1. Why Maintenance is so High Maintenance: How to Achieve Success
Tamara Johnson RN
Director Clinical Integration
Ivera Medical Corporation

2. Objectives Understand why CABSI and CLABSI are important
Top 10 Reasons Maintenance is High Maintenance
Understand the dynamics associated with Port Protection and compliance and their role in the “maintenance bundle”
Overcoming Port Protection challenges (Process Changes)

3. Clabsi timeline 2001 – Beginning of the term “Never Events”
2008 – CMS releases reimbursement guidelines which include Vascular Catheter Related BSIs (no CL modifier)
2011 – National Healthcare Safety Network begins monitoring mandatory surveillance reporting on CLABSI
2012 – Updated CLABSI Definitions from CDC
National Quality Forum – coalition of public and private healthcare sector leaders who are focused on ensuring healthcare quality and patient protection by providing measurement capabilities and public reporting
CEO – Ken Kizer
AHRQ – request to reduce infections by 50% by 2013
2013 – Updated CLABSI Definitions from CDC
2014 – Updated CLABSI Definitions from CDC

4. From our friends at the cDC…
Central Line Associate Blood Stream Infection (CLABSI) - a laboratory –confirmed bloodstream infection (LCBI) where the central line (CL) or umbilical catheter (UC) was in place for >2 calendar days on the date of the event, with day of device placement being Day1, and a CL or UC was in place on the date of event or the day before. If a CL or UC was in place for >2 calendar days and then removed, the LCBI criteria must be fully met on the day of discontinuation or the next day. If the patient is admitted or transferred into a facility with a central line in place (e.g., tunneled or implanted central line), day of first access is considered Day 1.1
1. )

5. A reminder about Great Vessels1
Aorta
Pulmonary Artery
Superior Vena Cava
Inferior Vena Cava
Brachiocephalic Veins
Internal Jugular Veins
Subclavian Veins
Common Femoral Veins
External Iliac Veins
Femoral Veins
Umbilical Artery/Vein in Neonates
1. )

6. A central line includes:
Central Venous Catheter (CVC)
Peripherally Inserted Central Catheter (PICC)
Dialysis Catheter
Umbilical Catheter
Hickman Catheter
Broviac Catheter
Groshong Catheter

7. Impact of CLabsi $34, 500 - $56, 000 per episode2
$54,000 - $75,000 in adult Surgical ICU3
80,000 ICU BSI’s a year – leading cause of ICU nosocomial infections4
250,000 CLABSI’s a year2
30,665 deaths a year from CLABSI5
2.) Moreau N. Nursing 2009;34:14-15
3.) Hollenbeak CS. J Infus Nurs. 2011:
4.) O’Grady NP, et al. American Journal Infection Control 2011;39(4suppl 1):51-34
5.) Klevens RM, et al. Public Health Rep. 2007;

8. Mechanisms leading to clabsi6
Pathogen migration along external surface – typically within first 7 days
Hub contamination leading to intraluminal colonization
Needleless connector contamination leading to intraluminal colonization
Established from a different source
Contaminated infusions
6.) The Joint Commission. Preventing Central Line–Associated Bloodstream Infections: A Global Challenge, a Global Perspective. Oak Brook, IL: Joint Commission Resources, May

9. Protecting our patients…
Implementation of “Bundles”
Bundle7 - a structured way of improving the processes of care and patient outcomes: a small, straightforward set of evidence-based practices — generally three to five — that, when performed collectively and reliably, have been proven to improve patient outcomes.
CDC Guidelines for CLABSI Bundles
Institute for Healthcare Improvement
7.)

10. CLABSI Bundles Central Line Insertion Practices (CLIP)8 Hand Hygiene
All 5 Maximal Barrier Precautions
Sterile Gloves
Sterile Gown
Cap
Mask Worn
Sterile drape covering entire patient
Chlorhexidene gluconate (CHG)
Insertion Site
Daily assessment to determine need
8.)

11. CLIP vs maintenance 1 vs ??? Extraluminal vs Intraluminal
CLIP = happens one time on a patient
Maintenance = happens all day long by a lot of different people (#1)
1 vs ???
“Bloodstream infections related to long-term CVC use are almost always a result of intraluminal biofilm development.” James Davis, RN, CIC
Senior Infection Prevention Analyst
Pennsylvania Patient Safety Authority

12. Central Line Maintenance “GUIDELINES”
Hand hygiene compliance ✔
Scrub access port or hub immediately prior to each use with appropriate antiseptic (70% IPA, CHG, provodine iodine) ✔
Access catheters with only sterile devices ✔
Dressing care. Replace wet, soiled or dislodged (using aseptic technique with clean or sterile gloves) ✔
Replacement of administration sets and needleless connectors ✔
Perform daily assessments to determine need for CVL ✔ #2
9.)

