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Central Line Infections Avoidable? Preventable?

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Presentation on theme: "Central Line Infections Avoidable? Preventable?"— Presentation transcript:

1 Central Line Infections Avoidable? Preventable?

2 What is a CLC-RBSI? Can we avoid them? The IHI tools The UHW experience

3 What is a CLC-RBSI? (Central Line Catheter–Related Blood Stream Infection)
Agree a definition

4 HELICS (Hospital in Europe Link for Infection Control through Surveillance)
CLC-RBSI The patient has a positive blood culture with a recognised pathogen Or 2 positive blood cultures drawn within 48 hours for a common skin contaminant And Clinical evidence of infection (fever/ hypotension) A culture positive line tip

5 HELICS (Hospital in Europe Link for Infection Control through Surveillance)
CLC infection Clinical signs of infection (fever/ hypotension) A positive line tip culture Symptoms resolve within 48 hours of line removal

6 What can cause the infection?
Poor insertion hygiene Poor insertion technique Lack of appropriate skills Poor line maintenance Lines remaining in place for an inappropriate length of time Use of 3 way taps

7 What is the cost to the patient?
CLC-RBSI’s are a major cause of morbidity A 2006 prevalence survey found that 42.3% of bloodstream infections in England are central line-related National Audit Office (2000) estimated the additional cost of a bloodstream infection to be £6,209 per patient

8 How to avoid/prevent Line Infections
Standardise practice Practice variation is the enemy of quality Measure our practice and outcomes Know the extent of the problem in order to show improvement over time Develop a checklist model Care Bundle It makes the right thing to do the easy thing to do

9 Care bundles explained
A global standard of care management A group of interventions related to a disease process that when implemented together result in better outcomes than when implemented individually Bundle components can easily be measured as completed or not completed: ‘all-or-none’ compliance

10 Bundle Aim To eliminate the piecemeal application of evidence-based guidelines that characterises the majority of clinical environments today To make it easier for clinicians to bring guidelines into practice

11 What else is a bundle? Methodology to spread the use of generally accepted science

12 What else is a bundle? Methodology to spread the use of generally accepted science Provide a “pressure” for teamwork

13 What else is a bundle? Methodology to spread the use of generally accepted science Provide a “pressure” for teamwork Simple, memorable checklist

14 What else is a bundle? Methodology to spread the use of generally accepted science Provide a “pressure” for teamwork Simple, memorable checklist Audit tool

15 What else is a bundle? Methodology to spread the use of generally accepted science Provide a “pressure” for teamwork Simple, memorable checklist Audit tool All aspects should be done to get the maximum benefit

16 Bundles bridge the “Guideline Gap”
Evidence Guidelines Practice Bundle

17 What makes a bundle so special?
The power of a bundle science behind it method of execution: with complete consistency  The changes in a bundle are not new; they’re well established best practices, but they’re often not performed uniformly, making treatment unreliable A bundle ties the changes together into a package of interventions that people know must be followed for: every patient every single time

18 Types of Care Bundles Ventilator Care Bundle Sepsis Care Bundle
Central Line Care Bundle

19 CLC Bundle.....insertion Hand hygiene Maximal barrier precautions
Decontaminate hands before and after each patient contact Use correct hand hygiene procedure Maximal barrier precautions PPE Single use gloves Eye/face protection Aseptic technique Sterile gown, gloves and full body drape Chlorhexidine skin antisepsis (2% Chlorhexidine Gluconate in 70% Isopropyl Alchohol) Catheter Optimal catheter site selection, with subclavian vein as the preferred site for non-tunnelled catheters Single lumen unless indicated otherwise Consider antimicrobial impregnated catheter if duration of 1-3 weeks and risk of CLC-RBSI high

20 CLC Bundle....maintenance
Hand hygiene Decontaminate hands before and after each patient contact Use correct hand hygiene procedure Catheter site inspection Regular observation for signs of infection ie. leakage, inflammation etc – AT LEAST DAILY Dressing A sterile, transparent, semi-permeable dressing should be in place Ensure dressing is intact and dry Catheter access Aseptic technique swabbing ports/hubs with 2% Chlorhexedine prior to access Administration set replacement Following administration of blood/blood products – immediately Following TPN – after 24 hours or 72 hours if no lipids All other fluid sets – after 72 hours TPN should be infused via dedicated lumen Daily review of line necessity with prompt removal of unnecessary lines

21 Central Line Care Bundle
How to measure Central Line Care Bundle 1. Hand hygiene Yes  No  (hands washed & alcohol gel used) 2. Maximal barrier precautions on insertion Yes  No  (user: cap, mask, sterile gown, sterile gloves patient: covered with large sterile drape) 3. Chlorhexidine skin antisepsis Yes  No  4. Optimal catheter site selection Yes  No  (document site in notes & reason for site selection) 5. Daily review & documentation of line necessity Yes  No  (To be documented in patients notes) 6. Ultra sound used for insertion Yes  No 

22 Results Structure in place Process in place
will result in the desired outcome

23 Structure Staff Equipment Documentation

24 Process Measure Compliance with all elements of the CLC Care Bundle
(insertion and maintenance)

25 Outcome Measure Avoid / reduce Central Line Catheter-Related Blood Stream Infections (CLC-RBSI)

26 S + P = O

27 How do we achieve reliable improvements to our systems?
Implementing evidence-based changes to improve patient outcomes Set time frames......how much, by when? Getting the data to show what impact the changes are having Spread

28 The Three Fundamental Questions for Improvement
What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? Source, API The Improvement Guide, p. 10

29 When you combine the 3 questions with the…
The Model for Improvement What are we trying to accomplish? When you combine the 3 questions with the… PDSA cycle, you get… How will we know that a change is an improvement? What change can we make that will result in improvement? Act Plan Study Do …the Model for Improvement.

