CREATING AN INTEGRATED CLABSI PREVENTION PROGRAM Presented by: Tracy Shamburger, RN, MSN and Karen Bailey, RN

CREATING AN INTEGRATED CLABSI PREVENTION PROGRAMPresented by:

Tracy Shamburger, RN, MSN and Karen Bailey, RN

OBJECTIVES Identify The Joint Commission (TJC) National Patient

Safety Goal 07.04.01 Elements of Performance

Cite the Mike Denton Infection Reporting Act (2009)

Define CLABSI and Central Lines per CDC Guidelines

Identify National Healthcare Safety Network (NHSN): ADPH HAI Reporting Requirements

Understand that the Comprehensive Unit-based Safety Program (CUSP) is a process for creating a culture of patient safety

Standards; Regulatory Compliance; & Reporting

Monitoring; Evidence Into Practice

Patient Safety

Evaluation& PI

CLABSIPrevention

The Joint CommissionNPSG.07.04.01

Institute for Healthcare Improvement (IHI)

National HealthcareSafety Network

(NHSN);CMS; ADPH

Comprehensive Unit-based Safety Program (CUSP)

EVALUATING COMPLIANCE WITH TJC NPSG.07.04.01

Conduct periodic hospital-wide risk assessments for CLABSI; monitor compliance with evidence-based practices; and evaluate the effectiveness of prevention efforts.

After conducting your risk assessment, do you have gaps in compliance or process improvement opportunities? If so, what are the gaps; are you conducting process reviews; and are your developing action plans to achieve compliance?

MONITORING AND REPORTING COMPLIANCE RATES

Compliance with evidence-based practices should be measured weekly or monthly and reported/charted to show progress towards goal of 100% compliance.

Compliance rate must be calculated with the whole bundle, not just parts.

CALCULATING COMPLIANCE RATES

# of pts with CVC during monitoring period who received all 5 elements of bundle (with documentation)

# of pts with CVC audited during the monitoring period

X 100 = Compliance Rate (%)

• Do you have a process for evaluating and reporting compliance rates with documentation? CLABSI rates?

SAMPLE COMPLIANCE RATES AND CLABSI REPORTING SCORECARD

JulyJuly AugAug SeptSept OctOct

How often did we harm How often did we harm (CLABSI)? (CLABSI)? Goal: Goal: <1CLABSI/1000 CL DAYS<1CLABSI/1000 CL DAYS

0.11/1000.11/10000

0.09/10000.09/1000 0.09/1000.09/10000

0.08/1000.08/10000

Compliance Rate? Compliance Rate? Goal: 90% or Goal: 90% or greatergreater

43%43% 82%82% 82%82% 88%88%

Are we improving based on Are we improving based on data monitoring? data monitoring?

YesYes YesYes YesYes YesYes

Where are we failing based on Where are we failing based on data monitoring? Non-data monitoring? Non-compliance Rate:compliance Rate:

57%57% 18%18% 18%18% 12%12%

a. Non-compliance with a. Non-compliance with insertion documentation: insertion documentation: NursesNurses

24%24% 10%10%3 nurses did not 3 nurses did not document CVC document CVC

insertion; Infusa insertion; Infusa Ports not Ports not

consistently consistently documented in the documented in the insertion screen as insertion screen as

POAPOA

9%9%3 nurses did not 3 nurses did not document CVC document CVC

insertion; Infusa insertion; Infusa Ports not Ports not

consistently consistently documented in the documented in the insertion screen as insertion screen as

POAPOA

9%9%2 M/S and 1 ICU 2 M/S and 1 ICU

nurse did not nurse did not document document

insertion screens; insertion screens; M/S staff are not M/S staff are not

consistently consistently documenting the documenting the insertion screen insertion screen for Infusa Ports for Infusa Ports

POAPOA

b. Non-compliance with barrier b. Non-compliance with barrier precautions: precautions: PhysiciansPhysicians

19%19% 8%8%3 MD failed to 3 MD failed to

wear full wear full barrier barrier

precautionsprecautions

9%9%3 MD failed to 3 MD failed to

wear full wear full barrier barrier


3%3%1 MD failed to 1 MD failed to

use full use full barrier barrier


c. System implementation c. System implementation issues:issues:**Processes exist for ER and OR staff to document data; **Processes exist for ER and OR staff to document data; however, the data is not flowing between modules for however, the data is not flowing between modules for M/S and ICUM/S and ICU

