CLABSI Prevention:

Resources & Best Practices Laurie Reyen MSN, RN

March 3, 2016

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Why CLABSI Prevention?

• Nurse Sensitive Indicator:

• AANC EO for Magnet Accreditation

• Hospital Acquired Condition Reportable at the State and National Level

• JC Patient Safety Goal

• Impact on the patient:

• Morbidity and Mortality

• Increase LOS : 7 to 21 days

• Increases cost of care: $ 35,000 – $45,000

• Impact on the organization:

• Decreased reimbursements from CMS

• Publically available- impacts the public’s trust and confidence

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CLABSI Prevention:Best Practices

Bundle Time

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CLABSI Prevention:Best Practices

CLIP Bundle

• Central Line Insertion Practices:

• Practice hand hygiene before and after device insertion

• Use maximal sterile barrier precautions (mask, large drape, cap, sterile gloves) for CVC insertion

• Prep skin with appropriate antiseptic: CHG, unless contraindicated

• Allow skin prep agent to dry before puncture

• Avoid using the femoral vein for central venous access in adult patients whenever possible

• Document compliance with CLIP bundle

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CLABSI Prevention: Best Practices

CVC Maintenance Bundle

• CVC Maintenance:

• Daily assessment of line necessity

• Critical assessment and decision making about condition of site/dressing

• Sterile CVC dressing change

• Access – 15 second scrub before entering line

• Standardized Cap change

• Curos cap

• 2% CHG Bathing

• Patient/family education about risk of CLABSI.

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CLABSI Prevention: Best Practices

Active Daily Management

• Active Daily Management

• Talk the Line

• LNQIT

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Indicator Symbol on

Tool

Interpretati

on of

Symbol

Action Required based on

Symbol

CHG

Date

Date reflects

last

documented

CHG treatment

If CHG treatment date is >24hrs

communicate with RN and CP as to the

importance of compliance with CHG

treatment. Follow up with those that

missed the treatment.

Foley CAUTION

SIGN

Indicates that

the patient has

an active Foley

catheter

Communicate with RN and discuss

clinical indication and CAUTI

prevention strategies. Discuss Nurse

Driven Protocol that allows for removal

of Foley without an MD order if clinical

indication is no longer met.

Central

Line,

Porta

Caths,

Dialysis

CAUTION

SIGN

Indicates the

patient has an

active Central

line, Dialysis

Catheter or

Porta-cath.

Communicate with RN clinical necessity

and CLABSI prevention strategies.

Enforce removal of line as soon as

indication is no longer being met.

Ensure dressing changes are up to

date. Review infection prevention

strategies including utilization of Curos

Caps.

CLABSI Prevention Resources: Policies

• Two major policies guide nursing practice:

• Central Line Policy 104

• Prevention of CVC Related Bloodstream Infections HS 1401

• Evidence Based Guidelines and Standards:

• CDC Guidelines for Prevention of Intravascular Catheter Related Infections

• INS - Infusion Nursing Standards of Practice, 2016

• Joint Commission Patient Safety Goal NPSG .07.04.01

• Use proven guidelines to prevent infection of the blood from central lines.

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CLABSI Prevention Resources:People

• Laurie Reyen, Subject Matter Expert

• PICC Team

• Clinical Epidemiologists

• Unit Specific

• Unit Champions

• CNS/Educators

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CLABSI Prevention Resources:

Surveillance Data

• Unit Specific Data is sent out monthly by Epidemiology, includes:

• CLABSI Rates

• CLABSI SIR

• CLIP Compliance

• Unit specific data is also available on unit dashboards.

