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The 5 Million Lives Campaign: “Preventing Central Line Infections” Institute for Healthcare Improvement

The 5 Million Lives Campaign: “Preventing Central Line Infections”

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The 5 Million Lives Campaign: “Preventing Central Line Infections”. Institute for Healthcare Improvement. The Central Line Bundle. Do Central Lines Cause Blood Stream Infections?. - PowerPoint PPT Presentation

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Page 1: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

The 5 Million Lives Campaign:

“Preventing Central Line Infections”

Institute for Healthcare Improvement

Page 2: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

The Central Line Bundle

Page 3: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

Do Central Lines Cause Blood Stream Infections?

➥ Central venous catheters (CVCs) disrupt the integrity of the skin, making infection with bacteria and/or fungi possible.

➥ Infection may spread to the blood stream (bacteremia) and hemodynamic changes and organ dysfunction (sepsis) may ensue.

➥ Approximately 90% of the catheter-related blood stream infections (BSIs) occur with CVCs.

Maki DG. Infections due to infusion therapy. In: Hospital Infections, Third Edition, Bennett JV, Brachman PS (eds), Little, Brown, Boston 1992.

Page 4: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

Incidence & Risk:

➥ 48% of ICU patients have central venous catheters, accounting for 15 million central venous catheter-days per year in ICUs.

➥ The case fatality rate for catheter-related blood stream infections approaches 20%.

➥ Attributable mortality ranges from 12-25% but was 3% in one meta-analysis.

Mermel LA. Ann Int Med 2000;132: 391-402Soufir L et al. Infect Control Hosp Epidemiol 1999 Jun;20(6):396-401.

Page 5: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

Incidence & Risk:

➥ Studies that control for underlying illness severity give lower estimates of attributable mortality.

➥ These data suggest that attributable mortality is between 4 and 20%.

➥ Thus, between 500-4000 U.S. patients die annually due to blood stream infections.

Pittet D, Tarara D, Wenzel RP. Jama. May 25 1994;271(20):1598-1601Soufir L et al. Infect Control Hosp Epidemiol 1999 Jun;20(6):396-401.

Page 6: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

BSI is Costly & Prolongs Care

! Attributable cost per blood stream infection is estimated to be $3,700 to $29,000.

! Nosocomial blood stream infections prolong hospitalization by a mean of 7 days.

Pittet D, Tarara D, Wenzel RP. Jama. May 25 1994;271(20):1598-1601Soufir L et al. Infect Control Hosp Epidemiol 1999 Jun;20(6):396-401.

Page 7: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

BSI Risk Factors

Risk Factors with Percutaneous or TunneledCatheters:

Site of insertion: Subclavian vein less risky than internal jugular or femoral vein.

Multiple ports/hubs: More manipulation and contamination.

Parenteral feeding: TPN and/or lipids

Infection elsewhere: Remote, e.g. UTI or wound.Mermel LA, Am J Med. Sep 16 1991;91(3B):197S-205SMcCarthy MC, J Parenter Enteral Nutr 1987; 11:259.

Page 8: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

BSI Risk Factors

Risk Factors with a Central Venous AccessDevice (C-VAD): Lower infection rates: 0.1 to 0.2 per 100 catheter days. Subcutaneous ports: 10-12 fold lower rate of infection

compared with tunneled catheters. Some risks remain:

– Colonization of catheter with organisms – IV catheterization longer than 72 hours – Inexperience of personnel inserting the C-VAD

Groeger JS, et al. Ann Intern Med 1993; 119:1168.

Page 9: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

CDC Guidelines

Major areas of emphasis: Education and training of providers who

insert lines Maximal sterile barrier precautions Use of 2% chlorhexidine for skin antisepsis Avoiding routine replacement Consider antiseptic/antibiotic impregnated

catheters if rate of infection remains high

O’Grady NP. MMWR Aug 9, 2002; 51: RR10, 1-29

Page 10: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

AHRQ-Sponsored Evidence Summary

Attributable mortality 4-20%

Analyses of costs very variable

Routine replacement does not reduce risk

Maximum barrier precautions reduce risk

CVCs coated with antiseptics or antibiotics might reduce risk but are expensive

Use of chlorhexidine skin prep reduces risk more than povidone-iodine

Saint S. http://www.ahrq.gov/clinic/evrptfiles.htm#ptsafety

Page 11: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

Opportunity Knocks

¿What if a series of interventions could markedly reduce the risk of BSI?

