Driving CLABSI Rate to Zero:

Building on Prevention With Strategic Practice and Cost-Saving Interventions

• Nearly one in 25 hospitalized patients in the United States acquires a

healthcare associated infection (HAI) each year.2

• 41,000 Central Line Associated Blood Stream Infections (CLABSI) occur

annually.1

• CLABSI is the most deadly HAI with a mortality rate between 12% and 25%.1

• The excess cost per case for nosocomial CLABSI ranges between $7,000 to

$29,000, costing the healthcare system nearly $1 billion annually.4

• CLABSI can be prevented by adherence to evidence-based prevention

guidelines.3

Purpose

• To reduce the CLABSI rate in an acute care hospital by implementing an

evidence-based prevention bundle.

Introduction

Materials and Methods

Discussion and Conclusions

Literature Cited

Contact Information

Tiffany Curtice, BSN, RN, VA-BC Erika Anderson, MSN, RN, CRNI, VA-BC Cheryl Bruns, BSN, RN, CRNI

Carol Hagele, RN, CRNI Rebecca Hiester, BSN, RN, RN-BC Nancy Davidson, MA, BSN, CNS-BC

Cynthia Oster, PhD, RN, APRN, MBA, ACNS-BC, ANP Lavone Hastings, BSN, RN-BC, M.MGT

• Evidence-based nursing practices to improve

patient outcomes have become the norm

• The IV Team sustains a culture of patient safety

and contributes to CLABSI rate reduction with

daily monitoring of central lines and just-in-time

peer review

• Implementation and adherence to a prevention

bundle can drive CLABSI rates to zero

• CLABSI rate decreased from 1.02 in FY12

to 0.00 from FY14 to present (FY= July-June)

• 100% reduction in number of CLABSIs:

FY12: N=10 FY13: N=6

FY14: N=0 FY15: N=0 FY16TD: N=0

• 86% adherence to prevention bundle FY16TD

(July-December)

• 923 CLABSI-free hospital days

• 1,032 CLABSI-free ICU days

Peer reviewed by South Denver Evidence-Based Practice, Research and Innovation Council; Castle Rock, Littleton, Parker and Porter Adventist Hospitals.

Tiffany Curtice, BSN, RN, VA-BC tiffanycurtice@centura.org

Results

1. Centers for Disease Control and Prevention. (March 4, 2011). Vital Signs: Central line-associated blood stream infections

– United States, 2001, 2008, and 2009. Morbidity and Mortality Weekly Report, 60(8); 243-248.

2. Magill, S.S., Hellinger, W., Cohen, J., Kay, R., Bailey, C., Boland, B., Carey, D., de Guzman, J., Dominguez, K., Edwards,

J.,Goraczewski, L., Horan, T., Miller, M., Phelps, M., Saltford, R., Seibert, J., Smith, B., Starling, P., Viergutz, B., Walsh, K.,

Rathore, M., Guzman, N., & Fridkin, S. (2012). Prevalence of healthcare-associated infections in acute care hospitals in

Jacksonville, Florida. Infection Control & Hospital Epidemiology, 33(3): 283-291.

3. O'Grady, N.P., Alexander, M., Burns, L.A., Dellinger, E.P., Garland, J., Heard, S.O., Lipsett, P.A., Masur, H., Mermel, L.A.,

Pearson, M.L., Raad, I.I., Randolph, A.G., Rupp, M.E., Saint, S.; Healthcare Infection Control Practices Advisory

Committee (HICPAC). (2011). Guidelines for the prevention of intravascular catheter-related infections. Clinical Infectious

Disease, 52(9): e162-93.

4. Scott, D. (2008). The direct medical costs of healthcare-associated infections in US hospitals and the benefits of

prevention. Retrieved 02/15/14 from http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf.

2011

• CLABSI evidence-based prevention bundle implemented

• Unit Champions

• Computer Based Training for Registered Nurses

• Standardized outcome metrics

• Cost analysis for antimicrobial PICCs

2012

• CLABSI rate target goal not achieved

• Education redesign

• Standardize intravascular catheter care

• Focus on intravascular catheter maintenance

• Daily audits conducted by IV Team to monitor adherence to prevention bundle

• Conduct just-in-time prevention bundle education

• Conduct just-in-time peer review including personal email

• Report unit specific outcome metrics monthly

2013

• CLABSI rate decreased but not at target goal

• Implement antimicrobial PICCs for specific at risk population

• Evidentiary review for second tier infection prevention interventions

• Implement CHG bathing for all central line patients

2014 to present

• Continue daily auditing of adherence to evidence-based infection prevention bundle

