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Disclosure
No Disclosures
13-07-2012 Free template from www.brainybetty.com 3
SUTTER ROSEVILLE MEDICAL CENTER Roseville California
315 Bed Acute Care, Community Based, Not For Profit Hospital, Includes: 32 Critical Care Beds, 16 Bed NICU, 55 Bed Rehabilitation Unit, 30 Bed Extended Vent Unit,
31 Bed Emergency Department (77,000 Visits) Level II Trauma Center
Speak Up for Pa,ent Safety
Design Safe Care Processes
Make Safe Choices
Spread Safe Prac,ces
Patient Safety
Preventing harm to patients
Culture of Patient Safety
The way we think, talk about, act/react, prevent, and learn about harm to patients
Reduced catheter dwell time (7-14 days)
Requires physician placement
Increased patient discomfort
Dressing/securement challenges
11 CLABSIs in 2005
Decline in patient satisfaction
Decline in IV team productivity
Decline in FTEs/IV team
Inpatient IV Team combined with Outpatient Infusion Clinic
Bundle Descriptors 2005
Average Monthly PICC Volume 60
PICC Volume 767
Insertion Success Rate 92%
Interventional Radiology Rate 8%
Maximum Barrier PICC team only
Insertion Site Antecubital
Technique Traditional/Modified Seldinger
Dressing 24 hour pressure gauze dressing then weekly
Skin Preparation Alchocol/Betadine
Protective disk with CHG Inconsistent
Line Securement device Inconsistent
Connector Positive Pressure Connector
Flushing Protocol Normal Saline followed by Heparin (positive pressure flush)
RN Training Annual In-Service Day
Line Monitoring Completed q week with dressing change
Current:
Current: Advanced vascular access team.
Current: 7A-11:30P coverage with 4-5 PICC nurses
Current: line of choice PICC, and peripheral IV. 40% decrease in CICCs.
CLABSI rate of Zero.
Prior:
2005: Primarily a peripheral IV team.
2005: 7A-7P coverage with one IV nurse
2005: line of choice, peripheral IV and Centrally Inserted Central Catheters (CICC).
CLABSI = 11
11
Set a standard of practice for choosing the…..
Right Line
Right Patient
Right Diagnosis
Right Therapy
Enhanced Flow Rates (1000ml.hr.) Hemodynamic Monitoring Power Injection (up to 5ml/sec.) Dual and Triple Lumen Larger lumen sizes- up to 17 gauge
Santolucito, J.B. (2007). Role of Peripherally Inserted Catheters in the Treatment of the Critically-ill. Journal of Vascular Access Devices, 12(4), 208-217.
1 Santolucito, J.B. (2007). Role of Peripherally Inserted Catheters in the Treatment of the Critically-ill. Journal of Vascular Access Devices, 12(4), 208-217.
Product
Practice
Interrelationship CR-BSI
Patient
Source: D.Macklin Technology and Practice: Collaboration for successful positive patient outcomes Infection Control Today Sept 2007. http://www.iceinstitute.com/education.html
CDC, SHEA, & IHI Recommendations Research Impact both extraluminal catheter
tract, and intraluminal fluid pathway New product technology Minimal bedside change Product ease of use
Hand Hygiene
Daily Monitoring
Maximal Barrier
Precau,ons
Chlorhexidine An,sepsis
Op,mal Catheter Site Selec,on
Daily Monitoring
CL Kit Revision
Ultrasound Guided
Maximal Barrier
Precau,ons
Change from Posi,ve Pressure Connector
IV Connector Septum
Disinfec,on
Flushing Protocols
Aids appropriate venous loca1on
Limits provider-‐to-‐pa1ent transmission through use of glove, gown, mask, drape, etc
Expanded to include Chloraprep®, Statlock®, Biopatch®
Neutral connector system prevents line blood-‐reflux, reducing colony opportunity
Vigilant cleaning of septum and change aEer each blood draw
Rou1ne 8 hourly, 10ml saline flush
Ongoing evalua1on of line necessity
Inser1on Maintenance Specialized nurse team relied on expanded bundle to perfect prac1ce IHI Central Line Bundle
SRMC Central Line Bundle
Interventions and Rationale
Intervention Maximum barrier
precautions, including addition of full body drape for all central line insertions
Rationale CDC recommends full
barrier precautions with CVC insertion: cap, mask, sterile gown, drape to fully cover patient.
Kit Contents Bouffant Cap, Mask, Gown, Alcohol swab
sticks, CHG skin prep, CHG containing sponge, O.R. Towel, and Drapes.