¿What if those interventions were already readily available in hospitals?

¿What if all of those interventions were done all of the time on each patient?

Page 12: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

Benefits of Reducing BSI

Better patient outcomes

Reduced mortality

Improved satisfaction Nursing Physician Patients and families

Financial benefits

Page 13: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

The Central Line Bundle

…is a group of interventions related to patients with intravascular central catheters that, when implemented together, result in better outcomes than when implemented individually.

Page 14: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

What is a Bundle?

A grouping of best practices with respect to a disease process that individually improve care, but when applied together result in substantially greater improvement.

The science behind the bundle is so well established that it should be considered standard of care.

Bundle elements are dichotomous and compliance can be measured: yes/no answers.

Bundles eschew the piecemeal application of proven therapies in favor of an “all or none” approach.

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© 2007 Institute for Healthcare Improvement

Central Line Bundle Elements

1. Hand hygiene

2. Maximal barrier precautions

3. Chlorhexidine skin antisepsis

4. Appropriate catheter site and administration system

5. Avoidance of routine replacement

Page 16: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

But, Does it Work?

ICUs that have implemented multifaceted interventionssimilar to the central-line bundle have nearly eliminatedCR-BSIs.

Berenholtz SM, Pronovost PJ, Lipset PA, et al. Eliminating catheterrelated bloodstream infection in the intensive care unit. Critical CareMedicine. 2004; 32:2014-2020.

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Page 17: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

Outcome and Cost Impact

Rate of CR-BSIs fell from 11.3 to 0 /1000 catheter days.

Prevented annually (estimated):↳ 43 CR-BSIs↳ 8 deaths↳ 559 ICU days

Estimated savings to hospital: $1,824,447

Page 18: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

Does it Work?

                                                          

                 

Baptist Memorial Hospital-Memphis, Memphis, TN

Reduced CR-BSI and ICU length of stay:

Page 19: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

Hand Hygiene 101

Wash hands if they are obviously soiled

Wash hands or use an alcohol based waterless hand cleaner

↳ Before and after invasive procedures ↳ Between patients ↳ After removing gloves ↳ Before eating ↳ After using the bathroom ↳ If contamination is suspected

Page 20: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

What are Maximal Barrier Precautions?

• For Provider:

– Hand hygiene– Non-sterile cap and mask

• All hair should be under cap• Mask should cover nose and mouth tightly

– Sterile gown and gloves

• For the Patient:

– Cover patient’s head and body with a large sterile drape

Page 21: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

Impact of Maximal Barrier Precautions (MBR)

Author/date Design Catheter Odds Ratio for infection w/o MBR

Mermel

1990

Prospective

Cross-sectional

Swan Ganz 2.2 (p<0.03)2.2 (p<0.03)

Raad

1994

Prospective

Randomized

Central 6.3 (p<0.03)6.3 (p<0.03)

OR=odds ratio MBR= inserter washes hands and wearsmask, sterile gown, sterile gloves and patient’s head & body

are covered with a large, sterile drape.

Page 22: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

Key Change: Central Line Checklist

Have the nurse document compliance with the insertion criteria at the time of insertion.

Create a culture of safety and prevention:

empower nurses to stop line placement if improper techniques are used

Instruct nurses in use of critical communication strategies to facilitate important exchanges.

e.g. “the sterile field has been contaminated,” rather than “YouYou contaminated the catheter!”

Page 23: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

Checklist Elements

• Before the procedureBefore the procedure, did they: – Wash hands?– Sterilize procedure site?– Drape entire patient in a sterile fashion?

• During the procedureDuring the procedure, did they:– Use sterile gloves, mask and sterile gown?– Maintain a sterile field?

• Verify:Verify: did all personnel assisting with procedure

follow the above precautions?

Page 24: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

Chlorhexidine Skin Antisepsis

A. Prepare skin with antiseptic/detergent Chlorhexidine 2% in 70% isopropyl alcohol.

B. Pinch wings on the “Chloraprep” applicator to pop the ampule. Hold the applicator down to allow the solution to saturate the pad.