• Root Cause Analysis for any occurrence

CLABSI Prevention Bundle Guidelines

Daily Audit Tool

CLABSI incidence rate decreased to, and sustained at, zero FY14 to present

Average adherence to prevention bundle guidelines increased to 86% in FY16TD

Celebration Poster

$474,000 ESTIMATED COST AVOIDANCE

FY12 to FY16TD

FY12 $20,000/case x 10 cases = $200,000

FY13 $16,000/case x 6 cases = $96,000

FY14-FY16 $16-17,000/case x 0 cases = $0

$104,000

Cost avoidance Year 1

$474,000

Cost avoidance to date

Abstract

CLABSI is the most deadly hospital-acquired infection with mortality rates

near 20%. Evidence-based nursing to improve CLABSI outcomes have

become the cultural and practice norm. In 2012, an evidence-based CLABSI

prevention bundle was implemented with daily audits. Evidentiary review

identified CHG bathing as a second tier intervention and a decision was made

to add CHG bathing to the bundle for all patients with a central line. In 2014,

fully integrated protocol practices were implemented into new-hire and float

pool orientation to enhance novice practitioner competence. Adherence to the

prevention bundle has improved hospital-wide from 60% to currently 86%.

CLABSI rates decreased from 1.02/1,000 catheter days in June 2012 to

0.00/1,000 catheter days in June 2013 and have continued through December

2015. Associated cost savings have exceeded $470,000 with accompanying

avoidance of potential harm to patients. This 102% rate reduction reflects 923

CLABSI-free days hospital-wide and 1,032 CLABSI-free days in the ICU.

Driving CLABSI to zero can be accomplished through evidence-based bundle

implementation, communication-focused strategies, intentional evaluation of

central line need/discontinuation, and integration of vascular access education

and support responsibilities.

2016 ANA Quality Conference, Lake Buena Vista, FL, March 9-11, 2016

Porter Adventist Hospital, Denver, Colorado

CLABSI PREVENTION BUNDLE Interventions applied to all patients with a central line

Insertion Care to Prevent CLABSI Follow Intravascular Catheter Insertion Checklist

Notify IV Team

Maintenance Care to Prevent CLABSI Assess daily for catheter need

o Remove intravascular catheters that are not needed

Scrub the hub for at least 15 seconds before accessing

Pulsatile flushing on all central lines o Clamp during last half ml of flush to avoid blood backup in catheter o When flushing central lines, always aspirate for blood return

If no blood return, the line may be occluded Do not use Contact IV team or Ad Coordinator

o Pulsatile flush TPN line with 10 ml NS during tubing changes

Tubing Change o Q 96 hours for continuous infusions o Q 24 hours for TPN and intermittent medications o Q 12 hours for propofol o Q 4 hours for blood tubing

Clave Change o Q 96 hours with primary tubing change for continuous infusions o Q 24 hours with tubing change for TPN o Q 24 hours if blood product given o As needed if contaminated, visible blood or debris within the connector, “cored

out”(clave end will have a black hole appearance)

Perform site care o Q 7 days or as needed if dressing is soiled, loose, or damp o For soiled, loose, or damp dressings, notify IV Team or Ad Coordinator to replace

If they are not available, cleanse with chlorhexidine, apply CHG disc, and cover with sterile occlusive dressing

Bathe daily with chlorhexidine

Patient hand washing at least 2 times per day and after bathroom use

INSTRUCTIONS for Patient Bathing with Chlorhexidine

Who: All patients with a central line What: Daily patient bathing with 2% chlorhexidine (a.k.a. CHG or Dyna-Hex2) Why: To decrease skin bacteria and reduce central line-associated blood stream infections How:

1. Rinse with water. 2. Wash with CHG. Pour small amount of CHG on soft DISPOSABLE cloth and wash.

Subclavian/IJ/PICC sites: wash from jaw line to umbilicus area

Femoral: wash from umbilicus to knees and avoid genital area 3. Rinse thoroughly with water and dry.

Caution: DO NOT USE ON FACE (including eyes, ears, and mouth) OR GENITAL AREA. Use soap and water for these areas.

0%

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Compliance with Prevention Tactics

Insertion Maintenance

0.0

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2.0

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CLABSI Incidence Rate

Hospital Rate ICU Rate NDNQI ICU mean all hospitals