13. Needleless connector disinfection
2007 Java Vol 12, No 3,

14. “Scrub the HuB”
15 seconds

15. Is 15 sec every single time, every single access a practical expectation today? 
Ideal web page load time 3.5 seconds
(2010 PhoCusWright/Akamai Study) #3

16. And the survey says…

18. Challenges with claBSIs
Many Ports of Entry into the bloodstream #4

19. Challenges with Clabsi
Cannot See Microorganisms – blessing and curse #5
Culture from a patient’s needleless connector.
– Wendy Kaler, MT, MPH, CIC

20. Challenges with Clabsi
No Immediate Accountability – Patient doesn’t yell OUCH! #6

21. Challenges with Clabsi
Dynamic Bedside environment – nurse gets interrupted every two minutes #7

22. PORT PROTECTION What is a Port Protector? 70% IPA in a cap
Medical grade foam pad
To be placed on any swab-able, luer-activated device
To disinfect and act as a physical barrier between accesses when not in use

23. How a port protector works
Passive Disinfection
Chemical agent – 70% Isopropyl Alcohol
Time of exposure – minutes (per DFU)
Physical barrier – up to days if not removed (per DFU)
No scrubbing necessary (for first access)
FDA 510(k)
Single use

24. Types of Port Protectors

25. Advantages to port protection
Minimizes risk
Disinfected and protected vs. exposed and contaminated
Consistent disinfection
No user variability #8
Saves time*
Hub Scrub not necessary for first access if port protector in place for specified time
Visible tool for managing compliance
Allow for complete compliance with TJC NPSG
Peer Reviewed Data
Studies have demonstrated reduction in CLABSI, Contaminated Blood Cultures, and Intraluminal contamination
What’s next?

26. Port protector CLINICAL study
Observational before-after study in adult oncology nursing unit (Sweet, 2012)
Control period – manual cleaning with alcohol wipes, retrospective CLABSI data
1 year, 472 patients, 6851 central line days
16 CLABSIs, 2.3 infections/1000 catheter days
Intervention period – using port protectors on neutral mechanical valve NC
6 months, 282 patients, 3005 central line days
1 CLABSI, 0.3 infections/1000 catheter days
Reduction of contaminated blood cultures taken from catheters
Possible reduction in CLABSI
Cost savings
Length of stay decrease
Readmission decrease
Increase in Patient Satisfaction
SAVED LIVES
Possible reduction in contaminated or false positive blood cultures
Reduction in unnecessary antibiotic usage

27. Port protector CLINICAL STUDY
Case-crossover study with PICCs indwelling for 5 or more days, 3 hospitals (Wright, 2012)
1.5 mLs of blood drawn from PICC for culture on days 5, 6, 7 and twice weekly thereafter
3 phases – 799 patients enrolled
Manual scrubbing – 32/252 (12.7%) contaminated. 4 cfu/mL median
Use of port protector 20/364 (5.5%) contaminated, p=0.002, 1 cfu/mL median
Return to manual scrubbing – 22/183 (12%) contaminated, 2 cfu/mL median
Avoid 21 CLABSI, 4 fewer deaths, 13 new admissions
Possible reduction in CLABSI
Cost savings
Length of stay decrease
Readmission decrease
Increase in Patient Satisfaction
SAVED LIVES
Possible reduction in contaminated or false positive blood cultures
Reduction in unnecessary antibiotic usage

28. Port protector CLINICAL STUDY
Observational before-after study in 2 adult ICUs (Ramirez, 2012)
Control period – manual disinfection with alcohol pad for 15 seconds, normal surveillance data
4 CLABSIs, 1.9 infections/1000 catheter days
Intervention period – application of port protectors on all NCs
1 CLABSI, 0.5 infections/1000 catheter days
Possible reduction in CLABSI
Cost savings
Length of stay decrease
Readmission decrease
Increase in Patient Satisfaction
SAVED LIVES
Possible reduction in contaminated or false positive blood cultures
Reduction in unnecessary antibiotic usage

29. SIX SIGMA PROJECT – TX HOSPITAL
1. Open MAR
2. Scan Medication
3. Prepare Medication
4. Open Alcohol Pad
= 66 sec
per injection
(Avg. time spent in 12hr shifts giving IV injections)
5. Scrub Hub for 15 sec
6. Dry for
15 sec
7. Administer Medication

30. Advantages to Port Protection
1. Open MAR
2. Scan Patient
3. Scan Medication
4. Prepare Medication
= 23.7 sec
per injection
6. Administer Medication
5. Remove Port Protector
7. Replace with new port protector
64 % reduction!