C. Press sponge against skin, apply chlorhexidine solution using a back and forth friction scrub for at least 30 seconds. Do not wipe or blot.

D. Allow antiseptic solution time to dry completelycompletely before puncturing the site ( ~ 2 minutes).

Page 25: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

Baseline Compliance With Best Practice

Example: At one hospital, providers were compliantwith best practice during 62% of the observedProcedures

Compliance Hand washing 62% Sterilized the procedure site 100% Draped the entire patient in a sterile fashion 85% Used a hat, mask and sterile gown 92% Used sterile gloves 100% Sterile dressing applied 100%

National compliance estimated to be 30%

Intervention:

Page 26: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

Central Line Site Care

Use line carts and dressing change kits

Standardize site care procedures

Store all equipment in the same place

Page 27: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

To Be Successful

Set an aim: “Reduce the incidence of central line catheter-related bloodstream infections using the central line bundle.”

Set a goal: “The rate of CR-BSI will decrease by 50% in one year using the central line bundle.”

Plan well: Adopt a change methodology thataccelerates improvement such

as The Model for Improvement.The Model for Improvement.

Page 28: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

Model for Improvement

Act Plan

Study Do

• What are we trying to accomplish?What are we trying to accomplish?

• How will we know that a change is an improvement?How will we know that a change is an improvement?

• What changes can we make that will result in an What changes can we make that will result in an improvement?improvement?

Page 29: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

Me and What Army?

➥ Form… a teama team↳Include a diverse staff.↳MDs, RNs, respiratory therapists.

➥ Identify… a project championa project champion ↳Someone who maintains visibility in the ICU.

➥ Identify… a process ownera process owner↳For concerns now and in the future.

Page 30: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

Identify stakeholders in intensive care.

3 groups: MDs, RNs, venous access teams.

Secure representation from each.↳ Facilitates physician buy-in.↳ Generates nursing support.

Engage Stakeholders

Page 31: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

Role of Leadership

Committed: staff cannot improve without supportive leadership.

Set the standard: “This is how we will practice.”

Resources: make time to work on testing.

Share data: to motivate staff for change.

Page 32: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

Starting the Project

➥ Is there a method in place now?

➥ Know your baseline performance:↳Randomly select 20 patients’ records who had

central lines placed. Apply the measures to them.

↳Be sure to check compliance with the total bundle as well, the “all or none” goal.

➥ Educate ICU staff (using your own data).

Page 33: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

Small Tests of Change

Small tests... 1 RN, 1 MD, 1 patient.

Move on to pilot test in one ICU:↳ Refine the process↳ Test on all shifts↳ Test on all patients with central lines

Measure your results to know if a change was an improvement.

Page 34: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

Supportive Interventions

Multidisciplinary Daily Rounds:Multidisciplinary Daily Rounds:

↳An opportunity to assess bundle related issues.↳ Invite and encourage the family to join in.

Daily Goal Sheets:Daily Goal Sheets:↳Maintenance of bundle items.

PhysiciansPhysicians NursesNurses NutritionNutrition RespiratoryRespiratory

Palliative CarePalliative Care ChaplaincyChaplaincy PharmacyPharmacy Case ManagementCase Management

Page 35: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

Measure: CR-BSI per 1000 Line Days

Central line-associated BSI rate per 1000central line-days:

Numerator: Number of central line-associated BSI x 1000.

Denominator: Number of central line-days (total number of days of exposure to central venous catheters by all patients in the selected population during the selected time period).

Page 36: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

Measure: Central Line Bundle Compliance

Central line bundle elements in place:

Numerator: Number of patients with central line bundle in place.

Denominator: Total number of pts on central lines per day of week of prevalence sample.

Page 37: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

Model for Improvement

Act Plan

Study Do

• What did we accomplish?What did we accomplish?

• Was that change an improvement?Was that change an improvement?

• What further changes will lead to more improvement?What further changes will lead to more improvement?

Page 38: The 5 Million Lives Campaign:  “Preventing Central Line Infections”

© 2007 Institute for Healthcare Improvement

Summary:

Central line infections are common.

Proven strategies exist to decrease CR-BSI line days.

Using the Central Line Checklist, most bundle elements are implemented.

Thousands of lives and millions of dollars saved with reliable adherence and bundle execution.