermittent Use
Mask for Everyone Within 3 Feet of Line
-Patient, Family, Caregivers
Sterile Gloves for Caregivers Touching Site
Clean Gloves for Central Line Handling w /Cap
Sterile Gloves for Sterile Procedure
(i.e. dressing changes and cap changes)
Sterile Dressing Changes
-Use Dressing Change Kit for standard dressing
-Wear Mask and Sterile Gloves
Change: -Every 7 Days Routinely
-Every 2 Days When Gauze is Present
-Anytime Dressing is Loose or Soiled
-Label Legibly
Refer to Rainbow Pediatric Central Line Dressing Guide
Sterile Needle Changes
-Clean Gloves for Rem oving Needle
-Mask and Sterile Gloves for Accessing Port
Change: -Every 7 Days Routinely
-When Cathflo is indicated
-Label Dressing Legibly
Daily Line Discussion
Daily Vascular Access Discussion in Rounds
-Discuss Need, Use, Entries, Plan and Removal
-Docum ent in Plan of Care
Consider: -IV versus Enteral
-Peripheral versus Central Lines
-Number of Line Entries
-Verify Central Line Orders are Correct
EMR Order Set
Central Line Order Set
-Choose Orders for Each Line and Label
-Schedule Cap, Tubing and Dressing Changes
-Docum ent Dressing in Use
•Entered by MD or RN; Validate Correct Scheduling
•Sign Completed Tasks Off When Completed
•Nursing Task Will Retime for Next Change-According
to Ordered Frequency
Refer to the Central Venous Access Devices (CVAD) Rainbow Policy and the Rainbow Pediatric Central Venous Access Devices (CVAD) Guidelines for Practice.
Rainbow Pediatric Central Line Dressing Guide
EMR Easy Reference
05/2012
Site Check Parameter
-Choose a NEW site check parameter for EACH line
under I&O Flow Sheet.
-Row Label with the Type.
-Use the drop down list (no free text).
-Place free text in the site or comments box.
-Time Column documentation is completed by :
-WNL or not WNL.
-Document the Site in the time column (1) one time.
Patients greater than 2 months of age
Standard Central Line Dressing kits are part of the NACHRI Central Line Maintenance Bundle. Use the standard dressing
unless there are complications requiring an alternate dressing regimen. The following chart depicts the standard and
indications for alternate central line dressings. The Pediatric Vascular Access Service or the Pediatric Surgical Nurse
Practitioners should be made aware when dressing intolerance is identified. They may have suggestions for further
intervention on assessment of individual patients.
Consider:
History/Assessment:
Dressing Suggestion:
Standard Dressing
-New Central Line
-No History of Allergy
-No History of Dressing Complications
-Intact, healthy skin
Standard Sterile Dressing Kit:
-Chlorhexidine scrub
-Cavilon Skin Prep
-IV Advanced Tegaderm
-Document in EMR for 7 Day Change
-History of Allergic Reaction to
Chlorhexidine Scrub
-Skin Assessment Results:
Red
Inflamed
Itchy, Hot or Prickly Feeling
Blister Formation Beginning
Alternate Sterile Dressing:
-Betadine Swabs (3)
-Sterile Saline Soaked Gauze Rinse
-Cavilon Skin Prep Barrier
-IV Advanced Tegaderm
-Document in EMR for 7 Day Change
-History of Allergic Reaction to
Tegaderm Dressing
-Skin Assessment Results:
Red Where Dressing Touches
Itchy
Warm
Alternate Sterile Dressing:
-Chlorhexidine Scrub
-Cavilon Skin Prep Barrier
around border where tape sticks
-Sterile gauze with Hypafix Tape
-Document in EMR for 2 Day Change
Altered Skin Integrity
-Skin Assessment Results:
Rash in Dressing Area
Broken Open Skin
Blistered Skin
Alternate Sterile Dressing:
-Betadine Swabs (3)
-Sterile Saline Soaked Gauze Rinse
-Cavilon Skin Prep Barrier
around border where tape sticks
-Sterile Gauze with Hypafix Tape
-Document in EMR for 2 Day Change
Excessive Sw eat or Moisture
-Skin Assessment Results:
Moist Skin
Moisture Under Dressing
Alternate Sterile Dressing:
-Chlorhexidine Scrub
-Cavilon Skin Prep Barrier
-Sterile Gauze Under IV Advanced
Tegaderm
-Document in EMR for 2 Day Change
The central line maintenance
bundle uses a standard
dressing kit.
(row label site and time column site should match)
-Discontinue the parameter with line removal.
-Comment on reason for removal.
-Discontinue parameter.
-Start a new parameter for each new line.
Refer to the RB&C Intravenous (IV) Site Assessment
Documentation Guidelines.
Central Line Order Set
-Choose the Central Line Care-Peds Order Set.
Allergy to Chlorhexidine
Tip: Verify scrub is allowed to dry
completely/moisture is not collecting
under dressing.
Note: Wet scrub agents under a
dressing can cause chemical
burns/reactions.
Allergy to Tegaderm
Tip: Verify skin prep barrier was used
and dry prior to dressing.
-Choose the dressing schedule and define dressing.
-Refer to Rainbow Pediatric Central Line Dressing Guide.
-Standard and alternate drop dow n w ill soon exist.
-Choose the tubing schedule.
-Choose the cap change schedule.
-Schedule for each lumen of the line.
-Choose needle change schedule for Mediports.
-Label tasks by clicking on the order title.
-Choose access type from list.
-Tasks will show on the Nursing Task List.
-Sign off as completed for next task to schedule
according to ordered frequency.
05/2012
Tip: Verify line is NOT leaking.
Tip: Verify dressing products were
allowed to dry completely.
Tip: Assess for drainage consistent
with infection/respond appropriately.
Alternate Sterile Dressing: *History of multiple line infections, consider CHG impregnated
dressings w ith a Physician order and Document in EMR central line order set.
Note: Chlorhexidine dressings do NOT use skin barrier. Change ev ery 7 days.