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Page 1: 11.00 11.30 sophie harnage - publiceren
Page 2: 11.00 11.30 sophie harnage - publiceren

Disclosure

  No Disclosures

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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

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Speak  Up  for  Pa,ent  Safety  

Design  Safe  Care  Processes  

Make  Safe  Choices  

Spread  Safe  Prac,ces  

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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

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  Reduced catheter dwell time (7-14 days)

  Requires physician placement

  Increased patient discomfort

  Dressing/securement challenges

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  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

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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

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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

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11

Set a standard of practice for choosing the…..

Right Line

Right Patient

Right Diagnosis

Right Therapy

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  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.

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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.

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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

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  CDC, SHEA, & IHI Recommendations   Research   Impact both extraluminal catheter

tract, and intraluminal fluid pathway   New product technology   Minimal bedside change   Product ease of use

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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

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Interventions and Rationale

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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.

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Kit Contents Bouffant Cap, Mask, Gown, Alcohol swab

sticks, CHG skin prep, CHG containing sponge, O.R. Towel, and Drapes.

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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

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  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

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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

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Kit Contents Mask, Cap, Gloves, Alcohol swabs, Alcoholic Chlorhexidine Swab

Sticks, Chlorhexidine-Containing Sponge, Tape Measure, 4X4’s, Dressing, Tape, Skin Protectant, and Drape.

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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

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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.

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  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

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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

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Intervention   Daily monitoring of ALL

Central lines by PICC team

Rationale   Continuous monitoring

of practice decreases complications and increases compliance with bundle

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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.

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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.

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  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.

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CLABSI indicated in graph below was inserted and maintained by contracted agency that did not follow Sutter Roseville Medical Center policies or bundle.

Dialysis

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PICC Team

Physician

CLABSI

Nurse

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Determined…Relentless…Tenacious

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