31. Even simple solutions have challenges
The “Silver Bullet Syndrome”
Hand Hygiene
Clean, Dry, Intact Dressings
Confusing Protocol
Forced Compliance vs. Non-Forced Compliance

32. compliance Forced Compliance Non-forced Compliance #9 Car keys
Need them to drive car
Non-forced Compliance
Seat Beat
Car drives fine without seatbelt
Need for HARD WIRED habit #9

33. Main Challenge?
IT ONLY TAKES EXPOSURE
ONE
#10

34. Thank You! Questions?

35. Challenge accepted Product Location Education – reinforce the “WHY”
Easy access – grab and go
Education – reinforce the “WHY”
Process vs. Product
Simple Protocols
All Patients, All Lines, All the Time
Eliminates confusion
Supports Behavioral Changes
Auditing
Reinforcement to “hardwire” new process – 21 Days
Management engagement
Visibility to actual practice

36. audit program – unit based
Real time feedback/education
Accountability
Share compliance results
Nursing leadership support
Clinical ladder
Magnet story
CUSP
HEN
IP Liaisons
“If can not measure it, you
can not improve it.” – Lord Kelvin

37. Advantages to port protection
Allows for complete compliance with JCAHO NSPG
Visual auditable tool (no shadowing!)
Allows for documentation of standardized procedure and allows for reporting

38. COMMUNICATION The single biggest problem with
is the illusion that it has taken place.
- George Bernard Shaw

39. REAL TIME COMMUNICATION
Post Compliance Rates
Staff nurses, management, CLABSI committee
Share Success Stories
Prime tubing in med room, place PP on
Celebrate Victories
Reward positive
Gain more champions

40. WEEKLY UNIT REPORTING

41. Celebrate successes

42. I don’t have time!

43. ORGANIZATIONS WHERE ONE breach in process CAN IMPACT lives…

44. Monitoring Process Compliance
High reliability organizations, i.e. military, aviation, nuclear power
Continuous monitoring of critical processes
# of observations
Multidisciplinary/multidepartmental
Process examples
Line insertion
Line entry
Provide feedback - immediate and monthly
Monitoring & Effect on CLABSI rate
Bundle use alone not associated with lower CLABSI rate.
Rate  when process monitored & achieved > 95% compliance
Furuya et al; Presentation at Fifth Decennial International Conference on HAI. March 2010, Atlanta.

45. SHEA/IDSA Practice recommendations
SHEA/IDSA Practice recommendations Infection control and hospital epidemiology, vol. 35, no. 7 (july 2014) pp
2014 Update
Section 1: Rationale and Statements of Concern
Section 2: Background – Strategies to Detect CLABSI
Section 3: Background – Strategies to Prevent CLABSI
Section 4: Recommended Strategies for CLABSI Prevention
Basic Practices
Special Approaches
Section 5: Performance Measures
Internal Reporting
External Reporting
Section 6: Examples of Implementation Strategies
Engage
Educate
Execute
Evaluate

46. $$$ Reimbursement FYI 2015 HAC Reduction Program (1%)
Penalty enforced after VBP & Readmission adjustments
Domain 1 – AHRQ 35%
PSI-7 CLABSI
PSI-13 Sepsis
Domain 2 – CDC Measure 65%
CAUTI
CLABSI
VBP (Zero Sum Bucket) (1.5% - 2% in 2017)
Improvement (Self) – current performance vs baseline
Achievement (Others) – how does current performance stack up to others
Both make up your Total Performance Score
Readmission Reduction Program (3%)

47. CONCLUSION Important tools to assist
CABSI and Central Line Definitions
Challenges with BSI Prevention
No immediate accountability
It only takes ONE exposure to put a patient at risk
Overcoming BSI Challenges
Education as to WHY
Monitoring maintenance care
ENGAGE NURSING LEADERSHIP – Unit based programs
Important tools to assist
Port Protection
Visual auditing tool
Means to communicate compliance

48. Any questions?