Preventing Catheter Related Bloodstream Infections

Suzanne Brungs MSN, MBA, RN Program Coordinator -VA Inpatient Evaluation Center (IPEC)

March 29, 2007

Background•Greater Cincinnati Health Council and VA GAPS (Getting at Patient Safety ) Center formed a patient safety workgroup in 2002. Set stretch goal: Get funding for patient safety project

•Agency for Healthcare Research and Quality (AHRQ) issued a matching federal grant solicitation for implementation of evidence-based practices that improve patient safety.

•Hospital CEOs agree to fund 50% of the project : Cincinnati Children’s Hospital Medical Center • The Christ Hospital • Fort Hamilton Hospital • Jewish Hospital • Mercy Mt. Airy • St. Elizabeth Medical Center •TriHealth •University Hospital • VA Medical Center

AHRQ Project Objectives• Demonstrate successful implementation evidence-based practices by

measuring – Adherence to processes and practice– Reduction of nosocomial infections in OR, ICU.– Economic impact

• Train leaders at each hospital in transformation strategies and methodology

• Share successful transformation and training strategies across Cincinnati• Change elements of safety culture through learning • Sustain implementation of new evidence based practices and

collaborative beyond project funding.

Project Randomization

9 Cincinnati Hospital Systems

Reduction in surgical site infections (5)

Reduction in central line infections (4)

Randomly assigned

Reduction in surgical site infections

Reduction in central line infections

Year 1

Year 2

1) Implementation of maximal sterile barriers will reduce catheter related blood stream infections.

2) Together, the sites can achieve goals faster than had the practice been implemented individually.

3) Systematic spread of practice within the organization can occur.

4) The methodology of change can be learned. The learning curve will be reduced the second year.

The project will demonstrate that:

Components to the project• Pre-Work

• Kick-off

• Learning sessions

• Data collection

• Dissemination

• Develop data to promote buy-in. Raise project profile with visible leadership support

• Change Theory / Methods• Evidence Base reduce rework

• Plan

• Reduce work• Share strategies• Stimulate success

• Measure processes and improvement, feedback, value to project approach

• Spread practice approach to other organizations, cities etc

Catheter-Related Bloodstream Infection (CR-BSI): The Evidence

• 150,000 cases of CR-BSI annually in U.S.

• 10% to 30% attributable mortality rate

• Annual cost between $300 million & $2 billion

• Maximum sterile barriers and chlorhexidine has been shown to save lives and costs.

• Results of multiple studies support initiatives to prevent/reduce CRBSI

150 – 200,000 people get Catheter-related blood stream infectionin United StatesHospitals

Up to 20% die

Modifiable risk factors for Catheter related blood stream infections

1. Location: Infection less with Peripheral than Central; Chest or Neck preferable to Groin placement.

4. Antibiotic impregnated line Chlorohexidine-Sulfadiazine <8 day Minocycline- Rifampin >8 day

5. Time: Shorter = Better but No benefit to Automatic line change Over wire changes

2. Site PrepChlorhexidine

3. Operator PrepGown, gloves, cap, Mask, Full drape

Make it right• Project leaders said “we have to take away what’s

wrong and give them only what’s right”• Central line kits included supplies not included in best

practices (small drape and betadine)

• Infection Control Practitioners contacted major companies providing kits to their facilities.

• Meetings detailed desirable elements including deletion of small drape and betadine and additional safety items.

• Kit available for use October 2004

• Dissatisfaction with drape hole size, customized drape with multiple holes proto-typed and tested here.

New Model - Repeated Use of the PDSA Cycle

Hunches Theories

Ideas

Changes That Result in

Improvement

A P

S D

APS

D

A P

S D

D SP A

DATA

Very Small Scale Test

Follow-up Tests

Wide-Scale Tests of Change

Implementation of Change

©2001 Institute for Healthcare Improvement

Proxima Drape - Medline

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1. Placement matters 2. Chlorhexidine Use 3. Maximal Barriers

Central Line Reference Cards were handed out

• Catheter-related septicemias are 6 times lower when maximum sterile barriers are used during central line insertion

• -Raad II, Hohn DC, Gilbreath J, et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insert. Infect Control Hosp Epidemiol. 1994; 15:231–238.

• The use of Chlorhexidine gluconate rather than povidone-iodine can reduce the risk for catheter-related bloodstream infection by approximately 50%.

• -Chaiyakunapruk, Nathorn . et al Chlorhexidine Compared with Povidone-Iodine Solution for Vascular Catheter-Site Care: A Meta-Analysis. [Article] Annals of Internal Medicine. 136(11):792-801, June 4, 2002.

• The use of PICC lines reduce infection and thrombotic risks

• -Laughran SC, Borzatta M Peripherally Inserted Central Catheters: A report of 2506 Catheter days. Journal of Parental and Enteral Nutrition 1996, 19(2) p 133-136

Central Line Reference Cards

Insertion Date: ____________ Time: ______________ Type of line: ______________ Site: _______________ Guide wire change _____ Yes _____ No Non-urgent ______ Urgent/emergency _____

OBSERVATIONS R-1 R-2 R-3 ATTENDING PICC RN

WASH/ DISINFECT HANDS YES NO YES NO YES NO YES NO YES NO

HEAD COVER YES NO YES NO YES NO YES NO YES NO

MASK YES NO YES NO YES NO YES NO YES NO

CHLORAPREP SWAB YES NO YES NO YES NO YES NO YES NO

STERILE SURGEON GOWN YES NO YES NO YES NO YES NO YES NO

STERILE GLOVES YES NO YES NO YES NO YES NO YES NO

FULL BODY DRAPE YES NO YES NO YES NO YES NO YES NO

SONA SITE/ SITE RITE YES NO YES NO YES NO YES NO YES NO

PROBE COVER YES NO YES NO YES NO YES NO YES NO

Hospital Admission date _____________ ICU admission date: __________ Hospital Discharge date _____________ ICU discharge date: __________ Line removal date __________ Infection _____ No _ ____ Yes Type: ______ CR-BSI ____ Lab confirmed bacteremia ______ exit site infection

2 Minutes to Save a Life. . .PRICELESS

Alcohol Hand Gel. . 10 seconds

Maximum Sterile

Barriers . . . . . . . . .50 seconds

Chloraprep. .Apply. .30 seconds

Dry. . 30 seconds

_________

2 minutes

Market Project

Dress for Success and Prevent Infection

For all Central Lines

Prep skin with Chloraprep

Sterile gown

Mask

Cap

Sterile gloves

Full body sheet

Please don’t forget to wash your hands.

Process Adherence Increased

0102030405060708090

100

1 2 3 4 5 6 7 8 9 10 11 12 13

Chloroprep Large Drape

Project Month

% A

dher

ence