14%14% **0%**0% **0%**0% **0%**0%

COMMUNICATE AND REPORT COMPLIANCE AND INFECTION RATES

TJC requires that you report CLABSI rate data and prevention outcome measures to key stakeholders, including leaders, nursing staff, and other clinicians

Regulatory guidelines require reporting CLABSI rates to the National Healthcare Safety Network (NHSN)



Patient Safety

Evaluation& PI

CLABSIPrevention




(NHSN);CMS; ADPH


CDC’S NATIONAL HEALTHCARE SAFETY NETWORK (NHSN): CENTRAL LINE

DEFINITION An intravascular catheter that terminates at or close to

the heart or in one of the great vessels which is used for infusion, withdrawal of blood, or hemodynamic monitoring.

-The Great Vessels Include the following: Aorta Superior Vena Cava Pulmonary Artery Brachiocephalic Veins Internal Jugular Veins Subclavian Veins Inferior Vena Cava External Iliac Veins Common Femoral Veins Umbilical Artery in neonates

INFUSION DEFINED Introduction of a solution through a blood vessel via a catheter

lumen. Includes: Continuous Infusions such as nutritional fluids,

medications, or Intermittent infusions such as flushes or IV antimicrobial administration, or

Administration of blood or blood products in the case of transfusion or hemodialysis.

CDC’S NATIONAL HEALTHCARE SAFETY NETWORK (NHSN): CENTRAL LINE BLOOD STREAM INFECTION

A Central Line Blood Stream(CLABSI) is a primary bloodstream infection (BSI) in a patient that had a Central line within the 48 hour period before the development of the BSI.

CDC’S NATIONAL HEALTHCARE SAFETY NETWORK (NHSN): AL HAI REPORTING Mike Denton Infection Reporting Act (2009; Rules

and Regulations Released-August 2010) -Requires Critical Access hospitals in Alabama to begin

reporting

certain HAIs using CDC’s NHSN.HAI Reporting Requirement

Denominator Requirement

Locations

CLABSIs Central Line Days Medical CCUsSurgical CCUs

Medical Surgical CCUsPediatric CCUs

CAUTIs Catheter Days Medical WardsSurgical Wards

Medical Surgical Wards

SSIs for Colon Surgeries and Abdominal Hysterectomies

(inpatient)

All inpatient procedures for Colon Surgeries and

Abdominal Hysterectomies

Any

ALABAMA CENTRAL LINE/CLABSI DATA ENTRY REQUIREMENTS

NHSN monthly reporting: Report central line device days Report CLABSI events

**You must have a monitoring plan for each month that you plan to report.

o Reporting Deadline for Alabama -All data must be entered into NHSN no later

than the last day of the subsequent month. Ex. January data is due by 28February).

NATIONAL HEALTHCARE SAFETY NETWORK (NHSN): CMS HAI

REPORTING

HAI Reporting Requirement

Denominator Requirement

Locations

CLABSIs Central Line Days All CCU locations

SSIs (2012) ?

oCMS Final Rule Passed (July 2010)

-Requires hospitals accepting Medicaid across the Nation to begin reporting certain HAIs using CDC’s NHSN January, 2011

Extended to 28 Feb 2011

CONSIDERATIONS: Have you evaluated all the different central lines utilized in

your facility that fit the definition of a central line?

oDo you have a Device Days Report?

oDo you consistently collect device day information at the same time each day?

oIf the patient is in CC/ICU, how do you capture positive blood cultures that return after the patient is transferred to a regular floor?

oHave you updated your NHSN monthly monitoring plan to include both CMS, and Alabama Central line/CLABSI reporting mandates? oAre your Locations Correctly Mapped?

oAre staff informed of their role in reporting HAIs?

Resources: http://www.adph.org/hai/

ALABAMA HAI REPORTING AWARENESS CAMPAIGN

SURVEILLANCE TIPSPeriodically check the accuracy of line day data

by visiting units and comparing reported catheter days with actual number of patient lines.

Remember….–Internal validation of central line data is critical!!

-when counting central line days, only count one central line day for patients with multiple central lines.

-Under reporting line days will artificially increase CLABSI rates.