30 The PDSA Cycle for Learning and Improvement
Act Plan Objective Questions & predications (why) Plan to carry out the cycle (who, what, where, when) Plan for data collection What changes are to be made? Next cycle? Study Do Complete the analysis of the data Compare data to predictions Summarize what was learned Carry out the plan Document problems and unexpected observations Begin analysis of the data

31 Use the PDSA Cycle for : Testing or adapting an improvement change
Implementing the change Spreading the change to the rest of your system

32 Repeated Use of the PDSA Cycle
Changes That Result in Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement A P S D DATA D S P A Implementation of Change A P S D Wide-Scale Tests of Change A P S D Hunches, theories, best practices Sequential building of knowledge under a wide range of conditions Follow-up Tests Very Small Scale Test

33 Use a PDSA form to organize, standardize and document your tests!

34 Plan Clear objective State predictions Who, what, where, when?
Describe data collection plan

35 Do Attempt to carry out plan
Document any problems or unexpected events Collect planned data Capture feedback or observations from those conducting the plan Suggestions to improve in the DO phase of the PDSA

36 Study Complete the analysis of the data
Analyse feedback or observations Compare data/feedback to predictions & summarise what was learned Suggestions

37 Act What will happen in the next PDSA cycle? Develop change further?
Test? Implement?

38 PDSA example: CLC Care Bundle
Routine use of CLC Bundle A P S D DATA D S P A Cycle 4: Repeat using 6 patients A P S D Cycle 3: Repeat using 2 patients, doctors/nurses for 1 week A P S D Cycle 2: Repeat using 2 patients and 2 doctors/nurses for 2 days CLC Bundle Cycle 1: 1 Doctor/1 Nurse / 1 patient/1 day use of Chlorhexedine 2%

39 Multiple PDSA Cycles Running on Parallel Ramps with Multiple Aims
Testing and adaptation Coloured aprons Use of Chlorhexedine 2% Stricter visiting times Alcohol gel each bed area Change Concepts

40 AIM Multiple PDSA Cycles Directed Toward a Single Aim
Concept D Concept C Concept B Concept A Change Concepts, Theories, Ideas

41 It all depends on the size and scope of the planned change!
What can you accomplish by Tuesday? It all depends on the size and scope of the planned change! Start small 1 patient, 1 nurse, 1 doctor, 1 day

42 References on Measurement and Improvement
Brook, R. et. al. “Health System Reform and Quality.” Journal of the American Medical Association 276, no. 6 (1996): Carey, R. and Lloyd, R. Measuring Quality Improvement in healthcare: A Guide to Statistical Process Control Applications. ASQ Press, Milwaukee, WI, 2001. Langley, G. et. al. The Improvement Guide. Jossey-Bass Publishers, San Francisco, 1996. Lloyd, R. Quality Health Care: A Guide to Developing and Using Indicators. Jones and Bartlett Publishers, Sudbury, MA, 2004. Nelson, E. et al, “Report Cards or Instrument Panels: Who Needs What? Journal of Quality Improvement, Volume 21, Number 4, April, 1995. Solberg. L. et. al. “The Three Faces of Performance Improvement: Improvement, Accountability and Research.” Journal of Quality Improvement 23, no.3 (1997): \ Associate in Process Improvement. The Improvement Handbook: Models, Methods and Tools for Improvement, Austin, TX, January 2005.

43 UHW experience

44 Compliance with CLC Bundle
Structure and Process Compliance with CLC Bundle

45 Lines Trolleys introduced Dressing packs introduced
Start small 1 doctor non-compliant Lines Trolleys introduced Dressing packs introduced Compliance tick-box stickers

46 Outcome Zero CLC infections

47 National surveillance in Wales
No agreed definition National surveillance in Wales HELICS agreed

48 A fundamental tenet of improvement in any industry is that if you want to improve you must develop a system to evaluate performance

49 Future challenges Spread

50 References on Measurement and Improvement
Brook, R. et. al. “Health System Reform and Quality.” Journal of the American Medical Association 276, no. 6 (1996): Carey, R. and Lloyd, R. Measuring Quality Improvement in healthcare: A Guide to Statistical Process Control Applications. ASQ Press, Milwaukee, WI, 2001. Langley, G. et. al. The Improvement Guide. Jossey-Bass Publishers, San Francisco, 1996. Lloyd, R. Quality Health Care: A Guide to Developing and Using Indicators. Jones and Bartlett Publishers, Sudbury, MA, 2004. Nelson, E. et al, “Report Cards or Instrument Panels: Who Needs What? Journal of Quality Improvement, Volume 21, Number 4, April, 1995. Solberg. L. et. al. “The Three Faces of Performance Improvement: Improvement, Accountability and Research.” Journal of Quality Improvement 23, no.3 (1997): \ Associate in Process Improvement. The Improvement Handbook: Models, Methods and Tools for Improvement, Austin, TX, January 2005.

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