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.
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