Patient Safety

Evaluation& PI

CLABSIPrevention




(NHSN);CMS; ADPH


COMPREHENSIVE UNIT-BASED SAFETY PROGRAM (CUSP)

NHSN and CUSP Participation

The main focus of the two year “On the CUSP: Stop BSI” project is to improve our culture of safety, thereby decreasing CLABSIs. Furthermore, participation in the project facilitates standards compliance, measurement, and reporting of CLABSI, along with other HAI data, to the CDC/NHSN

HOW DOES CUSP WORK?

“CUSP IS A PROCESS”

CUSP comprises five fundamental steps and is a continuous process.

CUSP guides you on a journey of education and communication; implementation and evaluation; review and transparency.

It starts with one high risk unit but provides a scalable intervention program that can be implemented throughout your organization.

FIVE FUNDAMENTAL STEPS TO CUSP

Engage Senior Leadership Open lines of communication between frontline

staff and administration

Educate leadership about clinical issues and safety hazards

Improve providers attitudes about leadership

Enlist administration in obtaining necessary resources to improve patient safety


Educate Staff on Science of Safety Ensure all current staff have viewed the Science

of Safety video and incorporate the video into new hire orientation (consider adding the video to annual review)

Evaluate HSOPS results; identify safety needs and develop a plan of action. Form a team to assist with these goals and monitor for improvement.


Implement Teamwork Tools Engage staff to be active team players, not

passive players

Breakdown physician – nurse barriers

Provide tools to facilitate teamwork and communication (ex: daily goals sheet)

Incorporate morning briefings and observing rounds


Identify Defects Use incident reports, liability claims, or sentinel

events

Survey staff and ask, “How will the next patient be harmed?”


Learn From Defects Incorporate a practical tool to address what

happened, why it happened, what you did to reduce future risk, and how to measure for reduced risk

Use resources such as the “Learning from Defect Tool” and “Investigating a CLABSI Tool” found on the CUSP: Stop BSI website

Plan to learn from at least one defect a month

APPLYING CUSP TO CLABSI PREVENTION

Begin by reviewing your TJC NPSG 07.04.01 risk assessment:


If you’ve already conducted a TJC risk assessment for NPSG.07.04.01, then you’ve already identified gaps, deficiencies, and/or process improvement opportunities

Now develop actionable plans to improve processes

Monitor compliance with evidence-based practices

Evaluate effectiveness of prevention efforts


Educate staff, patients, and family about CLABSIs and prevention

Implement policies aimed at reducing the risk of central line infections

Adhere to the CLABSI Prevention Bundle: Strict and consistent hand hygiene Maximum use of barrier precautions, including full

patient drape Site prep with Chlorhexidine Optimal site selection (avoid femoral insertions when

possible) Scrub the hub before accessing ports Remove catheters when no longer necessary; assess

daily need


Create a Central Line Insertion Kit or Cart

Devise and consistently use a Central Line Insertion Checklist

Empower nurses to stop the procedure if guidelines are not followed

Post the # of patients infected per month and your quarterly infection rates

Participate in monthly CUSP calls, enter data into MHA Care Counts, and complete the Monthly Team Check-up Tool

EVALUATING PROCESSES If your CLABSI rate is NOT going down,

evaluate your processes!

Determine if processes are breaking down and if so, develop a plan of action to correct the deficiencies!

Finally, CUSP is not exclusive to CLABSI prevention. It is a process to address your overall culture of patient safety. Once you understand the process, CUSP can be applied to any process improvement program i.e., other TJC National Patient Safety Goals:



Patient Safety

Evaluation& PI

SSIPrevention



(NHSN);CMS; ADPH




Patient Safety

Evaluation& PI

CAUTIPrevention



(NHSN);CMS; ADPH


CONCLUSION Creating an integrated CLABSI Prevention program is

about evaluating your TJC compliance; understanding how to define and report CLABSI to NHSN; and implementing CUSP processes that sustain a culture of patient safety!

The Alabama Department of Public Health and the Alabama Hospital Association truly wish every IP great success in this new venture! Odds are, now that you understand how all these elements are inter-related, you will probably discover that you’ve done more with the CUSP project than you thought.

The challenge, use CUSP processes to raise the bar with CLABSI prevention – take it to the next level: implement daily goal sheets; begin daily rounding with physicians; conduct AM briefings.

And remember to always ask, “How will the next patient be harmed; how can I prevent it from happening?”

QUESTIONS?QUESTIONS?

Documents

CREATING AN INTEGRATED CLABSI PREVENTION PROGRAM Presented by: Tracy Shamburger, RN, MSN and Karen Bailey, RN