“AIM FOR ZERO” - safetyandquality.gov.au · Hand Hygiene: “bare below the elbows” ANTT...
Transcript of “AIM FOR ZERO” - safetyandquality.gov.au · Hand Hygiene: “bare below the elbows” ANTT...
“AIM FOR ZERO”
Preventing NICU Bloodstream Infection following
Implementation of a Central Venous Line Bundle
Whitelaw J McPhee A 2014
Background
Catheter Related Blood Stream Infections
(CRBSI)
Infections a significant cause of death and
morbidity particularly in preterm infants
CRBSI are the predominant cause of neonatal late onset sepsis
CRBSI are essentially are preventable life threatening events
CRBSI Classification
Positive blood culture in absence other focus of infection
Line within 48 hours prior to BSI
Supportive haematological evidence of sepsis
Usually clinical signs or symptoms of localized infection
May be clinically unwell
CRBSI Measurement
Numerator: Number of CRBSI X 1000
Denominator: Central line days
Separate rates calculated for 2 birth weight categories: 1) <1000gms 2) ≥1000gms
NICU Demographics WCH 5044 births in 2012
NICU 14 funded beds
2013 Average occupancy 102 (86-114)
410 admissions: 19.5% <1000 grams
324 central venous lines (267 PCVC’s 57 UVC’s ) (51.2% in LBW group)
Innate Neonatal Risk Factors
Immature immunity
Immature gut
Deficient barrier function
Invasive device dependence
High frequency of handling by multiple HCW’s
The Problem: NICU CRBSI
7.0 /1000 line days <1000gms birth weight
8.2 /1000 line days ≥ 1000gm birth weight
Mean 14.5 days to onset of PCVC infection indicating line maintenance practices a problem
Low hand hygiene compliance (53.1%)
The Solution
Central Venous Line Care Bundle
A group of evidence based infection prevention
and control interventions that when bundled
together are more effective than any single action
Bundle Principles
1. Effective hand hygiene
2. Maximum sterile barrier precautions for line insertion
3. Chlorhexidine Gluconate skin antisepsis
4. Asepsis (ANTT)for insertion / maintenance
5. Daily assessment of central line necessity
The ANTT Model
ANTT designed for all invasive clinical procedures ‘from the community to the operating theatre’
ANTT is a Theory & Practice Framework teaching 10 foundation principles
of standardised safe aseptic practice
NICU ANTT Implementation
Launch; ward teaching board
Pre audits of clinical practice
Training : Mandatory elements
Recruitment of local trainers
Assessment 1.Theoretical:workbook
2. Practical assessment:
Assessment : post audit & annual update
Bundle Method
Bundle strategic plan for collaborative review
Hand hygiene education/audits
Implementation of ANTT
Multidisciplinary Clinical Guideline
Clinical credentialing of central line insertion
Visual teaching aids
Line data collection & surveillance
Insertion Bundle Principles
Hand Hygiene (5 & 3 minute surgical scrubs)
Catheter type/site selection
Maximal Barrier precautions: all participants
Surgical ANTT
Chlorhexidine prep (3 step prep)
Checklist & procedure sheet
documentation
Maintenance Bundle Principles
Hand Hygiene: “bare below the elbows”
ANTT
Chlorhexidine: “scrub the hub”
New administration sets for each new catheter
Emergency lines replaced by 24 hours
Daily review of line necessity
Suspected infection: tip culture
Aseptic blood culture collection
Outcomes
Hand Hygiene Compliance
HHA audit cycles
per cent
NICU Outcomes: ANTT % Compliance Insertion Bundle
0
20
40
60
80
100
120
ANTT Principles
Pre ANTT 54 100 63 72 63 54 18
Post ANTT 85 100 100 100 100 100 50
hand
hygienedon gloves aseptic field key parts non touch chlorhex
max barrier
precautions
per cent
NICU Outcomes: % ANTT Compliance Maintenance Bundle
0
20
40
60
80
100
120
ANTT Principles
Pre ANTT 71 55 50 57 76 32
Post ANTT 100 100 93 100 100 93
hand
hygiene
don
gloves
aseptic
fieldkey parts non touch chlorhex
per cent
Outcomes NICU CRBSI per 1000 line days
July 2010-December 2013: 6 monthly intervals
5.7
4
3.1
1.51.8
2.7
0
8.2
4.6
0 0 0 0
9.1 9.1 9.1 9.1 9.1 9.1 9.1
2.1
0
1
2
3
4
5
6
7
8
9
10
July-Dec 10 Jan-June 11 July-Dec 11 Jan-June 12 July-Dec 12 Jan-June 13 July-Dec 13
<1000gm
≥1000gm
CDC target 9.1 (<1000g)
Sustainability
Regular audits & prompt feedback
Mandatory HHA competency all new staff
IP&C orientation all new staff
Regular feedback
Staff incentives
Implementation Issues
Education: Capturing all staff
Medical Registrar / Nursing rotations
3 shifts
Sustaining Credentialing/Audit
ANTT (medical)
Hand Hygiene ( mandatory competency)
Practice change
Checklist
Lessons Learned
Culture
change
Continuity
IP&C resources
Collaboration
Multidisciplinary
Ownership
Consistency
Education Feedback Evaluation
Cost
Health care Community
Family
References 1. Australian Commission on Safety and Quality in Health Care Central
Line Insertion & Maintenance Guideline April 2012
2. CDC Healthcare Infection Control Practices Advisory Committee (HICPAC) 2011 Guidelines for the Prevention of Intravascular Catheter-Related Infectionshttp: //www.cdc.gov/hicpac/BSI/BSI-guidelines-2011. www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf
3. Institute for Healthcare Improvement 100,000 Lives Campaign Prevent Central Line Infections http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheCentralLineBundle.htm
4. NHMRC (2010) AUSTRALIAN GUIDELINES FOR THE PREVENTION AND CONTROL OF INFECTION IN HEALTHCARE Commonwealth of Australia 2010 http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/CD33_InfectionControlGuidelines2010.pdf
5. Rowley S, Aseptic Non Touch Technique , www.antt.org.uk [email protected]