Intervention All PICCs placed by
ultrasound guidance/ basilic vein, upper arm vein of choice
Rationale Normal skin bacteria counts
Subclavian/jugular 10,000 cfu/cm2
Anticubital fossa 10 cfu/cm2
Evidence has demonstrated increased safety
Recommended by Agency for Healthcare
Research Quality American College of
Emergency Physicians
Application of ECG placement/confirmation performed during insertion: Eliminates time previously spent waiting for X-ray confirmation readings Allows immediate release of the line/time savings Eliminates patient exposure to radiation/costs Saves time required for tip repositioning of malpositioned tips found after the end of the procedure
Intervention Central line dressing kit revised to
include Chlorhexidine-containing sponge and chlorhexidine swabs in each kit
Securement device added by PICC Nurse
Rationale Alcoholic Chlorhexidine
Swab Sticks and Chlorhexidine-containing sponge dressing around catheter at the insertion site reduces colonization
Supports current weekly dressing change practice
Minimized the impact on the bedside nurse
Kit Contents Mask, Cap, Gloves, Alcohol swabs, Alcoholic Chlorhexidine Swab
Sticks, Chlorhexidine-Containing Sponge, Tape Measure, 4X4’s, Dressing, Tape, Skin Protectant, and Drape.
Intervention Zero Fluid Displacement
Connector for all central lines
Rationale Supports Successful
Septum Disinfection Minimal priming volume
and no dead space Eliminates blood reflux in
lines No clamping required Saline Flush only
Intervention Cleanse IV connector
threads/septum with 70% isopropyl alcohol or alcoholic CHG for 10-15 seconds (squeeze an orange). Apply friction and scrub!!!
Rationale SHEA,IDSA,CDC,
recommends cleaning with an alcoholic chlorhexidine preparation or 70% alcohol prior to each access.
Rapid action time, kills on contact. Kills bacteria by denaturing proteins.
Vigorously scrub threads and septum of needleless connector prior to EVERY access.
Scrub the needleless connector with an alcohol prep for 15 seconds using friction, as if you were juicing an orange, before each access.
Purpose: Time + Friction= Disinfection
Intervention Flush all CVC lumens
(except implanted port and dialysis) with 10 ml normal saline every 8 hours as needed, utilizing a push-pause technique
Rationale Effective cleaning of
intraluminal surface removes fibrin
Minimizes bacterial opportunity for adherence
Prevents mixing of incompatible medications
Intervention Daily monitoring of ALL
Central lines by PICC team
Rationale Continuous monitoring
of practice decreases complications and increases compliance with bundle
Data Collection Tool
White Board White board tracks patients with CVCs: type of line and insertion site.
Data Collection Tool: tracks all patients with CVCs, type of line, site of insertion, dressing change, and possible complications.
Bundle Descriptors 2005 2006 2007 2008 2009 2010 2011
Average Monthly PICC Volume 60 131 189 187 159 160 158
Yearly PICC Volume 767 1570 2266 2243 1904 1929 1898
Insertion Success Rate 92% 98% 98%
Interventional Radiology Rate 8% 2% 1.5% 1%
Maximum Barrier PICC team only All central lines All central lines
Insertion Site Antecubital Upper Arm, Basilic Vein Upper Arm, Basilic Vein (preferred)
Technique Traditional/Modified Seldinger 100% Ultrasound Guided 100% Ultrasound Guided
Dressing 24 hour pressure
gauze dressing then weekly
No pressure dressing (exception excessive bleeding)
Weekly dressing change
No pressure dressing (exception excessive bleeding) Weekly dressing change
Skin Preparation Alchocol/Betadine Chlorhexidine Chlorhexidine Protective disk
with CHG Inconsistent Consistent Consistent
Line Securement device Inconsistent Consistent Consistent
Connector Positive Pressure Connector Neutral Connector Neutral Connector
Flushing Protocol
Normal Saline followed by Heparin (positive pressure
flush)
Flush 10ml NS every 8 hours and PRN use (push/pause
technique)
Flush 10ml NS every 8 hours and PRN use (push/pause technique)
RN Training Annual In-Service Day One-on-One Training at the bedside
One-on-One Training ,Vasc. Access Class,, housewide ongoing education
Line Monitoring Completed q week with dressing change
Completed daily during site checks. Completed daily during site checks.
Specialized PICC Teams can reduce the risk of CLABSIs
PICC Teams used as an improvement strategy to reduce CLABSIs
PICC Teams can lead to decreased infusion–related complications
PICC Teams can improve patient care outcomes PICC Teams can increase patient satisfaction
Clin Infect Dis. 2011 May;52(9):e162-193. Epub 2011 Apr.1 Infect Control Hosp Epidemiol. 2008 Oct;29 Suppl.1:S22-30. Joint Commission Resources, May 2012. http://www.PreventingCLABSIs.pdf.
CLABSI indicated in graph below was inserted and maintained by contracted agency that did not follow Sutter Roseville Medical Center policies or bundle.
Dialysis
PICC Team
Physician
CLABSI
Nurse
Determined…Relentless…Tenacious