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Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro Central Line Infections Avoidable? Preventable?

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Presentation on theme: "Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro Central Line Infections Avoidable? Preventable?"— Presentation transcript:

1 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro Central Line Infections Avoidable? Preventable?

2 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro What is a CLC-RBSI? Can we avoid them? The IHI tools The UHW experience

3 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro What is a CLC-RBSI? (Central Line Catheter–Related Blood Stream Infection) Agree a definition

4 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro 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) And –A culture positive line tip

5 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro 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 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro 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 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro What is the cost to the patient? CLC-RBSIs 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 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro 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 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro 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 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro 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 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro What else is a bundle? Methodology to spread the use of generally accepted science

12 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro What else is a bundle? Methodology to spread the use of generally accepted science Provide a pressure for teamwork

13 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro What else is a bundle? Methodology to spread the use of generally accepted science Provide a pressure for teamwork Simple, memorable checklist

14 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro 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 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro 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 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro Bundles bridge the Guideline Gap Evidence Guidelines Practice Bundle

17 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro 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; theyre well established best practices, but theyre 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 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro Types of Care Bundles Ventilator Care Bundle Sepsis Care Bundle Central Line Care Bundle

19 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro CLC Bundle.....insertion Hand hygiene –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 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro 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 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro How to measure 1. Hand hygieneYes No (hands washed & alcohol gel used) 2. Maximal barrier precautions on insertionYes No (user: cap, mask, sterile gown, sterile gloves patient: covered with large sterile drape) 3. Chlorhexidine skin antisepsisYes No 4. Optimal catheter site selectionYes 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 insertionYes No Central Line Care Bundle

22 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro Results Structure in place Process in place will result in the desired outcome

23 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro Structure Staff Equipment Documentation

24 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro Process Measure Compliance with all elements of the CLC Care Bundle (insertion and maintenance)

25 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro Outcome Measure Avoid / reduce Central Line Catheter- Related Blood Stream Infections (CLC- RBSI)

26 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro S + P = O

27 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro 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 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro 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 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro 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? The Model for Improvement ActPlan StudyDo When you combine the 3 questions with the… PDSA cycle, you get… … the Model for Improvement.

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

31 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro Use the PDSA Cycle for : Testing or adapting an improvement change Implementing the change Spreading the change to the rest of your system

32 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro Repeated Use of the PDSA Cycle Hunches, theories, best practices Changes That Result in Improvement AP SD A P S D AP SD D S P A DATA Very Small Scale Test Follow-up Tests Wide-Scale Tests of Change Implementation of Change 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 Sequential building of knowledge under a wide range of conditions

33 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro Use a PDSA form to organize, standardize and document your tests!

34 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro Plan Clear objective State predictions Who, what, where, when? Describe data collection plan

35 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro 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 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro Study Complete the analysis of the data Analyse feedback or observations Compare data/feedback to predictions & summarise what was learned Suggestions

37 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro Act What will happen in the next PDSA cycle? Develop change further? Test? Implement?

38 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro PDSA example: CLC Care Bundle CLC Bundle Routine use of CLC Bundle AP SD A P S D AP SD D S P A DATA Cycle 1: 1 Doctor/1 Nurse / 1 patient/1 day use of Chlorhexedine 2% Cycle 2: Repeat using 2 patients and 2 doctors/nurses for 2 days Cycle 3: Repeat using 2 patients, doctors/nurses for 1 week Cycle 4: Repeat using 6 patients

39 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro Multiple PDSA Cycles Running on Parallel Ramps with Multiple Aims Testing and adaptation A P S D A P S D A P S D D S P A A P S D A P S D A P S D D S P A A P S D A P S D A P S D D S P A A P S D A P S D A P S D D S P A Alcohol gel each bed area Coloured aprons Use of Chlorhexedine 2% Stricter visiting times Change Concepts

40 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro AIM Change Concepts, Theories, Ideas Concept B Concept C Concept A Concept D Multiple PDSA Cycles Directed Toward a Single Aim

41 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro What can you accomplish by Tuesday? It all depends on the size and scope of the planned change! 1 patient, 1 nurse, 1 doctor, 1 day Start small

42 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro 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, Langley, G. et. al. The Improvement Guide. Jossey-Bass Publishers, San Francisco, Lloyd, R. Quality Health Care: A Guide to Developing and Using Indicators. Jones and Bartlett Publishers, Sudbury, MA, Nelson, E. et al, Report Cards or Instrument Panels: Who Needs What? Journal of Quality Improvement, Volume 21, Number 4, April, 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 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro UHW experience

44 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro Structure and Process Compliance with CLC Bundle

45 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro 1 doctor non- compliant Dressing packs introduced Lines Trolleys introduced Start small Compliance tick-box stickers

46 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro Outcome Zero CLC infections

47 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro No agreed definition HELICS agreed National surveillance in Wales

48 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro A fundamental tenet of improvement in any industry is that if you want to improve you must develop a system to evaluate performance

49 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro Future challenges Spread

50 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro 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, Langley, G. et. al. The Improvement Guide. Jossey-Bass Publishers, San Francisco, Lloyd, R. Quality Health Care: A Guide to Developing and Using Indicators. Jones and Bartlett Publishers, Sudbury, MA, Nelson, E. et al, Report Cards or Instrument Panels: Who Needs What? Journal of Quality Improvement, Volume 21, Number 4, April, 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.

51 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd ar Fro


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