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Target Threshold Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16

UCLA Organizational Goals: Quality, Safety, & Service

Quality

Infection Prevention: Data retrieved from Epidemiology Department, Quality Dashboard, MAPS Report, Prevalence Day

Centra l Line Infections Standardized Infection Ratio (SIR)<1

<1: green; 1.01-1.5:

yellow; 1.6+: red0.00 0.00 0.00 1.78 2.07 0.00 1.59 0.00 2.02 0.00 1.79 2.20 0.00

CLABSI Mini -Root Cause Analys is Compl iance100%

>95: green; 90-94%:

yellow; <90%: red- - - 0% 100% - 100% - 100% - 100% 100% -

CAUTI Standardized Infection Ratio (SIR)<1

<1: green; 1.01-1.5:

yellow; 1.6+: red0.52 0.67 0.52 1.46 1.00 0.65 0.45 1.41 0.00 2.21 0.57 0.00 0.00

CAUTI Mini -Root Cause Analys is Compl iance100%

>95: green; 90-94%:

yellow; <90%: red0% 0% 0% 33% 50% 100% 100% 100% - 100% 100% - -

CVC Compl iance Bundle Checkl is t (ICUs only)100%

>95: green; 90-94%:

yellow; <90%: red100% 100% 96% 100% 100% 100% 99% 100% 95% 100% 100% 97% 100%

Hand Washing Between Patient Contact (MAPS)

RNs/CPs95% >95%: green; 91-94%:

yellow; <90%: red100% 100% 100% 100% 92% 96% 96% 99% 100% 98% 100% 100% 94%

CHG Treatment Performed in Last 2 Shi fts95%

>95%: green; 91-94%:

yellow; <90%: red100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Overal l Foley Care Compl iance95%

>95%: green; 91-94%:

yellow; <90%: red99% 93% 100% 99% 95% 100% 91% 99% 96% 99% 98% 100% 99%

FY 2015RR UCLA Medical Center

Performance DashboardFY 2016

CLABSI Prevention Resources:

Surveillance Data

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CLABSI Prevention Resources:

Surveillance Data

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Target Threshold Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16

UCLA Organizational Goals: Quality, Safety, & Service

Quality

Infection Prevention: Data retrieved from Epidemiology Department, Quality Dashboard, MAPS Report, Prevalence Day

Centra l Line Infections Standardized Infection Ratio (SIR)<1

<1: green; 1.01-1.5:

yellow; 1.6+: red0.00 0.00 0.00 1.78 2.07 0.00 1.59 0.00 2.02 0.00 1.79 2.20 0.00

CLABSI Mini -Root Cause Analys is Compl iance100%

>95: green; 90-94%:

yellow; <90%: red- - - 0% 100% - 100% - 100% - 100% 100% -

CAUTI Standardized Infection Ratio (SIR)<1

<1: green; 1.01-1.5:

yellow; 1.6+: red0.52 0.67 0.52 1.46 1.00 0.65 0.45 1.41 0.00 2.21 0.57 0.00 0.00

CAUTI Mini -Root Cause Analys is Compl iance100%

>95: green; 90-94%:

yellow; <90%: red0% 0% 0% 33% 50% 100% 100% 100% - 100% 100% - -

CVC Compl iance Bundle Checkl is t (ICUs only)100%

>95: green; 90-94%:

yellow; <90%: red100% 100% 96% 100% 100% 100% 99% 100% 95% 100% 100% 97% 100%

Hand Washing Between Patient Contact (MAPS)

RNs/CPs95% >95%: green; 91-94%:

yellow; <90%: red100% 100% 100% 100% 92% 96% 96% 99% 100% 98% 100% 100% 94%

CHG Treatment Performed in Last 2 Shi fts95%

>95%: green; 91-94%:

yellow; <90%: red100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Overal l Foley Care Compl iance95%

>95%: green; 91-94%:

yellow; <90%: red99% 93% 100% 99% 95% 100% 91% 99% 96% 99% 98% 100% 99%

FY 2015RR UCLA Medical Center

Performance DashboardFY 2016

CLABSI Prevention Resources:

Process Metrics

• Process metrics measured on prevalence day:

• CHG Compliance

• Curos Caps

• CVC Maintenance

• Learning from events:

• MRCAs provide useful information on gaps in practice, patient specific risk factors, and system failures.

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CLABSI Prevention Resources:

Process Metrics

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Unit Based Innovations

• 2 RN Dressing Change

• Standardized Dressing change days

• 8ICU CUSP Project

• Video Education- 6 East

•Good Video •Bad Video

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